Social Risk Factors Tied to Advanced CKM Syndrome Vary by Race, Ethnicity, and Sex

Nearly half of US adults may be living with advanced cardiovascular-kidney-metabolic (CKM) syndrome, a condition in which dysfunction of the heart, kidneys, and metabolic systems coexist and compound one another. A new study published in JAMA Network Open suggests that where and how people live play a substantial role in driving that risk. Researchers at the University at Buffalo found that social risk factors, including poverty, food insecurity, limited education, and depressive symptoms, were each independently associated with greater odds of advanced CKM syndrome, but these associations differed meaningfully by race, ethnicity, and sex.¹

The findings underscore the need for pharmacists and other clinicians to incorporate routine social risk screening into CKM syndrome prevention and to tailor interventions based on the specific vulnerabilities of the populations they serve.¹

Understanding the CKM Syndrome Framework

The American Heart Association (AHA) formally defined CKM syndrome in 2023, describing it as an interconnected cluster of cardiovascular, kidney, and metabolic disease driven by shared risk factors and biological pathways. The syndrome is staged from 0 to 4 based on the severity and progression of the disease, from the absence of any risk factors (stage 0) to established clinical cardiovascular disease (stage 4). Stages 3 and 4 are considered "advanced" and are marked by subclinical or manifest cardiovascular disease, very-high-risk chronic kidney disease, or a 10-year CVD risk of 20% or greater.²

Recent national data have indicated that up to 90% of US adults meet criteria for CKM syndrome at some stage, with roughly 15% classified in advanced stages. The burden of advanced disease is not uniformly distributed, with prior research establishing that marginalized populations face disproportionately higher prevalence and that cumulative social risk burdens substantially elevate the likelihood of disease progression.^1,3

Study Design and Population

The cross-sectional study drew on data from the National Health and Nutrition Examination Survey (NHANES) cycles spanning 2005 to 2018. The analytic sample included 28,218 adults 30 years or older, representing approximately 165.8 million US adults nationally after survey weighting was applied. The mean age of participants was 52.6 years, and 52% were female. In terms of race and ethnicity, 69.8% identified as non-Hispanic White, 10.1% as non-Hispanic Black, 12.7% as Hispanic, and 7.4% as other.¹

CKM syndrome was staged using AHA criteria adapted for the NHANES data set. Stages were then dichotomized: stages 0 through 2 were classified as nonadvanced, and stages 3 and 4 as advanced. Overall, 44.7% of participants—more than 12,600 individuals—had advanced CKM syndrome at the time of the survey.¹

Social risk factors were operationalized using 5 domains from the Healthy People 2030 framework: economic stability (income at or below 130% of the federal poverty level); neighborhood or built environment (household food insecurity, assessed by the USDA Food Security Survey Module); education access (less than a high school education); health care access (lack of insurance); and social or community context (depressive symptoms assessed by the Patient Health Questionnaire-9). Researchers tested for statistically significant interactions by age, sex, and race and ethnicity and conducted fully adjusted stratified analyses where interactions met significance thresholds.^1,4

Key Findings: Variation by Race and Ethnicity

In fully adjusted, race- and ethnicity-stratified logistic regression models, the associations between social risk factors and advanced CKM syndrome varied considerably across groups. Economic instability was significantly associated with elevated odds of advanced CKM syndrome among non-Hispanic Black adults (OR, 1.27; 95% CI, 1.08-1.50) and non-Hispanic White adults (OR, 1.22; 95% CI, 1.08-1.37), but the association was not statistically significant among Hispanic adults or those in the other race and ethnicity category.¹

Poor neighborhood or built environment—captured through food insecurity—was significantly associated with advanced CKM syndrome, specifically among non-Hispanic Black adults (OR, 1.20; 95% CI, 1.03-1.38) and individuals of other races and ethnicities (OR, 1.55; 95% CI, 1.04-2.32), with nonsignificant trends in non-Hispanic White and Hispanic populations. Limited education below high school was significantly associated with advanced CKM syndrome only among non-Hispanic White adults (OR, 1.29; 95% CI, 1.13-1.48) and did not reach significance in other groups.¹

Poor social or community context, reflected by depressive symptoms, was the only social risk factor to show a statistically significant association with advanced CKM syndrome across all racial and ethnic groups, with ORs ranging from 1.40 among non-Hispanic Black adults to 1.72 among Hispanic adults. This finding suggests that the psychological and social dimensions of CKM syndrome risk may transcend racial and ethnic group boundaries in ways that other social determinants do not.¹

Notably, limited health care access was associated with lower odds of advanced CKM syndrome across all racial and ethnic groups examined. The authors caution, however, that this counterintuitive finding likely reflects selection and detection biases rather than a protective effect. Uninsured individuals in the sample tended to be younger and to have lower rates of diagnosed comorbidities, suggesting that absence of insurance leads to underdiagnosis of advanced CKM syndrome rather than a lower true disease burden.¹

Key Findings: Variation by Sex

In sex-stratified analyses, all 4 social risk domains that were independently associated with elevated odds of advanced CKM syndrome in the overall sample—economic instability, food insecurity, limited education, and depressive symptoms—showed significant associations among women. Among men, the associations were present but less extensive: economic instability (OR, 1.18; 95% CI, 1.03-1.36), food insecurity (OR, 1.21; 95% CI, 1.01-1.45), and depressive symptoms (OR, 1.41; 95% CI, 1.19-1.68) remained significant, whereas limited education did not.¹

The sex-based differences may reflect distinct social vulnerabilities and help-seeking patterns. The study's authors note that women in the sample were more likely to have social risks associated with advanced disease and suggest that interventions targeting women—such as integration of social risk screening into obstetric, gynecological, and postpartum care settings, as well as linkage to childcare support and women-focused peer programs—may be particularly impactful.¹

Implications for Clinical Practice and Pharmacy

For pharmacists, who are among the most accessible health care professionals in the US, these findings carry practical significance. Pharmacists practicing in community, ambulatory care, or integrated health system settings are increasingly positioned to screen for social determinants of health alongside traditional clinical risk factors. The study's data suggest that asking about income instability, food security, educational background, and emotional well-being could help identify patients at significantly elevated risk for advanced CKM syndrome, particularly in non-Hispanic Black and non-Hispanic White communities.¹

The study's authors also recommend specific intervention models grounded in subgroup-specific risk profiles. Medical-financial navigation, which connects patients with food assistance, housing resources, or income support programs, may be most impactful for non-Hispanic Black and White adults, given the association between economic instability and advanced disease in those groups. Place-based strategies, such as mobile health units or community gardens, may better serve non-Hispanic Black and other racial populations in which neighborhood environments show significant associations. Given the breadth of the depressive symptom association across all groups, behavioral health integration and social isolation screening should be considered universal priorities in CKM syndrome risk management.¹

“Pharmacist-led screening for hypertension, blood glucose, and kidney function markers at no cost integrated into community health fairs, federally qualified health centers, and WIC clinics could surface undetected advanced CKM syndrome in populations currently invisible to the formal health system,” lead author Leonard E. Egede, MD, MS, FACP, chair of the Department of Medicine at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, said in an interview. “The priority should be low-barrier, high-visibility touchpoints that do not require insurance as a prerequisite for engagement.”

The authors also highlighted the Special Supplemental Nutrition Program for Women, Infants, and Children clinics and community health centers as potential delivery sites for women-specific interventions, given the particular vulnerability of women in this analysis and the accessibility of those settings.¹

Conclusion

The JAMA Network Open analysis adds important granularity to the growing literature on CKM syndrome, demonstrating that the influence of social risk on advanced disease is neither uniform nor interchangeable across demographic groups. Economic instability, food insecurity, limited education, and poor social or community context each independently elevate CKM syndrome risk—but in ways that differ by race, ethnicity, and sex. These findings make a compelling case for moving beyond one-size-fits-all approaches to CKM syndrome prevention and instead integrating systematic social risk screening with subgroup-tailored interventions into routine cardiovascular and pharmacist-led care.¹

“The evidence is clear that a one-size-fits-all social risk tool will miss meaningful variation,” Egede explained. “Stratified, targeted screening is not a nice-to-have; it is what the data support.”

REFERENCES

1. Ekwunife O, Wang X, Fraser RA, et al. Social risk factors and disparities in advanced cardiovascular-kidney-metabolic syndrome. JAMA Netw Open. 2026;9(5):e2610702. doi:10.1001/jamanetworkopen.2026.10702

2. Ndumele CE, Rangaswami J, Chow SL, et al; American Heart Association. Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association. Circulation. 2023;148(20):1606-1635. doi:10.1161/CIR.0000000000001184

3. Minhas AMK, Mathew RO, Sperling LS, et al. Prevalence of the cardiovascular-kidney-metabolic syndrome in the United States. J Am Coll Cardiol. 2024;83(18):1824-1826. doi:10.1016/j.jacc.2024.03.368

4. Healthy People 2030: social determinants of health. Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. Accessed May 26, 2026. https://health.gov/healthypeople/priority-areas/social-determinants-health