Diabetes risk in British adults in mid life: a national prevalence study of glycated haemoglobin

AIMS

Information on the population at risk of developing Type 2 diabetes in the UK is scarce. We used data from the 1958 British birth cohort to estimate geographical and socio-economic variations in HbA(1c) in mid life.

METHODS

Participants (n = 7799) born in England, Scotland and Wales and currently living in the UK. Individuals were classified according to the presence of Type 2 diabetes and by thresholds of HbA(1c). HbA(1c)> or = 5.5 was used as an indicator for possible subclinical alterations in glucose metabolism.

RESULTS

The majority of the population had HbA(1c) < 5.5% (79.3%); 16.7% had HbA(1c) 5.5-5.9%, 2.0% 6.0-6.9% and 0.6% had HbA(1c)> or = 7.0%. Individuals from manual socio-economic groups and those living in the East of England and Scotland had a higher prevalence of HbA(1c) at or above the upper normal range (5.5%).

CONCLUSIONS

Estimates from this nationwide sample suggest that a proportion of Britons are likely to have subclinical alterations in glucose metabolism by their mid 40s, and this proportion is greater in some socio-economic groups and geographical regions than in others.

Superiority of anti-reflux stent compared with conventional stents in the palliative management of patients with cancer of the lower esophagus and esophago-gastric junction: results of a randomized clinical trial

Palliation of inoperable esophageal cancer with covered stents aims to relieve progressive dysphagia and improve health-related quality of life (HRQoL). Introducing a stent across the esophagogastric junction in lower third tumors may predispose to unchecked gastro-esophageal reflux (GER). Esophageal stents incorporating an anti-reflux valve have been introduced to address this problem. We prospectively compared an anti-reflux stent with a standard stent in the palliation of inoperable lower third esophageal tumors. Forty-nine consecutive patients with malignant dysphagia were randomized to receive a standard (n = 25, group 1) or an anti-reflux stent (n = 24, group 2). HRQoL was assessed before stenting, at 1 week and at 2 months, utilizing European Organization for Research and Treatment of Cancer questionnaires QLQ-C30, QLQ-OES24 and reflux questionnaires. Esophageal pH testing was performed within 1 week of the stent insertion. Detailed statistical analysis was employed to assess general QoL, symptoms and pH scores in both groups. Both groups reported significantly improved QoL, health and dysphagia scores at 1 week and 2 months after stenting. Group 2 patients reported significantly (P < 0.05) better DeMeester symptom, general reflux scores, and normal pH profile at 1 week. At 2 months DeMeester symptom scores were significantly (P < 0.05) better in group 2 compared with group 1. Standard and anti-reflux stents afford comparable relief from dysphagia and improved quality of life in patients with inoperable lower third esophageal cancer. Anti-reflux stents, however, controlled symptomatic and physiologically relevant reflux and should therefore be considered as optimal palliation in this cohort.

Quantitative analysis of human endogenous retrovirus-W env in neuroinflammatory diseases

Although human endogenous retroviruses (HERVs) constitute 8% of the human genome, their role(s) in health and disease remain uncertain. Nonetheless, increased HERV gene activity has been reported in neuroinflammatory diseases such as multiple sclerosis (MS). The human endogenous retrovirus (HERV)-W7q envelope gene encodes a glycosylated envelope protein, syncytin-1, which is expressed in many tissues. Analysis of HERV envelopes (env) revealed a selectively increased abundance of syncytin-1 encoding RNA in brains from patients with MS (p<0.01) relative to non-MS patients. However, HERV env expression from blood-derived leukocytes did not differ between groups. A quantitative PCR-based assay for syncytin-1 RNA showed that median viral RNA levels were higher in brains of MS patients (5.0 log10 copies/microg RNA) relative to non-MS patients (4.6 log10 copies/microg RNA) (p<0.05). Median syncytin-1 DNA levels in MS brains (9.8 log10/microg DNA) were higher than non-MS brain tissue (7.9 log10/microg DNA) (p<0.001) without evidence of new integration events. In contrast, there were no differences in syncytin-1 RNA copy numbers between groups in both CSF (non-MS: 5.0 log10/ml versus MS: 3.8 log10/ml) and plasma (non-MS: 5.033 log10/ml versus MS: 2.9 log10/ml). These observations emphasize the selective induction of syncytin-1 in brain tissue of MS patients but also illustrate the complex dynamics of this retroelement in neuroinflammatory processes.

Drinking histories of self-identified lifetime abstainers and occasional drinkers: findings from the 1958 British Birth Cohort Study

AIMS

To investigate the validity of retrospective items used to distinguish people who have rarely or never consumed alcohol.

METHODS

The 1958 British Birth Cohort Study has followed 9377 individuals until age 45. Previous drinking (at 16, 23, 33 and 42 years) was investigated for two groups of 45-year-old non-drinkers, those reporting never having consumed alcohol ('never drinkers', n = 143, 1.5%), and having only consumed very infrequently ('occasional-only drinkers', n = 1149, 12.3%).

RESULTS

67% of never drinkers previously reported drinking, 25% were past weekly/daily drinkers; 56% of occasional-only drinkers reported weekly/daily consumption. The validity of the retrospective items was progressively questionable when presumed to cover longer time periods.

CONCLUSIONS

Substantial measurement error was evident when identifying 'occasional-only' and 'never' drinkers using retrospective items covering the lifecourse. Researchers investigating potential health benefits associated with moderate drinking need to incorporate more sophisticated methods when identifying sub-groups of non-drinkers.

Laryngopharyngeal reflux in patients with symptoms of gastroesophageal reflux disease

Laryngopharyngeal reflux (LPR) has been extensively studied in patients with laryngeal signs and symptoms, gastroesophageal reflux being identified in approximately 50%. Few studies have investigated the incidence and significance of LPR in GERD patients. Two-hundred and seventy-six consecutive patients referred with symptoms of gastroesophageal reflux had dual probe 24 h pH, esophageal manometry, GERD and ENT questionnaires. LPR was defined as at least three pharyngeal reflux events less than pH 5.0 with corresponding esophageal reflux, but excluding meal periods. Fourty-two percent of patients were positive for LPR on 24 h pH monitoring and 91.3% corresponded with an abnormal esophageal acid score. Distal esophageal acid exposure was significantly greater (P < 0.001) in patients with LPR but symptoms of GERD and regurgitation scores showed no significant differences between patients with positive and negative LPR on 24 h pH. There was no significant difference between the incidence of LPR in patients with or without laryngeal symptoms. There is a high incidence of LPR in patients with GERD but its significance for laryngeal symptoms is tenuous. Fixed distance dual probe pH monitoring allows documentation of conventional esophageal reflux and LPR.

The need for a national strategy for chronic pain management in Ireland

BACKGROUND

Chronic pain is defined as pain on a daily basis for more than six months. It affects 13% of the Irish population. Despite its prevalence and the impact on patient's quality of life there is no national strategy for this problem.

AIM

To determine the need for a national strategy for chronic pain in Ireland.

METHODS

The cost of low back pain (LBP) (common chronic pain condition), the level of education and research and current chronic pain clinic resources were investigated.

RESULTS

The cost of LBP in Ireland is enormous: disability payments from the Department of Social and Family Affairs amounted to euros 348 million and insurance payments cost euros 10.5 million. The number of teaching hours timetabled for pain education in the schools of Medicine, Physiotherapy, Dentistry, Nursing and Psychology in Ireland's six universities varied significantly (e.g. 11.5-72 hrs in nursing). Research grants awarded from state organisations were limited to one over a four-year period. No current chronic pain clinics comply with recommended International Association for the Study of Pain (IASP) guidelines.

CONCLUSION

A national strategy is needed to reduce costs, standardise teaching and increase pain clinic resources to maximise patient care.

Physical activity, television viewing and body mass index: a cross-sectional analysis from childhood to adulthood in the 1958 British cohort

OBJECTIVE

To investigate relationships between frequency of physical activity or television viewing and body mass index (BMI) cross-sectionally at six ages from childhood to adulthood, to better understand longitudinal relationships. To investigate how the relationships vary with age and gender and whether any relationships are due to confounding factors.

METHODS

The 1958 British birth cohort includes all births (approximately 17 000) in one week in March 1958. BMI and physical activity frequency were recorded at 11, 16, 23, 33 and 42 y and television viewing frequency at 11, 16 and 23 y. A total of 11 109 subjects provided BMI and activity data at 42 y. Relationships between BMI and (in)activity were investigated using linear regression.

RESULTS

At ages 11, 33 and 42 y in both sexes and at 23 y in female subjects, those who were more active had lower BMIs, and the relationships strengthened with age. At 42 y, the most active had a lower mean BMI than the least active, by 0.83 kg/m2 in men, and 1.03 kg/m2 in women. BMI and activity were unrelated at 16 y in female subjects, and 23 y in male subjects. At 16 y in males, the most active males had a mean BMI 0.25 kg/m2 higher than the least active. At 11 y in female subjects and 23 y in both sexes, those who watched television most frequently had higher BMIs. BMI and television viewing were unrelated at 11 y in males and at 16 y in both sexes. Relationships between BMI and activity or television viewing were largely unexplained by potential confounding factors.

CONCLUSIONS

The relationship between BMI and physical activity changes with age. In early adolescence and in adulthood, a higher activity level, or lower frequency of television viewing was associated with a lower BMI. In later adolescence (16 y), television viewing and activity were unrelated to BMI, except for an unexpected BMI-activity relationship in males. We suspect this relationship in males is primarily due to selection effects, whereby physically bigger boys, with a larger BMI, are more likely to take part in exercise activity, and possibly also to BMI being a less accurate predictor of fatness in adolescent boys.

CNS tuberculosis: a longitudinal analysis of epidemiological and clinical features

In a prospective Canadian cohort of 82 764 patients with tuberculosis (TB), the risk of developing central nervous system manifestations of TB (CNS-TB) (1%) was higher among younger, female, Aboriginal and foreign-born persons (P < 0.005), together with an elevated mortality risk (RR 4.23), compared to controls with only pulmonary TB. TB detection was lower in the CNS-TB group (P < 0.005), while the likelihood of being cured was also reduced (P < 0.005). CNS-TB remains a serious complication of TB in the industrialised world.

Adolescent drinking level and adult binge drinking in a national birth cohort

AIMS

To assess (i) continuities in binge drinking across adulthood and (ii) the association between adolescent drinking level and adult binge drinking.

DESIGN

Population-based prospective birth cohort.

SETTING

England, Scotland and Wales.

PARTICIPANTS

All births during one week in March 1958 (n = 8520 in analysis).

MEASUREMENTS

Alcohol consumption reported at 16, 23, 33 and 42 years. Binge drinkers were identified by dividing number of units of alcohol consumed in the last week by usual drinking frequency, with limits of >/=10 units/occasion for men and >/=7 for women.

FINDINGS

Four in five cohort members drank alcohol at least twice a month. Prevalences of binge drinking at 23, 33 and 42 years among men were 37%, 28% and 31% and among women 18%, 13% and 14%. Most binge drinkers in adulthood changed drinking status during this period. Nevertheless, binge drinking at age 23 increased the odds of binge drinking at 42 years: odds ratio (OR) 2.10 (95% CI 1.85, 2.39) for men; OR 1.56 (95% CI 1.29,1.89) for women. Women who rarely or never drank aged 16 were less likely than light drinkers (0-2 units/week) to binge drink as adults, OR at 23 years 0.65 (95% CI 0.55, 0.77). Men who were heavier drinkers (>/=7 units/week) at 16 years were more likely than light drinkers to binge drink throughout adulthood; at 42 years, OR 1.64 (95% CI 1.33, 2.08).

CONCLUSIONS

Binge drinking is common in British men and women throughout adulthood with continuities between the 20s and 40s. Adolescent drinking has a modest although important association with adult binge drinking.

Needle-localised biopsy of impalpable breast lesions: A novel adjunct to surgical technique and specimen mammography

Successful screening programmes have resulted in the more frequent detection of early impalpable breast tumours. Effective surgical management of impalpable lesions demands a precise approach to excision which is currently aided by radiologically guided needle-localisation of the lesion prior to operative removal. The surgical specimen procured is most commonly evaluated for tumour presence by specimen mammography intra-operatively or by histological analysis. The latter is more accurate but requires lengthy laboratory processing, which may result in re-operation if the primary excision is inadequate. Although advocated as the standard of care, specimen mammography remains an imperfect technique. In this article we describe a piece of surgical apparatus which attempts to address some of the concerns associated with specimen mammography. It is an inexpensive compression device which reduces operative time, avoids portable fluoroscopy, increased radiation and the necessity for specialised equipment

Are inequalities in height narrowing? Comparing effects of social class on height in two generations

OBJECTIVE

To determine whether social inequalities in height change across generations.

METHODS

The target population was from the 1958 British birth cohort, all born 3rd-9th March 1958, followed to 1991, and the offspring of one third of this population. Main outcomes were height measured at 7, 11, 16, and 33 years (cohort members) and once at 4-18 years (offspring). Multilevel models applied to associations of social class of origin with (a) child-to-adult growth trajectory (cohort members), (b) height (offspring), and (c) generational height increment.

RESULTS

Height inequalities were observed among cohort members, with differences >2.0 cm at all ages between classes I and II, and IV and V. By adulthood, the difference in mean height had declined significantly in boys and slightly in girls. A secular trend was seen between the two generations. While male offspring had a similar mean height to their fathers in classes I and II, boys in classes IV and V gained 2.1 cm (p<0.001). Height gains of female offspring were evident in all classes, with a greater gain in classes IV and V (non-significant). The social class effect on height was weaker among offspring, with a difference between classes I and II, and IV and V of less than 1 cm.

CONCLUSIONS

Social inequalities in height observed among the cohort weakened substantially in the next generation due to a greater height gain among offspring from manual classes. Inequalities in childhood height have narrowed between the two generations in this study.

Childhood disadvantage and health inequalities: a framework for policy based on lifecourse research

Tackling health inequalities is moving up the policy agenda of richer societies like the UK, with governments looking for evidence to guide policy review and development. Observational studies of how childhood disadvantage compromises health in adulthood are an important part of the evidence base, but are largely inaccessible to the policy community. We develop a framework which captures the findings of these studies. Our framework highlights how disadvantage in childhood adversely affects both socio-economic circumstances and health in adulthood through a set of interlocking processes. Key among these are children's developmental health (their physical, cognitive and emotional development) and health behaviours, together with the associated educational and social trajectories. In breaking down the link between childhood disadvantage and adult health into its constituent elements, the framework provides a basis for understanding where and how policies can make a difference. The paper argues that the process of policy review and development needs to include both new programmes and the mainstream policies in which they are embedded.

Changes in diet and physical activity in the 1990s in a large British sample (1958 birth cohort)

OBJECTIVES

To investigate whether adults studied in 1991 and 1999 (at ages 33 and 42 y) improved their diet and their physical activity level, in the direction of recommendations issued during the same period.

DESIGN

Longitudinal 1958 British birth cohort study.

SETTING

England, Scotland and Wales.

PARTICIPANTS

All births, 3rd-9th March, 1958. A minimum of 11 341 participants provided data at 33 y, 11 361 at 42 y.

MAIN OUTCOME MEASURES

Frequency of leisure time activity and consumption of (i) fried food, (ii) chips, (iii) wholemeal bread and (iv) fruit and salad/raw vegetables, at 33 and 42 y.

RESULTS

Most people changed their physical activity and dietary habits over the 8-y period. About a third of men and women increased, and a third decreased their activity frequency. Findings for fried food consumption were similar. A significantly greater proportion of cohort members decreased their chips consumption (32%), rather than increased it (17%) and increased their fruit and salad consumption (30%), rather than decreased it (25%). In all, 26% of men and 33% of women consistently ate, or switched to eating mostly wholemeal bread, while 56% of men and 48% of women consistently ate less or switched to eating less. Social gradients were seen for activity and diet in 1991, but associations between social factors or body mass index and change in activity or diet were inconsistent.

CONCLUSIONS

Lifestyle habits such as dietary intake and physical activity are slow to change. Current health promotion strategies may need to be supplemented with additional methods to affect the desired change in these habits.

Combination of low birth weight and high adult body mass index: at what age is it established and what are its determinants?

OBJECTIVE

To investigate growth trajectories and predictive factors for those with low birth weight and high adult BMI.

DESIGN

Birth cohort study.

SETTING

England, Scotland, and Wales.

PARTICIPANTS

All born 3-9 March, 1958.

MAIN OUTCOME MEASURES

People at "high risk" of adult disease were defined as having a combination of lower birth weight (in the lowest third of the distribution) and high BMI (in the highest third of the distribution at age 33).

RESULTS

284 of 3462 men and 338 of 3555 women were identified as "high risk". This group was shorter than other cohort members at age 7, on average by 1.2 cm (boys) and 1.8 cm (girls), with a deficit of about 3 cm in adult height. The "high risk" group had a similar mean weight to other subjects at age 7, but were heavier thereafter through to age 23. BMI was increased at all ages in the "high risk" group. Independent predictors include paternal BMI, maternal height and smoking in pregnancy, and social class. For each SD increase in father's BMI the odds of low birth weight/high BMI increased by about 20%. For maternal height, a 1 cm increase reduced the odds of low birth weight/high BMI by about 5%. Increased ORs for "high risk" were found for those with manual social origins (1.61 for men; 1.49 for women) and for maternal smoking in pregnancy (1.79 and 2.27 respectively).

CONCLUSIONS

Maternal short stature, low social class, and smoking during pregnancy influence the development of "high risk" for adult chronic disease. The causes of high risk therefore seem to reside in utero and even earlier, in the mother's lifetime, with adverse conditions having a detrimental affect and favourable conditions protecting against high risk.

Cigarette consumption and socio-economic circumstances in adolescence as predictors of adult smoking

AIM

To investigate effects of cigarette consumption level and socio-economic circumstances during adolescence on adult smoking.

METHODS

1958 British birth cohort (all births 3-9 March 1958). Logistic regression used to predict (i) smoking at 41 years and (ii) persistent smoking (at 23, 33 and 41 years) from cigarette consumption and socio-economic circumstances at 16 years, indicated by social class and educational qualifications.

RESULTS

Of 6537 subjects with full smoking history, 30% smoked at 16 years, 23% smoked at 41 years and 19% smoked at 23, 33 and 41 years (persistent smokers). Heavier smokers at 16, 23 and 33 years were more likely to smoke at 41 years than lighter smokers. The odds ratio (OR) of smoking at 41 years was 2.5 for men and 3.0 for women who smoked >/=60 cigarettes/week at age 16, relative to <20 cigarettes/week. Subjects from manual social backgrounds and those with no qualifications had elevated risks of being a smoker at 41 years or a persistent smoker. These effects were robust to adjustment for adolescent consumption level (e.g. adjusted OR for no qualifications was 3.8). However, adolescent consumption level modified the effect of educational achievements. Among lighter adolescent smokers, those gaining higher qualifications had lower prevalence of smoking at 41 years (16%) than men with no qualifications (83%); among heavier adolescent smokers, prevalence was more similar for subjects with higher (56%) and no qualifications (69%).

CONCLUSIONS

Socio-economic background appears to influence adult smoking behaviour separately from adolescent cigarette consumption which is a recognized measure of nicotine dependence. There was some evidence that effects of early nicotine dependence are modified by educational achievements.

Infant feeding and obesity through the lifecourse

In the 1958 British birth cohort (n = 12,857 at age 7), breast feeding and BMI were unrelated in childhood. Breast feeding was protective against increased BMI at ages 16 and 33 years in females, and at 33 years in males, but this effect was markedly reduced and no longer significant after adjustment for confounding factors.

Child to adult socioeconomic conditions and obesity in a national cohort

OBJECTIVE

Critical stages in childhood are suspected for adult obesity. We sought to identify (i) whether risk of adult obesity is influenced by childhood socioeconomic conditions in addition to those in adulthood; and (ii) whether conditions in childhood act independently or through their association with education or parental obesity.

DESIGN

Longitudinal, 1958 British birth cohort.

SUBJECTS

A total of 11 405 men and women followed to age 33 y.

MEASUREMENTS

Social class at birth and ages 7, 11, 16, 23 and 33 y. Obesity (BMI> or =30) at age 33 y.

RESULTS

Social class was related to obesity, cross-sectionally at ages 16 (women), 23 and 33 y, but not at younger ages. In analysis of adult obesity (age 33 y) and social class at five life stages, class at age 7 y significantly predicted obesity for women (adjusted odds ratio (OR)=1.31, that is, the odds increased by 31% for each decrease in social class). For men, class at birth and age 23 y predicted adult obesity (adjusted OR=1.19 and 1.16, respectively). Education was also associated with adult obesity, increasing the odds by 30% (men) and 35% (women) for each decrease in qualification level. Adjustment for education level and parental BMI did not abolish the effect on adult obesity of class at age 7 y among women, nor of class at birth among men, while class at age 23 y reduced to borderline significance.

CONCLUSIONS

Cross-sectional associations for social class and obesity can be misleading and obscure effects of childhood socioeconomic conditions. Influences around birth to age 7 y have a long-lasting impact on the risk of adult obesity.

Social inequalities in low birth weight in England and Wales: trends and implications for future population health

STUDY OBJECTIVE

To examine social inequalities and trends in low birth weight in England and Wales.

DESIGN

Analysis of routine birth data, comparing (a) couple and sole registered births, and (b) manual and non-manual occupational groups.

SETTING

England and Wales, 1993-2000.

MAIN RESULTS

Social inequalities in low birth weight were evident throughout 1993-2000: relative to the non-manual group, there is an increased risk for the manual group (range in RR 1.22-1.35) and sole registrations (RR 1.51-1.67). An estimated 6.5% (2979 births) of low birth weight in 2000 could have been avoided if risks associated with the manual group were absent, and 2.8% (1290 births) avoided if risks associated with sole registration were absent. Between 1993 and 2000, the low birthweight rate increased significantly with an estimated overall increase of 11%. Increases were evident in all social groups (15% in manual, 11% in sole registrations and 9% in non-manual); however relative to non-manual the increase in RRs were not statistically significant for manual or sole registrations. When multiple births are excluded, the rate of low birth weight is reduced but there is still a significant increase over time and social differentials are undiminished.

CONCLUSIONS

There are social inequalities in low birth weight in England and Wales that have not narrowed over an eight year period, 1993-2000. These inequalities are likely to affect childhood and adult health inequalities in the future, hence strategies will need to address differences in low birth weight and further monitoring of trends is therefore desirable.

Predicting outcome after appendicectomy

AIM

To validate an intraoperative appendicitis severity score (IASS) and examine outcome following emergency appendectomy.

METHODS

A prospective study was undertaken, enrolling consecutive patients undergoing emergency appendicectomy. Data were obtained independently on preoperative Alvarado scores, IASS (0-3: 0 no inflammation, 1 engorged appendix/no peritonitis, 2 peritoneal reaction/exudate or 3 evidence of perforation/abscess) and postoperative outcome parameters.

RESULTS

There were 149 patients identified with a mean age of 20.7 years. There was no association between Alvarado score and length of hospital stay, septic complication, patient sex or duration of symptoms (p>0.05). IASS was found to be an independent risk factor for septic complication, wound infection (p<0.05) and length of hospital stay (p<0.001). There was no correlation between preoperative duration of symptoms or time until surgery and intraoperative score.

CONCLUSIONS

This simple scoring system can identify patients more likely to suffer morbidity following emergency appendicectomy. Specifically, this system identifies patients who have a high risk of sepsis and therefore could be of use when comparing healthcare performance.