Abstract Background Spinal pain and disorders are a major burden on our population and health systems. Previous research showed people with diabetes were 1.35 times and 1.24 times more likely to report low back pain and neck pain than people without diabetes respectively, but diabetes was not a predictor of future spinal pain. Here we update a previous systematic review to determine whether in an adult population, diabetes is associated with low back, neck, or spinal pain. Methods The search was performed in PUBMED, Medline, CINAHL and EMBASE. Studies between 2017–2025, of cross-sectional, case–control, twin-control, and cohort designs, assessing diabetes and low back, neck, or spinal pain in adult populations, were included. Excluded were single-case studies, spinal pathologies, multiple chronic diseases, additional pain sites, and gestational or pre-diabetes. Two independent reviewers extracted data on the incidence of pain and reported associations. Odds ratios (ORs) of the association between the exposure (diabetes) and outcome (back, neck, or spinal pain) were calculated using a random effects model. Systematic review registration: PROSPERO registration CRD42022333064. Results A total of 15 studies were included with 11 studies included in the meta-analysis. When compared to people without diabetes, people with diabetes had 1.44 times higher odds of reporting low back pain (n = 592,901; OR 1.44; 95% Confidence Interval (CI) 1.20- 1.74; p = 0.001), a 1.11 times higher odds of reporting neck pain (n = 465,130; OR 1.11; 95%CI 1.13–1.20; p = < 0.001) and a 1.42 times higher odds of reporting spinal pain (n = 1,335,999; OR 1.42; 95%CI 1.26–1.63; p = < 0.001). Diabetes was significantly associated with 1.27 times higher odds of developing spinal pain (n = 35,435; OR 1.27; 95%CI 1.08–1.50; p = 0.004) and 1.44 higher odds of developing neck pain (n = 15,075; OR 1.44; 95%CI 1.09 -1.90; p = 0.010). There was no significant association between diabetes and developing low back pain (n = 21,215; OR 1.11; 95%CI 0.88–1.41, p = 0.388). Conclusions With the inclusion of fifteen additional studies providing an overall sample size five and a half times larger than the previous review, diabetes was associated with prevalent neck, low back and spinal pain, as well as incident neck and neck and spinal pain. Clinicians must be adept at identifying co-morbid conditions and risk factors, understanding the interplay between them and creating well managed networks to address these complex presentations.

Background:Multiple international growth reference systems exist for classifying child undernutrition and excess weight, yet different references yield systematically different prevalence estimates. This has important implications for surveillance in Pacific Islander populations, where both the Centers for Disease Control and Prevention (CDC) and WHO references are used across jurisdictions. Objectives:This study aimed to quantify classification discrepancies between WHO Growth Standards (ages 2-5 y), WHO Growth Reference (ages 6-8 y), and CDC Growth Charts (ages 2-8 y) in Pacific Islander children, and to assess implications for population health surveillance. Methods:This secondary cross-sectional analysis used 2014 data from the Children's Healthy Living Program (n = 5499 children aged 2-8 y from 11 Pacific jurisdictions). Weight and height were measured by trained, standardized measurers. Children were classified by each reference system using SAS programs provided by the WHO and CDC. Agreement was evaluated using McNemar's test, kappa coefficients, and percent agreement. Results:Height-for-age agreement was high across both age groups (≥98.3%). BMI-for-age agreement differed substantially by age: poor for ages 2 to 5 y (kappa = 0.26; 85.5% agreement) and high for ages 6 to 8 y (kappa = 0.86; 97.9% agreement). For ages 2 to 5 y, the WHO classified 11 percentage points more children as overweight than the CDC. When identical percentile cutoffs were applied across reference datasets, prevalence differences narrowed substantially, indicating that most discrepancies result from differing classification criteria rather than reference population differences. Conclusions:Growth reference selection introduces systematic measurement bias into Pacific Islander child health surveillance. Surveillance systems should maintain reference consistency over time, explicitly report reference criteria, and consider dual reporting to enable valid temporal and geographic comparisons. Future research should evaluate which reference better predicts health outcomes in this population.

Background Since the 1990s, spine disorders have remained the leading cause of global disability, disproportionately affecting economically marginalized individuals, rural populations, women, and older people. Back pain related disability is projected to increase the most in remote regions where lifestyle and work are increasingly sedentary, yet resources and access to comprehensive healthcare is generally limited. To help tackle this worldwide health problem, World Spine Care Canada, and the Global Spine Care Initiative (GSCI) launched a four-phase project aiming to address the profound gap between evidence-based spine care and routine care delivered to people with spine symptoms or concerns in communities that are medically underserved. Phase 1 conclusions and recommendations led to the development of a model of care that included a triaging system and spine care pathways that could be implemented and scaled in underserved communities around the world. Methods The current research protocol describes a site-specific customization and pre-implementation study (Phase 2), as well as a feasibility study (Phase 3) to be conducted in Cross Lake, an Indigenous community in northern Manitoba, Canada. Design: Observational pre-post design using a participatory mixed-methods approach. Relationship building with the community established through regular site visits will enable pre- and post-implementation data collection about the model of spine care and provisionally selected implementation strategies using a community health survey, chart reviews, qualitative interviews, and adoption surveys with key partners at the meso (community leaders) and micro (clinicians, patients, community residents) levels. Recruitment started in March 2023 and will end in March 2026. Surveys will be analyzed descriptively and interviews thematically. Findings will inform co-tailoring of implementation support strategies with project partners prior to evaluating the feasibility of the new spine care program. Discussion Knowledge generated from this study will provide essential guidance for scaling up, sustainability and impact (Phase 4) in other northern Canada regions and sites around the globe. It is hoped that implementing the GSCI model of care in Cross Lake will help to reduce the burden of spine problems and related healthcare costs for the local community, and serve as a scalable model for programs in other settings.

OBJECTIVE:The objective of this study was to explore the association between cognitive impairment and spinal pain in the older population in the United States. METHODS:We undertook a secondary analysis of cross-sectional data from the 1999 to 2000 and 2001 to 2002 National Health and Nutrition Examination Survey. The pooled data included a representative sample (n = 2975) of older adults (aged 60-85 years) in the United States. Cognitive impairment was assessed through the Digit Symbol Substitution Test. Spinal pain was defined with a multisite definition, including both nonspecific low back pain and neck pain present in the past 3 months. To account for the complex sampling design, logistic regression was performed using Taylor linearized variance estimation to compute weighted measures of associations. RESULTS:For older adults with spinal pain, the proportion of cognitive impairment increased with age, from 32.64% in the 60 to 64 age group to 93.83% in the 80 to 84 age group, which was also statistically significantly higher than the general population group and the group without spinal pain (P < .001). After controlling for demographic characteristics, socioeconomic status, and general health status, older adults with spinal pain had significantly increased odds of cognitive impairment (odds ratio 1.76, 95% confidence interval: 1.12, 2.79). Vulnerable subgroups (older, female, and less education) were identified. CONCLUSION:There was a significant association between cognitive impairment and spinal pain in the older adult population in the United States. Within this population, there were vulnerable subgroups for which spinal pain and cognitive impairment had a greater impact, namely people who are older, female, and those with less education.

Public Health serves a critical role in ensuring and maintaining population health by recognizing that health is influenced by individual, social, economic, environmental, structural, and political factors. Despite the core role that public health plays in communities, the field's workforce faces shortages which were already dire pre-pandemic. The Department of Public Health Sciences (DPHS) at the University of Hawai'i at Mānoa (UHM) provides bachelor, masters, and doctoral degrees and serves as an essential training ground for the public health workforce in Hawai'i. The purpose of this paper is to describe some of the ways DPHS is meeting the ever-growing demand for qualified health professionals, in local and global government and community health departments and organizations. Since the first graduating class in 1967, more than 7000 individuals have earned accredited degrees through DPHS, including over 500 diverse undergraduate and graduate alumni since Fall 2015. The quality of DPHS' program and instruction are consistently highly rated by students and alumni. The curriculum is continually enhanced through innovative programs, and actively engages students in advancing public health practice and gaining applied research skills through all steps of scholarship including publications. DPHS is proud to be part of the movement towards building and revitalizing the public health workforce through teaching, research, and service and continues to strive to foster practitioners who will represent and serve local communities, engage in meaningful research and service, and bridge connections across disciplines and geographies.

This prospective, community-based, active surveillance study aimed to report the incidence of moderate, severe, and serious adverse events (AEs) after chiropractic (n = 100) / physiotherapist (n = 50) visit in offices throughout North America between October-2015 and December-2017. Three content-validated questionnaires were used to collect AE information: two completed by the patient (pre-treatment [T0] and 2-7 days post-treatment [T2]) and one completed by the provider immediately post-treatment [T1]. Any new or worsened symptom was considered an AE and further classified as mild, moderate, severe or serious. From the 42 participating providers (31 chiropractors; 11 physiotherapists), 3819 patient visits had complete T0 and T1 assessments. The patients were on average 50±18 years of age and 62.5% females. Neck/back pain was the most common presenting condition (70.0%) with 24.3% of patients reporting no condition/preventative care. From the patients visits with a complete T2 assessment (n = 2136 patient visits, 55.9%), 21.3% reported an AE, of which: 7.9% were mild, 6.2% moderate, 3.7% severe, 1.5% serious, and 2.0% had missing severity rating. The most common symptoms reported with moderate or higher severity were discomfort/pain, stiffness, difficulty walking and headache. This study provides valuable information for patients and providers regarding incidence and severity of AEs following patient visits in multiple community-based professions. These findings can be used to inform patients of what AEs may occur and future research opportunities can focus on mitigating common AEs.

The social determinants of health (SDoH) influence health outcomes based on conditions from birth, growth, living, and age factors. Diabetes is a chronic condition, impacted by race, education, and income, which may lead to serious health consequences. In Hawai'i, approximately 11.2% of adults have been diagnosed with diabetes. The objective of this secondary cross-sectional study is to assess the relationship between the prevalence of diabetes and the social determinants of health among Hawai'i adults who participated in the Behavioral Risk Factor Surveillance System between 2018-2020. The prevalence of diabetes among adults was 11.0% (CI: 10.4-11.5%). Filipino, Japanese and Native Hawaiian adults had the highest prevalence of diabetes at 14.4% (CI: 12.7-16.2%), 14.2% (CI: 12.7-15.7%), and 13.2% (CI: 12.0-14.4%), respectively. Poverty level and education were significantly associated with diabetes status. Within employment categories, the adjusted odds ratio (AOR) for retired and unable to work adults were large at AOR: 1.51 (CI: 1.26-1.81) and AOR: 2.91 (CI: 2.28-3.72), respectively. SDoH can impact the development and management of diabetes. Understanding the role SDoH plays on diabetes status is crucial for promoting health equity, building community capacity, and improving diabetes management.

Spinal pain and chronic health conditions are highly prevalent, burdensome, and costly conditions, both in the United States and globally. Using cross-sectional data from the 2016 through 2018 National Health Interview Survey (n = 26,926), we explored associations between spinal pain and chronic health conditions and investigated the influence that a set of confounders may have on the associations between spinal pain and chronic health conditions. Variance estimation method was used to compute weighted descriptive statistics and measures of associations with multinomial logistic regression models. All four chronic health conditions significantly increased the prevalence odds of spinal pain; cardiovascular conditions by 58%, hypertension by 40%, diabetes by 25% and obesity by 34%, controlling for all the confounders. For all chronic health conditions, tobacco use (45–50%), being insufficiently active (17–20%), sleep problems (180–184%), cognitive impairment (90–100%), and mental health conditions (68–80%) significantly increased the prevalence odds of spinal pain compared to cases without spinal pain. These findings provide evidence to support research on the prevention and treatment of non-musculoskeletal conditions with approaches of spinal pain management.

Low back pain and depression have been globally recognized as key public health problems and they are considered co-morbid conditions. This study explores both cross-sectional and longitudinal comorbid associations between back pain and major depression in the adult population in the United States. We used data from the Midlife in the United States survey (MIDUS), linking MIDUS II and III with a sample size of 2358. Logistic regression and Poisson regression models were used. The cross-sectional analysis showed significant associations between back pain and major depression. The longitudinal analysis indicated that back pain at baseline was prospectively associated with major depression at follow-up (PR 1.96, CI: 1.41, 2.74), controlling for health behavioral and demographic variables. Major depression at baseline was also prospectively associated with back pain at follow-up (PR 1.48, CI: 1.04, 2.13), controlling for a set of related confounders. These findings of a bidirectional comorbid association fill a gap in the current understanding of these comorbid conditions and could have clinical implications for the management and prevention of both depression and low back pain.

IntroductionThe increasing prevalence of coexisting health conditions poses a challenge to healthcare providers and healthcare systems. Spinal pain (eg, neck and back pain) and spinal pathologies (eg, osteoporotic fractures and degenerative spinal disease) exist concurrently with other non-spinal health conditions (NSHC). However, the scope of what associations may exist among these co-occurring conditions is unclear. Therefore, this scoping review aims to map the epidemiological literature that reports associations between spine-related pain and pathologies (SPPs) and NSHCs.Methods and analysisThis scoping review will follow the JBI protocol and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. We will systematically search the literature using key words and MeSH terms for SPPs and NSHCs. Terminology/vocabulary for NSHCs will include those for communicable and non-communicable diseases as reported by WHO Global Burden of Disease reports. Five databases will be searched from inception: MEDLINE, EMBASE, APA PsycInfo, Scopus and Web of Science Core Collection. Papers published in English, in peer-reviewed journals, including measures of association between SPPs and NSHCs and using observational epidemiologic study designs will be included. Excluded will be studies of cadaveric, animal or health behaviours; studies with no measures of association and non-observational epidemiologic studies. Results will include the number of studies, the studies that have evaluated the measures of association and the frequency of the studied associations between SPPs and NSHCs. Results will be reported in tables and diagrams. Themes of comorbidities will be synthesised into a descriptive report.Ethics and disseminationThis scoping review was deemed exempt from ethics review. This review will provide a comprehensive overview of the literature that reports associations between SPPs and NSHCs to inform future research initiatives and practices. Results will be disseminated through publication in peer-reviewed journals and research conferences.Registration detailshttps://osf.io/w49u3.

The transcription factor Prdm16 functions as a potent suppressor of transforming growth factor-beta (TGF-β) signaling, whose inactivation is deemed essential to the progression of pancreatic ductal adenocarcinoma (PDAC). Using the KrasG12D-based mouse model of human PDAC, we surprisingly found that ablating Prdm16 did not block but instead accelerated PDAC formation and progression, suggesting that Prdm16 might function as a tumor suppressor in this malignancy. Subsequent genetic experiments showed that ablating Prdm16 along with Smad4 resulted in a shift from a well-differentiated and confined neoplasm to a highly aggressive and metastatic disease, which was associated with a striking deviation in the trajectory of the premalignant lesions. Mechanistically, we found that Smad4 interacted with and recruited Prdm16 to repress its own expression, therefore pinpointing a model in which Prdm16 functions downstream of Smad4 to constrain the PDAC malignant phenotype. Collectively, these findings unveil an unprecedented antagonistic interaction between the tumor suppressors Smad4 and Prdm16 that functions to restrict PDAC progression and metastasis.

OBJECTIVES:The purpose of this study was to compare Medicare healthcare expenditures for patients who received long-term treatment of chronic low back pain (cLBP) with either opioid analgesic therapy (OAT) or spinal manipulative therapy (SMT).METHODS:We conducted a retrospective observational study using a cohort design for analysis of Medicare claims data. The study population included Medicare beneficiaries enrolled under Medicare Parts A, B, and D from 2012 through 2016. We assembled cohorts of patients who received long-term management of cLBP with OAT or SMT (such as delivered by chiropractic or osteopathic practitioners) and evaluated the comparative effect of OAT vs SMT upon expenditures, using multivariable regression to control for beneficiary characteristics and measures of health status, and propensity score weighting and binning to account for selection bias.RESULTS:The study sample totaled 28,160 participants, of whom 77% initiated long-term care of cLBP with OAT, and 23% initiated care with SMT. For care of low back pain specifically, average long-term costs for patients who initiated care with OAT were 58% lower than those who initiated care with SMT. However, overall long-term healthcare expenditures under Medicare were 1.87 times higher for patients who initiated care via OAT compared with those initiated care with SMT (95% CI 1.65-2.11; P < .0001).CONCLUSIONS:Adults aged 65 to 84 who initiated long-term treatment for cLBP via OAT incurred lower long-term costs for low back pain but higher long-term total healthcare costs under Medicare compared with patients who initiated long-term treatment with SMT.

OBJECTIVE:Globally 37.9 million people are living with HIV/AIDS, and with mortality rates declining, there is an increasing focus on comorbidities including musculoskeletal (MSK) disorders. Therefore, the aim of this scoping review was to generate and summarize an overview of the existing scientific literature dealing with MSK complaints in people living with HIV/AIDS (PLWHAs). METHODS:This scoping review followed the five-stage methodological framework proposed by Arksey and O'Malley. We searched PubMed, EMBASE, CINAHL, and the Cochrane Library from inception to June 1, 2020. Two reviewers independently reviewed the articles for eligibility. A data extraction form was used to chart information such as author, year of publication, data source, sample size, country of origin, ethnicity, age, gender, antiretroviral therapy, MSK condition prevalence, and anatomical location. RESULTS:The search identified 10 522 articles. Of these, 27 studies were included after full-text screening for data extraction. Studies were conducted in thirteen different countries with diverse data sources such as outpatient clinic files, hospital records, primary care clinic files, and AIDS Service Organization files. PLWHAs have a variety of MSK conditions. Most studies reported spinal pain such as lower back or neck pain, but pain in the extremities and osteoarthritis (OA) were also represented. However, the frequencies of pain at various anatomical sites were highly variable. CONCLUSION:There is a lack of knowledge regarding MSK conditions in PLWHAs. Future studies designed to specifically study MSK complaints and disabilities are needed to gain a better picture of the impact of these conditions in PLWHAs and to inform prevention and treatment strategies globally in this often-underserved population.

Introduction: Several studies have indicated high cholesterol is paradoxically associated with low prevalence of atrial fibrillation (AF). However, the etiology is uncertain. One potential explanation might be the different trends in serum total cholesterol (TC) between AF and non-AF groups. Hypothesis: There are different 25-year trends in TC levels in older men with vs. without incident AF during the 25-year period. Methods: We used data from the Kuakini Honolulu Heart Program, a longitudinal cohort study since 1965. Participants were 3,741 Japanese-American men living in Hawaii who participated in the 4th exam cycle. TC level was repeatedly measured at baseline (mid-life, ages 45-68 years) and after 25 years (late-life, ages 71-93 years). The amount of TC reduction between mid- and late-life was categorized into quartiles. AF was diagnosed by 12-lead ECG at mid- and late-life. We excluded participants who were diagnosed with AF at mid-life (prevalent cases). Results: AF incidence was 4.4% over 25 years. Mid-life TC levels were similar between those with incident AF vs. those without (218.6±36.0mg/dl vs 218.6±35.4mg/dl, p=0.91). However, in those with incident AF, the drop in TC levels between mid- and late-life was significantly larger than in those without AF (-39.4±35.8mg/dl vs -27.9±38.0mg/dl, p<0.001) (Fig1). Moreover, after multivariable adjustment, there was a biological gradient between AF incidence and reduction of TC levels over 25 years (P for tend p<0.001). As a result, the group with incident AF showed significantly lower late-life TC levels compared with the non-AF group (179.7±32.9mg/dl vs 190.3±33.0mg/dl, p<0.001) at late-life (Fig1). Conclusions: Incident AF over 25 years was associated with a greater decrease in serum TC levels between mid- and late-life. The paradoxical associations between AF prevalence and low TC levels might be explained by the different trends in drop from mid- to late-life TC between those with vs. without incident AF.

Objective:The purpose of this study was to describe the types of equestrian-related musculoskeletal injuries and their management. Methods:We retrospectively reviewed the charts of 19 patients who presented with injuries from equestrian activities at a chiropractic practice from December 2000 to December 2020. Deidentified data were extracted from the charts and summarized. Results:Of the 19 patients, 42.3% presented with acute trauma, 38.5% had overuse injuries, and 19.2% had chronic injuries as a result of previous trauma. We found that 90% of overuse injuries and 18.2% of acute injuries led to chronic conditions that needed ongoing management. Conclusion:From this sample of patients, there was a high percentage of overuse and chronic injuries for patients who participated in equestrian activities.

Study Design. We combined elements of cohort and crossover-cohort design. Objective. The objective of this study was to compare longterm outcomes for spinal manipulative therapy (SMT) and opioid analgesic therapy (OAT) regarding escalation of care for patients with chronic low back pain (cLBP). Summary of Background Data. Current evidence-based guidelines for clinical management of cLBP include both OAT and SMT. For long-term care of older adults, the efficiency and value of continuing either OAT or SMT are uncertain. Methods. We examined Medicare claims data spanning a five-year period. We included older Medicare beneficiaries with an episode of cLBP beginning in 2013. All patients were continuously enrolled under Medicare Parts A, B, and D. We analyzed the cumulative frequency of encounters indicative of an escalation of care for cLBP, including hospitalizations, emergency department visits, advanced diagnostic imaging, specialist visits, lumbosacral surgery, interventional pain medicine techniques, and encounters for potential complications of cLBP. Results. SMT was associated with lower rates of escalation of care as compared to OAT. The adjusted rate of escalated care encounters was approximately 2.5 times higher for initial choice of OAT vs. initial choice of SMT (with weighted propensity scoring: rate ratio 2.67, 95% confidence interval 2.64-2.69, P < .0001). Conclusion. Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy.

OBJECTIVE:The objective of this study was to compare patients' perspectives on the use of spinal manipulative therapy (SMT) compared to prescription drug therapy (PDT) with regard to health-related quality of life (HRQoL), patient beliefs, and satisfaction with treatment. METHODS:Four cohorts of Medicare beneficiaries were assembled according to previous treatment received as evidenced in claims data: SMT, PDT, and 2 crossover cohorts (where participants experienced both types of treatments). A total of 195 Medicare beneficiaries responded to the survey. Outcome measures used were a 0-to-10 numeric rating scale to measure satisfaction, the Low Back Pain Treatment Beliefs Questionnaire to measure patient beliefs, and the 12-item Short Form Health Survey to measure HRQoL. RESULTS:Recipients of SMT were more likely to be very satisfied with their care (84%) than recipients of PDT (50%; P = .002). The SMT cohort self-reported significantly higher HRQoL compared to the PDT cohort; mean differences in physical and mental health scores on the 12-item Short Form Health Survey were 12.85 and 9.92, respectively. The SMT cohort had a lower degree of concern regarding chiropractic care for their back pain compared to the PDT cohort's reported concern about PDT (P = .03). CONCLUSION:Among older Medicare beneficiaries with chronic low back pain, long-term recipients of SMT had higher self-reported rates of HRQoL and greater satisfaction with their modality of care than long-term recipients of PDT. Participants who had longer-term management of care were more likely to have positive attitudes and beliefs toward the mode of care they received.

Heart disease remains the leading cause of death globally by gender and region. Smoking and alcohol drinking are known modifiable health behaviors of heart disease. Utilizing data from the US Health and Retirement Study and the China Health and Retirement Longitudinal Study, this study examines heart disease disparities and the association with smoking and drinking behavior among men and women in the US and China. Smoking and drinking behavior were combined to neither, smoke-only, drink-only, and both. In the US, the prevalence was higher in men (24.5%, 95% CI: 22.5–26.6%) than in women (20.6%, 95% CI: 19.3–22.1%) and a higher prevalence was found in the smoke-only group for both genders. In contrast, women in China had higher prevalence (22.9%, 95% CI: 21.7–24.1%) than men (16.1%, 95% CI: 15.1–17.2%), and the prevalence for women who smoked or engaged in both behaviors were ~1.5 times (95% CI: 1.3–1.8, p < 0.001) those who did not smoke or drink, but no statistical difference were found in men. The findings might be due to differences in smoking and drinking patterns and cultures by gender in the two countries and gender inequality among older adults in China. Culturally tailored health promotion strategies will help reduce the burden of heart disease.

Introduction: Several studies have indicated high cholesterol is paradoxically associated with low prevalence of atrial fibrillation/flutter (AF). However, the etiology is uncertain. One potential explanation might be the confounding effect of age exemplifying prevalence-incidence (Neyman's) bias. However, this bias has not often been discussed in depth in the literature. Therefore, we conducted a cross-sectional analysis to test the hypothesis that there is a paradoxical association between lipid profile and AF prevalence. Methods: This is a cross-sectional study design, using data from the Kuakini Honolulu Heart Program. Participants were 3741 Japanese-American men between 71 and 93 years old living in Hawaii. Serum total cholesterol (TC) level was measured and categorized into quartiles. AF was diagnosed by 12?lead Electrocardiogram. We categorized age into quartiles (71-74, 75-77, 78-80 and 81+ years). Results: We observed opposite associations between AF and TC among different age groups. For participants age >_75, higher TC levels were paradoxically associated with lower prevalence of AF after multivariable adjustment, i.e. the odds ratios of AF comparing the highest TC quartile with the lowest TC quartile for age 75-77, 78-80 and 81+ years were 0.17 (95% confidence interval [CI], 0.06-0.52), 0.28 (95% CI, 0.07-1.09) and 0.14 (95% CI, 0.03-0.62), respectively. Conversely, for those who were 71-74 years old, the odds ratio of AF was 2.09 (95% CI, 0.76-5.75) between the highest and the lowest TC quartiles. Conclusions: There is a paradoxical association of TC with AF in Japanese-American men age >_75, but not <75 years. The paradox might be explained by Neyman's bias. (c) 2020 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).