Project Summary The new Multi-ethnic Observational Study in American Asian and Pacific Islander Communities (MOSAAIC) cohort represents a pioneering longitudinal study designed to make substantial contributions to our understanding of the health and health disparities within populations of Asian, Native Hawaiian, and Pacific Oceanic ancestry. The overall objective of this study is to establish an epidemiologic cohort comprising a minimum of 10,000 individuals aged 18-64, residing in the United States, who have Native Hawaiian ancestry or affiliations with Asian nations (East, Southeast, or South) or Pacific Islands in their family heritage or place of birth, and to examine the prevalence and incidence of cardiometabolic and mental health conditions and their associated risk factors. Within the first 6 months of initiation, the investigators have developed a functioning organizational structure and through this, have drafted a core protocol. The key features of this protocol include a baseline survey covering a broad range of topics, a brief physical exam (anthropometry, ECG, and spirometry) and biospecimen collection (saliva, blood, urine, and stool). Follow-up at 6 months,12 months, and annually thereafter will include health updates and additional exposure assessments. Selected health outcomes (e.g., myocardial infarction, stroke, heart failure) will be documented and adjudicated. To accommodate changes in NHLBI requirements (expansion of age eligibility and country of origin groups), address gaps in the understanding of protocol requirements, and the interests of the investigators in enhancing critical data, we propose to: 1) Enhance participant recruitment and retention strategies with additional participant recruitment and materials in official study languages and capitation payments associated with completed follow-up contacts to assist with staffing costs of follow-up and medical record collection and to provide an associated participant incentive; and to 2) Improve the quality and scientific rigor of study data, clinical measures, and biospecimens though more in depth assessments (a second spirometry following bronchodilation and linkage of culturally adapted nutritional assessments with nutrient databases), additional standardization of ECG equipment and biospecimen supplies, the feasibility study of PBMC collection, and the incorporation of a baseline repeatability study to assess the reliability of our novel data collection items. These enhancements to the core study will strengthen the overall cohort and the inference that can be drawn from it.