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Article History

Received: 18 November 2025

Accepted: 23 December 2025

First Online: 21 February 2026

Acknowledgements

: We thank A. Tobarran (Office of Information Technology, Emory Healthcare) and G. Najarro (Georgia Clinical and Translational Science Alliance, Emory School of Medicine) for facilitating access to the Epic Cosmos platform, as well as K. Yates, M. Howat and D. Sandman from the Epic Cosmos team for their support. We also thank P. Vellanki (Division of Endocrinology, Emory School of Medicine) for her thoughtful comments. A previous version of this article was submitted to the medRxiv preprint server ( ) on 8 October 2024.

: Data for the NIH-funded cohort studies are available to registered users on request from the NIDDK Central Repository (NIDDK-CR; ) and NHLBI BioLINCC ( ). Epic Cosmos access is available through institutional representatives of participating institutions and the Epic Cosmos team after completing certification requirements.

: The code for reproducing the subtypes is available on .

: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

: JSV and ZL conceptualised the study. JSV, ZL and SL developed the analytic plan with inputs from JCH. ZL and JSV led the data extraction and analysis, and wrote the first draft. All authors contributed to interpretation of the data. ZL and JSV are the guarantors of this work, and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors critically reviewed and approved the final version of the manuscript.