Cardiovascular-Kidney-Metabolic Health in US Adults Under the 2026 Multisociety Guideline: Stage Redistribution From 1999 to 2023 and Population Burden Through 2050

Summary Background The 2026 multisociety guideline frames cardiovascular, kidney, and metabolic health as a staged pathway. National surveillance should distinguish early-risk expansion from advanced-disease accumulation because they require different responses. Methods We analysed 66,553 adults aged 20 years or older across 11 non-overlapping National Health and Nutrition Examination Survey periods from 1999-2000 to August 2021-August 2023. Staging incorporated adiposity, glycaemia, metabolic risk, KDIGO kidney risk, PREVENT 10-year cardiovascular disease risk, and clinical cardiovascular disease. We estimated age-standardised prevalence and secular trends and projected population burden through 2050. Robustness analyses included complete-case estimation, alternative staging thresholds, exclusion of the latest survey period, and rolling temporal validation. Findings In 2021-2023, 88.5% (95% CI 87.2-89.9) of US adults were in stage 1 or higher, and 62.1% (59.9-64.4) were in stages 2-4. From 1999-2000 to 2021-2023, stage 0 decreased by 4.3 percentage points and stage 1 increased by 7.9 points, whereas stages 3-4 remained stable. Adiposity and diabetes increased, while hypertension and hypertriglyceridaemia declined. The prevalence of stages 2-4 ranged from 54.4% among college graduates to 69.6% among adults with less than a high-school education. Under population ageing alone, 189.5 million adults were projected to be in stages 2-4 by 2050. Rolling temporal validation yielded a mean absolute error of 1.6 percentage points. Interpretation The distribution of CKM stages in the US population shifted towards earlier metabolic risk without a parallel increase in advanced-stage disease. Policy should combine upstream prevention, equitable access to detection and treatment, and preparation for a growing older population requiring integrated care. Funding This work was supported by the Special Project for Clinical and Basic Science and Technology Innovation of Guangdong Medical University (GDMULCJC2024112 and GDMULCJC2025138). Research in context Evidence before this study We searched PubMed from database inception to July 25, 2026, without language restrictions, using combinations of “cardiovascular-kidney-metabolic”, “CKM stage”, “NHANES”, “United States”, “prevalence”, “trend”, “projection”, and “2026 guideline”. Previous studies established the high prevalence of CKM syndrome, quantified overlap among its component conditions, and described demographic, social, and mortality gradients. We identified no national analysis that applied the 2026 multisociety staging framework across all non-overlapping public NHANES periods through August 2023 while distinguishing changes in stage distribution from the demographic translation of prevalence into future absolute care demand. Added value of this study Across 66,553 adults and 11 survey periods, the increase in any CKM was explained chiefly by a smaller proportion of adults in stage 0 and a larger proportion in stage 1; stages 3-4 remained stable. The analysis also distinguishes relative prevalence from absolute service demand, documents marked contemporary education and income gradients in stages 2-4, and shows that the central interpretation persists in complete-case, alternative-threshold, and latest-cycle-exclusion analyses. Rolling temporal validation produced a mean absolute prediction error of 1.6 percentage points. Implications of all the available evidence The evidence supports a dual and explicitly equitable response. Upstream policy should reduce entry into the CKM continuum through obesity and diabetes prevention, while health systems expand primary-care, cardiovascular, kidney, and metabolic capacity for an ageing population already meeting stage 2-4 criteria. Stable age-standardised advanced-stage prevalence should not be interpreted as stable workload, particularly when lower educational attainment and income are associated with substantially higher burden.