Women's Health Initiative Strong and Healthy Pragmatic Physical Activity Intervention Trial for Cardiovascular Disease Prevention: Design and Baseline Characteristics

BACKGROUND

National guidelines promote physical activity to prevent cardiovascular disease (CVD), yet no randomized controlled trial has tested whether physical activity reduces CVD.

METHODS

The Women's Health Initiative (WHI) Strong and Healthy (WHISH) pragmatic trial used a randomized consent design to assign women for whom cardiovascular outcomes were available through WHI data collection (N = 18 985) or linkage to the Centers for Medicare and Medicaid Services (N30 346), to a physical activity intervention or "usual activity" comparison, stratified by ages 68-99 years (in tertiles), U.S. geographic region, and outcomes data source. Women assigned to the intervention could "opt out" after receiving initial physical activity materials. Intervention materials applied evidence-based behavioral science principles to promote current national recommendations for older Americans. The intervention was adapted to participant input regarding preferences, resources, barriers, and motivational drivers and was targeted for 3 categories of women at lower, middle, or higher levels of self-reported physical functioning and physical activity. Physical activity was assessed in both arms through annual questionnaires. The primary outcome is major cardiovascular events, specifically myocardial infarction, stroke, or CVD death; primary safety outcomes are hip fracture and non-CVD death. The trial is monitored annually by an independent Data Safety and Monitoring Board. Final analyses will be based on intention to treat in all randomized participants, regardless of intervention engagement.

RESULTS

The 49 331 randomized participants had a mean baseline age of 79.7 years; 84.3% were White, 9.2% Black, 3.3% Hispanic, 1.9% Asian/Pacific Islander, 0.3% Native American, and 1% were of unknown race/ethnicity. The mean baseline RAND-36 physical function score was 71.6 (± 25.2 SD). There were no differences between Intervention (N = 24 657) and Control (N = 24 674) at baseline for age, race/ethnicity, current smoking (2.5%), use of blood pressure or lipid-lowering medications, body mass index, physical function, physical activity, or prior CVD (10.1%).

CONCLUSION

The WHISH trial is rigorously testing whether a physical activity intervention reduces major CV events in a large, diverse cohort of older women. Clinical Trials Registration Number: NCT02425345.

Accelerometer-Measured Sedentary Patterns are Associated with Incident Falls in Older Women

BACKGROUND/OBJECTIVE

Falls cause significant problems for older adults. Sedentary time is associated with lower physical function and could increase the risk for falls.

DESIGN

Prospective study.

SETTING

Sites across the United States.

PARTICIPANTS

Older women (N = 5,545, mean age 79 years) from the Women's Health Initiative Objective Physical Activity and Cardiovascular Health study.

MEASUREMENTS

Accelerometers worn at the hip for up to 1 week collected measures of daily sedentary time and the mean sedentary bout duration, a commonly used metric for sedentary accumulation patterns. For up to 13 months after accelerometer wear, women reported daily whether they had fallen on monthly calendars.

RESULTS

In fully adjusted models, the incident rate ratios (95% confidence interval) for quartiles 1 (lowest), 2, 3, and 4 of sedentary time respectively were 1.0 (ref.), 1.07 (0.93-1.24), 1.07 (0.91-1.25), and 1.14 (0.96-1.35; P-trend = .65) and for mean sedentary bout duration was 1.0 (ref.), 1.05 (0.92-1.21), 1.02 (0.88-1.17), and 1.17 (1.01-1.37; P-trend = .01), respectively. Women with a history of two or more falls had stronger associations between sedentary time and falls incidence compared with women with a history of no or one fall (P for interaction = .046).

CONCLUSIONS

Older women in the highest quartile of mean sedentary bout duration had a significantly increased risk of falling. Women with a history of frequent falling may be at higher risk for falling if they have high sedentary time. Interventions testing whether shortening total sedentary time and/or sedentary bouts lowers fall risk are needed to confirm these observational findings.

Group exercise membership is associated with forms of social support, exercise identity, and amount of physical activity

Exploring whether the mechanisms underlying the positive relationship between group exercise and physical activity are forms of social support - emotional, validation, informational, instrumental, and companionship and exercise identity. Participants (n=506; M age = 34.3) completed a 235-item questionnaire assessing physical activity, exercise identity, social support, and other determinants of physical activity. Exploratory path analysis was used to model group exercise membership, forms of social support, exercise identity, and metabolic equivalent (MET) minutes/wk. Women and men had similar yet varying results. For women, group exercise membership was significantly associated with MET-minutes/wk (β = 0.11) and exercise identity (β = 0.17). There was a significant association between exercise identity and MET-minutes/wk (β = 0.38). Women perceived belonging to an exercise group provides emotional (β = 0.36), validation (β = 0.25), informational (β = 0.35), instrumental (β = 0.19), and companionship (β = 0.46) support. Validation (β = 0.11), informational (β = 0.21), and companionship (B = 0.17) were significantly associated with exercise identity for women. For men, group exercise membership was not significantly associated with MET-minutes/wk or exercise identity. Exercise identity was significantly associated with MET-minutes/wk (β = 0.46). Men perceived belonging to their group provides emotional (β = 0.31), validation (β = 0.32), informational (β = 0.33), and companionship (β = 0.34). Validation (β = 0.22), informational (β = 0.30), and emotional (β = 0.23) were significantly associated with exercise identity for men. Belonging to an exercise group is associated with forms of social support that strengthen exercise identity.

Abstract PS7-28: Association between epigenetic age acceleration and postmenopausal breast cancer risk in the Women’s Health Initiative

Earlier age of menopause and bilateral oophorectomy are associated with accelerated biologic aging based on epigenetic clocks. While these relationships suggest women with greater epigenetic age acceleration (AgeAccel) might be at a reduced risk of postmenopausal breast cancer, prior studies conflict with this theory. We hypothesized this paradox may be attributable to an interaction between epigenetic and reproductive aging on cancer risk. We evaluated this premise among 5,044 postmenopausal women in the Women’s Health Initiative (WHI) Observational Study and Clinical Trial with AgeAccel estimated in whole blood. Among a subset of 1,135 of these women, estradiol (E2) and sex hormone-binding globulin were assayed in baseline serum samples. For WHI participants with DNA methylation assays, we modeled the log odds of incident postmenopausal breast cancer during follow-up as a function of AgeAccel, adjusting for age at menopause, race/ethnicity, age at WHI screening, bilateral oophorectomy, nulliparity, alcohol consumption, smoking, body mass index, duration of postmenopausal hormone therapy use, exercise, clinical trial arm, and hysterectomy status at baseline. We repeated this analysis among the subset of participants with DNA methylation and E2 assays, and appraised the degree to which bioavailable E2 levels contributed to the observed association between AgeAccel and incident postmenopausal breast cancer. Finally, we evaluated whether bioavailable E2 levels modified the relationship between AgeAccel and cancer risk. Generalized estimating equations were used to model associations with AgeAccel, integrating repeated measures among a subset of participants and using inverse probability weights to account for sample selection probabilities. Based on our fully adjusted models, increased extrinsic AgeAccel was associated with decreased odds of incident postmenopausal invasive breast cancer during follow-up. This association was consistent among the subset of participants with E2 assays, and robust to adjustment for bioavailable E2 concentration. We found the inverse relationship between extrinsic AgeAccel and incident breast cancer was strongest among white non-Hispanic women with low levels of bioavailable E2. This study represents the largest investigation of the association between AgeAccel and postmenopausal breast cancer risk, and the first evaluation of how bioavailable E2 levels may influence this relationship. Our analyses inform our understanding of the relationship between the epigenetic and reproductive aging process, and the potential implications for postmenopausal breast cancer risk.

Citation Format: Alexandra M. Binder, Lesley Tinker, Robert Wallace, JoAnn E. Manson, Lihong Qi, Parveen Bhatti, Eric A. Whitsel, Andrea Z. LaCroix, Steve Horvath. Association between epigenetic age acceleration and postmenopausal breast cancer risk in the Women’s Health Initiative [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS7-28.

Abstract OT-21-01: Personalized breast cancer screening in a population-based study: Women informed to screen depending on measures of risk (WISDOM)

Background: WISDOM is a 100,000 healthy women preference-tolerant, pragmatic study comparing traditional annual screening to personalized risk-based breast screening. The novelty of WISDOM personalized screening is the integration of previously validated genetic and clinical risk factors (age, family history, breast biopsy results, ethnicity, mammographic density) into a single risk assessment model that directs the starting age, timing, and frequency of screening. The goal of WISDOM is to determine if personalized screening, compared to annual screening, is as safe, less morbid, enables prevention, and is more accepted by women. The study is registered on ClinicalTrials.gov, NCT02620852. Methods: Women aged 40-74 years with no history of breast cancer, DCIS or previous double mastectomy can join the study online at wisdomstudy.org. Participants can either elect randomization or self-select a study arm. Then, they provide electronic consent and sign the Release for Medical Information via DocuSign. For all participants, 5-year risk of developing breast cancer is calculated according to the Breast Cancer Surveillance Consortium (BCSC) model. Participants in the personalized arm undergo panel-based mutation testing (BRCA1, BRCA2, TP53, PTEN, STK11, CDH1, ATM, PALB2, and CHEK2), and their 5-year risk is calculated using the BCSC score combined with a Polygenic Risk Score (BCSC-PRS) that includes 229 single nucleotide polymorphisms (SNPs) known to increase breast cancer risk. The SNPs and mutations are assessed by saliva-based testing through Color Genomics. Five-year risk level thresholds are used to stratify participants as low-, moderate- and high risk. Risk stratification determines age to start, stop, and frequency of screening in the personalized arm. Accrual: As of July 2020 the WISDOM Study is open to all eligible women in the United States. To date, 38,762 eligible women have registered, and 28,706 women have consented to participate in the trial. The median age is 56 years. Seventy-seven percent of participants are Caucasian, 2% African-American, 5% Asian, and 8% of self-reported Hispanic ethnicity. WISDOM is partnering with Blue Cross Blue Shield Association for regional plan opt-in coverage, self-insured companies (Salesforce, Genentech, Qualcomm, CalPERS) and Medi-Cal (Inland Empire Health Plan) using a coverage with evidence progression approach. Accrual expansion and diversity: To ensure that resulting data are meaningful and potentially practice-changing for all populations of women, the WISDOM Study is enhancing the diversity of our participant population by establishing WISDOM sites in diverse areas with large African-American (Alabama, Louisiana, Illinois) and Latina (Florida) populations. These new recruitment sites, intentionally selected for the diverse communities they serve, have established partnerships with community organizations and outreach navigators. Additionally, we have translated the WISDOM Study to Spanish to facilitate access by Latina communities. With the engagement of patient advocates and community partnerships, expanding diversity in the study population will strengthen our scientific knowledge of breast cancer risk and improve access to personalized breast cancer screening recommendations for all women. Enrollment will continue through 2022. Conclusions: Results of 5 years follow-up will enable us to demonstrate whether personalized screening improves outcomes for future patients and it improves healthcare value by reducing screen volumes and costs without jeopardizing outcomes.

Citation Format: Irene Acerbi, Allison Stover Fiscalini, Mandy Che, Yiwey Shieh, Lisa Madlensky, Jeffrey Tice, Elad Ziv, Martin Eklund, Amie Blanco, Barry Tong, Deborah Goodman, Lamees Nassereddine, Nancy Anderson, Heather Harvey, Steele Fors, Hannah L Park, Antonia Petruse, Skye Stewart, Janet Wernisch, Larissa Risty, Ian Hurley, Barbara Koenig, Celia Kaplan, Robert Hiatt, Neil Wenger, Vivian Lee, Diane Heditsian, Susie Brain, Leah Sabacan, Tianyi Wang, Barbara A Parker, Alexander Borowsky, Hoda Anton-Culver, Arash Naeim, Andrea Kaster, Melinda Talley, Laura van 't Veer, Andrea Z LaCroix, Olufunmilayo I Olopade, Deepa Sheth, Augustin Garcia, Rachel Lancaster, Wisdom Study and Athena Breast Health Network Investigators and Advocate Partners, Laura Esserman. Personalized breast cancer screening in a population-based study: Women informed to screen depending on measures of risk (WISDOM) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-21-01.

Evaluation of Light Physical Activity Measured by Accelerometry and Mobility Disability During a 6-Year Follow-up in Older Women

IMPORTANCE

Almost 1 in 4 women older than 65 years is unable to walk 2 to 3 blocks, and mobility disability is a key factor associated with loss of independence. Lack of moderate to vigorous-intensity physical activity is associated with mobility disability, but whether lighter physical activity is associated with mobility disability is unknown.

OBJECTIVE

To determine the association of light-intensity physical activity and incident mobility disability among older women.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included women enrolled in the Objectively Measured Physical Activity and Cardiovascular Health study, an ancillary study of the Women's Health Initiative, between March 2012 and April 2014, with follow-up through March 31, 2018. The Women's Health Initiative was a population-based, multisite study that recruited from 40 clinical sites across the US. Participants in the present analysis included 5735 of 7058 ambulatory, community-dwelling women aged 63 years and older who returned an accelerometer with usable data, were free of mobility disability, and had follow-up data on mobility status. Data were analyzed from August 2018 to May 2019.

EXPOSURES

Light-intensity physical activity, defined as movement requiring energy expenditure between 1.6 and 2.9 metabolic equivalents, captured using an accelerometer over 7 days.

MAIN OUTCOMES AND MEASURES

Incident mobility disability, defined as the first self-reported inability to walk 1 block or up a flight of stairs at annual follow-up, and persistent incident mobility disability, defined as incident mobility loss that persisted through the end of follow-up.

RESULTS

A total of 5735 participants were included for primary analysis of all incident mobility disability (mean [SD] age, 78.5 [6.6] years [range, 63-97 years]; 2811 [49.0%] White participants). Compared with women in the lowest quartile of light-intensity physical activity, lower risk of incident mobility disability was observed in quartile 2 (multivariable hazard ratio [HR], 0.78; 95% CI, 0.67-0.90), quartile 3 (HR, 0.60; 95% CI, 0.51-0.71), and quartile 4 (HR, 0.60; 95% CI, 0.51-0.71) (P < .001). This beneficial association was stronger for persistent mobility disability in quartile 2 (multivariable HR, 0.72; 95% CI, 0.60-0.85), quartile 3 (HR, 0.55; 95% CI, 0.46-0.67), and quartile 4 (HR, 0.52; 95% CI, 0.42-0.63) (P < .001). Stratified analyses showed the association was stronger among women with a body mass index of less than 30.0 (HR, 0.73; 95% CI, 0.66-0.82) compared with women with a body mass index of 30.0 or higher (HR, 0.91; 95% CI; 0.79-1.04; P = .04 for interaction).

CONCLUSIONS AND RELEVANCE

In this cohort study, increased time spent in light-intensity physical activity was associated with reduced incident mobility disability. These findings support placing greater emphasis on promoting light-intensity physical activity for preserving mobility in later life.

Sedentary Behavior and Diabetes Risk Among Women Over the Age of 65 Years: The OPACH Study

OBJECTIVE

To evaluate whether sedentary time (ST) and/or sedentary behavior patterns are related to incident diabetes in the U.S.'s oldest age-groups.

RESEARCH DESIGN AND METHODS

Women without physician-diagnosed diabetes (n = 4,839, mean ± SD age = 79 ± 7 years) wore accelerometers for ≥4 days and were followed up to 6 years for self-reported newly diagnosed diabetes requiring treatment with medications. Hazard ratios (HRs) for incident diabetes were estimated across quartiles of accelerometer-measured ST and mean bout duration with use of Cox proportional hazards models. We conducted isotemporal substitution analyses using Cox regression and tested associations with risk for diabetes after statistically replacing ST with light physical activity (PA) or moderate-to-vigorous PA (MVPA) and after replacing light PA with MVPA.

RESULTS

During 20,949 person-years, 342 diabetes cases were identified. Women in ST quartile (Q)2, Q3, and Q4 (vs. Q1) had incident diabetes HR 1.20 (95% CI 0.87-1.65), 1.33 (0.97-1.82), and 1.21 (0.86-1.70); P _trend = 0.04. Respective HRs following additional adjustment for BMI and MVPA were 1.04 (95% CI 0.74-1.47), 1.04 (0.72-1.50), and 0.85 (0.56-1.29); P _trend = 0.90. Fully adjusted isotemporal substitution results indicated that each 30 min of ST replaced with MVPA (but not light PA) was associated with 15% lower risk for diabetes (HR 0.85 [95% CI 0.75-0.96]; P = 0.01); the HR for replacing 30 min of light PA with MVPA was 0.85 (95% CI 0.73-0.98); P = 0.03. Mean bout duration was not associated with incident diabetes.

CONCLUSIONS

Statistically replacing ST or light PA with MVPA was associated with lower diabetes risk in older women. While reducing ST is important for several health outcomes, results indicate that to reduce diabetes risk among older adults, the primary public health focus should be on increasing MVPA.

Markers of Kidney Function and Longitudinal Cognitive Ability Among Older Community-Dwelling Adults: The Rancho Bernardo Study

BACKGROUND

Reduced kidney function has been associated with cognitive decline. Most studies have examined a single marker of kidney function and have limited duration of follow-up.

OBJECTIVE

This study evaluated associations between markers of kidney function (urine albumin, estimated glomerular filtration rate [eGFR], and hyperuricemia) with cognitive performance over time.

METHODS

This is a longitudinal study of 1,634 community-dwelling adults (mean age = 71.7 years), with kidney function markers and cognitive ability measured at baseline (1992-1996) and at up to five additional time points with a maximum of 23.4 years (mean = 8.1 years) of follow-up. Associations between kidney function and cognitive performance were assessed using linear mixed effects models. Testing for interaction by sex was conducted.

RESULTS

Albuminuria (urine albumin-to-creatinine ratio [ACR]≥30 mg/g) was associated with steeper annual declines in global cognitive function (MMSE, β= -0.12, p = 0.003), executive function (Trails B, β= 4.50, p < 0.0001) and episodic memory (Buschke total recall, β= -0.62, p = 0.02) scores in men. Results were similar when cognitive test scores were regressed on latent trajectory classes of ACR. In men, hyperuricemia (serum uric acid [SUA]≥6.8 mg/dl for men and SUA≥6.0 mg/dl for women) was associated with lower baseline MMSE (β= -0.70, p = 0.009) scores but not with MMSE change over time. No such associations were detected in women. There were no significant associations between eGFR and cognitive performance for either sex.

CONCLUSION

In older men, albuminuria is an independent predictor of subsequent cognitive decline. More investigations are needed to explain the observed sex differences and the potential relationship between hyperuricemia and poorer global cognition.

Association of Sedentary Time and Incident Heart Failure Hospitalization in Postmenopausal Women

BACKGROUND

The 2018 US Physical Activity Guidelines recommend reducing sedentary behavior (SB) for cardiovascular health. SB's role in heart failure (HF) is unclear.

METHODS

We studied 80 982 women in the Women's Health Initiative Observational Study, aged 50 to 79 years, who were without known HF and reported ability to walk ≥1 block unassisted at baseline. Mean follow-up was 9 years for physician-adjudicated incident HF hospitalization (1402 cases). SB was assessed repeatedly by questionnaire. Time-varying total SB was categorized according to awake time spent sitting or lying down (≤6.5, 6.6-9.5, >9.5 h/d); sitting time (≤4.5, 4.6-8.5, >8.5 h/d) was also evaluated. Hazard ratios and 95% CI were estimated using Cox regression.

RESULTS

Controlling for age, race/ethnicity, education, income, smoking, alcohol, menopausal hormone therapy, and hysterectomy status, higher HF risk was observed across incremental tertiles of time-varying total SB (hazard ratios [95% CI], 1.00 [referent], 1.15 [1.01-1.31], 1.42 [1.25-1.61], trend P<0.001) and sitting time (1.00 [referent], 1.14 [1.01-1.28], 1.54 [1.34-1.78], trend P<0.001). The inverse trends remained significant after further controlling for comorbidities including time-varying myocardial infarction and coronary revascularization (hazard ratios: SB, 1.00, 1.11, 1.27; sitting, 1.00, 1.09, 1.37, trend P<0.001 each) and for baseline physical activity (hazard ratios: SB 1.00, 1.10, 1.24; sitting 1.00, 1.08, 1.33, trend P<0.001 each). Associations with SB exposures were not different according to categories of baseline age, race/ethnicity, body mass index, physical activity, physical functioning, diabetes, hypertension, or coronary heart disease.

CONCLUSIONS

SB was associated with increased risk of incident HF hospitalization in postmenopausal women. Targeted efforts to reduce SB could enhance HF prevention in later life.

A Menopause Strategies-Finding Lasting Answers for Symptoms and Health (MsFLASH) Investigation of Self-Reported Menopausal Palpitation Distress

Background: Study to describe the degree of menopausal palpitation distress and its demographic, clinical, symptom, and quality-of-life (QOL) correlates. Analysis of existing, baseline, data from peri- and postmenopausal women, 42 to 62 years of age, who participated in the Menopause Strategies-Finding Lasting Answers for Symptoms and Health (MsFLASH) clinical trials testing interventions for vasomotor symptoms (n = 759). Up to 46.8% of menopausal women report having palpitations, yet the symptom is relatively understudied. Little is known about palpitation distress or its correlates. Materials and Methods: Degree of distress from "heart racing or pounding" was self-reported over the past two weeks as "not at all," "a little bit," "moderately," "quite a bit," or "extremely." Other measures included self-report forms, clinic-verified body mass index (BMI), vasomotor symptom diaries, and validated symptom and QOL tools. Results: The percentage who reported palpitation distress was 19.6%, 25.2%, and 33.5% in the three trials or 25.0% overall. In multivariate analysis, the odds of reporting palpitation distress was lower in past smokers (odds ratio [OR] = 0.59 [95% confidence interval (CI) 0.38-0.90]) and current smokers (OR = 0.48 [0.27-0.87]) relative to never-smokers and lower with every 5 kg/m² higher BMI (OR = 0.82 [0.69-0.98]).The odds of reporting palpitation distress was higher with every five point more severe insomnia (OR = 1.28 [1.05-1.54]), five point worse depressive symptoms (OR = 1.47 [1.11-1.95]), five point worse perceived stress (OR = 1.19 [1.01-1.39]), and one point worse menopausal QOL (OR = 1.29 [1.06-1.57]). Conclusions: Menopausal palpitation distress is common and associated with demographic, clinical, symptom, and QOL factors. Findings can be used for screening in clinical practice and to justify additional research on this understudied symptom.

Accelerometer-Measured Physical Activity Levels and Fatigue in Older Women

The authors examined whether the associations between physical activity (PA) levels and fatigue vary by body mass index and physical performance, and whether substituting sedentary time (ST) with low light PA, high light PA, and moderate to vigorous PA (MVPA) was associated with better mean fatigue scores. In total, 6,111 participants (aged 65 years and older) were from the Women's Health Initiative Objective Physical Activity and Cardiovascular Health Study. PA levels were from a hip-worn GT3X accelerometer. Overall fatigue, energy, and weariness subdomains were from the RAND-36 Vitality subscale. Isotemporal substitution models examined the time-substitution effects. Interactions were observed between MVPA and short physical performance battery performance measure (p < .05). Substituting ST with 34.3 min of MVPA was associated on average with a 1.63-point improvement in fatigue score. Substituting ST with 50.2 min of low light PA and 34.3 min of MVPA was associated on average with an energy score improvement of 1.18 and 2.06 points respectively. Substituting ST with 34.3 min of MVPA was associated on average with a 1.08-point improvement in weariness score (p < .05 for all).

Accelerometer-Measured Sleep Duration and Clinical Cardiovascular Risk Factor Scores in Older Women

BACKGROUND

Evidence suggests that short and long sleep durations are potential lifestyle factors associated with cardiovascular disease (CVD). Research on sleep duration and CVD risk is limited by use of self-report sleep measures, homogeneous populations, and studies on individual CVD risk factors. For women, risk of CVD and inadequate sleep duration increases with age. We hypothesized that accelerometer-measured sleep duration was associated with 10-year predicted probability of future CVD risk in a cohort of aging women.

METHODS

This cross-sectional analysis included 3,367 older women (mean age 78.9 years; 53.3% White), from the Objective Physical Activity and Cardiovascular Health Study, ancillary study to the Women's Health Initiative. Women wore ActiGraph GT3X+ accelerometers on the hip for 24 hours/7 days. A 10-year predicted probability of future CVD risk, the Reynolds Risk Score (RRS), was computed using age, systolic blood pressure, high-sensitivity C-reactive protein (CRP), total and HDL cholesterol, diabetes mellitus status, smoking status, and family history of CVD. Average nightly sleep duration was derived from accelerometer data. Adjusted linear regression models investigated the association between sleep duration and RRS.

RESULTS

Results suggested a U-shaped relationship between sleep duration and RRS, with both short and long sleep associated with higher RRS (p < .001). The association remained significant after adjustments for race/ethnicity, education, lifestyle factors, and health status indicators.

CONCLUSION

In older women, actigraphy-ascertained sleep duration was associated with a 10-year predicted probability of future CVD risk. This study supports sleep duration as a modifiable risk factor for CVD in older women.

Associations of Coffee and Tea Consumption With Survival to Age 90 Years Among Older Women

BACKGROUND

Coffee and tea are two of the most widely consumed beverages worldwide and have been associated with reduced risk of mortality in some studies. However, it is unknown whether consumption of these beverages is associated with survival to an advanced age.

OBJECTIVE

To examine associations of coffee and tea consumption with survival to age 90 years.

DESIGN

Prospective cohort study among participants from the Women's Health Initiative, recruited during 1993 to 1998 and followed up until March 31, 2018.

SETTING

The setting included 40 US clinical centers.

PARTICIPANTS

A racially and ethnically diverse cohort of 27,480 older women, aged 65 to 81 years at baseline.

MEASUREMENTS

Women were classified as having either survived to age 90 years or died before this age. Consumption of caffeinated and decaffeinated coffee and caffeinated tea was assessed at baseline and categorized as 0, 1, 2 to 3, or 4 or more cups/day. Associations of coffee and tea consumption with survival to age 90 years were examined using logistic regression models adjusted for sociodemographic characteristics, lifestyle behaviors, dietary quality, and chronic disease history.

RESULTS

A total of 14,659 (53.3%) women survived to age 90 years during follow-up. Caffeinated coffee, decaffeinated coffee, or caffeinated tea consumption was not significantly associated with survival to age 90 years after adjusting for confounders. Findings did not significantly vary by smoking, body mass index, or race/ethnicity.

CONCLUSION

No amount of coffee or tea consumption was associated with late-age survival among older women. These findings may be reassuring to older women who consume coffee and tea as part of their daily diets but do not support drinking these beverages to achieve longevity.

Cognitive Resilience to Alzheimer's Disease Pathology in the Human Brain

BACKGROUND

Past research has focused on risk factors for developing dementia, with increasing recognition of "resilient" people who live to old age with intact cognitive function despite pathological features of Alzheimer's disease (AD).

OBJECTIVE

To evaluate demographic factors, mid-life characteristics, and non-AD neuropathology findings that may be associated with cognitive resilience to AD pathology.

METHODS

We analyzed data from 276 autopsy cases with intermediate or high levels of AD pathology from the Adult Changes in Thought study. We defined cognitive resilience as having Cognitive Abilities Screening Instrument scores ≥86 within two years of death and no clinical dementia diagnosis; non-resilient people had dementia diagnoses from AD or other causes before death. We compared mid-life characteristics, demographics, and additional neuropathology findings between resilient and non-resilient people. We used multivariable logistic regression to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for being resilient compared to not being resilient adjusting for demographic and neuropathology factors.

RESULTS

We classified 68 (25%) people as resilient and 208 (75%) as not resilient. A greater proportion of resilient people had a college degree (50%) compared with non-resilient (32%, p = 0.01). The odds of being resilient were significantly increased among people with a college education (OR = 2.01, 95% CI = 1.01-3.99) and significantly reduced among people with additional non-AD neuropathology findings such as hippocampal sclerosis (OR = 0.28, 95% CI = 0.09-0.89) and microinfarcts (OR = 0.34, 95% CI = 0.15-0.78).

CONCLUSION

Increased education and absence of non-AD pathology may be independently associated with cognitive resilience, highlighting the importance of evaluating co-morbid factors in future research on mechanisms of cognitive resilience.

Device-assessed physical activity and sedentary behavior in a community-based cohort of older adults

BACKGROUND

Few studies characterize older adult physical activity and sitting patterns using accurate accelerometer and concurrent posture measures. In this descriptive paper, we report accelerometer data collection protocols, consent rates, and physical behavior measures from a population-based cohort study (Adult Changes in Thought, ACT).

METHODS

The ACT study holds enrollment steady at approximately 2000 members of Kaiser Permanente Washington aged 65+ without dementia undergoing detailed biennial assessments. In 2016 the ACT-Activity Monitor (ACT-AM) sub-study was initiated to obtain data from wearing activPAL and ActiGraph devices for 7 days following regular biennial visits. We describe the methods protocol of ACT-AM and present characteristics of people who did and did not consent to wear devices. We compute inverse probability of response weights and incorporate these weights in linear regression models to estimate means and 95% confidence intervals (CI) of device-based pattern metrics, adjusted for wear time and demographic factors, and weighted to account for potential selection bias due to device-wear consent.

RESULTS

Among 1885 eligible ACT participants, 56% agreed to wear both devices (mean age 77 years, 56% female, 89% non-Hispanic white, 91% with post-secondary education). On average, those who agreed to wear devices were younger and healthier. Estimated mean (95% CI) activPAL-derived sitting, standing, and stepping times were 10.2 h/day (603-618 min/day), 3.9 h/day (226-239 min/day), and 1.4 h/day (79-84 min/day), respectively. Estimated mean ActiGraph derived sedentary (Vector Magnitude [VM] < =18 counts/15 s), light intensity (VM 19-518 counts/15 s), and moderate-to-vigorous intensity (VM > 518 counts/15 s) physical activity durations were 9.5 h/day (565-577 min/day), 4.5 h/day (267-276 min/day), and 1.0 h/day (59-64 min/day). Participants who were older, had chronic conditions, and were unable to walk a half-mile had higher sedentary time and less physical activity.

CONCLUSIONS

Our recruitment rate demonstrates the feasibility of cohort participants to wear two devices that measure sedentary time and physical activity. Data indicate high levels of sitting time in older adults but also high levels of physical activity using cut-points developed for older adults. These data will help researchers test hypotheses related to physical behavior and health in older adults in the future.

Abstract 2359: Endogenous progestogens and colorectal cancer risk among postmenopausal women

Progestogens are sex steroid hormones that serve as precursors to androgens, estrogens, and corticosteroids. While known to influence breast and endometrial cancer risk, the exact roles progestogens play in cancer development are poorly characterized–especially for colorectal cancer. Nor have we been able to determine the utility of measuring circulating progestogens for cancer risk prediction in epidemiologic studies and clinical settings. These gaps in knowledge are largely attributable to the difficulty in measuring hormones among postmenopausal women, when concentrations are low. To address this problem, we developed a highly sensitive and reliable liquid chromatography-tandem mass spectrometry assay to measure concentrations of seven markers of endogenous progestogen metabolism: pregnenolone (a progestogen precursor), progesterone, the two 17-alpha-hydroxy (17OH) forms of these hormones (which are androgen precursors), and three progesterone metabolites. These markers were measured in prediagnostic serum collected from women in a case-cohort study within the Breast and Bone Follow-up to the Fracture Intervention Trial (B~FIT). From the 15,595 postmenopausal women in B~FIT, we followed women not using exogenous hormones at baseline (1992-1993) for up to twelve years: 187 women with incident colorectal cancer diagnosed during follow-up and a subcohort of 495 women selected on strata of age (10-year windows) and clinical center. We used Cox regression models to estimate risk for colorectal cancer (hazard ratios [HR], 95% confidence intervals [CI]); models were adjusted for age, body mass index, clinic site, and enrollment arm from the original clinical trial. High concentrations of progestogens were not associated with colorectal cancer risk (quintile(Q)5 vs. Q1: pregnenolone HR 0.71, CI 0.40-1.25; progesterone HR 1.25, CI 0.71, 2.22). A trend of increasing risk was suggested, but imprecise across quintiles of 17OH-pregnenolone (Q2 to Q5 HRs 0.75 to 1.44, p-trend 0.06), but no association was noted with 17OH-progesterone. Using 5-knot splines, we identified non-linear risk relationships with several of the progestogens–indicating that biologic mechanisms unique to each hormone may exist. However, circulating progestogens were generally unrelated to colorectal cancer risk in postmenopausal women, which is in line with prior work indicating that circulating estrogen metabolites are also not associated with risk.

Citation Format: Kara A. Michels, Roni T. Falk, Ashley M. Geczik, Doug C. Bauer, Diana S. Buist, Jane A. Cauley, Cher M. Dallal, Trisha F. Hue, James V. Lacey, Andrea Z. LaCroix, Jeffrey A. Tice, Xia Xu, Louise A. Brinton, Britton Trabert. Endogenous progestogens and colorectal cancer risk among postmenopausal women [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 2359.

Prompts to increase physical activity at points-of-choice between stairs and escalators: what about escalator climbers?

Since 1980, many studies have evaluated whether stair-use prompts increased physical activity by quantifying changes in stair use. To more completely evaluate changes in physical activity, this study addressed the often-overlooked assessment of climbing up escalators by evaluating the degree to which stair-use sign prompts increased active ascent-defined as stair use or escalator climbing. Over 5 months, at an airport stairs/escalator point of choice, we video-recorded passersby (N = 13,544) who ascended either stairs or escalators, on 10 days with signs and 10 days without signs. Ascenders using the stairs, standing on the escalator, and climbing the escalator were compared on days with versus without signs using multivariable logistic regression. The percentage of ascenders on days with versus without signs were as follows: stair use, 6.9 versus 3.6 percent; escalator standing, 75.2 versus 76.0 percent; and escalator climbing, 18.5 versus 20.4 percent. Signs more than doubled the odds of stair use (vs. escalator use; OR = 2.25; 95% CI = 1.90-2.68; p < .001). Signs decreased the odds of escalator climbing (vs. escalator standing or stair use); OR = 0.90; 95% CI = 0.82-0.99; p = .028). Signs increased the odds of active ascent versus escalator standing by 15 percent (OR = 1.15; 95% CI = 1.05-1.25; p = .002). Although stair-use prompts increased stair use more than twofold (125%), they increased active ascent by only 15 percent, partly because escalator climbing-a behavior not targeted by the intervention-decreased. Although our results corroborated the established consensus that point-of-choice prompts increase stair use, future studies should test interventions designed to increase active ascent.

Short Physical Performance Battery and Incident Cardiovascular Events Among Older Women

Background The Short Physical Performance Battery (SPPB) is an inexpensive, reliable, and easy-to-implement measure of lower-extremity physical function. Strong evidence links SPPB scores with all-cause mortality, but little is known about its relationship with incident cardiovascular disease (CVD). Methods and Results Women (n=5043, mean age=79±7) with no history of myocardial infarction or stroke completed 3 timed assessments-standing balance, strength (5 chair stands), and usual gait speed (4 m walk)-yielding an SPPB score from 0 (worst) to 12 (best). Women were followed for CVD events (myocardial infarction, stroke, or CVD death) up to 6 years. Hazard ratios were estimated for women with Very Low (0-3), Low (4-6), Moderate (7-9), and High (10-12) SPPB scores using Cox proportional hazard models adjusted for demographic, behavioral, and health-related variables including objective measurements of physical activity, blood pressure, lipids, and glucose levels. Restricted cubic splines tested linearity of associations. With 361 CVD cases, crude incidence rates/1000 person-years were 41.0, 24.3, 16.1, and 8.6 for Very Low, Low, Moderate, and High SPPB categories, respectively. Corresponding fully adjusted hazard ratios (95% CIs) were 2.28 (1.50-3.48), 1.70 (1.23-2.36) 1.49 (1.12-1.98), and 1.00 (referent); P-trend <0.001. The dose-response relationship was linear (linear P<0.001; nonlinear P>0.38). Conclusions Results suggest SPPB may provide a measure of cardiovascular health in older adults beyond that captured by traditional risk factors. Because of its high test-retest reliability and low administrative burden, the SPPB should be a routine part of office-based CVD risk assessment.

Dietary Intakes of Women's Health Initiative Long Life Study Participants Falls Short of the Dietary Reference Intakes

BACKGROUND

Understanding how nutrient intake in older women compares with recommendations is important. The Academy of Nutrition and Dietetics position statement summarizes the nutrient needs of older adults (aged ≥60 years) based on a systematic review.

OBJECTIVE

The objective of this study was to compare nutrient intake of Women's Health Initiative Long Life Study participants to the Dietary Reference Intakes for nutrients reviewed in the Academy of Nutrition and Dietetics position statement.

DESIGN

The study is a cross-sectional analysis.

PARTICIPANTS/SETTING

Participants (n=7,875) were mailed the General Nutrition Assessment Food Frequency Questionnaire during 2012-2013, of whom 77% (n=6,095) completed it, and 5,732 were included in the analytic sample after exclusion for implausible energy intakes.

MAIN OUTCOME MEASURES

Mean intake of energy and protein, calcium, fiber, folate, potassium, sodium, vitamins B-12, D, E, and K were described overall and compared with recommendations.

STATISTICAL ANALYSES PERFORMED

Demographic and lifestyle characteristics were summarized using descriptive statistics. The proportion of participants meeting recommendations was computed.

RESULTS

Mean age of completers was 79±7 years and 53.5% were non-Hispanic white, 30% were non-Hispanic black, and 16.5% were Hispanic/Latina. Only one-third of women consumed ≥21 g/day fiber, whereas fewer met the Recommended Dietary Allowance for calcium (18.6%), vitamin E (16.9%), and vitamin D (1.7%). Just more than half (56%) of participants met the Recommended Dietary Allowance for protein of 0.8 g/kg body weight/day, and just less than half (47.0%) met potassium guidelines.

CONCLUSIONS

These findings suggest older women within the Women's Health Initiative were generally not achieving recommended intake for several key nutrients highlighted by the Academy of Nutrition and Dietetics position statement. These findings underscore the need to identify effective approaches for improving the nutrient density of dietary intake in older women.

Diurnal patterns of sedentary behavior and changes in physical function over time among older women: a prospective cohort study

BACKGROUND

Sedentary behavior (SB) is linked to negative health outcomes in older adults. Most studies use summary values, e.g., total sedentary minutes/day. Diurnal timing of SB accumulation may further elucidate SB-health associations.

METHODS

Six thousand two hundred four US women (mean age = 79 ± 7; 50% White, 34% African-American) wore accelerometers for 7-days at baseline, yielding 41,356 person-days with > 600 min/day of data. Annual follow-up assessments of health, including physical functioning, were collected from participants for 6 years. A novel two-phase clustering procedure discriminated participants' diurnal SB patterns: phase I grouped day-level SB trajectories using longitudinal k-means; phase II determined diurnal SB patterns based on proportion of phase I trajectories using hierarchical clustering. Mixed models tested associations between SB patterns and longitudinal physical functioning, adjusted for covariates including total sedentary time. Effect modification by moderate-vigorous-physical activity (MVPA) was tested.

RESULTS

Four diurnal SB patterns were identified: p1 = high-SB-throughout-the-day; p2 = moderate-SB-with-lower-morning-SB; p3 = moderate-SB-with-higher-morning-SB; p4 = low-SB-throughout-the-day. High MVPA mitigated physical functioning decline and correlated with better baseline and 6-year trajectory of physical functioning across patterns. In low MVPA, p2 had worse 6-year physical functioning decline compared to p1 and p4. In high MVPA, p2 had similar 6-year physical functioning decline compared to p1, p3, and p4.

CONCLUSIONS

In a large cohort of older women, diurnal SB patterns were associated with rates of physical functioning decline, independent of total sedentary time. In particular, we identified a specific diurnal SB subtype defined by less SB earlier and more SB later in the day, which had the steepest decline in physical functioning among participants with low baseline MVPA. Thus, diurnal timing of SB, complementary to total sedentary time and MVPA, may offer additional insights into associations between SB and physical health, and provide physicians with early warning of patients at high-risk of physical function decline.

Factors associated with the contemplative stage of readiness to initiate osteoporosis treatment

We investigated the factors associated with readiness for initiating osteoporosis treatment in women at high risk of fracture. We found that women in the contemplative stage were more likely to report previously being told having osteoporosis or osteopenia, acknowledge concern about osteoporosis, and disclose prior osteoporosis treatment.

INTRODUCTION

Understanding factors associated with reaching the contemplative stage of readiness to initiate osteoporosis treatment may inform the design of behavioral interventions to improve osteoporosis treatment uptake in women at high risk for fracture.

METHODS

We measured readiness to initiate osteoporosis treatment using a modified form of the Weinstein Precaution Adoption Process Model (PAPM) among 2684 women at high risk of fracture from the Activating Patients at Risk for OsteoPOroSis (APROPOS) clinical trial. Pre-contemplative participants were those who self-classified in the unaware and unengaged stages of PAPM (stages 1 and 2). Contemplative participants were those in the undecided, decided not to act, or decided to act stages of PAPM (stages 3, 4, and 5). Using multivariable logistic regression, we evaluated participant characteristics associated with levels of readiness to initiate osteoporosis treatment.

RESULTS

Overall, 24% (N = 412) self-classified in the contemplative stage of readiness to initiate osteoporosis treatment. After adjusting for age, race, education, health literacy, and major osteoporotic fracture in the past 12 months, contemplative women were more likely to report previously being told they had osteoporosis or osteopenia (adjusted odds ratio [aOR] (95% CI) 11.8 (7.8-17.9) and 3.8 (2.5-5.6), respectively), acknowledge concern about osteoporosis (aOR 3.5 (2.5-4.9)), and disclose prior osteoporosis treatment (aOR 4.5 (3.3-6.3)) than women who self-classified as pre-contemplative.

CONCLUSIONS

For women at high risk for future fractures, ensuring women's recognition of their diagnosis of osteoporosis/osteopenia and addressing their concerns about osteoporosis are critical components to consider when attempting to influence stage of behavior transitions in osteoporosis treatment.