Defining a minimum income for healthy living (MIHL): older age, England

Costs of healthy living for older adults: the need for dynamic measures of health-related poverty to support evidence-informed policy-making and real-time decision-making

OBJECTIVES

This study aimed to examine the dynamic properties of the costs of healthy living for older adults and to compare these costs to the timing and levels of Pension Credit for older adults on low incomes.

STUDY DESIGN

This was a longitudinal descriptive study.

METHODS

We used monthly inflation data and the concept of a 'Minimum Income for Healthy Living' (MIHL) to estimate the dynamic changes in MIHL from 2003 to 2022 and compared these costs with Pension Credit levels for older adults on low incomes.

RESULTS

Progress in closing the gap between the MIHL and Pension Credit has been reversed by recent sharp increases in costs. From April 2021 to April 2022, the MIHL for single older adults rose from £5.57 per week below to £8.29 per week above Pension Credit levels.

CONCLUSIONS

There is a need for dynamic measures of health-related poverty to support evidence-informed policy-making and real-time decision-making to mitigate the health impacts on older adults.

Sixteen Years since the Convention on the Rights of Persons with Disabilities: What Have We Learned since Then?

Persons with disabilities have historically been subjected to discrimination and exclusion, placing them in dangerous situations of social vulnerability. The Convention on the Rights of Persons with Disabilities, passed on the 13th of December 2006, was an important legislative landmark for valuing the rights of this population group. This study involved a bibliometric analysis of 1024 research articles published in Scopus on the social, workplace, educational, and financial inclusion of persons with disabilities since the Convention. The results show an increase in scientific production, and there is also a great deal of multi-disciplinarity, which has led to important breakthroughs for the all-encompassing inclusion of this section of the population. The most productive journals, authors, institutions, and countries, as well as the international cooperation networks, are presented here. The review concludes by setting out the main themes and trends in the research.

Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low- and middle-income countries

BACKGROUND

Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age, or HIV infection) are a social protection intervention addressing a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided only if recipients follow prescribed behaviours, e.g. use a health service or attend school) is unknown.

OBJECTIVES

To assess the effects of UCTs on health services use and health outcomes in children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure, and to compare the effects of UCTs versus CCTs.

SEARCH METHODS

For this update, we searched 15 electronic academic databases, including CENTRAL, MEDLINE and EconLit, in September 2021. We also searched four electronic grey literature databases, websites of key organisations and reference lists of previous systematic reviews, key journals and included study records.

SELECTION CRITERIA

We included both parallel-group and cluster-randomised controlled trials (C-RCTs), quasi-RCTs, cohort studies, controlled before-and-after studies (CBAs), and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (≥ 18 years) in LMICs. Comparison groups received either no UCT, a smaller UCT or a CCT. Our primary outcomes were any health services use or health outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened potentially relevant records for inclusion, extracted data and assessed the risk of bias. We obtained missing data from study authors if feasible. For C-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method using a random-effects model. Where meta-analysis was impossible, we synthesised results using vote counting based on effect direction. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 34 studies (25 studies of 20 C-RCTs, six CBAs, and three cohort studies) involving 1,140,385 participants (45,538 children, 1,094,847 adults) and 50,095 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative syntheses. These analysed 29 independent data sets. The 24 UCTs identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 81.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT; three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection or performance bias, or both). Most studies were funded by national governments or international organisations, or both. Throughout the review, we use the words 'probably' to indicate moderate-certainty evidence, 'may/maybe' for low-certainty evidence, and 'uncertain' for very low-certainty evidence. Health services use We assumed greater use of any health services to be beneficial. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09; I² = 2%; 5 C-RCTs, 4972 participants; low-certainty evidence). Health outcomes At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (RR 0.79, 95% CI 0.67 to 0.92; I² = 53%; 6 C-RCTs, 9367 participants; moderate-certainty evidence). UCTs may have increased the likelihood of having been food secure over the previous month, at 13 to 36 months into the intervention (RR 1.25, 95% CI 1.09 to 1.45; I² = 85%; 5 C-RCTs, 2687 participants; low-certainty evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01; I² = 79%; 4 C-RCTs, 9347 participants; low-certainty evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. We found no study on the effect of UCTs on mortality risk. Social determinants of health UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.04 to 1.09; I² = 0%; 8 C-RCTs, 7136 participants; moderate-certainty evidence). UCTs may have reduced the likelihood of households being extremely poor, at 12 to 36 months into the intervention (RR 0.92, 95% CI 0.87 to 0.97; I² = 63%; 6 C-RCTs, 3805 participants; low-certainty evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, participation in labour, and parenting quality. Healthcare expenditure Evidence from eight cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 36 months into the intervention (low-certainty evidence). Equity, harms and comparison with CCTs The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services or had any illness, or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three.

AUTHORS' CONCLUSIONS

This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), two social determinants of health (i.e. the likelihoods of attending school and being extremely poor), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.

Minimum income for healthy living and frailty in adults over 65 years old in the English Longitudinal Study of Ageing: a population-based cohort study

OBJECTIVE

To test whether minimum income for healthy living of a person aged 65 years or older (MIHL₆₅) is associated with frailty in older adults.

DESIGN AND SETTING

Secondary analysis of the English Longitudinal Study of Ageing, a multiwave prospective cohort study in England, UK.

PARTICIPANTS

A subset (n=1342) of English Longitudinal Study of Ageing participants, who at wave 1 in 2002 were aged 65 years or older, without any limiting long-standing illnesses, and who had the information required to calculate MIHL₆₅ in 2002, 2004 and 2006 and two measures of frailty in 2008.

MAIN OUTCOME MEASURES

Frailty defined using Fried's phenotype criteria and Rockwood's Index of deficits.

RESULTS

The odds of frailty in 2008 were significantly higher for participants living below MIHL₆₅ in 2002, both on Fried's phenotype criteria (OR 2.56, 95% CI 1.57 to 4.19) and Rockwood's Index (OR 2.83, 95% CI 1.74 to 4.60). These associations remained after adjustment for age and gender for both Fried's phenotype (OR 1.85, 95% CI 1.18 to 2.90) and Rockwood's Index (OR 2.15, 95% CI 1.38 to 3.35). Compared with those whose income during 2002-2006 was always above MIHL₆₅, the odds of frailty in 2008 for those below MIHL₆₅ were two-to-three times higher, with a tendency for the ORs to increase in line with the length of time spent below MIHL₆₅ (ORs (95% CIs) were: Fried's phenotype, below MIHL₆₅ once: 2.02 (1.23 to 3.34); twice: 2.52 (1.37 to 4.62); thrice: 3.53 (1.65 to 7.55). Rockwood's Index: once: 2.34 (1.41 to 3.86); twice: 3.06 (1.64 to 5.71); thrice: 2.56 (1.22 to 5.34)). These associations remained after adjustment for age and gender on Rockwood's Index, but not Fried's phenotype.

CONCLUSIONS

These results provide some support for the idea that frailty at older ages is associated with not having sufficient income to lead a healthy life.

Threshold-effect of income on periodontitis and interactions with race/ethnicity and education

OBJECTIVES

The aims of this study were to explore the shape of the relationship of income and education with periodontal health, and to assess the interactions between them and race/ethnicity.

METHOD

Individual level data from the Brazilian National Oral Health Survey in 2010 (Pesquisa Nacional de Saúde Bucal-SB Brasil 2010) were obtained for 9,779 subjects. Relations between per capita income and education with periodontal health were smoothed using Locally Weighted Scatter-plot Smoother (Lowess) technique. Multivariable logistic regression was used to assess independent effects of income, education, race/ethnicity adjusted for age, sex and time since last dental appointment.

RESULTS

Prevalence of adults with moderate to severe and severe periodontitis was 17.6 and 6.5%, respectively. The relationship between periodontal health and income was curvilinear, showing a threshold of no relationship for income levels higher than US$ 600/month. In multivariable analysis, after controlling for covariates, only income was significantly associated with periodontal health. There was no significant interaction of income with race or education, neither between race and education.

CONCLUSION

The relation between periodontal health and income was curvilinear and indicated the presence of a threshold, supporting income transfer programs. Beyond the threshold, only education presented a negative linear relationship with moderate to severe periodontitis.

Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low- and middle-income countries

BACKGROUND

Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age or HIV infection) are a type of social protection intervention that addresses a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided so long as the recipient engages in prescribed behaviours such as using a health service or attending school) is unknown.

OBJECTIVES

To assess the effects of UCTs for improving health services use and health outcomes in vulnerable children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure and to compare to effects of UCTs versus CCTs.

SEARCH METHODS

We searched 17 electronic academic databases, including the Cochrane Public Health Group Specialised Register, the Cochrane Database of Systematic Reviews (the Cochrane Library 2017, Issue 5), MEDLINE and Embase, in May 2017. We also searched six electronic grey literature databases and websites of key organisations, handsearched key journals and included records, and sought expert advice.

SELECTION CRITERIA

We included both parallel group and cluster-randomised controlled trials (RCTs), quasi-RCTs, cohort and controlled before-and-after (CBAs) studies, and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (18 years or older) in LMICs. Comparison groups received either no UCT or a smaller UCT. Our primary outcomes were any health services use or health outcome.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened potentially relevant records for inclusion criteria, extracted data and assessed the risk of bias. We tried to obtain missing data from study authors if feasible. For cluster-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method with random effects. We assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

We included 21 studies (16 cluster-RCTs, 4 CBAs and 1 cohort study) involving 1,092,877 participants (36,068 children and 1,056,809 adults) and 31,865 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative synthesis. The 17 types of UCTs we identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 53.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT, and three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection and/or performance bias). Most studies were funded by national governments and/or international organisations.Throughout the review, we use the words 'probably' to indicate moderate-quality evidence, 'may/maybe' for low-quality evidence, and 'uncertain' for very low-quality evidence. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09, P = 0.07, 5 cluster-RCTs, N = 4972, I² = 2%, low-quality evidence). At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (odds ratio (OR) 0.73, 95% CI 0.57 to 0.93, 5 cluster-RCTs, N = 8446, I² = 57%, moderate-quality evidence). Evidence from five cluster-RCTs on food security was too inconsistent to be combined in a meta-analysis, but it suggested that at 13 to 24 months' follow-up, UCTs could increase the likelihood of having been food secure over the previous month (low-quality evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01, 4 cluster-RCTs, N = 9347, I² = 79%, low-quality evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. No evidence was available on the effect of a UCT on the likelihood of having died. UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.03 to 1.09, 6 cluster-RCTs, N = 4800, I² = 0%, moderate-quality evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, extreme poverty, participation in child labour, adult employment or parenting quality. Evidence from six cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 24 months into the intervention (low-quality evidence). The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services, the likelihood of having had any illness or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three.

AUTHORS' CONCLUSIONS

This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), one social determinant of health (i.e. the likelihood of attending school), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.

Income, Wealth and Health Inequalities - A Scottish Social Justice Perspective

This paper considers health inequalities through a social justice perspective. The authors draw on a variety of existing sources of evidence, including experiential, scientific and contextual knowledge. The authors work with NHS Health Scotland, a national Health Board working to reduce health inequalities and improve health. Working closely with the Scottish Government and with a variety of stakeholders across different sectors, NHS Health Scotland's vision for a fairer, healthier Scotland is founded on the principles of social justice. The paper takes social justice as the starting point and explores what it means for two interlinked paradigms of social injustice-health inequality and income inequality. Utilising the wealth of evidence synthesised by NHS Health Scotland as well as drawing on the writings and evidence of philosophers, epidemiologists, the Scottish Government and international bodies, the authors explore the links between income and wealth inequality, social justice, the right to health and health inequalities. The paper ends by considering the extent to which there is appetite for social change in Scotland by considering the attitudes of the people of Scotland and of Britain to poverty, inequality and welfare.

[Occupational characteristics and lifestyle of teachers in a city of northeast Brazil]

Objective To analyze the characteristics of work, lifestyle profile and its association with professional development cycles teachers of the state system of Jequié (BA). Materials and Methods Cross-sectional study with a random sample of 304 teachers who answered a questionnaire on sociodemographic information, occupational and lifestyle. The phases of professional development cycles adopted were: entry, consolidation, diversification and stabilization. For analysis, we used descriptive statistics and measures of association using the chi-square test (0.05) and multinomial logistic regression. Results It was observed that most teachers maintained a regular behavior for the general life style, with the increase statistically significant levels only to feed positive behavior. Conclusions We conclude that there is need to carry out programs to encourage the adoption of an active lifestyle among the teachers, especially after the entry phase in his career where negative behavior became more pronounced.

Social Structural Influences on Healthy Aging: Community-Level Socioeconomic Conditions and Survival Probability of Becoming a Centenarian for Those Aged 65 to 69 in South Korea

This study estimated the associations between community-level socioeconomic conditions and survival probability of becoming a centenarian (SPBC) for those aged 65 to 69 in South Korea to determine the social structural influences on healthy aging. The indicators of socioeconomic and data of centenarians were obtained from Statistics Korea database 2014: population census and social survey. Significant positive correlations were found between SPBC and community-level socioeconomic conditions (minimum cost of living and economically active population, water supply and sewerage, pave a road with asphalt, and urbanization). SPBC male and female predictors had higher economic level and base facilities (R2)=0.578, p<.001). The study provides evidence that community-level socioeconomic conditions are important correlates of SPBC for those aged 65 to 69 in South Korea. These strategies should include social structural influences on successful aging in the overall socioeconomic conditions.

Contribution of food prices and diet cost to socioeconomic disparities in diet quality and health: a systematic review and analysis

CONTEXT

It is well established in the literature that healthier diets cost more than unhealthy diets.

OBJECTIVE

The aim of this review was to examine the contribution of food prices and diet cost to socioeconomic inequalities in diet quality.

DATA SOURCES

A systematic literature search of the PubMed, Google Scholar, and Web of Science databases was performed.

STUDY SELECTION

Publications linking food prices, dietary quality, and socioeconomic status were selected.

DATA EXTRACTION

Where possible, review conclusions were illustrated using a French national database of commonly consumed foods and their mean retail prices.

DATA SYNTHESIS

Foods of lower nutritional value and lower-quality diets generally cost less per calorie and tended to be selected by groups of lower socioeconomic status. A number of nutrient-dense foods were available at low cost but were not always palatable or culturally acceptable to the low-income consumer. Acceptable healthier diets were uniformly associated with higher costs. Food budgets in poverty were insufficient to ensure optimum diets.

CONCLUSIONS

Socioeconomic disparities in diet quality may be explained by the higher cost of healthy diets. Identifying food patterns that are nutrient rich, affordable, and appealing should be a priority to fight social inequalities in nutrition and health.

Later life health in Europe: how important are country level influences?

In this article, we examine the extent and pattern of country level differences in later life health in Europe and compare five competing explanations for this variation. We used data from 14 European countries, drawn from Northern (Denmark and Sweden), Western (Austria, France, Ireland, Germany Belgium, the Netherlands and Switzerland), Mediterranean (Spain, Italy and Greece) and Eastern (Poland and Czechia) regions of Europe, N = 33,528. Our results suggest that about a quarter (24%) of the overall variation in later life health in Europe appears to be due to country level differences. The Scandinavian countries along with Germany, the Netherlands and Switzerland appear to have the best health, whereas Spain, Italy and Poland had the lowest health score. Country level influences on health were largely associated with differences in the level of egalitarianism of each country as measured by the Gini coefficient, with more inequality being associated with poorer health. Differences in health-related lifestyle, as approximated by the prevalence of obesity in each country, also had a substantial macrolevel influence on later life health, with a lower national prevalence of obesity being associated with better health. Our results indicate the presence of systematic macrolevel health variation in Europe and suggest that policies to reduce income inequality as well as population interventions to promote healthier lifestyles and decrease the prevalence of obesity have the potential to improve population health and potentially offset some of the challenges posed by population ageing in Europe.

Rights-based approaches to addressing food poverty and food insecurity in Ireland and UK

Food poverty is an important contributing factor to health inequalities in industrialised countries; it refers to the inability to acquire or eat an adequate quality or sufficient quantity of food in socially acceptable ways (or the uncertainty of being able to do so). Synonymous with household food insecurity, the issue needs to be located within a social justice framework. Recognising the clear interdependence between the right to food and the right to health, this paper explores how international human rights obligations could inform approaches to addressing food poverty and insecurity with specific reference to Ireland and the UK. Little attention has been paid to how countries should meet their obligations to respect, protect and fulfil the right to food in developed countries. The paper contributes by examining the social and policy circumstances which inhibit poor households from obtaining sufficient food to eat healthily, along with strategies and interventions from State and civil society actors in the two countries. In practice, problems and potential solutions have largely been directed towards the individual rather than at social determinants, particularly as research on environmental factors such as distance to shops has produced equivocal results. Other key structural aspects such as income sufficiency for food are broadly ignored by the State, and anti-poverty strategies are often implemented without monitoring for effects on food outcomes. Thus scant evidence exists for either Ireland or the UK meeting its rights to food obligations to date, in terms of roles and responsibilities in ensuring access to affordable, available and appropriate food for all.

The effect of housing on the mental health of older people: the impact of lifetime housing history in Whitehall II

BACKGROUND

This study describes differences in trajectories of self-reported mental health in an ageing cohort, according to their housing, while controlling for confounders.

METHODS

The General Health Questionnaire was measured on six occasions as part of Whitehall II cohort study of office-based British civil servants (1985-2009); 10,308 men and women aged 35-55 at baseline.

RESULTS

Home-ownership was the predominant tenure at baseline and increased over the life-course, but the social gradient remained. In the bivariate analysis, by phase nine, renters had higher (poorer mental health) GHQ scores (55.48) than owner occupiers (51.98). Those who reported difficulty paying bills or problems with housing had higher GHQ scores at baseline (financial difficulties 57.70 vs 54.34; house problems 58.06 vs 53.99) and this relative difference increased by phase nine (financial difficulties 59.64 vs 51.67; house problems 56.68 vs 51.22). In multivariate models, the relative differences in GHQ scores by tenure increased with age, but were no longer significant after adjusting for confounders. Whereas GHQ scores for those with housing problems and financial difficulties were still significantly higher as participants grew older.

CONCLUSION

The social gradient in the effect of home ownership on mental health, which is evident at baseline, diminishes as people get older, whereas housing quality and financial problems become relatively more important in explaining older people's health. Inequalities in housing quality and ability to deal with household financial problems will become increasingly important mental health issues as the population ages.

A minimum income for healthy living (MIHL) – older New Zealanders

Governments around the developed world are seeking to meet the challenges of the ageing population through strategies which promote a holistic approach to ageing, captured in catch-phrases such as ‘successful’, ‘active’, ‘positive’ and ‘healthy’ ageing. These strategies are supported by a growing body of research, with a particular emphasis on the prerequisites for health and quality of life. Drawing on that research, and using a methodology developed by the London School of Hygiene and Tropical Medicine, the ‘Minimum Income for Healthy Living (MIHL): Older New Zealanders’ study used a health lens to investigate the retirement income needs of older New Zealanders living independently in the community. The MIHL was estimated for people living alone, couples, renters and debt-free home owners. In each case, the MIHL estimates were appreciably higher than the universal state pension paid to older New Zealanders. People living alone and those renting their homes were shown to be worse off than couples and debt-free home owners, respectively. The results highlight that many older New Zealanders are living on an income which may not be enough to support a healthy life. This has important implications for the demand for health, residential and social services and brings life to the question of what level of income might be needed in retirement.

Influence of area and individual lifecourse deprivation on health behaviours: findings from the British Women's Heart and Health Study

BACKGROUND

Variable findings have been reported on the contribution of census-based measures of area deprivation over and above that of individual socioeconomic position (SEP) on health outcomes. This study aims to examine the association between residence in a deprived area and health behaviours (diet, smoking and physical inactivity), and how this association is influenced by lifecourse SEP of individuals.

DESIGN

A population-based longitudinal study of women aged 60-79 years in 1999-2001 recruited from one general practice in each of 23 British towns.

METHODS

Three thousand five hundred twenty-two women were included in the analyses. Area deprivation scores were derived from postcode for residence and lifecourse SEP scores were calculated using 10 individual level indicators of childhood and adult circumstances. To allow direct comparisons of effect of area deprivation and individual SEP, we standardized both measures by generating relative indices of inequality.

RESULTS

Both area deprivation and lifecourse SEP were independent predictors of eating fruit and vegetables [odds ratio (OR): 2.87, 95% confidence interval (CI): 2.22-3.72; comparing highest with lowest area Index of Multiple Deprivation of inequality (OR: 3.07, 95% CI: 2.33-4.06) for lifecourse SEP index of inequality] and exercise habits (OR: 2.39, 95% CI: 1.86-3.06 area deprivation; OR: 2.7, 95% CI: 2.07-3.51 individual SEP). Area deprivation was a stronger predictor of smoking behaviour (OR: 2.34, 95% CI: 1.91-3.08) than individual lifecourse SEP (OR: 1.51, 95% CI: 1.17-1.95).

CONCLUSION

Most health behaviours among older women were independently associated with both living in deprived areas and individual lifecourse SEP. This suggests that additional health promotion approaches focusing on improving environments would have potential to improve health behaviour.

Income and oral health relationship in Brazil: is there a threshold?

OBJECTIVES

We explored the relationship between income and two oral health outcomes in Brazil, in order to assess the shape of this relationship.

METHODS

Individual-level data from a national oral health survey were obtained for 22 634 15- to 19-year-old subjects from 330 municipalities. Relationships between income (equivalized household income) and oral health were smoothed using the locally weighted ordinary least squares regression (LOWESS) technique in order to assess the relationship between material circumstances and oral health. We also ranked individuals based on equivalized household income, supplemented by information from total household income, interviewees' earnings, number of cars in the household and years of education, in order to assess the relationship between social position and oral health.

RESULTS

The relationship between oral health and equivalized household income showed a threshold and, assuming causality, income levels higher than R$850 per month did not improve oral health further. The relationship between oral health and social position was linear. Correlations of oral health with the ranking variable (social position) were stronger than with equivalized household income, regardless of the income level, and did not decrease after controlling for income.

CONCLUSIONS

The relation of oral health in teenagers with equivalized household income (material circumstances) showed a threshold, but the relation with a ranking variable (social position) was linear. Maybe differences in oral health between individuals are influenced by both their material circumstances (up to a certain level of income) and their social position in relation to others, i.e. social status (at any income level).

Conference on "Multidisciplinary approaches to nutritional problems". Rank Prize Lecture. Global nutrition challenges for optimal health and well-being

Optimal health and well-being are now considered the true measures of human development. Integrated strategies for infant, child and adult nutrition are required that take a life-course perspective to achieve life-long health. The major nutrition challenges faced today include: (a) addressing the pending burden of undernutrition (low birth weight, severe wasting, stunting and Zn, retinol, Fe, iodine and folic acid deficits) affecting those individuals living in conditions of poverty and deprivation; (b) preventing nutrition-related chronic diseases (obesity, diabetes, CVD, some forms of cancer and osteoporosis) that, except in sub-Saharan Africa, are the main causes of death and disability globally. This challenge requires a life-course perspective as effective prevention starts before conception and continues at each stage of life. While death is unavoidable, premature death and disability can be postponed by providing the right amount and quality of food and by maintaining an active life; (c) delaying or avoiding, via appropriate nutrition and physical activity interventions, the functional declines associated with advancing age. To help tackle these challenges, it is proposed that the term 'malnutrition in all its forms', which encompasses the full spectrum of nutritional disorders, should be used to engender a broader understanding of global nutrition problems. This term may prove particularly helpful when interacting with policy makers and the public. Finally, a greater effort by the UN agencies and private and public development partners is called for to strengthen local, regional and international capacity to support the much needed change in policy and programme activities focusing on all forms of malnutrition with a unified agenda.