Racial and Ethnic Disparities in All-Cause and Cause-Specific Mortality Among US Youth.

Importance: Mortality rates in US youth have increased in recent years. An understanding of the role of racial and ethnic disparities in these increases is lacking. Objective: To compare all-cause and cause-specific mortality trends and rates among youth with Hispanic ethnicity and non-Hispanic American Indian or Alaska Native, Asian or Pacific Islander, Black, and White race. Design, Setting, and Participants: This cross-sectional study conducted temporal analysis (1999-2020) and comparison of aggregate mortality rates (2016-2020) for youth aged 1 to 19 years using US Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database. Data were analyzed from June 30, 2023, to January 17, 2024. Main Outcomes and Measures: Pooled, all-cause, and cause-specific mortality rates per 100 000 youth (hereinafter, per 100 000) for leading underlying causes of death were compared. Injuries were classified by mechanism and intent. Results: Between 1999 and 2020, there were 491 680 deaths among US youth, including 8894 (1.8%) American Indian or Alaska Native, 14 507 (3.0%) Asian or Pacific Islander, 110 154 (22.4%) Black, 89 251 (18.2%) Hispanic, and 267 452 (54.4%) White youth. Between 2016 and 2020, pooled all-cause mortality rates were 48.79 per 100 000 (95% CI, 46.58-51.00) in American Indian or Alaska Native youth, 15.25 per 100 000 (95% CI, 14.75-15.76) in Asian or Pacific Islander youth, 42.33 per 100 000 (95% CI, 41.81-42.86) in Black youth, 21.48 per 100 000 (95% CI, 21.19-21.77) in Hispanic youth, and 24.07 per 100 000 (95% CI, 23.86-24.28) in White youth. All-cause mortality ratios compared with White youth were 2.03 (95% CI, 1.93-2.12) among American Indian or Alaska Native youth, 0.63 (95% CI, 0.61-0.66) among Asian or Pacific Islander youth, 1.76 (95% CI, 1.73-1.79) among Black youth, and 0.89 (95% CI, 0.88-0.91) among Hispanic youth. From 2016 to 2020, the homicide rate in Black youth was 12.81 (95% CI, 12.52-13.10) per 100 000, which was 10.20 (95% CI, 9.75-10.66) times that of White youth. The suicide rate for American Indian or Alaska Native youth was 11.37 (95% CI, 10.30-12.43) per 100 000, which was 2.60 (95% CI, 2.35-2.86) times that of White youth. The firearm mortality rate for Black youth was 12.88 (95% CI, 12.59-13.17) per 100 000, which was 4.14 (95% CI, 4.00-4.28) times that of White youth. American Indian or Alaska Native youth had a firearm mortality rate of 6.67 (95% CI, 5.85-7.49) per 100 000, which was 2.14 (95% CI, 1.88- 2.43) times that of White youth. Black youth had an asthma mortality rate of 1.10 (95% CI, 1.01-1.18) per 100 000, which was 7.80 (95% CI, 6.78-8.99) times that of White youth. Conclusions and Relevance: In this study, racial and ethnic disparities were observed for almost all leading causes of injury and disease that were associated with recent increases in youth mortality rates. Addressing the increasing disparities affecting American Indian or Alaska Native and Black youth will require efforts to prevent homicide and suicide, especially those events involving firearms.

Association Between Partisan Affiliation of State Governments and State Mortality Rates Before and During the COVID-19 Pandemic.

Policy Points The increasing political polarization of states reached new heights during the COVID-19 pandemic, when response plans differed sharply across party lines. This study found that states with Republican governors and larger Republican majorities in legislatures experienced higher death rates during the COVID-19 pandemic-and in preceding years-but these associations often lost statistical significance after adjusting for the average income and health status of state populations and for the policy orientations of the states. Future research may help clarify whether the higher death rates in these states result from policy choices or have other explanations, such as the tendency of voters with lower incomes or poorer health to elect Republican candidates. CONTEXT: Increasing polarization of states reached a high point during the COVID-19 pandemic, when the party affiliation of elected officials often predicted their policy response. The health consequences of these divisions are unclear. Prior studies compared mortality rates based on presidential voting patterns, but few considered the partisan orientation of state officials. This study examined whether the partisan orientation of governors or legislatures was associated with mortality outcomes during the COVID-19 pandemic. METHODS: Data on deaths and the partisan orientation of governors and legislators were obtained from the Centers for Disease Control and Prevention and the National Conference of State Legislatures, respectively. Linear regression was used to measure the association between Republican representation (percentage of seats held) in legislatures and (1) age-adjusted, all-cause mortality rates (AAMRs) in 2015-2021 and (2) excess death rates during three phases of the COVID-19 pandemic, controlling for median household income, the prevalence of four risk factors (obesity, chronic obstructive pulmonary disease, heart attack, stroke), and state policy orientation. Associations between excess death rates and the governor's party were also examined. FINDINGS: States with Republican governors or greater Republican representation in legislatures experienced higher AAMRs during 2015-2021, lower excess death rates during Phase 1 of the COVID-19 pandemic (weeks ending March 28, 2020, through June 13, 2020), and higher excess death rates in Phases 2 and 3 (weeks ending June 20, 2020, through April 30, 2022; p < 0.05). Most associations lost statistical significance after adjustment for control variables. CONCLUSIONS: Mortality was higher in states with Republican governors and greater Republican legislative representation before and during much of the pandemic. Observed associations could be explained by the adverse effects of policy choices, reverse causality (e.g., popularity of Republican candidates in states with lower socioeconomic and health status), or unmeasured factors that predominate in states with Republican leaders.

Identifying bright spot communities: Socioecological, workforce, and healthcare delivery factors influencing opioid mortality.

Context: There were 50,000 U.S. opioid overdose deaths in 2019. Millions suffer from opioid addiction. Identifying protective factors for low community opioid mortality may have important implications for addressing the opioid epidemic. This study was funded through the Virginia (VA) Department of Medical Assistance Services (DMAS) through a SUPPORT Act Grant. Objective: To identify "Bright Spot" communities in Virginia with protective factors associated with reduced opioid mortality and morbidity. Study Design: Ecologic study. Dataset: Virginia All Payer Claims Database (APCD), Virginia Department of Health (VDH) statewide medical examiner registry, and American Community Survey (ACS). Time Period: 2016-2019; 2019 data cited here. Population Studied: APCD includes VA residents with medical claims through commercial, Medicaid, and Medicare coverage. VDH data includes fatal drug overdoses. ACS surveys all VA residents. Outcome Measures: Primary outcome: fatal opioid overdoses. Secondary outcomes: emergency room visits for overdoses and opioid-related diagnoses, outpatient diagnoses for opioid-related disorder, prescription rate for opioids, and prescription rate for buprenorphine. Results: Opioid mortality was associated with higher rates of community poverty (r=.38, p<.0001) and disability (r=.52, r<.0001). Opioid mortality was associated with inequality, with higher Gini index associated with higher opioid mortality (r=.23, p<.0001). A higher percentage of black residents was associated with increased fatal opioid overdoses (r=.37, p<.0001) and ED visits for overdoses (r=.30, p<.0001). A higher percentage of white residents correlated with increased outpatient visits for opioid use disorder (r=.24, p<.0001) and higher rates of buprenorphine (r=.34, p<.0001) and opioid prescriptions (r=.31, p <.0001). Conclusions: These findings suggest significant racial disparities in opioid outcomes. Communities with a higher percentage of black residents are more likely to have higher opioid mortality and a lower rate of outpatient treatment. This association may be affected by the time period used in the analysis (2015-2019), as nationally there has been an increasing rate of synthetic opioid deaths in Black communities. These measures have been incorporated into a multivariate analysis to identify Bright Spot communities, which will be discussed during the presentation.

Changes in the Relationship Between Income and Life Expectancy Before and During the COVID-19 Pandemic, California, 2015-2021.

Importance: The COVID-19 pandemic caused a large decrease in US life expectancy in 2020, but whether a similar decrease occurred in 2021 and whether the relationship between income and life expectancy intensified during the pandemic are unclear. Objective: To measure changes in life expectancy in 2020 and 2021 and the relationship between income and life expectancy by race and ethnicity. Design, Setting, and Participants: Retrospective ecological analysis of deaths in California in 2015 to 2021 to calculate state- and census tract-level life expectancy. Tracts were grouped by median household income (MHI), obtained from the American Community Survey, and the slope of the life expectancy-income gradient was compared by year and by racial and ethnic composition. Exposures: California in 2015 to 2019 (before the COVID-19 pandemic) and 2020 to 2021 (during the COVID-19 pandemic). Main Outcomes and Measures: Life expectancy at birth. Results: California experienced 1 988 606 deaths during 2015 to 2021, including 654 887 in 2020 to 2021. State life expectancy declined from 81.40 years in 2019 to 79.20 years in 2020 and 78.37 years in 2021. MHI data were available for 7962 of 8057 census tracts (98.8%; n = 1 899 065 deaths). Mean MHI ranged from $21 279 to $232 261 between the lowest and highest percentiles. The slope of the relationship between life expectancy and MHI increased significantly, from 0.075 (95% CI, 0.07-0.08) years per percentile in 2019 to 0.103 (95% CI, 0.098-0.108; P < .001) years per percentile in 2020 and 0.107 (95% CI, 0.102-0.112; P < .001) years per percentile in 2021. The gap in life expectancy between the richest and poorest percentiles increased from 11.52 years in 2019 to 14.67 years in 2020 and 15.51 years in 2021. Among Hispanic and non-Hispanic Asian, Black, and White populations, life expectancy declined 5.74 years among the Hispanic population, 3.04 years among the non-Hispanic Asian population, 3.84 years among the non-Hispanic Black population, and 1.90 years among the non-Hispanic White population between 2019 and 2021. The income-life expectancy gradient in these groups increased significantly between 2019 and 2020 (0.038 [95% CI, 0.030-0.045; P < .001] years per percentile among Hispanic individuals; 0.024 [95% CI: 0.005-0.044; P = .02] years per percentile among Asian individuals; 0.015 [95% CI, 0.010-0.020; P < .001] years per percentile among Black individuals; and 0.011 [95% CI, 0.007-0.015; P < .001] years per percentile among White individuals) and between 2019 and 2021 (0.033 [95% CI, 0.026-0.040; P < .001] years per percentile among Hispanic individuals; 0.024 [95% CI, 0.010-0.038; P = .002] years among Asian individuals; 0.024 [95% CI, 0.011-0.037; P = .003] years per percentile among Black individuals; and 0.013 [95% CI, 0.008-0.018; P < .001] years per percentile among White individuals). The increase in the gradient was significantly greater among Hispanic vs White populations in 2020 and 2021 (P < .001 in both years) and among Black vs White populations in 2021 (P = .04). Conclusions and Relevance: This retrospective analysis of census tract-level income and mortality data in California from 2015 to 2021 demonstrated a decrease in life expectancy in both 2020 and 2021 and an increase in the life expectancy gap by income level relative to the prepandemic period that disproportionately affected some racial and ethnic minority populations. Inferences at the individual level are limited by the ecological nature of the study, and the generalizability of the findings outside of California are unknown.

Educational Disparities in Adult Mortality Across U.S. States: How Do They Differ, and Have They Changed Since the Mid-1980s?

Adult mortality varies greatly by educational attainment. Explanations have focused on actions and choices made by individuals, neglecting contextual factors such as economic and policy environments. This study takes an important step toward explaining educational disparities in U.S. adult mortality and their growth since the mid-1980s by examining them across U.S. states. We analyzed data on adults aged 45-89 in the 1985-2011 National Health Interview Survey Linked Mortality File (721,448 adults; 225,592 deaths). We compared educational disparities in mortality in the early twenty-first century (1999-2011) with those of the late twentieth century (1985-1998) for 36 large-sample states, accounting for demographic covariates and birth state. We found that disparities vary considerably by state: in the early twenty-first century, the greater risk of death associated with lacking a high school credential, compared with having completed at least one year of college, ranged from 40 % in Arizona to 104 % in Maryland. The size of the disparities varies across states primarily because mortality associated with low education varies. Between the two periods, higher-educated adult mortality declined to similar levels across most states, but lower-educated adult mortality decreased, increased, or changed little, depending on the state. Consequently, educational disparities in mortality grew over time in many, but not all, states, with growth most common in the South and Midwest. The findings provide new insights into the troubling trends and disparities in U.S. adult mortality.

Perioperative interdisciplinary approach for reduction of opioid use in pediatric tonsillectomy: Protocol using dexmedetomidine and bupivicaine as adjunct agents.

IMPORTANCE: Pediatric tonsillectomy is a common procedure now being performed most often for patients with obstructive sleep apnea, which has been associated with increased sensitivity to the respiratory side effects of opioid medications. This study investigates a strategy to decrease the use of opiate medications in a particularly vulnerable population. OBJECTIVE: Describe an interdisciplinary approach between Otolaryngologists and Anesthesiologists to decrease opiate use in tonsillectomy patients. Demonstrate safety of this protocol. Evaluate the effect of the protocol on intraoperative need for opiate medications and inhaled anesthetic use. Perform cost analysis of the protocol. DESIGN: Retrospective case-control study with cost analysis. SETTING: Tertiary Care Hospital. PARTICIPANTS: Pediatric patients undergoing tonsillectomy at a tertiary care hospital. INTERVENTIONS: Preoperative and intraoperative dexmedetomidine with local bupivacaine injection into the tonsillar fossa. MEASURES: Intraoperative need for sevoflurane, opiate, and propofol. Post-operative pain scores, and utilization of post-operative opiate, acetaminophen, and ibuprofen pain medications. Post-operative adverse events. Cost analysis of protocol. RESULTS: This protocol led to a decrease in intraoperative opiate use by 49.6%, a decrease in intraoperative sevofluorane use by 18%, and a lower reported maximum post-operative pain score without any increase in adverse events. The protocol added a small increase in medication cost of $4.07 to each procedure. CONCLUSION: The use of dexmedetomidine and local anesthetic in pediatric tonsillectomy is a safe and effective protocol that allows for the reduction of opiate use and improved post-operative pain control. KEY POINTS: Question: Can the combination of dexmedetomidine and infiltration of local anesthetic reduce overall opioid use for peediatric patients undergoing tonsillectomy? FINDINGS: In this case-control study, use of dexmedetomidine and local anesthetic injected into the tonsillar fossa led to a decrease in intraoperative opiate use by 49.6%, a decrease in intraoperative sevofluorane use by 18%, and a lower reported maximum pain score without an increase in adverse events. Meaning: Use of dexmedetomidine and local anesthetic as anesthetic adjuncts may help reduce need for intraoperative opiates and decrease the use of volatile anesthetic agents in pediatric tonsillectomy patients, which are undesirable medications in the pediatric population for their respective respiratory depression and potentially neurotoxic side effects.

Understanding the role of violence as a social determinant of preterm birth.

BACKGROUND: Preterm birth is one of the leading causes of infant morbidity and mortality. Although major strides have been made in identifying risk factors for preterm birth, the complexities between social and individual risk factors are not well understood. OBJECTIVE: This study examines the association between neighborhood youth violence and preterm birth. STUDY DESIGN: A 10-year live birth registry data set (2004 through 2013) from Richmond, VA, a mid-sized, racially diverse city, was analyzed (N = 27,519). Data were geocoded and merged with census tract and police report data. Gestational age at birth was classified as <32 weeks, 32-36 weeks, and term ≥37 weeks. Using police report data, youth violence rates were calculated for each census tract area and categorized into quartiles. Hierarchical models were examined fitting multilevel logistic regression models incorporating randomly distributed census tract-specific intercepts assuming a binary distribution and a logit link function. RESULTS: Nearly a fifth of all births occurred in areas with the highest quartiles of violence. After adjusting for maternal age, race/ethnicity, education, paternal presence, parity, adequacy of prenatal care, pregnancy complications, history of preterm birth, insurance, and tobacco, alcohol, and drug use, census tracts with the highest level of violence had 38% higher odds of very preterm births (adjusted odds ratio, 1.38; 95% confidence interval, 1.06-1.80), than census tracts with the lowest level of violence. CONCLUSION: There is an association between high rate of youth violence and very preterm birth. Findings from this study may help inform future research to develop targeted interventions aimed at reducing community violence and very preterm birth in vulnerable populations.

Maternal race and intergenerational preterm birth recurrence.

BACKGROUND: Preterm birth is a complex disorder with a heritable genetic component. Studies of primarily White women born preterm show that they have an increased risk of subsequently delivering preterm. This risk of intergenerational preterm birth is poorly defined among Black women. OBJECTIVE: Our objective was to evaluate and compare intergenerational preterm birth risk among non-Hispanic Black and non-Hispanic White mothers. STUDY DESIGN: This was a population-based retrospective cohort study, using the Virginia Intergenerational Linked Birth File. All non-Hispanic Black and non-Hispanic White mothers born in Virginia 1960 through 1996 who delivered their first live-born, nonanomalous, singleton infant ≥20 weeks from 2005 through 2009 were included. We assessed the overall gestational age distribution between non-Hispanic Black and White mothers born term and preterm (<37 weeks) and their infants born term and preterm (<37 weeks) using Cox regression and Kaplan-Meier survivor functions. Mothers were grouped by maternal gestational age at delivery (term, ≥37 completed weeks; late preterm birth, 34-36 weeks; and early preterm birth, <34 weeks). The primary outcomes were: (1) preterm birth among all eligible births; and (2) suspected spontaneous preterm birth among births to women with medical complications (eg, diabetes, hypertension, preeclampsia and thus higher risk for a medically indicated preterm birth). Multivariable logistic regression was used to estimate odds of preterm birth and spontaneous preterm birth by maternal race and maternal gestational age after adjusting for confounders including maternal education, maternal age, smoking, drug/alcohol use, and infant gender. RESULTS: Of 173,822 deliveries captured in the intergenerational birth cohort, 71,676 (41.2%) women met inclusion criteria for this study. Of the entire cohort, 30.0% (n = 21,467) were non-Hispanic Black and 70.0% were non-Hispanic White mothers. Compared to non-Hispanic White mothers, non-Hispanic Black mothers were more likely to have been born late preterm (6.8% vs 3.7%) or early preterm (2.8 vs 1.0%), P < .001. Non-Hispanic White mothers who were born (early or late) preterm were not at an increased risk of early or late preterm delivery compared to non-Hispanic White mothers born term. The risk of early preterm birth was most pronounced for Black mothers who were born early preterm (adjusted odds ratio, 3.26; 95% confidence interval, 1.77-6.02) compared to non-Hispanic White mothers. CONCLUSION: We found an intergenerational effect of preterm birth among non-Hispanic Black mothers but not non-Hispanic White mothers. Black mothers born <34 weeks carry the highest risk of delivering their first child very preterm. Future studies should elucidate the underlying pathways leading to this racial disparity.

Discordant pregnancy intentions in couples and rapid repeat pregnancy.

BACKGROUND: Rapid repeat pregnancy (RRP) is a major problem in the United States. Few studies have explored the influence of partner agreement on pregnancy intention and RRP. OBJECTIVE: We sought to examine the association between couple pregnancy intentions and RRP among women in the United States. STUDY DESIGN: Data came from the 2006 through 2010 National Survey of Family Growth. Multiparous women who cohabited with 1 husband/partner before conception of second pregnancy were included (N = 3463). The outcome, RRP, was categorized as experiencing a second pregnancy within 24 months of the first pregnancy resolution, or ≥24 months from the first pregnancy resolution. Maternal and paternal pregnancy intentions were categorized into 4 dyads: both intended (M+P+); maternal intended and paternal unintended (M+P-); maternal unintended and paternal intended (M-P+); and both unintended (M-P-). Multiple logistic regression was conducted to determine the association between couple pregnancy intentions and RRP. RESULTS: Nearly half (49.4%) of women had RRP. Approximately 15% of respondents reported discordant couple pregnancy intentions and 22%, maternal and paternal unintendedness. Compared to couples who both intended their pregnancy (M+P+), the odds of RRP was higher when fathers intended pregnancy but not mothers (adjusted odds ratio, 2.51; 95% confidence interval, 1.45-4.35) and lower if fathers did not intend pregnancy but mothers did (adjusted odds ratio, 0.77; 95% confidence interval, 0.70-0.85). No difference was observed between concordant couple pregnancy intentions (M-P- vs M+P+). CONCLUSION: Findings highlight the important role of paternal intention in reproductive decisions. Study results suggest that RRP is strongly influenced by paternal rather than maternal pregnancy intentions. Clinicians and public health workers should involve partners in family planning discussions and counseling on optimal birth spacing.

Sexual discordance and sexual partnering among heterosexual women.

This study examined characteristics of self-identified heterosexual women who were concordant or discordant in their sexual behavior and the association of discordance and sexual partnering among those aged 15-44 years from the 2006-2010 National Survey of Family Growth (n = 7,353). Sexual concordance was defined as reporting a heterosexual identity and no female partners in the past year; discordance was reporting a heterosexual identity and having at least one female partner in the past year. Sexual partnering was defined as being concurrent, serially monogamous or monogamous with a male partner in the previous year. Polytomous logistic regression models evaluated the association between sexual discordance and sexual partnering. Among self-identified heterosexual, sexually active women, 11.2 % reported ever having had a same sex partner. Heterosexually discordant women who had both male and female partners in the previous year were 5.5 times as likely to report having a concurrent relationship (95 % CI 2.77-11.09) and 2.4 times as likely to report engaging in serially monogamous relationships (95 % CI 1.19-4.97) with male partners. Discordance between heterosexual identity and same sex behavior is a factor in risky behaviors. Women who have sex with women and men may act as bridges for the transmission of STDs, particularly to their female partners. Sexual education should include information inclusive of non-heteronormative behaviors and identities to provide sexual minorities with the tools and information they need. Clinical guidelines should ensure that all women are offered counseling and screening for reproductive and sexual health.

Developing a maternally linked birth dataset to study the generational recurrence of low birthweight in Virginia.

This paper examined the generational recurrence of low birthweight (LBW) among first-born singletons using a statewide maternally-linked birth dataset. An intergenerational dataset was created by linking 2005-2009 to 1960-1997 Virginia resident live birth data. Maternal information from the recent birth cohort was linked to infant information in the historic birth file using various combinations of mother's name and birthdate. The linked dataset contained 170,624 records (87 % of all eligible records). The analysis dataset was limited to non-Hispanic black and non-Hispanic white first-born singleton infants linked to their mother's own birth record (n = 69,702). Maternal birthweight was a significant predictor of LBW for first-born singletons. The birthweight distribution for both non-Hispanic black and non-Hispanic white infants was shifted toward lower birthweights for infants whose mothers were born LBW. Even after adjusting for known maternal risk factors in the current pregnancy, non-Hispanic black (AOR = 1.6 [95 % CI 1.4, 1.8]) and non-Hispanic white (AOR = 2.0 [95 % CI 1.8, 2.3]) infants had increased odds of being born LBW if their mother was born LBW. A mother's early life experiences can impact the health of her children. These findings underscore the importance of applying a life course perspective to the prevention of LBW. Routine linkage of maternal and infant birth data is needed to strengthen the evidence base for policies and programs that address issues affecting maternal and child health throughout the life course.

Residential segregation and gonorrhea rates in US metropolitan statistical areas, 2005-2009.

BACKGROUND: The residential segregation of black populations, often in areas of high-economic disadvantage and low social status, may play a crucial role in the observed racial inequities in sexually transmitted disease rates. METHODS: An ecological analysis of 2005 to 2009 average gonorrhea rates was performed across 277 US metropolitan statistical areas (MSAs). The black isolation index and Gini index of income inequality were used as proxy measures for racial and economic residential segregation respectively, derived from 2005 to 2009 US Census estimates. We used logistic regression modeling to produce estimates of odds ratios (ORs) and 95% confidence intervals (CIs) for the association between the segregation indices, both independently and in combination, on gonorrhea rates in MSAs. Effect measure modification was assessed by calculating the relative excess risk due to interaction between the 2 indices. RESULTS: Compared with MSAs with low levels of racial segregation, MSAs with high levels of racial segregation had increased odds of high gonorrhea rates (adjusted OR, 3.37; 95% CI, 1.23-9.21). Similarly, higher levels of income inequality predicted higher gonorrhea rates, although this association did not persist after adjustment for potential confounders (adjusted OR, 1.54; 95% CI, 0.74-3.24). In combined models, the influence of racial residential segregation on gonorrhea rates was stronger than that of income inequality-based segregation; there was no evidence of additivity or a multiplicative interaction. CONCLUSIONS: Residential segregation by race or income equality may be a key component in the perpetuation of high rates of gonorrhea and other sexually transmitted diseases among black populations in the United States.

The Mediating Effect of Sleep Duration on the Association between Food Insecurity and Childhood Obesity.

Background: Childhood obesity has increased globally during the past four decades. Food insecurity could heighten the risk of obesity. However, little is known about the underlying mechanism. This study aims to investigate the mediating role of sleep duration in the association between food insecurity and childhood obesity and whether there are differences by age, sex, and race/ethnicity. Method: Data from the National Survey of Children's Health for the years 2016-2020 were used, including children 10-17 years of age. We employed causal mediation analysis within a counterfactual framework to decompose the total effect of food insecurity into natural direct and indirect effects and estimate the proportion mediated. Result: The prevalence of obesity was 15.8% in our study sample. Children with food insecurity had 78% higher odds [odds ratio (OR) = 1.78, 95% confidence interval (CI): 1.70-1.86] of having obesity compared with children who were food secure. Overall, only 6.13% of this association was mediated by sleep duration. The association between food insecurity and obesity was stronger in females (OR = 1.96, 95% CI: 1.84-2.10) than males (OR = 1.66, 95% CI: 1.56-1.75), but the proportion mediated by sleep duration was larger in males (7.13%) than females (5.22%). Evidence of mediation was more pronounced in children 10-11 years of age and non-Hispanic Asian children (proportion mediated = 14.85% and 11.21%, respectively). Conclusion: Food insecurity is associated with an increased prevalence of obesity among children. Although a small proportion of this association is mediated by sleep duration, these results suggest that sleep should be considered when assessing the link between food insecurity and childhood obesity.