Late-Stage Concentration of Cardiovascular-Kidney-Metabolic Syndrome Burden in US Adults: Disability-Adjusted Life Years Across AHA Stages, 2005 to 2023

Background: Cardiovascular prevention is increasingly prioritised using burden estimates, yet disability-adjusted life years (DALYs) reward late-stage treatment by construction. Whether that bias is large for cardiovascular-kidney-metabolic (CKM) syndrome, and where the population is accumulating relative to where the burden sits, is unknown. Methods: We pooled nine National Health and Nutrition Examination Survey cycles (2005-2023) and assigned CKM stages 0-4 from measured blood pressure, adiposity, glycaemia, lipids, kidney function, urine albumin, self-reported cardiovascular disease, and 10-year PREVENT risk. Years lived with disability used GBD disability weights. Years of life lost combined national death counts, stage-specific mortality from linked mortality files (1999-2018), and period life tables. A second aim attributed burden to smoking and physical inactivity, two exposures outside the CKM definition. Results: In 2021-2023, 13.8% of adults were stage 0, 21.3% stage 1, 49.1% stage 2, 6.5% stage 3, and 9.3% stage 4. CKM accounted for 20.0 million DALYs annually (7,881 age-standardised per 100,000), of which 4.1 million were YLD and 15.9 million attributable YLL. Stages 3-4, 15.8% of adults, generated 76% of attributable YLL; stage 4 alone generated 65% of YLD and 49% of attributable YLL. Adjusted mortality rose from stage 2 (hazard ratio 1.39) through stage 4 (3.22), while stage 1 did not differ from stage 0 (0.99; 95% CI, 0.78-1.25). Between 2006 and 2016, stage 0 prevalence fell 2.3% per year and stage 1 rose 3.1% per year. Smoking and physical inactivity accounted for 30.5% of burden (95% CI, 25.7-35.1). Conclusions: CKM burden is concentrated in stages 3-4, where excess mortality begins, while the population has been shifting into stage 1, where mortality is normal. DALY-based prioritisation will therefore systematically underfund the stage in which the next generation of patients is being created.