The Role of Sexual Function in Quality of Life Among Midlife and Older Women: The Study of Women's Health Across the Nation.

Objective: To examine how (1) partnered sexual activity, and (2) sexual functioning, contribute to global quality of life (QOL) and health-related quality of life (HRQL) among midlife and older women, and whether importance of sex modifies these associations. Materials and Methods: Women in the Study of Women's Health Across the Nation (SWAN), a multiethnic/racial cohort study, aged 42-52 at recruitment, were followed for ∼20 years. The Ladder of Life and Short Form-36 physical component summary (PCS) and mental component summary (MCS) assessed Global QOL (N = 3,263) and HRQL (N = 2,576), respectively. Primary predictors were (1) having partnered sexual activity (yes/no), and (2) sexual functioning among those with partnered sexual activity. Sociodemographic, health, lifestyle, and psychosocial covariates were included. Results: Importance of sex modified covariate-adjusted association of having partnered sexual activity with global QOL. Adjusted associations of partnered sexual activity with PCS and MCS were not statistically significant. Sexual functioning, among women with partnered sexual activity, was positively associated with global QOL (adjusted p = 0.03), regardless of importance of sex; unrelated to PCS; but positively associated with MCS (adjusted p = 0.03), particularly when sex was "very/quite important." Conclusions: Partnered sexual activity and better sexual functioning are related to QOL for mid-aged and older women, and are stronger when sex is considered important. Partnered sexual activity and sexual functioning are less consistently related to HRQL when adjusted for covariates, and importance modifies only the association between sexual functioning and MCS. Understanding the importance of sex to midlife and older women contextualizes the impact of sex on QOL.

Method for Activity Sleep Harmonization (MASH): a novel method for harmonizing data from two wearable devices to estimate 24-h sleep-wake cycles.

Background: Daily 24-h sleep-wake cycles have important implications for health, however researcher preferences in choice and location of wearable devices for behavior measurement can make 24-h cycles difficult to estimate. Further, missing data due to device malfunction, improper initialization, and/or the participant forgetting to wear one or both devices can complicate construction of daily behavioral compositions. The Method for Activity Sleep Harmonization (MASH) is a process that harmonizes data from two different devices using data from women who concurrently wore hip (waking) and wrist (sleep) devices for ≥ 4 days. Methods: MASH was developed using data from 1285 older community-dwelling women (ages: 60-72 years) who concurrently wore a hip-worn ActiGraph GT3X + accelerometer (waking activity) and a wrist-worn Actiwatch 2 device (sleep) for ≥ 4 days (N = 10,123 days) at the same time. MASH is a two-tiered process using (1) scored sleep data (from Actiwatch) or (2) one-dimensional convolutional neural networks (1D CNN) to create predicted wake intervals, reconcile sleep and activity data disagreement, and create day-level night-day-night pairings. MASH chooses between two different 1D CNN models based on data availability (ActiGraph + Actiwatch or ActiGraph-only). MASH was evaluated using Receiver Operating Characteristic (ROC) and Precision-Recall curves and sleep-wake intervals are compared before (pre-harmonization) and after MASH application. Results: MASH 1D CNNs had excellent performance (ActiGraph + Actiwatch ROC-AUC = 0.991 and ActiGraph-only ROC-AUC = 0.983). After exclusions (partial wear [n = 1285], missing sleep data proceeding activity data [n = 269], and < 60 min sleep [n = 9]), 8560 days were used to show the utility of MASH. Of the 8560 days, 46.0% had ≥ 1-min disagreement between the devices or used the 1D CNN for sleep estimates. The MASH waking intervals were corrected (median minutes [IQR]: -27.0 [-115.0, 8.0]) relative to their pre-harmonization estimates. Most correction (-18.0 [-93.0, 2.0] minutes) was due to reducing sedentary behavior. The other waking behaviors were reduced a median (IQR) of -1.0 (-4.0, 1.0) minutes. Conclusions: Implementing MASH to harmonize concurrently worn hip and wrist devices can minimizes data loss and correct for disagreement between devices, ultimately improving accuracy of 24-h compositions necessary for time-use epidemiology.

Derivation and external validation of a risk score for clinically important declines in health and function among two longitudinal cohorts of women in the mid-life.

OBJECTIVES: Women in mid-life often develop chronic conditions and experience declines in physical health and function. Identifying factors associated with declines provides opportunity for targeted interventions. We derived and externally validated a risk score for clinically important declines over 10 years among women ages 55-65 using the Physical Component Summary Score (PCS) of the SF-36. DESIGN: Derivation and validation of a risk score. SETTING: Two longitudinal cohorts from sites in the USA were used. PARTICIPANTS: Women from the Study of Women's Health Across the Nation (SWAN) and women from the Women's Health Initiative (WHI) Observational Study and/or clinical trials. OUTCOME MEASURES: A clinically important decline over 10 years among women ages 55-65 using the PCS of the SF-36 predictors was measured at the beginning of the 10 years of follow-up. RESULTS: Seven factors-lower educational attainment, smoking, higher body mass index, history of cardiovascular disease, history of osteoarthritis, depressive symptoms and baseline PCS level-were found to be significant predictors of PCS decline among women in SWAN with an area under the curve (AUC)=0.71 and a Brier Score=0.14. The same factors were associated with a decline in PCS in WHI with an AUC=0.64 and a Brier Score=0.18. Regression coefficients from the SWAN analysis were used to estimate risk scores for PCS decline in both cohorts. Using a threshold of a 30% probability of a significant decline, the risk score created a binary test with a specificity between 89%-93% and an accuracy of 73%-79%. CONCLUSIONS: Seven clinical variables were used to create a valid risk score for PCS declines that was replicated in an external cohort. The risk score provides a method for identifying women at high risk for a significant mid-life PCS decline.

Physical and Behavioral Factors Associated With Improvement in Physical Health and Function Among US Women During Midlife.

Importance: Women often experience physiological and functional changes in their health during midlife. Identifying women who have clinically important improvements in physical health and function and evaluating the factors associated with these improvements can identify intervention targets at midlife. Objective: To identify factors associated with improvements in physical health and function among women during midlife. Design, Setting, and Participants: Participants were part of the Study of Women's Health Across the Nation (SWAN), a diverse cohort of US women early in midlife, and followed up annually for up to 21 years between 1996 and 2017. Analyses were based on visit 8 (2004-2006) through visit 15 (2015-2017). Statistical analysis was conducted from October 2021 to March 2023. Exposures: Sociodemographic indicators, health status measures, and comorbidities measured at visit 8. Main Outcomes and Measures: The main outcome was a clinically important (≥5 points) improvement in the physical component score (PCS) of the 36-item Short-Form Health Survey between visit 8 and visit 15. Results: Of the 1807 women (at visit 8: mean [SD] age, 54.5 [2.7] years; 898 [50%] White participants) in SWAN who qualified for analysis, 265 (15%) experienced a clinically important improvement in PCS over a median of 11.1 years (IQR, 10.9-11.4 years). Factors associated with improvement in PCS included no financial strain (odds ratio [OR], 1.73; 95% CI, 1.18-2.52), no sleep disturbances (OR, 1.43; 95% CI, 1.05-1.96), no osteoarthritis (OR, 1.42; 95% CI, 1.01-1.99), and having a higher physical activity score (OR, 1.17; 95% CI, 1.00-1.37) as assessed at visit 8. Women who had a higher PCS at visit 8 (OR, 0.84; 95% CI, 0.83-0.86), who had a higher body mass index (OR, 0.95; 95% CI, 0.93-0.97), or who were taking more medications (OR, 0.93; 95% CI, 0.88-0.98) had lower odds of an improved PCS. Conclusions and Relevance: This cohort study of women in midlife suggests that approximately 15% of women experienced clinically important improvements in health and function over an 11-year period. Several potentially modifiable factors associated with improvements may inform women of variables to target for future interventions.

Sleep timing, sleep regularity, and psychological health in early late life women: Findings from the Study of Women's Health Across the Nation (SWAN).

OBJECTIVES: To examine the associations of actigraphy-assessed sleep timing and regularity with psychological health in early late life women, whose circadian rhythms may be impacted by aging. DESIGN: Cross-sectional. PARTICIPANTS: A racially/ethnically diverse sample of 1197 community-dwelling women (mean age 65 years) enrolled in the Study of Women's Health Across the Nation. MEASURES: Actigraphy-assessed sleep measures included timing (mean midpoint from sleep onset to wake-up) and regularity (standard deviation of midpoint in hours). Psychological health measures included a composite well-being score, the Center for Epidemiological Studies Depression Scale, and the Generalized Anxiety Disorder-7 Scale. Linear and logistic regression models, adjusted for covariates (including sleep duration), tested associations between sleep and psychological health measures. RESULTS: After covariate adjustment, a sleep midpoint outside of 2:00-4: 00 AM was significantly associated with depressive symptoms (ß = 0.88, 95% CI = 0.06, 1.70) and scoring above the cut-point for clinically significant depressive symptoms (OR = 1.72, 95% CI = 1.15, 2.57). Sleep irregularity was significantly associated with lower psychological well-being (ß = -0.18, 95% CI = -0.33, -0.03), depressive (ß = 1.36, 95% CI = 0.29, 2.44) and anxiety (ß = 0.93, 95% CI = 0.40, 1.46) symptoms, and scoring above the cut-point for clinically significant depressive (OR = 1.68, 95% CI = 1.01, 2.79) and anxiety (OR = 1.62, 95% CI = 1.07, 2.43) symptoms. CONCLUSION: Above and beyond sleep duration, a sleep midpoint outside of 2:00-4:00 AM was associated with depressive symptoms while sleep irregularity was associated with multiple psychological health domains in late life women.

Risk of high depressive symptoms after the final menstrual period: the Study of Women's Health Across the Nation (SWAN).

OBJECTIVE: To examine depressive symptoms during postmenopause and the contribution of depressive symptom trajectories before the final menstrual period (FMP) and psychosocial/health factors to postmenopause depressive symptoms. METHODS: Longitudinal analysis of depressive symptoms (Center for Epidemiologic Studies-Depression scale) collected every 1 to 2 years from 1996 to 2017 from 1,551 midlife women in the Study of Women's Health Across the Nation for a median follow-up of 19.0 years. Latent class growth analysis identified depression trajectories from baseline to FMP. Multivariable random effects (woman as random effect) linear or logistic regression models were conducted. RESULTS: Women had higher odds of reporting high depressive symptom score (≥16) during postmenopause than when they were premenopausal (OR = 1.49, 95% CI, 1.09-2.04), but not when perimenopausal. Three pre-FMP trajectories were identified: Group 1 (47.7%), consistently low scores, Group 2 (39.9%), moderate scores below the high depressive symptom threshold, and Group 3 (12.4%), consistently high scores. Both the moderate (OR = 2.62, 95% CI, 1.89-3.66) and high score (OR = 6.88, 95% CI, 4.72-10.02) groups, compared with the consistently low group, had significantly higher postmenopausal depressive symptom scores. Other pre-FMP variables associated with high postmenopausal depressive symptoms were: higher odds of childhood trauma/maltreatment, poor role physical, high anxiety symptoms, sleep problems, high vasomotor symptoms, and lower odds for chronological aging and lower social support. CONCLUSIONS: Compared with premenopause, postmenopause remains a period of increased risk for higher depressive symptoms, especially for women with pre-FMP depressive symptoms. Pre-FMP depressive symptom trajectories are highly predictive of postmenopause depressive symptoms independent of health and psychosocial factors.

Excessive Gestational Weight Gain and Long-Term Maternal Cardiovascular Risk Profile: The Study of Women's Health Across the Nation.

Background: Excessive gestational weight gain (GWG) is consistently linked with maternal risk of obesity. However, the literature on its long-term cardiovascular risk is minimal and conflicting. We evaluated whether excessive GWG is associated with a high-risk cardiovascular profile among parous women in midlife. Materials and Methods: Participants were women in the multiethnic cohort Study of Women's Health Across the Nation with a history of live birth(s). Excessive GWG was defined according to Institute of Medicine guidelines and collected by self-recall. Outcomes were the atherosclerotic cardiovascular disease (ASCVD) risk score and C-reactive protein (CRP), measured at the study baseline when mean age was 47 years, and at 10 follow-up visits (1996-2017). We estimated the association of excessive GWG with outcomes through linear mixed model regression. Results: The analytic sample included 1318 women with 3049 singleton births. Over 40% (536) reported one or more pregnancies with excessive GWG. Longitudinal models estimated that at a mean age of 67, women with a history of excessive GWG had a 9.8% (9.2, 10.5) 10-year ASCVD risk, compared to 9.5% (8.9, 10.1) for those without, and mean CRP of 2.20 mg/L (1.89, 2.57) versus 1.85 mg/L (1.61, 2.14), respectively, adjusted for participant characteristics. Conclusions: In this multiethnic cohort of parous women, a history of excessive GWG was associated with a small, but statistically significant difference in ASCVD risk, and a moderate, statistically significant difference in CRP across midlife. More research is necessary to understand the mechanistic pathway between excessive GWG and long-term maternal cardiovascular health.

Factors Associated With 10-Year Declines in Physical Health and Function Among Women During Midlife.

Importance: Women in midlife often develop chronic conditions and experience declines in physical health and function. Identifying factors associated with declines in physical health and function among these women may allow for targeted interventions. Objective: To examine the factors associated with clinically important 10-year declines in the physical component summary score (PCS) of the Short Form 36 (SF-36), a widely used patient-reported outcome measure, in women in midlife. Design, Setting, and Participants: This longitudinal cohort study collected data from geographically dispersed sites in the US. Participants were part of the Study of Women's Health Across the Nation (SWAN), a racially and ethnically diverse cohort of women enrolled at or immediately before the menopause transition. Women have been followed for up to 21 years, between 1996 and 2016, with annual visits. Data were analyzed from October 2020 to March 2021. Exposures: Demographic indicators, health status measures, and laboratory and imaging assessments. Main Outcomes and Measures: The main outcome was a clinically important decline (≥8 points) on the PCS, based on the 10-year difference in scores between ages 55 and 65 years. Results: From the SWAN cohort of 3302 women, 1091 women (median [IQR] age, 54.8 [54.3-55.4] years; 264 [24.2%] Black women; 126 [11.6%] Chinese women; 135 [12.4%] Japanese women; 566 [51.9%] White women) were eligible for analyses based on duration of follow-up and availability of SF-36 data. At age 55, women had a median (IQR) body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 27.0 (23.2-32.6), a median (IQR) baseline PCS of 53.1 (46.8-56.7), 108 women (9.9%) were current smokers, and 938 women (86.3%) had at least 1 comorbidity. Between ages 55 and 65 years, the median (IQR) change in PCS was -1.02 (-6.11 to 2.53) points with 206 women (18.9%) experiencing declines of 8 points or more. In multivariable models, factors associated with clinically important decline included higher baseline PCS (odds ratio [OR], 1.08; 95% CI, 1.06-1.11), greater BMI (OR, 1.06; 95% CI, 1.03-1.09), less educational attainment (OR, 1.87; 95% CI, 1.32-2.65), current smoking (OR, 1.93; 95% CI, 1.14-3.26), osteoarthritis (OR, 1.46; 95% CI, 1.01-2.09), clinically significant depressive symptoms (OR, 2.03; 95% CI, 1.34-3.09), and cardiovascular disease (OR, 2.06; 95% CI, 1.26-3.36). Conclusions and Relevance: In this cohort study, clinically important declines in women's physical health and function were relatively common between ages 55 and 65 years. Several variables associated with these declines were identified as potentially useful components in a clinical score identifying women at increased risk of physical health and functional declines.

Does childhood maltreatment or current stress contribute to increased risk for major depression during the menopause transition?

BACKGROUND: The menopausal transition (MT) poses an increased risk for major depression (MD), but not for all women. Current and past stress are toxic risk factors for depression throughout life. The MT may be a time of increased sensitivity to stress, especially among women with a lifetime history of major depressive disorder (MDD). We evaluated whether women who experienced childhood maltreatment (CM) or current stressful events or ongoing problems were at increased risk for MD during the MT. METHODS: At the Pittsburgh site of the Study of Women's Health Across the Nation, 333 midlife women were interviewed approximately annually over 15 years with the Structured Clinical Interview for the Diagnosis of DSM-IV Axis I Disorders and provided health and psychosocial data including the Childhood Trauma Questionnaire. Repeated measures logistic regression analyses were conducted separately for women with and without lifetime MDD at study entry. RESULTS: Among women with lifetime MDD, CM, but not current stress, interacted with menopausal status to increase the risk for MD during postmenopause (ORs ranged from 2.71 to 8.04). All stressors were associated with increased odds of MD. Among women without lifetime MDD, current stress was related to risk for MD, but the effect did not vary by menopausal status. CONCLUSIONS: Women with MDD prior to midlife and who experienced CM were at greatest risk for MD after the MT. Women without prior MDD were at increased risk for MD during peri- and postmenopause. Healthcare providers should monitor women at risk for MD even after the MT.

The relationship between 19-year trends in medication use and changes in physical function among women in the mid-life: A Study of Women's Health Across the Nation pharmacoepidemiology study.

PURPOSE: Medication side effects are a major concern in aging adults who report using an increasing number of medications. The relationship between accumulating medication use and physical function has not been examined in a longitudinal cohort. METHODS: We conducted a longitudinal cohort study using prospectively collected data from the Study of Women's Health Across the Nation (SWAN). Community-dwelling women from five US cities were followed for up to 20 years. The exposure of interest was the number of prescription medications. They were examined as a count variable and then for specific categories of medication. The outcome of interest was physical function measured repeatedly using the short form (SF)-36 physical function (PF) scale. Linear mixed models, using repeated measures of sociodemographics and comorbidities were assessed. RESULTS: 1452 participants qualified for the analyses with a median follow-up of 19.2 years. At baseline, the mean age was 46.5 years and 53.5% reported White race. Fully adjusted models demonstrated a reduction in the SF-36 PF of 0.99 for each additional prescription medication used or a 6.14-point reduction for women reporting more than five medications and an 8.92-point reduction among those reporting more than 10 medications. These results were similar across race and ethnicity. Specific medication categories with a significant and largely negative impact (at least a two-point reduction) on physical component score included beta-blockers, analgesics, glucocorticoids, anticonvulsants, anxiolytics, anticoagulants, and anti-depressants. CONCLUSIONS: There is a moderate association between increasing medication use and decreasing physical function among women transitioning through the mid-life.

Associations of accelerometer-determined sedentary behavior and physical activity with physical performance outcomes by race/ethnicity in older women.

To determine the cross-sectional associations of accelerometer-measured time spent in physical activity intensity categories (sedentary, low and high light intensity, or moderate to vigorous intensity physical activity (MVPA) with physical performance outcomes [stair climb ascent, 40 foot walk test, and short physical performance battery (SPPB)] in older women and examine differences by race/ethnicity. Data were from 1,256 Study of Women's Health Across the Nation (SWAN) participants [aged 64.9 (2.7) years at Visit 15 (2015-16); 54.1% non-White]. Three sets of adjusted multivariable linear or logistic regression models were built to test the study objectives using the backward elimination approach to identify relevant covariates. In the full analytic sample, a 10 min increment in MVPA was related to faster performance on the stair climb [ß = -0.023 (95% CI: -0.04, -0.005) seconds] and 40 foot walk test [ß = -0.066 (95% CI: -0.133, -0.038) seconds], and a 9% lower odds [OR: 0.91; 95% CI: 0.87, 0.96; p = 0.004] of limitations based on the SPPB. Statistically significant differences by race/ethnicity were found for the stair climb ascent time as MVPA was associated with better performance for White, Chinese, and Japanese participants while high light intensity physical activity, but not MVPA, was deemed beneficial in Black women. Findings from the isotemporal substitution models were consistent. Findings further support the importance of MVPA on physical performance outcomes in older women. Further research is needed to examine the complex associations between physical (in)activity and physical performance outcomes by race/ethnicity to provide more targeted recommendations.

Associations between longitudinal trajectories of insomnia symptoms and sleep duration with objective physical function in postmenopausal women: the Study of Women's Health Across the Nation.

STUDY OBJECTIVES: Examine the association between trajectories of self-reported insomnia symptoms and sleep duration over 13 years with objective physical function. METHODS: We utilized data from 1,627 Study of Women's Health Across the Nation participants, aged 61.9 ± 2.7 years at the end of the 13-year follow-up. Latent class growth models identified trajectories of insomnia symptoms (trouble falling asleep, frequent night-time awakenings, and/or early morning awakening) and sleep duration over 13 years. Physical function tests were performed at the end of the 13-year period: 40-ft walk, 4-m walk, repeated chair stand, grip strength, and balance. Multivariable regression analyses examined each physical function measure according to the insomnia symptom or sleep duration trajectory group. RESULTS: Five insomnia symptom trajectories and two sleep duration trajectories were identified. Women with a consistently high likelihood of insomnia symptoms and women with a decreased likelihood of insomnia symptoms (i.e. improving) had slower gait speed (3.5% slower 40-ft walk [consistently high], 3.7% slower 4-m walk [improving]; each p ≤ .05) than those with a consistently low likelihood of insomnia symptoms. In contrast, women with a steep increase in the likelihood of insomnia symptoms over time and women with persistent insufficient sleep duration had lower odds of having a balance problem (odds ratio [OR] = 0.36 and OR = 0.61, respectively; each p < .02) compared to those with a consistently low likelihood of insomnia symptoms and those with persistent sufficient sleep duration, respectively. CONCLUSION: These results suggest that women's sleep during midlife has important implications for maintaining physical function during the transition into older adulthood.

Gestational Weight Gain and Long-term Maternal Obesity Risk: A Multiple-Bias Analysis.

BACKGROUND: Lifecourse research provides an important framework for chronic disease epidemiology. However, data collection to observe health characteristics over long periods is vulnerable to systematic error and statistical bias. We present a multiple-bias analysis using real-world data to estimate associations between excessive gestational weight gain and mid-life obesity, accounting for confounding, selection, and misclassification biases. METHODS: Participants were from the multiethnic Study of Women's Health Across the Nation. Obesity was defined by waist circumference measured in 1996-1997 when women were age 42-53. Gestational weight gain was measured retrospectively by self-recall and was missing for over 40% of participants. We estimated relative risk (RR) and 95% confidence intervals (CI) of obesity at mid-life for presence versus absence of excessive gestational weight gain in any pregnancy. We imputed missing data via multiple imputation and used weighted regression to account for misclassification. RESULTS: Among the 2,339 women in this analysis, 937 (40%) experienced obesity in mid-life. In complete case analysis, women with excessive gestational weight gain had an estimated 39% greater risk of obesity (RR = 1.4, CI = 1.1, 1.7), covariate-adjusted. Imputing data, then weighting estimates at the guidepost values of sensitivity = 80% and specificity = 75%, increased the RR (95% CI) for obesity to 2.3 (2.0, 2.6). Only models assuming a 20-point difference in specificity between those with and without obesity decreased the RR. CONCLUSIONS: The inference of a positive association between excessive gestational weight gain and mid-life obesity is robust to methods accounting for selection and misclassification bias.

Midlife Factors Related to Psychological Well-Being at an Older Age: Study of Women's Health Across the Nation.

Background: Psychological well-being (PWB) is predictive of future health and mortality. Midlife is a pivotal time in women's lives and may impact future PWB. This study, based on a longitudinal cohort of women, sought to identify how personal and social resources and modifiable behaviors at midlife relate to women's PWB in later life, and to determine if psychological resilience in later life moderates the impact of health problems on PWB. Materials and Methods: We assessed the association of midlife factors with PWB ∼9 years later in 1693 women from the multiracial/ethnic Study of Women's Health Across the Nation (SWAN) cohort. PWB was a composite score with cognitive and affective components. Midlife factors included sociodemographics, health, menopause-related, and psychosocial factors collected over the course of midlife. Results: In a multivariable model, greater PWB at an older age was associated with the following at midlife: less financial strain, greater physical activity, not smoking, better physical functioning, and fewer sleep problems. More positive attitudes toward menopause and aging, less cynicism, greater optimism, less trait anxiety, greater spirituality, and greater resilience were also independently associated with better PWB. Chinese women reported lower PWB compared with whites. Later life resilience moderated the impact of sleep problems on PWB. Conclusions: Several modifiable factors at midlife are associated with better PWB in older women and highlight the importance of healthy behaviors such as physical activity and good sleep hygiene at midlife. Interventions to increase optimism, spirituality, and resilience are also worth exploring.

The impact of breast cancer on physical activity from midlife to early older adulthood and predictors of change post-diagnosis.

PURPOSE: To examine physical activity (PA) patterns from pre- to post-diagnosis, and compare these changes to women without breast cancer. To determine pre-diagnosis predictors of PA change, post-diagnosis, in breast cancer survivors (BCS). METHODS: Data were from 2314 Study of Women's Health Across the Nation (SWAN) participants, average age of 46.4 ± 2.7 years at baseline (1996-1997). In Pink SWAN, 151 women who reported an incident breast cancer diagnosis over 20 years were classified as BCS; the remaining 2163 women were controls. LOESS plots and linear mixed models were used to illustrate and compare PA changes (sports/exercise [primary measure] and total PA) from pre- to post-diagnosis (or corresponding period) in BCS versus controls. Adjusted linear regression models were used to determine pre-diagnosis predictors of at-risk post-diagnosis PA change patterns (consistently low and decreased PA). RESULTS: No differences in pre- to post-diagnosis PA (or corresponding period) were observed in BCS versus controls. Among BCS, the odds of at-risk post-diagnosis PA change patterns was 2.50 (95% CI 0.96-6.48) times higher for those who reported sleep problems at ≥ 50% (compared to 0%) of pre-diagnosis visits and 3.49 (95% CI 1.26-9.65) times higher for those who were overweight or obese at all (compared to no) pre-diagnosis visits. No other statistically significant predictors were noted. CONCLUSIONS: Age-related declines in PA were not amplified by a breast cancer diagnosis. Given the beneficial role of PA across the cancer control continuum, efforts to increase or maintain adequate PA, post-diagnosis, should be continued. IMPLICATIONS FOR CANCER SURVIVORS: While age-related physical activity declines were not amplified breast cancer diagnosis, efforts to identify breast cancer survivors at increased risk for post-diagnosis physical activity declines (or maintenance of low activity) may be a high-yield strategy to improve prognosis and quality of life.

Health-related quality of life among breast cancer survivors and noncancer controls over 10 years: Pink SWAN.

BACKGROUND: The goal of this study was to compare health-related quality of life (HRQL) from diagnosis to 10 years postdiagnosis among breast cancer survivors (BCS) and women without cancer over the same period and to identify BCS subgroups exhibiting different HRQL trajectories. METHODS: Our analysis included 141 BCS and 2086 controls from the Study of Women's Health Across the Nation (SWAN), a multiracial/ethnic cohort study of mid-life women assessed approximately annually from 1995 to 2015. Pink SWAN participants reported no cancer at SWAN enrollment and developed (cases) or did not develop (controls) incident breast cancer after enrollment. We assessed HRQL with SF-36 Mental Component Summary and Physical Component Summary scores. We modeled each as a function of case/control status, years since diagnosis, years since diagnosis squared, and the interaction terms between case/control status and the 2 time variables in linear models. We characterized heterogeneity in postdiagnosis HRQL of cases using group-based trajectories. RESULTS: BCS had significantly lower HRQL compared with controls at diagnosis and 1 year postdiagnosis. By 2 years, BCS and controls no longer differed significantly. Among BCS, 2 trajectory groups were identified for both scores. For the Mental Component Summary, 88.4% of BCS had consistently good and 11.6% had very low scores. For the Physical Component Summary, 73.9% had good scores, and 26.1% had consistently low scores. Prediagnosis perceived stress and current smoking were related to being in the low mental trajectory group, and a higher number of comorbidities was related to being in the low physical trajectory group. CONCLUSION: Although the majority of BCS have HRQL similar to non-cancer controls after 2 years, subgroups of BCS continue to have low HRQL. Prediagnosis stress, comorbidities, and smoking are vulnerability factors for long-term, low HRQL in BCS.

Understanding Racial/Ethnic Disparities in Physical Performance in Midlife Women: Findings From SWAN (Study of Women's Health Across the Nation).

OBJECTIVES: Evaluate degree to which racial/ethnic differences in physical performance are mediated by sociodemographic, health, behavioral, and psychosocial factors. METHODS: Physical performance was evaluated using a decile score derived from grip strength, timed 4 m walk, and timed repeat chair stand in 1,855 African American, Caucasian, Chinese, Hispanic, and Japanese women, mean age = 61.8 (SD = 2.7) in the Study of Women's Health Across the Nation. Mediators included education, financial strain, comorbidities, pain, body mass index (BMI), physical activity, and perceived stress. Structural equation models provided estimates of the total difference in physical performance between Caucasians and each race/ethnic groups and differences due to direct effects of race/ethnicity and indirect effects through mediators. RESULTS: The mean decile score for Caucasian women was 16.9 (SD = 5.6), 1.8, 2.6, and 2.1 points higher than the model-estimated scores in African Americans, Hispanics and Chinese, respectively, and 1.3 points lower than the Japanese. Differences between Caucasians and the Chinese and Japanese were direct effects of race/ethnicity whereas in African Americans and Hispanics 75% or more of that disparity was through mediators, particularly education, financial strain, BMI, physical activity, and pain. DISCUSSION: Addressing issues of poverty, racial inequality, pain, and obesity could reduce some racial/ethnic disparity in functional limitations as women age.

The Effect of Gestational Weight Gain Across Reproductive History on Maternal Body Mass Index in Midlife: The Study of Women's Health Across the Nation.

Background: Excessive weight gain during pregnancy is common and has been shown to be associated with increased long-term maternal weight. However, less is known on whether there is a cumulative effect of excessive gestational weight gain (GWG) over multiple pregnancies. Methods: Data from the Study of Women's Health Across the Nation were used, restricted to parous women with no history of stillbirth or premature birth. The effect of the number of excessive GWG pregnancies on body mass index (BMI) in midlife (age 42-53) was analyzed using multivariable linear regression. Fully adjusted models included parity, inadequate GWG, demographic, and behavioral characteristics. Results: The 1181 women included in this analysis reported a total of 2693 births. Overall, 466 (39.5%) were categorized as having at least one pregnancy with excessive GWG. The median BMI at midlife was 26.0 kg/m2 (interquartile range 22.5-31.1). In fully adjusted models, each additional pregnancy with excessive GWG was associated with 0.021 higher estimated log BMI (p = 0.031). Among women with 1-3 births, adjusted mean (95% confidence interval) BMI for those with 0, 1, 2, and 3 excessive GWG pregnancies was 25.4 (24.9-25.9), 26.8 (26.1-27.5), 27.5 (26.6-28.4), and 28.8 (27.3-30.5), respectively. Conclusions: In this multiethnic study of women with a history of term live births, the number of pregnancies with excessive GWG was associated with increased maternal BMI in midlife. Our findings suggest that prevention of excessive GWG at any point in a woman's reproductive history can have an impact on long-term maternal health.

Midlife Predictors of Health-Related Quality of Life in Older Women.

Background: Midlife represents an important time to evaluate health status and health behaviors that may affect health-related quality of life (HRQL) in later years. This study examines change in women's HRQL over 11 years from ages 47-59 to 57-69 and identifies midlife characteristics that predict HRQL at older ages. Methods: Physical (PCS) and mental component summaries (MCS) of the SF-36 were used to assess HRQL from 2002 to 2013 in 2,614 women from the Study of Women's Health Across the Nation (SWAN), a multiethnic/racial cohort study. We used locally weighted scatterplot smoothing (LOESS) models to obtain unadjusted predicted mean trajectories of PCS and MCS as a function of age. Results: LOESS predicted PCS declined from 51.6 to 47.1, whereas MCS increased from 49.2 to 53.1. In multivariable models, controlling for baseline PCS, higher baseline physical activity (p = .002) and increase in physical activity from baseline (p < .0001) predicted better PCS. Time since baseline (ie, aging; p < .001), higher baseline body mass index (p < .0001), increased body mass index over time (p < .0001), smoking (p < .05), two or more medical conditions (p < .0001), sleep problems (p < .0001), and urinary incontinence (p < .0001) were related to lower PCS. Early (p = .004) and late postmenopause (p = .001; vs. premenopause) and aging (p = .05) predicted higher MCS. Predictors of lower MCS were less than very good health (p < .0001), sleep problems (p < .0001), stressful life events (p < .0001), higher perceived stress (p < .0001), and higher trait anxiety (p = .004). Race/ethnicity was related to MCS, but not PCS. Conclusions: Several potentially modifiable midlife factors, such as improved sleep hygiene, physical activity, and body mass index, might improve HRQL for older women.

Physical activity trajectories during midlife and subsequent risk of physical functioning decline in late mid-life: The Study of Women's Health Across the Nation (SWAN).

The purpose of this study was to examine the importance of midlife physical activity on physical functioning in later life. Data are from 1771 Study of Women's Health Across the Nation (SWAN) participants, aged 42-52 (46.4±2.7) years at baseline (1996-97). Latent class growth analysis was used to identify physical activity trajectory groups using reported sports and exercise index data collected at seven time-points from baseline to Visit 13 (2011-13); objective measures of physical functioning performance were collected at Visit 13. The sports and exercise index (henceforth: physical activity) is a measure of moderate to vigorous intensity physical activity during discretionary periods of the day. Multivariable linear regression analyses were used to model each continuous physical performance measure as a function of the physical activity trajectory class. Across midlife, five physical activity trajectory classes emerged, including: lowest (26.2% of participants), increasing (13.4%), decreasing (22.4%), middle (23.9%), and highest (14.1%) physical activity. After full adjustment, women included in the middle and highest physical activity groups demonstrated ≥5% better physical functioning performance than those who maintained low physical activity levels (all comparisons; p<0.05). Statistically significant differences were also noted when physical activity trajectory groups were compared to the increasing physical activity group. Results from the current study support health promotion efforts targeting increased (or maintenance of) habitual physical activity in women during midlife to reduce future risk of functional limitations and disability. These findings have important public health and clinical relevance as future generations continue to transition into older adulthood.