Group-based Multi-trajectory Modeling Research Articles

Association between multimorbidity trajectories, healthcare utilization, and health expenditures among middle-aged and older adults: China Health and Retirement Longitudinal Study

BackgroundTo identify the latent groups of multimorbidity trajectories among middle-aged and older adults and examine their associations with healthcare utilization and health expenditures. MethodsWe included adults aged ≥45 years who participated in the China Health and Retirement Longitudinal Study from 2011 to 2015 and were without multimorbidities (<2 chronic conditions) at baseline. Multimorbidity trajectories underlying 13 chronic conditions were identified using group-based multi-trajectory modeling based on the latent dimensions. Healthcare utilization included outpatient care, inpatient care, and unmet healthcare needs. Health expenditures included healthcare costs and catastrophic health expenditures (CHE). Random-effects logistic regression, random-effects negative binomial regression, and generalized linear regression models were used to examine the association between multimorbidity trajectories, healthcare utilization, and health expenditures. ResultsOf the 5548 participants, 2407 developed multimorbidities during follow-up. Three trajectory groups were identified among those with new-onset multimorbidity according to the increasing dimensions of chronic diseases: “digestive-arthritic” (N = 1377, 57.21 %), “cardiometabolic/brain” (N = 834, 34.65 %), and “respiratory/digestive-arthritic” (N = 196, 8.14 %). All trajectory groups had a significantly increased risk of outpatient care, inpatient care, unmet healthcare needs, and higher healthcare costs than those without multimorbidities. Notably, participants in the “digestive-arthritic” trajectory group had a significantly increased risk of incurring CHE (OR = 1.70, 95%CI: 1.03–2.81). LimitationsChronic conditions were assessed using self-reported measures. ConclusionsThe growing burden of multimorbidity, especially multimorbidities of digestive and arthritic diseases, was associated with a significantly increased risk of healthcare utilization and health expenditures. The findings may help in planning future healthcare and managing multimorbidity more effectively.

Trajectories of parental harshness and exposure to community violence differentially predict externalizing and internalizing mental health problems in legal system-involved youth.

Youth with legal system involvement are especially likely to experience parental harshness (PH) and exposure to community violence (ETV), two common forms of life stress. However, most studies examine these stressors separately or collapse across them in ways that preclude examination of their co-occurrence. Consequently, it is unclear 1) how PH and ETV simultaneously fluctuate across development and 2) how these fluctuations predict future mental health problems in legal system-involved youth. We used group-based multi-trajectory modeling to estimate simultaneous trajectories of PH and ETV in 1027 legal system-involved youth and regression analyses to understand how trajectory membership predicted mental health problems three years later. Four trajectories of co-occurrence were identified (1: Low; 2: Moderate and Decreasing; 3: Moderate PH/High ETV; 4: High PH/Moderate ETV). Compared to the Low trajectory, all trajectories with PH/ETV elevations predicted violent crime and substance problems; trajectory 3 (Moderate PH/High ETV) predicted nonviolent crime and depression/anxiety symptoms; trajectory 4 (High PH/Moderate ETV) predicted depression diagnosis. These results elucidate how PH and ETV typically co-occur across adolescence for legal system-involved youth. They also reveal important commonalities and dissociations among types of mental health problems.

Trajectories of Psychopathic Traits, Anxiety, and Violence Exposure Differentially Predict Antisociality in Legal System-Involved Youth.

Psychopathic traits are associated with several forms of antisociality, including criminal offending, legal system involvement, and substance use. Some research suggests that primary (high psychopathic traits, low negative emotions) versus secondary (high psychopathic traits, high negative emotions and/or negative experiences and environments) variants confer different levels of risk for antisociality. However, research has not examined trajectories of co-occurring fluctuations in psychopathic traits, negative emotions, and negative experiences and environments or how trajectory membership relates to antisociality. We implemented group-based multi-trajectory modeling in a sample of 809 justice-involved male (n = 681) and female (n = 128) youth from the Pathways to Desistance Study to address these gaps. We identified four trajectories of co-occurring change in psychopathic traits, anxiety, and violence exposure spanning three years: Low (low levels of each factor); Moderate Psychopathic Traits, High Negative Emotions and Experiences (moderate-decreasing psychopathic traits and high-decreasing anxiety/violence exposure); Potential Primary Psychopathic Traits (elevated-decreasing psychopathic traits, moderate-decreasing anxiety, moderate-stable violence exposure); and High/Secondary Psychopathic Traits (high-stable psychopathic traits, elevated-stable anxiety, high-decreasing violence exposure). Compared to the Low trajectory, all trajectories predicted greater violent crime and substance use three and four years later. Additionally, compared to the Low trajectory, the Potential Primary Psychopathic Traits trajectory predicted more nonviolent offending three years later. Finally, the High/Secondary Psychopathic Traits trajectory showed the most persistent antisociality, predicting more nonviolent crime, higher substance dependence symptoms, and higher likelihood of arrest three and four years later. Youth with co-occurring high psychopathic traits, anxiety, and violence exposure appear most at risk for severe antisociality.

Multiple Trajectories of Body Mass Index and Waist Circumference and Their Associations with Hypertension and Blood Pressure in Chinese Adults from 1991 to 2018: A Prospective Study.

Body mass index (BMI) and waist circumference (WC) have been suggested to be involved in the etiology of hypertension. The present study aimed to determine multiple trajectories of BMI and WC, then examined their associations with the risks of hypertension and high blood pressure in Chinese adults. The study used China Health and Nutrition Survey data from 1991 to 2018. The sample included 9651 adults aged 18 years or older. We used group-based multi-trajectory modeling to identify trajectories. We estimated the relationships between the trajectories and the risks of hypertension with a Cox proportional hazards regression model and the trajectories' relationships with blood pressure levels with a generalized linear model. We identified four trajectories for each gender: low stable BMI, low increasing WC (group 1); medium increasing BMI, medium increasing WC (group 2); increasing BMI to overweight, increasing WC to central obesity (group 3), increasing BMI to obesity, increasing central obesity WC (group 4). Group 1 was the reference group. Among males in groups 2, 3, and 4, the adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) of hypertension were 1.30 (1.15-1.48), 1.86 (1.58-2.18), and 2.60 (2.02-3.34), respectively. The systolic blood pressure (SBP) and diastolic blood pressure (DBP) of males in group 4 increased by 11.90 mm of mercury (mmHg) and 7.75 mmHg, respectively. Among females in groups 2, 3, and 4, the HR and 95% CI of hypertension were 1.35 (1.18-1.54), 1.92 (1.62-2.26), and 2.37 (1.85-3.03), respectively. The SBP and DBP of females in group 4 increased by 8.84 mmHg and 5.79 mmHg, respectively. These data indicated that increases in BMI and WC were associated with unfavorable hypertension risks. Attention to both BMI and WC trajectories has the potential to prevent hypertension.

Multi-Trajectories of Intrinsic Capacity Decline and Their Impact on Age-Related Outcomes: A 20-Year National Longitudinal Cohort Study.

The existence of intrinsic capacity (IC) subtypes and their distinct impacts on age-related outcomes remain unexplored. This study sought to investigate IC impairment trajectories across domains and their associations with the risk of age-related outcomes, including falls, functional limitations, reduced quality of life (QoL) and mortality at 4- and 8-year follow-ups. The study sample comprised 1,782 older adults residing in the community from the Taiwan Longitudinal Study on Ageing (TLSA). Utilizing group-based multitrajectory modeling, distinct subtypes of IC decline trajectories across various domains were identified. Cox proportional hazard models and multivariable logistic regression analyses were employed to assess the associations between the identified subtypes and age-related outcomes. We identified four subtypes of IC decline: robust with mild decline (n=902), hearing loss with cognitive decline (n=197), physio-cognitive decline (PCD) with depression (n=373), and severe IC decline (n=310). Over the 4-year study period, compared to the robust with mild decline group, hearing loss with cognitive decline group exhibited a significantly higher risk of diminished QoL (OR=2.53 [1.66-3.86], p>0.01), whereas those in the PCD with depression group experienced an elevated risk of falls (OR=1.62 [1.18-2.23], p>0.01), as well as functional limitation (OR=2.61 [1.81-3.75], p>.01). Individuals in the severe IC decline group faced a substantially increased risk of all outcomes of interest. Distinct subtypes of IC decline across different domains have varying impacts on age-related outcomes, highlighting the need for a personalized approach to promote healthy ageing at the population level, while further investigation into specific pathophysiological mechanisms is warranted as well.

Grip strength, gait speed, and trajectories of cognitive function in community-dwelling older adults: A prospective study.

This study investigated whether grip strength and gait speed predict cognitive aging trajectories and examined potential sex-specific associations. Community-dwelling older adults (n=19,114) were followed for up to 7 years, with regular assessment of global function, episodic memory, psychomotor speed, and executive function. Group-based multi-trajectory modeling identified joint cognitive trajectories. Multinomial logistic regression examined the association of grip strength and gait speed at baseline with cognitive trajectories. High performers (14.3%, n=2298) and low performers (4.0%, n=642) were compared to the average performers (21.8%, n=3492). Grip strength and gait speed were positively associated with high performance and negatively with low performance (P-values<0.01). The association between grip strength and high performance was stronger in women (interaction P<0.001), while gait speed was a stronger predictor of low performance in men (interaction P<0.05). Grip strength and gait speed are associated with cognitive trajectories in older age, but with sex differences. There is inter-individual variability in late-life cognitive trajectories.Grip strength and gait speed predicted cognitive trajectories in older age.However, sex-specific associations were identified.In women, grip strength strongly predicted high, compared to average, trajectory.In men, gait speed was a stronger predictor of low cognitive performance trajectory.

Multi-trajectory analysis of changes in physical activity and body mass index in relation to retirement: Finnish Retirement and Aging study.

Physical activity and body mass index (BMI) have been reported to change around retirement. The objective was to examine the concurrent changes in physical activity and BMI around retirement, which have not been studied before. In addition, the associations of different demographic characteristics with these changes were examined. The prospective cohort study consisted of 3,351 participants in the ongoing Finnish Retirement and Ageing Study (FIREA). Repeated postal survey, including questions on physical activity and body weight and height, was conducted once a year up to five times before and after the retirement transition, the mean follow-up time being 3.6 years (SD 0.7). Group-based multi-trajectory modeling was used to identify several clusters with dissimilar concurrent changes in physical activity and BMI within the studied cohort. Of the participants, 83% were women. The mean age at the last wave before retirement was 63.3 (SD 1.4) years. Four clusters with different trajectories of physical activity and BMI were identified. BMI remained stable around retirement transition in all four clusters, varying from normal weight to class II obesity. The association of BMI trajectories with physical activity levels were inverse, however, each activity trajectory showed a temporary increase during the retirement transition. Retirement seems to have more effect on physical activity than BMI, showing a temporary increase in physical activity at the time of retirement.

Fetal growth trajectories of babies born large-for-gestational age in the LIFECODES Fetal Growth Study

Babies born large-for-gestational age have an increased risk of adverse health outcomes, including birth injuries, childhood obesity, and cardiometabolic disorders. However, little work has been done to characterize patterns of fetal growth among large-for-gestational age births, which may further elucidate high- and low-risk subgroups. This study aimed to identify subgroups of large-for-gestational age births based on trajectories of fetal growth derived from prenatal ultrasound measurements and explore differences in sociodemographic, pregnancy, and birth outcome characteristics across subgroups. This study identified and described trajectories of fetal growth among large-for-gestational age births (n=235) in the LIFECODES Fetal Growth Study. Ultrasound measurements of fetal growth in middle to late pregnancy were abstracted from health records. Group-based multi-trajectory modeling was applied to measurements of head circumference, abdominal circumference, and femur length z-scores to identify multivariate trajectories of fetal growth. Moreover, sociodemographic variables, pregnancy characteristics, and birth outcomes based on trajectory membership were summarized. This study identified 4 multivariate trajectories of fetal growth among large-for-gestational age births: catch-up growth (n=28), proportional abdominal circumference-to-femur length growth (n=67), disproportional abdominal circumference-to-femur length growth (n=96), and consistently large (n=44). Fetuses in the "catch-up growth" group exhibited small relative sizes in midpregnancy (ie, below average head circumference, abdominal circumference, and femur length z-scores) and large relative sizes in late pregnancy. Growth among these births was driven by increases in relative abdominal circumference and head circumference sizes. Participants who delivered births assigned to this group were less likely to have normal glucose control (40% vs 65%-75%) and more likely to have pregestational diabetes mellitus (36% vs 10%-17%) than other large-for-gestational age subgroups. In addition, the babies in this trajectory group were more likely to have macrosomia (86% vs 67%-73%) and to be admitted to the neonatal intensive care unit (32% vs 14%-21%) than other large-for-gestational age subgroups. In contrast, babies in the "consistently large" group had the largest relative size for all growth parameters throughout gestation and experienced a lower risk of adverse birth outcomes than other large-for-gestational age subgroups. This study characterized several trajectories of fetal growth among large-for-gestational age births, which were related to different pregnancy characteristics and the distribution of adverse birth outcomes. Although the number of individuals within some trajectories was small, a subgroup that exhibited a catch-up growth phenotype during gestation was identified, which may be uniquely associated with exposure to pregestational diabetes mellitus and a higher risk of admission to the neonatal intensive care unit. These results have highlighted that the risk of adverse outcomes may not be evenly distributed across all large-for-gestational age births.

Association between multimorbidity trajectories and incident disability among mid to older age adults: China Health and Retirement Longitudinal Study

BackgroundAlthough multimorbidity is a risk factor for disability, the relationship between the accumulative patterns of multimorbidity and disability remains poorly understood. The objective of this study was to identify the latent groups of multimorbidity trajectories among mid to older age adults and to examine their associations with incident disability.MethodsWe included 5,548 participants aged ≥ 45 years who participated in the China Health and Retirement Longitudinal Study from 2011 to 2018 and had no multimorbidity (≥ 2 chronic conditions) at baseline. The group-based multi-trajectory modeling was used to identify distinct trajectory groups of multimorbidity based on the latent dimensions underlying 13 chronic conditions. The association between multimorbidity trajectories and incident disability was analyzed using the generalized estimating equation model adjusting for potential confounders.ResultsOf the 5,548 participants included in the current analysis, 2,407 (43.39%) developed multimorbidity during the follow-up. Among participants with new-onset multimorbidity, four trajectory groups were identified according to the combination of newly diagnosed diseases: “Cardiometabolic” (N = 821, 34.11%), “Digestive-arthritic” (N = 753, 31.28%), “Cardiometabolic/Brain” (N = 618, 25.68%), and “Respiratory” (N = 215, 8.93%). Compared to participants who did not develop multimorbidity, the risk of incident disability was most significantly increased in the “Cardiometabolic/Brain” trajectory group (OR = 2.05, 95% CI: 1.55–2.70), followed by the “Cardiometabolic” (OR = 1.96, 95% CI: 1.52 –2.53) and “Digestive-arthritic” (OR = 1.70, 95% CI: 1.31–2.20) trajectory groups.ConclusionsThe growing burden of multimorbidity, especially the comorbid of cardiometabolic and brain diseases, may be associated with a significantly increased risk of disability for mid to older age adults. These findings improve our understanding of multimorbidity patterns that affect the independence of living and inform the development of strategies for the primary prevention of disability.

Multiple trajectories of any intensities of physical activity are better than sustained sedentary time on improving waist circumference and body mass index among Chinese adults: China Health and Nutrition Survey, 2004-2018

Higher levels of physical activity (PA) may be associated with more favorable measures of adiposity, and sedentary time (ST) is associated with adverse health outcomes independent of PA. We hypothesized that multiple routes of different PA intensities PA combined with ST would be associated with coexisting latent waist circumference (WC) and body mass index (BMI) trajectories among Chinese adults. Thus, we aimed to determine multiple routes of PA and ST and their associations with trajectories of WC and BMI. We used data from 13 137 adults in the China Health and Nutrition Survey between 2004 and 2018. Using group-based multitrajectory modeling, we determined multiple trajectories of light-, moderate-, and vigorous-intensity PA (LPA, MPA) and ST (PA trajectories) and concurrent WC and BMI trajectories. Then, we explored logit regressions between them. We identified 4 PA trajectories. The majority (high LPA, 43.5%) exhibited decreasing high LPA levels. The rest were high ST (9.0%), decreased MPA (15.8%), and high vigorous-intensity PA (31.7%). People with high ST showed higher odds of having abdominal obesity (odds ratio [OR]=2.23) or severe abdominal obesity (OR=1.73) than those with decreased MPA (OR=1.85 and 1.71) and high LPA (OR=1.43 for abdominal obesity). They also showed higher odds of being overweight (OR=1.73) than those with decreased MPA (OR=1.58) and high LPA (OR=1.39). Any level of PA is better than sustained ST for improving adiposity indicators among Chinese adults.

An application of group-based trajectory modeling to define fetal growth phenotypes among small-for-gestational-age births in the LIFECODES Fetal Growth Study

Reductions in fetal growth are associated with adverse outcomes at birth and later in life. However, identifying fetuses with pathologically small growth remains challenging. Definitions of small-for-gestational age are often used as a proxy to identify those experiencing pathologic growth (ie, fetal growth restriction). However, this approach is subject to limitation as most newborns labeled small-for-gestational age are constitutionally, not pathologically, small. Incorporating repeated ultrasound measures to examine fetal growth trajectories may help distinguish pathologic deviations in growth from normal variability, beyond a simple definition of small-for-gestational age. This study aimed to characterize phenotypes of growth using ultrasound trajectories of fetal growth among small-for-gestational-age births. This study identified and described trajectories of fetal growth among small-for-gestational-age births (<10th percentile weight for gestational age; n=245) in the LIFECODES Fetal Growth Study using univariate and multivariate trajectory modeling approaches. Available ultrasound measures of fetal growth (estimated fetal weight, head circumference, abdominal circumference, and femur length) from health records were abstracted. First, univariate group-based trajectory modeling was used to define trajectories of estimated fetal weight z scores during gestation. Second, group-based multi-trajectory modeling was used to identify trajectories based on concurrent measures of head circumference, abdominal circumference, and femur length z scores. Last, how these trajectories were related to patient demographics, pregnancy characteristics, and birth outcomes compared with those observed among appropriate-for-gestational-age controls was described. Of note, 3 univariate trajectories of estimated fetal weight and 4 multivariate trajectories of fetal growth among small-for-gestational-age births were identified. In our univariate approach, infants with the smallest estimated fetal weight trajectory throughout pregnancy had poorer outcomes, including the highest risk of neonatal intensive care unit admission. The remaining univariate trajectory groups did not have an elevated risk of adverse birth outcomes relative to appropriate-for-gestational-age controls. In our multivariate approach, 2 groups at increased or moderately increased risk of neonatal intensive care unit admission were identified, including infants that remained extremely small for all parameters throughout pregnancy and those who had disproportionately smaller femur length and abdominal circumference compared with head circumference. The remaining multivariate trajectory groups did not have an elevated risk of adverse birth outcome relative to appropriate-for-gestational-age controls. Latent class group-based trajectory modeling applied to ultrasound measures of fetal growth may help distinguish pathologic vs constitutional growth profiles among newborns born small-for-gestational age. Although trajectories cannot be fully characterized until delivery, limiting the direct clinical application of these methods, they may still contribute to the development of approaches for separating growth restriction from constitutional smallness.

Potential modifiable factors associated with late-life cognitive trajectories.

ObjectiveThere is variability across individuals in cognitive aging. To investigate the associations of several modifiable factors with high and low cognitive performance.MethodsData came from 17,724 community-dwelling individuals aged 65–98 years. Global cognition, verbal fluency, episodic memory, and psychomotor speed were assessed over up to seven years. Group-based multi-trajectory modeling identified distinct cognitive trajectories. Structural equation modeling examined the direct/indirect associations of social/behavioral factors and several chronic conditions with cognitive trajectories.ResultsSeven trajectory subgroups were identified. In the structural equation modeling we compared two subgroups-participants with the highest (14.2%) and lowest (4.1%) cognitive performance with the average subgroup. Lower education, never alcohol intake, and frailty directly predicted increased risk of low performance, and decreased likelihood of high performance. Hypertension (RR: 0.69, 95%CI: 0.60–0.80), obesity (RR: 0.84, 95%CI: 0.73–0.97), diabetes (RR: 0.69, 95%CI: 0.56–0.86) and depression (RR: 0.68, 95%CI: 0.54–0.85) only predicted lower likelihood of high cognitive performance, while dyslipidemia was only associated with low performance (RR: 1.30, 95%CI: 1.07–1.57). Living alone predicted increased risk of low cognitive performance and several comorbidities. Smoking did not predict cognitive trajectories but was associated with increased risk of diabetes, obesity and frailty. Findings were similar when examining the direct associations between modifiable risk factors and all seven cognitive subgroups.ConclusionsAlthough several modifiable factors were associated with high performance, and reversely with low performance, this was not observed for obesity, hypertension and dyslipidemia. Further, health behaviors may affect cognitive function indirectly, via geriatric conditions. This indicates that strategies to promote healthy cognitive aging, may be distinct from those targeting dementia prevention.

Natural History Trajectories of Frailty in Community-Dwelling Older Japanese Adults.

BackgroundThe gap between the average life expectancy and healthy life expectancy remains wide. Understanding the natural history of frailty development is necessary to prevent and treat frailty to overcome this gap. This study elucidated the trajectories of 5 frailty assessment components using group-based multitrajectory modeling.MethodsOverall, 845 community-dwelling older adults (aged 65–91 years; 433 males and 412 females) who underwent longitudinal frailty assessments at least 3 times were included in the analysis. The mean follow-up period (±SD, range) was 7.1 (±2.3, 3.8–11.3) years. In each wave, the physical frailty was assessed for the following 5 partially modified components of the Cardiovascular Health Study criteria: shrinking, weakness, exhaustion, slowness, and low activity. Using group-based multitrajectory modeling, we identified subgroups that followed distinctive trajectories regarding the 5 frailty components.ResultsFive frailty trajectory groups were identified: weakness-focused frail progression group (Group 1 [G1]; 10.9%), robust maintenance group (Group 2 [G2]; 43.7%), exhaustion-focused prefrail group (Group 3 [G3]; 24.3%), frail progression group (Group 4 [G4]; 6.7%), and low activity–focused prefrail group (Group 5 [G5]; 14.4%). The Cox proportional hazards model analysis showed that G1, G4, and G5 had significantly higher mortality risks after adjusting for sex and age (G2 was the reference group).ConclusionBased on the natural history of frailty, the 5 distinctive trajectory groups showed that some individuals remained robust, while others remained predominantly prefrail or progressed primarily owing to physical mobility decline. Therefore, identifying individuals belonging to these progressive frailty groups and providing interventions according to the characteristics of each group may be beneficial.

Psychological Distress, Cognition, and Functional Disability Trajectory Profiles of Aging in Primary Care Older Adults

ABSTRACT Objectives To identify profiles of aging by combining psychological distress, cognition and functional disability, and their associated factors. Methods Data were drawn from the Étude sur la Santé des Aînés-Services study and included 1585 older adults. Sociodemographic, psychosocial, lifestyle and health factors were informed from structured interviews. Group-based multi-trajectory modeling and multinomial logistic regression were used to identify aging profiles and correlates. Sampling weights were applied to account for the sampling plan. Results The weighted sample size was 1591. Three trajectories were identified: a favorable (79.0%), intermediate (14.5%), and severe scenario (6.5%). Factors associated with the severe scenario were older age, male gender, lower education, the presence of anxiety disorders, low physical activity, and smoking. Membership in the intermediate scenario was associated with daily hassles, physical disorders, anxiety and depression, antidepressant/psychotherapy use, low physical activity, and no alcohol use. High social support was protective against less favorable profiles. Conclusions Symptoms of anxiety and depression and high burden of physical disorders were associated with less favorable trajectories. Modifiable lifestyle factors have a significant effect on healthy aging. Clinical implications Assessment and management of anxio-depressive symptoms are important in older adults. Clinical interventions including access to psychotherapy and promotion of healthier lifestyles should be considered.

Prevention-effective adherence trajectories among transgender women indicated for PrEP in the United States: a prospective cohort study

Adherence to pre-exposure prophylaxis (PrEP) during periods of PrEP-indication (i.e., prevention-effective adherence) is critical for preventing HIV. We sought to describe factors associated with prevention-effective adherence trajectories among transgender women (TW) to inform PrEP implementation strategies. Using data from The LITE American Cohort (n=728), we performed group-based multi-trajectory modeling (GBMTM) to identify clusters of TW with similar trajectories of PrEP adherence and indication, and sociodemographic, biobehavioral, and structural correlates of each trajectory. We identified five trajectories: (1) consistent indication/no PrEP (15.3%), (2) initial indication/no PrEP (47.1%), (3) declining indication/discontinued PrEP (9.5%), (4) consistent indication/PrEP adherent (18.5%), and (5) increasing indication/initiated PrEP (9.6%). TW diagnosed with an STI were more likely to follow a consistent indication/no PrEP trajectory compared to consistent indication/PrEP adherent trajectory (adjusted Relative Risk Ratio [aRRR], 2.54; 95% confidence interval [CI], 1.16-5.57). TW who experienced homelessness were more likely to follow PrEP discontinuation and initiation trajectories relative to PrEP adherence (aRRR, 2.71; 95% CI, 1.10-6.70 and 2.83; 95% CI, 1.13-7.05, respectively). Over a quarter of TW followed trajectories suggestive of prevention-effective adherence, while 15% did not initiate PrEP despite consistent indication. Findings highlight missed opportunities for PrEP engagement at STI diagnosis and suggest structural interventions addressing housing instability may improve prevention-effective adherence among TW.

Abstract P047: Depressive Symptom Trajectory Associated With Step Counts From Smartwatch: The Electronic Framingham Heart Study

Introduction: Depression is a common and serious medical illness world-wide. Studies have demonstrated a protective effect of physical activity on depression, but few studies have examined the prospective association between depressive symptoms and objectively measured physical activity. Objective: To investigate if antecedent depressive symptoms predict subsequent daily step counts among participants enrolled in the electronic Framingham Heart Study (eFHS). We hypothesize that the trajectory group with a larger proportion of participants having depressive symptoms and antidepressant use is associated with a lower level of physical activity. Methods: We used group-based multi-trajectory modeling to construct depressive symptom trajectory patterns using both depressive symptoms and antidepressant use collected from eFHS participants who attended three FHS health exams over fourteen years. The presence of depressive symptoms was defined at each exam with a Center for Epidemiological Studies-Depression (CES-D) score &gt; 16. At the final exam, participants were provided with a study smartwatch to measure daily step counts. We excluded: a) person-day records with less than 5 hours of wear-time, or less than 1000 steps recorded in a day; b) participants who failed to return data for ≥1 day per week in the first month. We performed linear mixed effects models to examine the association between depressive symptom trajectories and average daily step counts during the first 30 days of smartwatch use and one-year of follow-up adjusting for age, sex, wear-hour, BMI, and smoking status. We used p&lt;0.05 for significance. Results: We identified two depressive symptom trajectory groups for the 724 eFHS participants (mean age 53 years, 60% women). The “low-stable” group (n=578; mean follow-up 286±110 days) consisted of &lt;5% of participants with depressive symptoms and &lt;3% of those with antidepressant medication use across the three exams. The “high-increasing” group ( n = 146; 269±114 days) consisted of &gt;21% of participants with depressive symptoms and &gt;46% of those with antidepressant medication use across the three exams. Compared to the low-stable trajectory group, the participants in the high-increasing depressive symptoms group walked 475 (95% CI: 24-927) fewer daily steps during the first 30 days of smartwatch use ( p = 0.04) and walked 550 (95% CI: 109-991) fewer daily steps during one-year of follow-up ( p = 0.01). Conclusion: Participants in the group with a larger proportion of antecedent depression and anti-depressant use walked significantly fewer steps compared to the group with a smaller proportion of antecedent depression and anti-depressant use. Our findings suggest that interventions via mHealth technologies that target mood may play an important role in promoting physical activity.

Characterizing sustained social anxiety in individuals at clinical high risk for psychosis: trajectory, risk factors, and functional outcomes.

While comorbidity of clinical high-risk for psychosis (CHR-P) status and social anxiety is well-established, it remains unclear how social anxiety and positive symptoms covary over time in this population. The present study aimed to determine whether there are more than one covariant trajectory of social anxiety and positive symptoms in the North American Prodrome Longitudinal Study cohort (NAPLS 2) and, if so, to test whether the different trajectory subgroups differ in terms of genetic and environmental risk factors for psychotic disorders and general functional outcome. In total, 764 CHR individuals were evaluated at baseline for social anxiety and psychosis risk symptom severity and followed up every 6 months for 2 years. Application of group-based multi-trajectory modeling discerned three subgroups based on the covariant trajectories of social anxiety and positive symptoms over 2 years. One of the subgroups showed sustained social anxiety over time despite moderate recovery in positive symptoms, while the other two showed recovery of social anxiety below clinically significant thresholds, along with modest to moderate recovery in positive symptom severity. The trajectory group with sustained social anxiety had poorer long-term global functional outcomes than the other trajectory groups. In addition, compared with the other two trajectory groups, membership in the group with sustained social anxiety was predicted by higher levels of polygenic risk for schizophrenia and environmental stress exposures. Together, these analyses indicate differential relevance of sustained v. remitting social anxiety symptoms in the CHR-P population, which in turn may carry implications for differential intervention strategies.

Three-variate trajectories of metabolic control, body mass index, and insulin dose: Heterogeneous response to initiation of pump therapy in youth with type 1 diabetes.

ObjectiveContinuous subcutaneous insulin infusion (CSII) in youths with type 1 diabetes (T1D) is often associated with lower HbA1c, lower total daily insulin dose (TDD), and lower body mass index (BMI) compared with multiple daily injections (MDI). Individual responses to CSII are diverse. The aim was to identify unique three‐variate patterns of HbA1c, BMI standard deviation score (SDS), and TDD after switching to CSII.MethodsFive thousand one hundred and thirty‐three youths (≤20 years; 48% boys; median age at pump start 12.5 years) with T1D duration ≥3 years at CSII initiation were selected from the multicenter DPV registry. We applied group‐based multitrajectory modeling to identify groups of individuals following similar trajectories. Measurements were aggregated quarterly during a 3‐year follow‐up period. Trajectory variables were changes of HbA1c, BMI‐SDS, and TDD from baseline (delta = quarterly aggregated values at each time point [i] minus the respective baseline value).ResultsFour groups of diverging Delta‐HbA1c, Delta‐BMI‐SDS, and Delta‐TDD patterns were identified. All showed improvements in HbA1c during the first 3 months. Group 1 (12%) was characterized by modest HbA1c increase thereafter, TDD reduction, and stable BMI‐SDS. In Group 2 (39%), increasing HbA1c, decreasing BMI‐SDS, and stable TDD were found. By contrast, sustainably improved HbA1c, increasing BMI‐SDS, and stable TDD were observed in Group 3 (32%). Group 4 (17%) was characterized by increasing levels for HbA1c, BMI‐SDS, and TDD. Between‐group differences in baseline HbA1c, BMI‐SDS, TDD as well as in sex ratio, age at diabetes onset and at pump start were observed.ConclusionsDefinite trajectories of glycemic control, BMI, and TDD over 3 years after CSII initiation were identified in youths with T1D allowing a more personalized treatment recommendation.

Smoking trajectories from adolescence to early adulthood as a longitudinal predictor of mental health in adulthood: evidence from 21 years of a nationally representative cohort.

To measure the prospective relationship between smoking trajectories from adolescence to young adulthood and mental health in later adulthood and test whether this relationship was mediated by concurrent co-use of alcohol and marijuana. Longitudinal study using data drawn from rounds 1 to 18 of the National Longitudinal Survey of Youth 1997 (NLSY97), a nationally representative cohort study spanning 21 years. United States. The analytical sample included those who completed survey items about smoking behaviors on at least half the data collection opportunities in adolescence and young adulthood (n = 8570, 48.9% female, 66.2% white). Mental health in adulthood was measured using the five-item Mental Health Inventory (MHI-5; range = 0-100) at round 18. Seven trajectories of smoking from adolescence to young adulthood were identified by group-based multi-trajectory modeling, using data over 11 years from rounds 1 to 11. Late-onset moderate smokers [β = -1.95, 95% confidence interval (CI) = -3.61 to -0.29], late-onset accelerated smokers (β = -2.53, 95% CI = -4.28 to -0.78), early-onset heavy smokers (β = -3.72, 95% CI = -5.59 to -1.85) and early-onset moderate smokers (β = -2.66, 95% CI = -4.48 to -0.84) showed poorer regression-adjusted mean MHI-5 scores in later adulthood than stable abstainers, even after controlling for baseline mental health and covariates. Whether or not a difference in MHI-5 scores was present between quitters and stable abstainers was inconclusive. The concurrent co-use of alcohol and marijuana in young adulthood significantly mediated the relationship between smoking trajectory and mental health. Continued smoking, especially early-onset and heavy smoking from adolescence to young adulthood, appears to increase the risk of poor mental health later in mid-adulthood, and quitting smoking in young adulthood may mitigate such risk even among early-onset smokers. Mediation analyses underscore the role of using multiple substances in this pathway.

Trajectories of Suffering in the Last Year of Life Among Patients With a Solid Metastatic Cancer.

Reducing suffering at the end of life is important. Doing so requires a comprehensive understanding of the course of suffering for patients with cancer during their last year of life. This study describes trajectories of psychological, spiritual, physical, and functional suffering in the last year of life among patients with a solid metastatic cancer. We conducted a prospective cohort study of 600 patients with a solid metastatic cancer between July 2016 and December 2019 in Singapore. We assessed patients' psychological, spiritual, physical, and functional suffering every 3 months until death. Data from the last year of life of 345 decedents were analyzed. We used group-based multitrajectory modeling to delineate trajectories of suffering during the last year of a patient's life. We identified 5 trajectories representing suffering: (1) persistently low (47% of the sample); (2) slowly increasing (14%); (3) predominantly spiritual (21%); (4) rapidly increasing (12%); and (5) persistently high (6%). Compared with patients with primary or less education, those with secondary (high school) (odds ratio [OR], 3.49; 95% CI, 1.05-11.59) education were more likely to have rapidly increasing versus persistently low suffering. In multivariable models adjusting for potential confounders, compared with patients with persistently low suffering, those with rapidly increasing suffering had more hospital admissions (β=0.24; 95% CI, 0.00-0.47) and hospital days (β=0.40; 95% CI, 0.04-0.75) during the last year of life. Those with persistently high suffering had more hospital days (β=0.70; 95% CI, 0.23-1.17). The course of suffering during the last year of life among patients with cancer is variable and related to patients' hospitalizations. Understanding this variation can facilitate clinical decisions to minimize suffering and reduce healthcare costs at the end of life.