Body Image,Attractiveness,and Sexual Satisfaction Among Midlife Women: A Qualitative Study

Abstract

Background:

Women often undergo physical changes during the menopause transition, but the relationship between body image and sexual function in midlife is unclear. We used a qualitative approach to explore how body image relates to sexual function and satisfaction in midlife women.

Materials and Methods:

We conducted 19 individual interviews and 3 focus groups (total N = 39) among sexually active women 45–60 years of age using a semistructured guide. Sessions were audiorecorded and transcribed. Two investigators developed a codebook using an iterative process; the primary investigator then coded all data. Codes relating to body image were examined to identify key themes.

Results:

The mean age was 58 (range 46–59); 54% were White, 36% Black, and 10% were of another race. Most (72%) were peri- or postmenopausal. All but two women identified as heterosexual. Feeling attractive was an important reason for sexual activity. Changes in appearance, especially weight gain and breast changes, were common among these women. Women's body image impacted their sexual satisfaction; women who felt self-conscious about their bodies reported that these concerns had a negative impact on their sexual satisfaction, whereas women who felt confident discussed better sexual satisfaction, even in the face of bodily changes. Black women were more likely to discuss feeling confident than White women.

Conclusions:

Feeling attractive is important to sexual satisfaction in midlife women. Bodily changes, especially weight gain, are common during midlife. While many women are self-conscious about their appearance, some women develop increased self-acceptance. Supporting positive body image may help midlife women maintain sexual satisfaction with aging.

Introduction

Sexuality is an important component of the quality of life to many women as they age.¹ The majority of midlife (approximate age 40–60) women are sexually active, and sex remains important to them.^1,2 However, prior studies suggest that negative changes in sexual function as women move through midlife are common.^3

–6 Reasons for these negative changes in sexual function may include biological (e.g., decreases in sex hormones), psychological (e.g., development of mood symptoms), interpersonal (e.g., sexual dysfunction in a sexual partner), and sociocultural (e.g., negative stigma around sexuality in older women) processes. In addition, many women experience changes in their bodies,^4,7 including weight gain or redistribution of weight⁸; changes in sexual organs such as sagging of breasts^8,9 and vaginal changes¹⁰; and changes in their face and hair, such as the development of wrinkles or gray hair.⁹ These changes potentially impact a woman's body image, defined as a person's perceptions of the esthetics or attractiveness of her own body,¹¹ and in turn her sexual function and satisfaction.

Models of female sexual response can help healthcare providers and researchers more deeply understand and contextualize changes in sexual function. While prior models focused on physical aspects, a newer model, proposed by Rosemary Basson, highlights both physical and emotional aspects of female sexual response.¹² This model emphasizes that sexual desire is often triggered, not spontaneous, for women. A woman's feelings about her own body and attractiveness may be an important aspect of whether or not desire occurs for her. This model also highlights that participating in sexual activity results in not only physical outcomes, but also emotional outcomes, both of which are important to women. Feelings of attractiveness may be part of these emotional outcomes.

While body dissatisfaction and negative body image are extremely common among women,^13

–16 including midlife and older women,^17

–20 body image does not necessarily worsen as women age.^{13,15,16,21,22} In fact, the importance of personal appearance to women decreases with age.^21,22 Prior findings indicate that as women get older, they are less likely to compare themselves to other women,¹³ self-monitor their bodies,²¹ or worry about attractiveness.²³ When selecting an ideal body, college-aged women tend to select a thinner figure than do older women.²⁴ As one author put it, as women age, “physical appearance is no longer such a central part of who they are.”²² In theory, this shift could potentially permit women to feel less self-conscious during sexual activity, thereby improving their sexual satisfaction.

There are differences between Black women and White women with regard to body image. Black women consistently report more positive body image than White women, even at higher weights.^{15,25

–29} Black women more likely believe men prefer heavier women^26,27,30 and are more likely to report being at an ideal weight than White women.^31
–33 However, many Black women still feel self-conscious about their bodies and engage in self-monitoring and attempts to lose weight,^34,35 and a more recent meta-analysis suggests that ethnic differences in body image are not as vast as previously thought.³⁶ These studies highlight the importance of including a diverse sample when studying body image in women.

The relationship between body image and sexual function has been examined in prior quantitative studies, but most were conducted among college-aged women, not midlife women, and these studies are often limited by the use of nonvalidated measures of body image, sexual function, and sexual satisfaction. In the literature among younger women, negative body image was correlated with sexual problems, sexual dysfunction, and sexual dissatisfaction.^{37

–44} However, in the limited literature among midlife women, findings were mixed. In two studies, no associations were found between body image and sexual satisfaction, particularly after controlling for other factors (such as menopausal and mood symptoms).^13,45 The third study did find a correlation between self-reported declines in attractiveness and perceived declines in sexual function, but no relationship between self-reported declines in attractiveness and sexual satisfaction.⁴⁶ This third study did not use validated measures.

Because they use standardized questions and answer choices, quantitative studies may overlook nuances and individual variations in women's experiences. Qualitative research allows women to speak at length, using their own words, to describe aspects of phenomena that are most relevant to them. To our knowledge, no qualitative studies have specifically addressed the role of body image in sexual function and satisfaction in midlife women. In this study, our aim was to use individual interviews and focus groups to explore the role of body image in sexual function and satisfaction in a racially diverse group of women 45–60 years of age.

Materials and Methods

We recruited women from the general population of Pittsburgh, PA in 2014 and 2015. Women were recruited using flyers placed in community spaces and doctors' offices; social media advertisements; online newsletters; and the University of Pittsburgh Clinical and Translational Science Institute (CTSI) research registry. Interested women contacted the study team and were screened for eligibility over the telephone. We included women who were 45–60 years old and had any partnered sexual activity in the prior 12 months. Sexual activity was broadly defined and included penetrative sex, oral sex, and intimate touching. Eligible women could choose to participate in either an individual interview or a focus group. Individual interviews allowed women who do not feel comfortable speaking in a group to participate, while focus groups allowed researchers to potentially uncover unique themes due to group synergy. We used both to obtain a variety of perspectives.

At the beginning of each interview or focus group, an informed consent script was read to the potential participant. This script highlighted that participation was voluntary and could be discontinued at any time; that all information would be kept confidential; and outlined potential risks and benefits of the study. Women could then choose to remain and participate in the study or leave. The University of Pittsburgh Institutional Review Board approved this study.

All interviews and focus groups were conducted by a facilitator (M.H.) with extensive training and experience in qualitative research involving sensitive subject matters. The facilitator took minimal notes during interviews, while the principal investigator (H.N.T.) sat in the corner during focus groups and took notes, but did not participate in any discussion; the principal investigator was not present at interviews. Both interviews and focus groups lasted ∼60 minutes and followed a semistructured interview guide (Supplementary Data; Supplementary Data are available online at www.liebertpub.com/jwh). Consistent with the emergent nature of qualitative research, not all questions on the interview guide were asked of every participant, and some participants may have been asked follow-up questions not included in the interview guide. The overall study was focused broadly on sexual function and satisfaction in midlife women, with some specific probing questions regarding body image.

Interviews and focus groups were audiorecorded and transcribed verbatim, omitting any names or other individual identifiers. A random 10% section of each transcript was reviewed against the audio recording for accuracy. The facilitator and principal investigator used an iterative approach to develop a codebook (a list of short phrases with clear definitions and examples from the transcripts) until a final codebook was agreed upon. The principal investigator then used this codebook to assign codes to all data. A fine-grained, editing style was used to assign codes.⁴⁷ This involves examining small phrases of text within the transcript and assigning a code that summarizes the theme or idea communicated within that text. The text can then be reorganized, if necessary, so that its meaning can be more clearly seen.⁴⁸ Because themes were similar in interviews and focus groups, the same codebook was used for both. The primary investigator coded all interviews and focus groups, and the facilitator coded a randomly selected 25% of interviews to compare with the principal investigator. Overall kappa was 0.84, indicating excellent intercoder agreement. Women also completed brief demographic questionnaires, which were linked to transcripts using an anonymous identifier. Atlas.ti software (Atlas.ti Scientific Software Development GmbH, Berlin, Germany) was used to assist with coding. Using a thematic analysis approach, all codes regarding body image were examined, and key themes and representative quotes were identified.

Results

Demographics

We conducted 19 individual interviews and 3 focus groups of 5–7 women each (total N = 39) (Table 1). The mean age was 52, and 59% were married or living with a partner. Fifty-four percent of women were non-Hispanic White, 36% were non-Hispanic Black, and 10% were of another race/ethnicity (two mixed race women, one Asian woman, and one Hispanic White woman). Percentages of pre-, peri-, and postmenopausal women, assessed by participant self-report, were 13, 44, and 28, respectively (15% of women marked “unsure”). All but two women self-identified as heterosexual, with one reporting homosexual and one marking both homosexual and not sure.

Table 1.

Participant Characteristics

	Individual interviews (N = 20)	Focus groups (three groups, total N = 19)
Age, years, mean (range)	52.3 (45–58)	53.4 (46–59)
Married or cohabitating, N (%)	12 (60)	11 (61)^a
Race/ethnicity, N (%)
White	8 (40)	13 (68)
Black	9 (45)	5 (26)
Other	3 (15)	1 (5)
College degree or higher education status, N (%)	9 (45)	12 (63)
Self-reported menopausal status, N (%)
Premenopausal	3 (15)	2 (10)
Perimenopausal	9 (45)	8 (42)
Postmenopausal	4 (20)	7 (36)
Not sure	4 (20)	2 (10)
Sexual orientation
Heterosexual	20 (100)	17 (89)
Homosexual	0 (0)	1 (5)
Bisexual	0 (0)	0 (0)
Not sure	0 (0)	1 (5)^b

One woman did not answer the marital status question.

One woman marked both homosexual and not sure.

Three major themes emerged: (1) feeling attractive was an important reason for sexual activity; (2) changes in appearance, especially weight gain and breast changes, were common; and (3) response to changes in appearance affected sexual satisfaction.

Feeling attractive as an important reason for sexual activity

Many women expressed that feeling attractive was an important reason for sexual activity. A 56-year-old White woman said, “Most important with my sex life, probably number one would be feeling like my husband wants me, that he desires me.” A 48-year-old White woman indicated, “[E]verybody wants to feel needed. Everybody wants to feel desired. Everybody wants to know their partner is all about them. You need to feel that. If you can't feel pretty, if you can't feel happy, I mean, there's something missing, you know?” Women discussed how feeling desired was especially important in the context of a long-term relationship. They wanted confirmation that their partner was still physically attracted to them, even if they had been together for years. A 55-year-old White woman said, “[Having sex] validates that he wants to stay in the marriage, that he still feels attracted to me.”

Some women also emphasized that feeling attractive was not only an important outcome of sex, but also a prerequisite for sex. Some women needed to feel “sexy” to initiate, be receptive to, or enjoy sexual activity.

[I]f I go to the gym and start eating better, if I feel better about myself, I'm more sexual and I feel more desire. Very hard to feel any of that when I feel like huge and fat … just bleh, out of shape, really big, I feel very unattractive. And it doesn't matter how many times he tells me otherwise. If I don't feel it, I'm just not as much fun in bed. (47-year-old Asian American woman)

In contrast, there were several women who mentioned how feeling attractive had become a less important reason for sex as they got older. When they were younger, they were more likely to have sex to feel “validated”—to feel that they were sexy and attractive—but that this was no longer a major sexual motivator.

Interviewer: You mentioned when you were younger the orgasm being more of a driving force.

A 58-year-old White woman: That, and feeling sexy and attractive and all that other stuff, it was almost like part of your identity. Like having someone say that you were sexy was kind of what you were going after. I don't go after looking sexy anymore … I'm satisfied with what I do, who I am, and having sex or being sexy isn't a part of that.

Other women agreed that, as they got older, they felt more self-confident and did not need as much external validation. Women also discussed how, particularly in the context of a long-term relationship, feeling attractive became less important to their sexual satisfaction as time went by.

Interviewer: And do concerns about your looks or your body affect your sexual satisfaction at all?

A 53-year-old White woman: You know what? Yes, but I've managed to kind of put those things on the back burner and not let them bother me … [I]n the early times of our relationship, I was a bit self-conscious about my weight … I don't think that physical attractiveness is necessarily the most important thing in a relationship. Physical looks fade over the time of your life … And there's got to be much more important things that hold that relationship together other than physical attractiveness.

Changes in appearance: weight gain and breast changes

Many women discussed changes in their appearance as they aged. Dissatisfaction with body weight was particularly common. Some women reported they had been overweight for some time, whereas others reported gaining weight during the menopause transition. Most expressed a strong desire to lose weight. Many women emphasized that the weight bothered them more than their partners, particularly for the women who were in long-term relationships. Women stated that their partners would reassure them that they still found them attractive.

A 56-year-old White woman: You know, that's one thing: he's never made me feel like—there's times where my weight has been up. And when he married me, I was like 110 pounds. I was big tits, little waist, I was tiny. And as I had kids, gained weight … And he has never ever—and he's even said … “Oh honey, it's just more to hold on to,” that type of comment. He's never made me like, “You are undesirable because of how you look.” [H]e's never made me feel that way.

Interviewer: And have you ever felt that way just from your …

Respondent: Myself? … Yeah. I think most women do. I mean, I don't want the lights on. I don't want you to see my cellulite … or my thighs or that my boobs are sagging … you kind of want to leave a lot of that to their imagination …

While many women were critical of their own weight, they also felt it was important for a person to accept his or her partner regardless of weight gain or other changes in appearance. A 55-year-old Black woman said, “If you really care about someone, you accept them how they are, because even though I might be 50 pounds heavier, I'm still [name], there's just a little more of me … I'm still the same person.” These women emphasized that love ought to be unconditional, and not depend on physical appearance.

Women also discussed changes in the breasts, such as sagging or stretch marks, which affected their sex lives. Some traced these changes to the time of menopause, whereas others attributed it to getting older.

A 56-year-old White woman: Once you get over menopause, your breasts change. They are not as perky, firm, and when you lay down, [laughter] you try to get them to conform the way they're supposed to. And honest to God, and my husband always, he says “It doesn't matter,” but it does matter! It bothers me tremendously that that also has changed. [laughs]

A 46-year-old White woman: I don't think I've gone … through menopause yet, but … I've always been big busted… And so gravity, took over a long time ago.

Similar to weight gain, this woman indicates her breast changes bother her more than they do her partner. Two women also mentioned medical procedures that had changed the appearance and sensitivity of their breasts.

I have had a bilateral preventive mastectomy … And I had reconstructive surgery and I have implants but they aren't exactly the same. So … It's kind of in the back of my mind … one's kind of higher than the other. And if I move a certain way … they kind of dimple or indent. And there's no sensation. If I'm naked they look a little bit different. Now my husband doesn't care … but it's just not the same. (58-year-old White woman)

Women's response to changes in appearance affected sexual satisfaction

We found that there are important relations among body image, sexual activity, and sexual satisfaction. For the women who expressed negative body image related to weight gain, sagging breasts, and other issues, feeling self-conscious often had a negative impact on sexual satisfaction.

Interviewer: Do concerns about your looks or your body affect your sexual satisfaction?

A 48-year-old White woman: Oh hell yes … You know, I'm not 20 years old anymore … there's some days where you really feel your age … I feel chubbier than I used to be or … I'm not as flexible as I used to be … there are days that I feel like insecure about myself … I think that's just part of being a woman in general.

A 56-year-old White woman: And then you're doing something and then all of a sudden your back hurts or your neck's hurting and you can't … some of it's flexibility and some of it's just that you feel so old. And that does have an effect.

A 55-year-old White woman: Sometimes—you're saying, “I feel so old.” And I say, I look so old … Because I remember when I was younger … I know he doesn't look the way he looked when he was younger but still in my mind, I think there I am on top of you and I'm like hanging on to you … [laughter] and my chin, my cheeks, everything. I mean, seriously though, that sometimes will stick with me.

Women who were self-conscious about their bodies described feeling more restricted and less “free” in the bedroom. They also discussed a desire to “cover up” by keeping the lights dim or off during sex, or wearing clothing or underwear that was less revealing. Thoughts about their body distracted them when they were participating in sexual activity.

Interviewer: Do concerns about your looks or body affect your sexual satisfaction?

A 55-year-old White woman: Absolutely. [E]ven 34 years later, sometimes I don't want him to see me naked. Now how sick is that? I've had two children with this man.

Interviewer: And has there been anything that has changed around that as you've aged?

Woman: Hell yeah. [laughs] There's all this. I have more boobs now but it's because I'm fat everywhere. Yeah, I'd like to get rid of my crappy insecurities that I have grown up with … I wish I could just be a normal woman that could be naked in front of my own husband after 34 years and not feel self-conscious …

Of note, she indicates that her bodily insecurities are not new with midlife. Many women echoed this.

There was a smaller subset of women who did not have any insecurity and felt confident and attractive. One woman said, “You know, I'm 53, I take good care of myself, and so I generally feel attractive and [partner's name] helps me feel attractive.” For many women, even in the face of weight gain or other bodily changes, they felt increased self-acceptance as they got older.

A 57-year-old Black woman: [F]or me [sex] really, really is intense … [A]fter [my] hysterectomy, I became extremely uninhibited … Every time it gets better. I think as you get older, for me, it was more of a comfort level. Just being more comfortable with yourself.

A 46-year-old White woman: Yeah, I would have to agree with her … now as I'm getting older in age, sex for me is more intense …

A 57-year-old White woman: I think for me, the physical feeling is probably less intense than when I was young, but the emotional piece of it is much better. I can feel more playful, I can be less inhibited, I'm more comfortable with my body. I'm able to express myself better and accept his expression better. So even physically, although it's not fantastic as it was, there's other pieces that compensate to make it better. I'd rather be here than there.

These women attribute their higher sexual satisfaction with aging to higher self-acceptance and self-confidence.

Some women noted that they had always been heavy but had always felt confident in their bodies. Other women discussed that only recently were they able to accept their heavier bodies and feel confident.

Interviewer: [D]o concerns about your looks or your body affect your sexual satisfaction?

A 48-year-old Black woman: Used to, it used to. Not anymore, [laughs] not anymore. I'm comfortable with my chunkiness, [laughs] and my partner, he's OK, with it, and he's gotten used to … so I'm comfortable now, but back in the day, I wasn't really comfortable … [laughs] I'm more comfortable with my body now than I was as a teenager.

For some women, finding a supportive partner was key to feeling sexually attractive. In addition, a few women indicated that they had successfully lost weight, and that their sexual function had improved as a result. Weight loss made certain sexual positions easier, energy levels higher, and gave them increased confidence. A 55-year-old White woman said, “I've lost about 20 pounds in the last month … So it makes me feel better … we have better sex because I've lost weight … [Extra weight] gets in the way sometimes. But he has noticed that I don't have this heaviness here anymore, you can feel my hipbone. And he'll say to me, ‘I like to grab you by your hips,’ so it makes me feel better …”

White women in this study were more likely to report feeling self-conscious, whereas Black women were more likely to report feeling confident. Several of the Black women discussed how their partners made them feel accepted regardless of their size or appearance. In contrast, several White women discussed how they felt self-conscious, even if their partners were reassuring. Overall, both White and Black women reported that their partners were typically reassuring to them with regard to their appearance, but Black women seemed more likely to accept this reassurance than White women. When asked if feeling attractive was a reason for sex, one 47-year-old Black woman said:

Not really. I know my husband will take me as-is, regardless of me being attractive to him …

Interviewer: Do concerns about your looks or your body affect your sexual satisfaction at all?

Respondent: No, not really. My husband could care less … [laughs] I know with my husband, it [weight] doesn't make a difference.

In contrast, a 53-year-old White woman expressed:

Sometimes there will be a woman walking down the street … and they're pretty and they're built like a brick house and he'll look at them … And I do catch myself saying to him, “I don't see you looking at me like that.” … He'll always say to me, “I'll love you no matter what.” … And I guess I get jealous, I don't like him looking at other women and it makes me feel like I'm a big fat thing, like you're not looking at me like you look at them. … I would like to lose this weight and feel good about myself and I could walk around naked. But I never do, I always cover up …

Discussion

In this qualitative study of sexual satisfaction among midlife women, we found that: (1) feeling attractive was an important reason for sexual activity; (2) changes in appearance, especially weight gain and breast changes, were common; and (3) how women responded to those changes impacted their sexual activity and satisfaction. Women who felt insecure and self-conscious about their bodies noted these concerns had a negative impact on their sexual satisfaction, whereas women who felt confident and attractive discussed better sexual satisfaction, even in the face of bodily changes. The latter group typically noted their self-acceptance had increased with age. Black women were more likely to discuss feeling confident and attractive than White women.

Feeling attractive was an important aspect of sexual activity for women in our study, similar to a prior qualitative study,⁹ but feelings of self-consciousness and insecurity were common among the women in our study, especially concerns about being overweight. Many felt that bodily dissatisfaction was a universal experience for women. Indeed, prior studies have shown that body dissatisfaction and negative body image are common among women across the lifespan.^{13

–20} However, as mentioned in the introduction, the importance of personal appearance to women decreases with age,^21,22 similar to the reports of some women in our study. Our findings, and prior findings, suggest that while women may continue to have negative thoughts about their bodies as they get older, they tend to worry about it less.^13,21,23

Women in the present study who were self-conscious about their bodies reported that it negatively affected their sexual satisfaction. They felt more restricted during sexual activity, and discussed wanting to have the lights low or wanting to be more covered up. Prior studies, mostly among college-aged women, have similarly suggested body dissatisfaction is associated with worse sexual function, particularly in the domains of desire and arousal.^{42,46,49
–51} Grogan explains that many women feel that their sexual relationships suffer because they are self-conscious about their bodies, despite reassurances from their partners as to their attractiveness.¹⁶ The women in our study discussed a similar phenomenon of self-consciousness and distraction during sex. The women in the present study often reported persistent insecurities about their bodies despite reassurances from partners as to their attractiveness. Prior research has shown that women believe that men prefer a much thinner “ideal” than men actually do,^24,52 which may explain the difficulty women have in accepting their partners' reassurances.

A smaller but still considerable proportion of women in our study denied bodily insecurity, reporting they felt attractive and confident. Some women felt more confident at midlife than when they were younger. This confidence translated into better sexual function. Support and reassurance from a partner was often a key part of boosting self-image and thereby sexual function in these women, which has been reported in other studies.⁵⁰ It seems that reassurances from partners regarding the women's attractiveness were common; some women were able to accept these reassurances, and their positive body image was buoyed by them, while others wondered if their partners were just being kind, or indicated that they still felt unattractive despite partner reassurance.

Black women in the present study were more likely to discuss feeling self-confident than White women. As this study was not designed to make racial/ethnic comparisons, conclusions should be regarded with caution. However, these findings are consistent with prior work.^{15,25

–33} In our study, this self-confidence often resulted in overall better sexual satisfaction. These findings should be further explored and confirmed in future qualitative and quantitative research, particularly among midlife women.

Overall, these findings suggest that self-confidence and self-acceptance are key ingredients to a satisfying sex life with aging. Healthcare providers should support a healthy lifestyle that includes a balanced diet and regular exercise, while also supporting self-acceptance and positive body image among midlife women. Promoting positive body image could be an important component of behavioral interventions for midlife women with sexual dysfunction.^53,54

This study has limitations. As is typical in qualitative research, sample sizes are smaller to allow a greater depth of data, and results are not considered widely generalizable. Future studies could benefit from utilizing a mixed-methods approach, which employs both qualitative and quantitative analyses. We only included women who were sexually active in the prior 12 months, as we were interested in current sexual experiences. There may be women who are not sexually active at all due to poor body image. Given the sample size, our ability to examine racial and ethnic differences was limited; our findings should be further examined in larger, ethnically diverse samples. Some of the women in the study discussed body image spontaneously, others in response to a probing question regarding body image (see interview guide in Supplementary Data).

Our study has significant strengths. The qualitative approach allowed women to speak their own words about their experiences at length. In addition, we had women from a variety of races and ethnicities represented. Our use of both focus groups and interviews allowed us to capitalize on the group synergy that can occur in groups of peers, while also allowing us to speak with women who may not be comfortable discussing sexuality in a group setting.

Conclusions

In this qualitative study of midlife women, we found that body image and feelings of attractiveness are of key importance to women's sexual satisfaction. It is common for women to undergo changes in appearance as they move through midlife. How women responded to these changes is important to their sexual satisfaction. Supporting positive body image and self-confidence are keys to helping women maintain sexual satisfaction with aging.

Footnotes

Acknowledgments

The authors gratefully acknowledge the women who participated in this study. They also acknowledge Lee Hart, Constance Lappa, and Judith Volkar, who contributed to modifications of the interview guide and interpretation of data. This work was supported by a grant from the Agency on Healthcare Research and Quality (K12-HS022989). H.N.T. is also supported by a grant from the National Institute of Health's National Institute on Aging (K23-AG052628). R.C.T. is supported by a grant from the National Institute of Health's National Heart, Lung, and Blood Institute (K24-HL123565). This study was used as the University of Pittsburgh CTSI research registry for recruitment, which is funded by the National Institute of Health (UL1TR001857).

Author Disclosure Statement

No competing financial interests exist.

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