Dynamics of racial disparities in all-cause mortality during the COVID-19 pandemic.

As research documenting disparate impacts of COVID-19 by race and ethnicity grows, little attention has been given to dynamics in mortality disparities during the pandemic and whether changes in disparities persist. We estimate age-standardized monthly all-cause mortality in the United States from January 2018 through February 2022 for seven racial/ethnic populations. Using joinpoint regression, we quantify trends in race-specific rate ratios relative to non-Hispanic White mortality to examine the magnitude of pandemic-related shifts in mortality disparities. Prepandemic disparities were stable from January 2018 through February 2020. With the start of the pandemic, relative mortality disadvantages increased for American Indian or Alaska Native (AIAN), Native Hawaiian or other Pacific Islander (NHOPI), and Black individuals, and relative mortality advantages decreased for Asian and Hispanic groups. Rate ratios generally increased during COVID-19 surges, with different patterns in the summer 2021 and winter 2021/2022 surges, when disparities approached prepandemic levels for Asian and Black individuals. However, two populations below age 65 fared worse than White individuals during these surges. For AIAN people, the observed rate ratio reached 2.25 (95% CI = 2.14, 2.37) in October 2021 vs. a prepandemic mean of 1.74 (95% CI = 1.62, 1.86), and for NHOPI people, the observed rate ratio reached 2.12 (95% CI = 1.92, 2.33) in August 2021 vs. a prepandemic mean of 1.31 (95% CI = 1.13, 1.49). Our results highlight the dynamic nature of racial/ethnic disparities in mortality and raise alarm about the exacerbation of mortality inequities for Indigenous groups due to the pandemic.

Impact of Vietnam-era G.I. Bill eligibility on later-life blood pressure distribution: evidence from the Vietnam draft lottery natural experiment.

We quantified the impact of Vietnam-era G.I Bill eligibility, which subsidized college education for eligible Veterans, on the later-life blood pressure distribution by exploiting the Vietnam draft lottery natural experiment. We restricted Health and Retirement Study data (2006-2018) to men born between 1947-1953 (N=1,970). We estimated intention-to-treat effects at the mean and 1st-99th quantiles of blood pressure using linear and quantile regressions. Our outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP), hypertension, and self-reported stroke. We proxied G.I. Bill eligibility using lottery-defined draft eligibility. We also conducted analyses stratified by childhood socioeconomic status (cSES) defined based on a previously validated measure. Draft eligibility reduced mean blood pressure outcomes (e.g., effect on SBP: -1.33 [95% confidence interval (CI) -2.85, 0.19]). Draft eligibility also had larger protective effects at higher quantiles of the SBP and DBP distributions relative to lower quantiles (effects on SBP at the 10th and 90th quantiles: -0.33mmHg [95% CI -2.35,1.68]; -3.00mmHg [95% CI -5.68,-0.32]). Draft eligibility had protective effects on blood pressure among low and medium cSES men but opposite effects among high cSES men. G.I. Bill eligibility reshaped the blood pressure distribution to one of lower morbidity risk, particularly among low and medium cSES men.

Causal Inference About the Effects of Interventions From Observational Studies in Medical Journals.

Importance: Many medical journals, including JAMA, restrict the use of causal language to the reporting of randomized clinical trials. Although well-conducted randomized clinical trials remain the preferred approach for answering causal questions, methods for observational studies have advanced such that causal interpretations of the results of well-conducted observational studies may be possible when strong assumptions hold. Furthermore, observational studies may be the only practical source of information for answering some questions about the causal effects of medical or policy interventions, can support the study of interventions in populations and settings that reflect practice, and can help identify interventions for further experimental investigation. Identifying opportunities for the appropriate use of causal language when describing observational studies is important for communication in medical journals. Observations: A structured approach to whether and how causal language may be used when describing observational studies would enhance the communication of research goals, support the assessment of assumptions and design and analytic choices, and allow for more clear and accurate interpretation of results. Building on the extensive literature on causal inference across diverse disciplines, we suggest a framework for observational studies that aim to provide evidence about the causal effects of interventions based on 6 core questions: what is the causal question; what quantity would, if known, answer the causal question; what is the study design; what causal assumptions are being made; how can the observed data be used to answer the causal question in principle and in practice; and is a causal interpretation of the analyses tenable? Conclusions and Relevance: Adoption of the proposed framework to identify when causal interpretation is appropriate in observational studies promises to facilitate better communication between authors, reviewers, editors, and readers. Practical implementation will require cooperation between editors, authors, and reviewers to operationalize the framework and evaluate its effect on the reporting of empirical research.

Youth Experiencing Parental Death Due to Drug Poisoning and Firearm Violence in the US, 1999-2020.

Importance: Youth (those aged <18 years) parental death has been associated with negative health outcomes. Understanding the burden of parental death due to drug poisoning (herein, drugs) and firearms is essential for informing interventions. Objective: To estimate the incidence of youth parental death due to drugs, firearms, and all other causes. Design, Setting, and Participants: This cross-sectional observational study was conducted using vital registration, including all US decedents, and census data from January 1990 through December 2020. Data were analyzed from May 30, 2023, to March 28, 2024. Exposures: Parental death due to drug poisoning or firearms. Main Outcomes and Measures: A demographic matrix projection model was used to estimate the number and incidence of youth experiencing parental death, defined as the death of 1 or more parents, per 1000 population aged less than 18 years. Analyses evaluated parental deaths by drugs, firearms, and all other causes from 1999 through 2020 by race and ethnicity. Results: Between 1999 and 2020, there were 931 785 drug poisoning deaths and 736 779 firearm-related deaths with a mean (SD) age of 42.6 (16.3) years. Most deaths occurred among males (73.8%) and White decedents (70.8%) followed by Black (17.5%) and Hispanic (9.5%) decedents. An estimated 759 000 (95% CI, 722 000-800 000) youth experienced parental death due to drugs and an estimated 434 000 (95% CI, 409 000-460 000) youth experienced parental death due to firearms, accounting for 17% of all parental deaths. From 1999 to 2020, the estimated number of youth who experienced parental death increased 345% (95% CI, 334%-361%) due to drugs and 39% (95% CI, 37%-41%) due to firearms compared with 24% (95% CI, 23%-25%) due to all other causes. Black youth experienced a disproportionate burden of parental deaths, based primarily on firearm deaths among fathers. In 2020, drugs and firearms accounted for 23% of all parental deaths, double the proportion in 1999 (12%). Conclusions and Relevance: Results of this modeling study suggest that US youth are at high and increasing risk of experiencing parental death by drugs or firearms. Efforts to stem this problem should prioritize averting drug overdoses and firearm violence, especially among structurally marginalized groups.

The Integration of Clinical Trials With the Practice of Medicine: Repairing a House Divided.

Importance: Optimal health care delivery, both now and in the future, requires a continuous loop of knowledge generation, dissemination, and uptake on how best to provide care, not just determining what interventions work but also how best to ensure they are provided to those who need them. The randomized clinical trial (RCT) is the most rigorous instrument to determine what works in health care. However, major issues with both the clinical trials enterprise and the lack of integration of clinical trials with health care delivery compromise medicine's ability to best serve society. Observations: In most resource-rich countries, the clinical trials and health care delivery enterprises function as separate entities, with siloed goals, infrastructure, and incentives. Consequently, RCTs are often poorly relevant and responsive to the needs of patients and those responsible for care delivery. At the same time, health care delivery systems are often disengaged from clinical trials and fail to rapidly incorporate knowledge generated from RCTs into practice. Though longstanding, these issues are more pressing given the lessons learned from the COVID-19 pandemic, heightened awareness of the disproportionate impact of poor access to optimal care on vulnerable populations, and the unprecedented opportunity for improvement offered by the digital revolution in health care. Four major areas must be improved. First, especially in the US, greater clarity is required to ensure appropriate regulation and oversight of implementation science, quality improvement, embedded clinical trials, and learning health systems. Second, greater adoption is required of study designs that improve statistical and logistical efficiency and lower the burden on participants and clinicians, allowing trials to be smarter, safer, and faster. Third, RCTs could be considerably more responsive and efficient if they were better integrated with electronic health records. However, this advance first requires greater adoption of standards and processes designed to ensure health data are adequately reliable and accurate and capable of being transferred responsibly and efficiently across platforms and organizations. Fourth, tackling the problems described above requires alignment of stakeholders in the clinical trials and health care delivery enterprises through financial and nonfinancial incentives, which could be enabled by new legislation. Solutions exist for each of these problems, and there are examples of success for each, but there is a failure to implement at adequate scale. Conclusions and Relevance: The gulf between current care and that which could be delivered has arguably never been wider. A key contributor is that the 2 limbs of knowledge generation and implementation-the clinical trials and health care delivery enterprises-operate as a house divided. Better integration of these 2 worlds is key to accelerated improvement in health care delivery.

Impacts of Individual Patient Language and Neighborhood Ethnic Enclave on COVID-19 Test Positivity Among Hispanic/Latinx Patients in San Francisco.

BACKGROUND: Given the known disparities in COVID-19 within the Hispanic/Latinx community, we sought to examine the interaction between individual-level and neighborhood-level social determinants of health using linked electronic health record data. METHODS: We examined electronic health record data linked to neighborhood data among Hispanic/Latinx patients tested for COVID-19 between March 1, 2020, and February 28, 2021, from 2 large health care systems in San Francisco. Hispanic/Latinx ethnic enclave is measured using an index of census-tract level indicators of ethnicity, nativity, and language. Multilevel logistic regression models examined associations between ethnic enclave and COVID-19 positivity (COVID-19+), adjusting for patient-level sociodemographic and clinical characteristics and health system. Cross-level interactions were used to test whether associations between ethnic enclave and COVID-19+ differed by patient language preference. RESULTS: Among 26,871 patients, mean age was 37 years, 56% had Spanish-language preference, and 21% were COVID-19+. In unadjusted models, patients living in the highest versus lowest Hispanic/Latinx enclave had 3.2 higher odds of COVID-19+ (95% CI, 2.45-4.24). Adjusted, the relationship between ethnic enclave and COVID-19+ was attenuated, but not eliminated (odds ratio: 1.4; 95% CI, 1.13-1.17). Our results demonstrated a significant cross-level interaction, such that the influence of ethnic enclave was modified by patient language preference. For individuals with Spanish-language preference, risk of COVID-19+ was high regardless of neighborhood context, whereas for those with English preference, neighborhood ethnic enclave more than doubled the odds of infection. CONCLUSIONS: Findings suggest that a multilevel and intersectional approach to the study of COVID-19 inequities may illuminate dimensions of health inequity that affect marginalized communities and offer insights for targeted clinical and community-based interventions.

Contemporary screen time modalities and disruptive behavior disorders in children: a prospective cohort study.

BACKGROUND: Cross-sectional studies have demonstrated associations between screen time and disruptive behavior disorders (conduct disorder and oppositional defiant disorder); however, prospective associations remain unknown. This study's objective was to determine the prospective associations of contemporary screen time modalities with conduct and oppositional defiant disorder in a national cohort of 9-11-year-old children. METHODS: We analyzed data from the Adolescent Brain Cognitive Development (ABCD) Study (N = 11,875). Modified Poisson regression analyses were conducted to estimate the associations between baseline child-reported screen time (total and by modality) and parent-reported conduct or oppositional defiant disorder based on the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-5) at 1-year follow-up, adjusting for potential confounders. RESULTS: Participants reported an average of 4 hr of total screen time per day at baseline. Each hour of total screen time per day was prospectively associated with a 7% higher prevalence of conduct disorder (95% CI 1.03-1.11) and a 5% higher prevalence of oppositional defiant disorder (95% CI 1.03-1.08) at 1-year follow-up. Each hour of social media per day was associated with a 62% higher prevalence of conduct disorder (95% CI 1.39-1.87). Each hour of video chat (prevalence ratio [PR] 1.21, 95% CI 1.06-1.37), texting (PR 1.19, 95% CI 1.07-1.33), television/movies (PR 1.17, 95% CI 1.10-1.25), and video games (PR 1.14, 95% CI 1.07-1.21) per day was associated with a higher prevalence of the oppositional defiant disorder. When examining thresholds, exposure to >4 hr of total screen time per day was associated with a higher prevalence of conduct disorder (69%) and oppositional defiant disorder (46%). CONCLUSIONS: Higher screen time was prospectively associated with a higher prevalence of new-onset disruptive behavior disorders. The strongest association was between social media and conduct disorder, indicating that future research and interventions may focus on social media platforms to prevent conduct disorder.

Racial and sociodemographic predictors of COVID-19 compared with influenza, appendicitis, and all-cause hospitalization: retrospective cohort analysis.

OBJECTIVE: To determine whether inequities in COVID-19 infection and hospitalization differ from those for common medical conditions: influenza, appendicitis, and all-cause hospitalization. DESIGN: Retrospective study based on electronic health records of three healthcare systems in San Francisco (university, public, and community) examining (1) racial/ethnic distribution in cases and hospitalization among patients with diagnosed COVID-19 (March-August 2020) and patients with diagnosed influenza, diagnosed appendicitis, or all-cause hospitalization (August 2017-March 2020), and (2) sociodemographic predictors of hospitalization among those with diagnosed COVID-19 and influenza. RESULTS: Patients 18 years or older with diagnosed COVID-19 (N = 3934), diagnosed influenza (N = 5932), diagnosed appendicitis (N = 1235), or all-cause hospitalization (N = 62,707) were included in the study. The age-adjusted racial/ethnic distribution of patients with diagnosed COVID-19 differed from that of patients with diagnosed influenza or appendicitis for all healthcare systems, as did hospitalization from these conditions compared to any cause. For example, in the public healthcare system, 68% of patients with diagnosed COVID-19 were Latine, compared with 43% of patients with diagnosed influenza, and 48% of patients with diagnosed appendicitis (p < 0.05). In multivariable logistic regressions, COVID-19 hospitalizations were associated with male sex, Asian and Pacific Islander race/ethnicity, Spanish language, and public insurance in the university healthcare system, and Latine race/ethnicity and obesity in the community healthcare system. Influenza hospitalizations were associated with Asian and Pacific Islander and other race/ethnicity in the university healthcare system, obesity in the community healthcare system, and Chinese language and public insurance in both the university and community healthcare systems. CONCLUSIONS: Racial/ethnic and sociodemographic inequities in diagnosed COVID-19 and hospitalization differed from those for diagnosed influenza and other medical conditions, with consistently higher odds among Latine and Spanish-speaking patients. This work highlights the need for disease-specific public health efforts in at-risk communities in addition to structural upstream interventions.

Evaluating the association between in-person work and the risk of SARS-CoV-2 infection through June 2021.

OBJECTIVES: Recent studies have evaluated COVID-19 outbreaks and excess mortality by occupation sectors. Studies on SARS-CoV-2 infection across occupation and occupation-related factors remain lacking. In this study, we estimate the effect of in-person work on SARS-CoV-2 infection risk and describe SARS-CoV-2 seroprevalence among working adults. METHODS: We used Wave 1 data (May to June 2021) from CalScope, a population-based seroprevalence study in California. Occupation data were coded using the National Institute for Occupational Safety and Health Industry and Occupation Computerized Coding System. Dried blood spot specimens were tested for antibodies to establish evidence of prior infection. We estimated the causal effect of in-person work on SARS-CoV-2 infection risk using the g-formula and describe SARS-CoV-2 seroprevalence across occupation-related factors. RESULTS: Among 4335 working adults, 53% worked in person. In-person work was associated with increased risk of prior SARS-CoV-2 infection (risk difference: 0.03; [95% CI: 0.02-0.04]) compared with working remotely. Workers that reported job loss or who were without medical insurance had higher evidence of prior infection. Amongst in-person workers, evidence of prior infection was highest within farming, fishing, and forestry (55%; [95% CI: 26%-81%]); installation, maintenance, and repair (23%; [12%-39%]); building and grounds cleaning and maintenance (23%; [13%-36%]); food preparation and serving related (22% [13%-35%]); and healthcare support (22%; [13%-34%]) occupations. Workers who identified as Latino, reported a household income of <$25K, or who were without a bachelor's degree also had higher evidence of prior infection. CONCLUSIONS: SARS-CoV-2 infection risk varies by occupation. Future vaccination strategies may consider prioritizing in-person workers.

Diabetes Screening by Race and Ethnicity in the United States: Equivalent Body Mass Index and Age Thresholds.

BACKGROUND: Racial/ethnic minority populations in the United States have increased rates of diabetes compared with White populations. The 2021 guidelines from the U.S. Preventive Services Task Force recommend diabetes screening for adults aged 35 to 70 years with a body mass index (BMI) of 25 kg/m2 or greater. OBJECTIVE: To determine the BMI threshold for diabetes screening in major racial/ethnic minority populations with benefits and harms equivalent to those of the current diabetes screening threshold in White adults. DESIGN: Cross-sectional study. SETTING: NHANES (National Health and Nutrition Examination Survey), 2011 to 2018. PARTICIPANTS: Nonpregnant U.S. adults aged 18 to 70 years (n = 19 335). MEASUREMENTS: A logistic regression model was used to estimate diabetes prevalence at various BMIs for White, Asian, Black, and Hispanic Americans. For each racial/ethnic minority group, the equivalent BMI threshold was defined as the BMI at which the prevalence of diabetes in 35-year-old persons in that group is equal to that in 35-year-old White adults at a BMI of 25 kg/m2. Ranges were estimated to account for the uncertainty in prevalence estimates for White and racial/ethnic minority populations. RESULTS: Among adults aged 35 years with a BMI of 25 kg/m2, the prevalence of diabetes in Asian Americans (3.8% [95% CI, 2.8% to 5.1%]), Black Americans (3.5% [CI, 2.7% to 4.7%]), and Hispanic Americans (3.0% [CI, 2.1% to 4.2%]) was significantly higher than that in White Americans (1.4% [CI, 1.0% to 2.0%]). Compared with a BMI threshold of 25 kg/m2 in White Americans, the equivalent BMI thresholds for diabetes prevalence were 20 kg/m2 (range, <18.5 to 23 kg/m2) for Asian Americans, less than 18.5 kg/m2 (range, <18.5 to 23 kg/m2) for Black Americans, and 18.5 kg/m2 (range, <18.5 to 24 kg/m2) for Hispanic Americans. LIMITATION: Sample size limitations precluded assessment of heterogeneity within racial/ethnic groups. CONCLUSION: Among U.S. adults aged 35 years or older, offering diabetes screening to Black Americans and Hispanic Americans with a BMI of 18.5 kg/m2 or greater and Asian Americans with a BMI of 20 kg/m2 or greater would be equivalent to screening White adults with a BMI of 25 kg/m2 or greater. Using screening thresholds specific to race/ethnicity has the potential to reduce disparities in diabetes diagnosis. PRIMARY FUNDING SOURCE: Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology.

Cost-Effectiveness of Hypertension Treatment by Pharmacists in Black Barbershops.

BACKGROUND: In LABBPS (Los Angeles Barbershop Blood Pressure Study), pharmacist-led hypertension care in Los Angeles County Black-owned barbershops significantly improved blood pressure control in non-Hispanic Black men with uncontrolled hypertension at baseline. In this analysis, 10-year health outcomes and health care costs of 1 year of the LABBPS intervention versus control are projected. METHODS: A discrete event simulation of hypertension care processes projected blood pressure, medication-related adverse events, fatal and nonfatal cardiovascular disease events, and noncardiovascular disease death in LABBPS participants. Program costs, total direct health care costs (2019 US dollars), and quality-adjusted life-years (QALYs) were estimated for the LABBPS intervention and control arms from a health care sector perspective over a 10-year horizon. Future costs and QALYs were discounted 3% annually. High and intermediate cost-effectiveness thresholds were defined as <$50 000 and <$150 000 per QALY gained, respectively. RESULTS: At 10 years, the intervention was projected to cost an average of $2356 (95% uncertainty interval, -$264 to $4611) more per participant than the control arm and gain 0.06 (95% uncertainty interval, 0.01-0.10) QALYs. The LABBPS intervention was highly cost-effective, with a mean cost of $42 717 per QALY gained (58% probability of being highly and 96% of being at least intermediately cost-effective). Exclusive use of generic drugs improved the cost-effectiveness to $17 162 per QALY gained. The LABBPS intervention would be only intermediately cost-effective if pharmacists were less likely to intensify antihypertensive medications when systolic blood pressure was ≥150 mm Hg or if pharmacist weekly time driving to barbershops increased. CONCLUSIONS: Hypertension care delivered by clinical pharmacists in Black barbershops is a highly cost-effective way to improve blood pressure control in Black men.

Sociodemographic Correlates of Contemporary Screen Time Use among 9- and 10-Year-Old Children.

OBJECTIVE: To determine sociodemographic correlates of contemporary screen time use among a diverse population-based sample of 9- and 10-year-old children. STUDY DESIGN: In 2021, we analyzed cross-sectional baseline (2016-2018) data from the Adolescent Brain Cognitive Development study (n = 10 755). Multiple linear regression analyses were conducted to estimate associations between sociodemographic factors (sex, race/ethnicity, country of birth, household income, parental education) and 6 contemporary forms of screen time (television, videos [eg, YouTube], video games, social networking, texting, and video chat). RESULTS: On average, children reported 3.99 hours of screen time per day across 6 modalities, with the most time spent watching/streaming television shows/movies (1.31 hours), playing video games (1.06 hours), and watching/streaming videos (1.05 hours). On average, Black children reported 1.58 more hours of screen time per day and Asian children reported 0.35 less hours of screen time per day compared with White children (mean 3.46 hours per day), and these trends persisted across most modalities. Boys reported higher overall screen time (0.75 hours more) than girls, which was primarily attributed to video games and videos. Girls reported more time texting, social networking, and video chatting than boys. Higher income was associated with lower screen time usage across all modalities except video chat. However, in high-income households, Latinx children reported 0.65 more hours of screen time per day than White children. CONCLUSIONS: Given the sociodemographic differences in child screen use, guideline implementation strategies can focus on key populations, encourage targeted counseling by pediatricians, and adapt Family Media Use Plans for diverse backgrounds.

Social epidemiology of early adolescent problematic screen use in the United States.

OBJECTIVE: To determine sociodemographic correlates of problematic screen use (social media, video games, mobile phones) among a racially/ethnically and socioeconomically diverse population-based sample of 10-14-year-old early adolescents. STUDY DESIGN: We analyzed cross-sectional data from the Adolescent Brain Cognitive Development Study (Year 2, 2018-2020; N = 8753). Multiple linear regression analyses were used to estimate associations between sociodemographic factors (age, sex, race/ethnicity, primary language, household income, parental education) and adolescent-reported problematic video game (Video Game Addiction Questionnaire), social media (Social Media Addiction Questionnaire), and mobile phone use (Mobile Phone Involvement Questionnaire). RESULTS: Boys reported higher problematic video game use while girls reported higher problematic social media and mobile phone use. Native American, black, and Latinx adolescents reported higher scores across all problematic screen measures compared to non-Latinx white adolescents. Having unmarried/unpartnered parents was associated with higher problematic social media use. Although higher household income was generally protective against problematic video game use, these associations were weaker for black than white adolescents (p for interaction <0.05). CONCLUSIONS: Given the sociodemographic differences in problematic screen use, digital literacy education strategies can focus on at-risk populations, encourage targeted counseling by pediatricians, and adapt family media use plans for diverse backgrounds. IMPACT: While sociodemographic differences in screen time are documented, we examined sociodemographic differences in problematic screen use in a large, diverse sample of early adolescents in the US. Boys reported higher problematic video game use while girls reported higher problematic social media and mobile phone use. Native American, black, and Latinx adolescents reported higher scores across all problematic screen measures compared to non-Latinx white adolescents. Although higher household income was generally protective against problematic video game use, these associations were weaker for black than white adolescents. Beyond time spent on screens, pediatricians, parents, and educators should be aware of sociodemographic differences in problematic screen use.

Physical activity from young adulthood to middle age and premature cardiovascular disease events: a 30-year population-based cohort study.

BACKGROUND: Although physical activity is generally protective of cardiovascular disease (CVD), less is known about how young adult physical activity relates to premature CVD events. The objective of this study was to determine the association between level and change in physical activity from young adulthood to middle age and incidence of premature CVD events before age 60. METHODS: We analyzed data collected across four urban sites from nine visits over 30 years of follow-up (1985-2016) from the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective community-based cohort study of 5115 Black and White women and men aged 18-30 years at baseline (1985-1986). Linear mixed models were used to develop individualized moderate-to-vigorous intensity self-reported physical activity trajectories per participant. Fatal and nonfatal coronary heart disease (CHD), heart failure, and stroke outcomes were analyzed separately and as a combined CVD event outcome. RESULTS: Overall, physical activity declined in young adults as they progressed through middle age. Lower physical activity scores (per 100 exercise units) in 18 year-olds were associated with higher odds of premature CHD (AOR 1.14, 95% CI 1.02-1.28), heart failure (AOR 1.21, 95% CI 1.05-1.38), stroke (AOR 1.20, 95% CI 1.04-1.39), and any CVD (AOR 1.15, 95% CI 1.06-1.24) events. Each additional annual 1-unit reduction in the physical activity score was associated with a higher annual odds of incident heart failure (1.07, 95% CI 1.02-1.13), stroke (1.06, 95% CI 1.00-1.13), and CVD (1.04, 95% CI 1.01-1.07) events. Meeting the minimum (AOR 0.74, 95% CI 0.0.57-0.96) and twice the minimum (AOR 0.55, 95% CI 0.34-0.91) Department of Health and Human Services physical activity guidelines through follow up was protective of premature CVD events. CONCLUSIONS: Given recent trends in declining physical activity with age and associated premature CVD events, the transition from young adult to midlife is an important time period to promote physical activity.

Moderate-to-vigorous intensity physical activity from young adulthood to middle age and metabolic disease: a 30-year population-based cohort study.

OBJECTIVES: To determine the association between moderate-to-vigorous intensity physical activity (MVPA) trajectories (course over age and time) through the adult life course and onset of metabolic disease (diabetes and dyslipidaemia). METHODS: We analysed prospective community-based cohort data of 5115 participants in the Coronary Artery Risk Development in Young Adults study, who were black and white men and women aged 18-30 years at baseline (1985-1986) at four urban sites, collected through 30 years of follow-up. Individualised MVPA trajectories were developed for each participant using linear mixed models. RESULTS: Lower estimated MVPA score at age 18 was associated with a 12% (95% CI 6% to 18%) higher odds of incident diabetes, a 4% (95% CI 1% to 7%) higher odds of incident low high-density lipoprotein (HDL) and a 6% (95% CI 2% to 11%) higher odds of incident high triglycerides. Each additional annual 1-unit reduction in the MVPA score was associated with a 6% (95% CI 4% to 9%) higher annual odds of diabetes incidence and a 4% (95% CI 2% to 6%) higher annual odds of high triglyceride incidence. Analysing various MVPA trajectory groups, participants who were in the most active group at age 18 (over 300 min/week), but with sharp declines in midlife, had higher odds of high low-density lipoprotein and low HDL incidence, compared with those in the most active group at age 18 with subsequent gains. CONCLUSION: Given recent trends in declining MVPA across the life course and associated metabolic disease risk, young adulthood is an important time period for interventions to increase and begin the maintenance of MVPA.

The American Heart Association 2030 Impact Goal: A Presidential Advisory From the American Heart Association.

Each decade, the American Heart Association (AHA) develops an Impact Goal to guide its overall strategic direction and investments in its research, quality improvement, advocacy, and public health programs. Guided by the AHA's new Mission Statement, to be a relentless force for a world of longer, healthier lives, the 2030 Impact Goal is anchored in an understanding that to achieve cardiovascular health for all, the AHA must include a broader vision of health and well-being and emphasize health equity. In the next decade, by 2030, the AHA will strive to equitably increase healthy life expectancy beyond current projections, with global and local collaborators, from 66 years of age to at least 68 years of age across the United States and from 64 years of age to at least 67 years of age worldwide. The AHA commits to developing additional targets for equity and well-being to accompany this overarching Impact Goal. To attain the 2030 Impact Goal, we recommend a thoughtful evaluation of interventions available to the public, patients, providers, healthcare delivery systems, communities, policy makers, and legislators. This presidential advisory summarizes the task force's main considerations in determining the 2030 Impact Goal and the metrics to monitor progress. It describes the aspiration that these goals will be achieved by working with a diverse community of volunteers, patients, scientists, healthcare professionals, and partner organizations needed to ensure success.

Sheltering in Place and the Likelihood of Nonnatural Death.

Increasing hospitalizations for COVID-19 in the United States and elsewhere have ignited debate over whether to reinstate shelter-in-place policies adopted early in the pandemic to slow the spread of infection. The debate includes claims that sheltering in place influences deaths unrelated to infection or other natural causes. Testing this claim should improve the benefit/cost accounting that informs choice on reimposing sheltering in place. We used time-series methods to compare weekly nonnatural deaths in California with those in Florida. California was the first state to begin, and among the last to end, sheltering in place, while sheltering began later and ended earlier in Florida. During weeks when California had shelter-in-place orders in effect, but Florida did not, the odds that a nonnatural death occurred in California rather than Florida were 14.4% below expected levels. Sheltering-in-place policies likely reduce mortality from mechanisms unrelated to infection or other natural causes of death.

A Randomized Study to Assess the Effect of Including the Graduate Record Examinations Results on Reviewer Scores for Underrepresented Minorities.

Whether requiring Graduate Record Examinations (GRE) results for doctoral applicants affects the diversity of admitted cohorts remains uncertain. This study randomized applications to 2 population-health doctoral programs at the University of California San Francisco to assess whether masking reviewers to applicant GRE results differentially affects reviewers' scores for underrepresented minority (URM) applicants from 2018-2020. Applications with GRE results and those without were randomly assigned to reviewers to designate scores for each copy (1-10, 1 being best). URM was defined as self-identification as African American/Black, Filipino, Hmong, Vietnamese, Hispanic/Latinx, Native American/Alaska Native, or Native Hawaiian/Other Pacific Islander. We used linear mixed models with random effects for the applicant and fixed effects for each reviewer to evaluate the effect of masking the GRE results on the overall application score and whether this effect differed by URM status. Reviewer scores did not significantly differ for unmasked versus masked applications among non-URM applicants (ß = 0.15; 95% CI: -0.03, 0.33) or URM applicants (ß = 0.02, 95% CI: -0.49, 0.54). We did not find evidence that removing GREs differentially affected URM compared with non-URM students (ß for interaction = -0.13, 95% CI: -0.55, 0.29). Within these doctoral programs, results indicate that GRE scores neither harm nor help URM applicants.