Disparities in obesity-related cardiovascular-induced mortality trends in the U.S. of America over two decades.

Background: Cardiovascular disease (CVD) remains the leading cause of death in the U.S., and the growing prevalence of obesity has amplified this burden. Despite extensive research on their pathophysiologic interplay, long-term mortality trends among adults with both conditions remain insufficiently characterized. Methods: Using national death certificate data from the CDC WONDER database (1999-2020), we examined age-adjusted mortality rates (AAMRs) for CVD with obesity listed as a contributing cause among adults aged ≥25 years. Temporal trends were analyzed using joinpoint regression to estimate annual percent change (APC) and average annual percent change (AAPC) with 95% confidence intervals, stratified by sex, ethnicity, census region, state, and urbanization level. Results: From 1999 to 2020, the national AAMR increased steadily across all subgroups. Males had higher mortality and a steeper rise than females (AAPC 5.94% vs. 4.40%), with female rates accelerating after 2018. Non-Hispanic Black (NH Black) adults consistently experienced the highest mortality, while Hispanic and NH Black populations exhibited the sharpest recent increases. The South and Midwest regions showed the fastest growth (AAPC >5%), and nonmetropolitan areas surpassed metropolitan ones (AAPC 5.69% vs. 4.98%). Oklahoma displayed the most pronounced escalation nationwide (AAPC 10.52%). Conclusions: Over two decades, obesity-related CVD mortality has risen markedly and unevenly across demographic and geographic lines in the U.S. These findings highlight the intensifying intersection of cardiometabolic disease and social inequity, underscoring the urgent need for equity-centered prevention and investment in vulnerable communities.