Background: Given indications of widening disparities in mortality for people with serious mental illness, understanding and reducing their risk of cardiovascular disease (CVD) and improving health-related quality of life is an urgent public health priority. This study examined CVD risk factor clustering, health-related quality of life (HRQoL), and their correlates among people with SMI who were overweight/obese (i.e., BMI ≥ 25) and living in supportive housing. Methods: Baseline data were used from participants enrolled in a clinical trial examining the effectiveness of a peer-led healthy lifestyle program. univariate analyses were used to describe the distribution of individual risk factors and the cumulative number of CVD risk factors. Bivariate and regression analyses were used to explore correlates of individual CVD risk factors, the cumulative number of risk factors, and HRQoL Physical and Mental Health Composite Scores. Results: Participants were 48.7 years old, on average (sd = 11.6) and the majority identi ed as male (57.3%) and as racial/ethnic minorities (82%; primarily non-Hispanic black). Most participants (75.4%) had at least two co-occurring CVD risk factors and almost half (46.7%) had three or more, most commonly obesity, smoking, and hypertension. Prevalence of individual risk factors, particularly smoking and diabetes, varied by demographic and clinical characteristics. Identifying as female, older age, and taking second generation antipsychotic medication were associated with having more co-occurring CVD risk factors, while having completed high school was associated with fewer risks. Number of co-occurring CVD risk factors, identifying as female, and greater psychiatric symptoms were negatively associated with physical HRQoL. Older age, lower psychiatric symptoms, and greater internal locus of control were positively associated with mental HRQoL. Conclusion: Even when compared to other studies examining CVD risk among individuals diagnosed with schizophrenia, our study sample generally had higher rates of clustering of multiple risk factors, highlighting the need for urgent intervention among those living in supportive housing. Demographic and clinical factors further identify those who may have the highest risk as well as factors that may adversely affect perceived health status and functioning. Reducing CVD risk and improving HRQoL will likely require expanding access to quality care, adapting intervention approaches to subpopulations, and providing increased support to facilitate health behavior change and perceived control for modi able risk factors. Trial Registration: This trial was registered through ClinicalTrials.gov on June 26, 2014. The registration number is NCT02175641.

The recognition that where people live matters to their health has deep roots, highlighted in the works of Hippocrates, W. E. B. Du Bois, and in contemporary research on environmental and placebased factors that shape health. 1,2 Although health systems have come to accept their role in helping change community conditions in support of health, their complex institutional, financial, and sociopolitical considerations can prevent positive change or lead to more harm. We suggest that the concept of spatial justice must be incorporated in health system actions to improve population health.Spatial justice 3 refers to the relationship between people and places as mediated by historical and current values, assumptions, beliefs, policies, investments, and practices. The National Academies of Sciences, Engineering, and Medicine Roundtable on Population Health Improvement recently hosted a workshop on spatial justice as a driver of health in the context of societal emergencies, including pandemics and climate change. Participants-planners, architects, social scientists, community organizers, residents, policy makers, and others-examined how space is organized, used, allocated, owned, and who is or is not included in decisions about design, building, and use of spaces.

Services (DHHS), has set health promotion and disease prevention objectives and targets every decade in an effort to engage a broad constituency in achieving health gains for the nation. A subset of objectives-the Leading Health Indicators (LHIs)-are intended to sharply focus attention on the highest priorities. At the request of DHHS, the National Academies of Sciences, Engineering, and Medicine appointed a committee in 2019, on which we served and which 1 of us staffed. The committee was charged with informing the selection of LHIs through 2 reports, the first to provide recommendations regarding the criteria for LHIs and the other to recommend a slate of LHIs. Criteria

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