Cohort profile: the Scottish health surveys cohort: linkage of study participants to routinely collected records for mortality, hospital discharge, cancer and offspring birth characteristics in three nationwide studies

Health and household environment factors linked with early alcohol use in adolescence: a record-linked, data-driven, longitudinal cohort study

Introduction

Early alcohol use has significant association with poor health outcomes. Individual risk factors around early alcohol use have been identified, but a holistic, data-driven investigation into health and household environmental factors on early alcohol use is yet to be undertaken.

Objectives

This study aims to investigate the relationship between preceding health events, household exposures and early alcohol use during adolescence using a two-stage data-driven approach.

Methods

In stage one, a study population (N = 1,072) were derived from the Millennium Cohort Study (MCS) Wales (born between 2000-2002). MCS data were first linked with electronic-health records. Factors associated with early (<=eleven years old) alcohol use were identified using feature selection and stepwise logistic regression. In stage two, analogous risk factors from MCS were recreated for whole population (N = 59,231) of children (born between 1998-2002 in the Welsh Demographic Service Dataset) using routine data to predict the alcohol-related health events in hospital or GP records.

Results

Significant risk factors from stage two included poor maternal mental (adjusted odds ratio [aOR] = 1.31) and physical health (aOR = 1.25), living with someone with alcohol-related problem (aOR = 2.16), single-adult household (aOR = 1.45), ever in deprivation (aOR = 1.66), child's high hyperactivity (aOR = 3.57), and conduct disorder (aOR = 3.26). Children with health events, whose health needs are supported (e.g., are taken to the doctor), are at lower risk of early alcohol use.

Conclusion

Health events of the family members and the child can act as modifiable exposures and may therefore inform the development of prevention initiatives. Families with known alcohol problems, living in deprivation, experiencing child behavioural problems and those who are not taken to the doctor are at higher risk of early drinking behaviour and should be prioritised for early years support and interventions to target problem drinking in young people.

Serum ferritin and incident cardiometabolic diseases in Scottish adults

Background

Iron stores, estimated as ferritin levels, and type 2 diabetes (T2D) have been associated previously, while findings regarding coronary heart disease (CHD) and cerebrovascular disease (CEVD) are still inconclusive. No study has focused on simultaneous evaluation of associations between iron stores and the above cardiometabolic diseases (CMD) in the same population. We aim to evaluate the association between serum ferritin and risk of T2D, CHD and CEVD in Scottish population over a wide range of ferritin levels.

Methods

Longitudinal study in 6,497 participants of the 1995 and 1998 Scottish health surveys, who were followed-up until 2011. Cox regression models were conducted adjusting for age, sex/menopausal status, fibrinogen, GGT levels, smoking, alcohol consumption, total cholesterol, HDL-cholesterol, blood pressure, and BMI. Ferritin was used as continuous (sex/menopausal status-specific Z score) and categorical variable (sex/menopausal status-specific quartiles, quintiles and sextiles).

Results

During follow-up, 4.9% of the participants developed T2D, 5.3% CHD, and 2.3% CEVD. By using ferritin quartiles, serum ferritin was positively associated with T2D, CHD and CEVD but only the association with T2D remained after adjustment for covariates [Quartile 4 v. 1: adjusted HR 95% CI 1.59 (1.10–2.34); P = 0.006]. When ferritin sextiles were used (6 v. 1), the ferritin-CEVD association became slightly stronger and significant [adjusted HR 95% CI 2.08 (1.09–3.94); P = 0.024].

Conclusions

Iron stores relate differently to each CMD. Serum ferritin levels were positively and independently associated with incident T2D, and with incident CEVD if higher cut-off points for high ferritin levels were considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01450-7.

Association of alcohol consumption with morbidity and mortality in patients with cardiovascular disease: original data and meta-analysis of 48,423 men and women

BACKGROUND

Light-to-moderate alcohol consumption has been reported to be cardio-protective among apparently healthy individuals; however, it is unclear whether this association is also present in those with disease. To examine the association between alcohol consumption and prognosis in individuals with pre-existing cardiovascular disease (CVD), we conducted a series of meta-analyses of new findings from three large-scale cohorts and existing published studies.

METHODS

We assessed alcohol consumption in relation to all-cause mortality, cardiovascular mortality, and subsequent cardiovascular events via de novo analyses of 14,386 patients with a previous myocardial infarction, angina, or stroke in the UK Biobank Study (median follow-up 8.7 years, interquartile range [IQR] 8.0-9.5), involving 1640 deaths and 2950 subsequent events, and 2802 patients and 1257 deaths in 15 waves of the Health Survey for England 1994-2008 and three waves of the Scottish Health Survey 1995, 1998, and 2003 (median follow-up 9.5 years, IQR 5.7-13.0). This was augmented with findings from 12 published studies identified through a systematic review, providing data on 31,235 patients, 5095 deaths, and 1414 subsequent events. To determine the best-fitting dose-response association between alcohol and each outcome in the combined sample of 48,423 patients, models were constructed using fractional polynomial regression, adjusting at least for age, sex, and smoking status.

RESULTS

Alcohol consumption was associated with all assessed outcomes in a J-shaped manner relative to current non-drinkers, with a risk reduction that peaked at 7 g/day (relative risk 0.79, 95% confidence interval 0.73-0.85) for all-cause mortality, 8 g/day (0.73, 0.64-0.83) for cardiovascular mortality and 6 g/day (0.50, 0.26-0.96) for cardiovascular events, and remained significant up to 62, 50, and 15 g/day, respectively. No statistically significant elevated risks were found at higher levels of drinking. In the few studies that excluded former drinkers from the non-drinking reference group, reductions in risk among light-to-moderate drinkers were attenuated.

CONCLUSIONS

For secondary prevention of CVD, current drinkers may not need to stop drinking. However, they should be informed that the lowest risk of mortality and having another cardiovascular event is likely to be associated with lower levels of drinking, that is up to approximately 105g (or equivalent to 13 UK units, with one unit equal to half a pint of beer/lager/cider, half a glass of wine, or one measure of spirits) a week.

Is Cohort Representativeness Passé? Poststratified Associations of Lifestyle Risk Factors with Mortality in the UK Biobank

Supplemental Digital Content is available in the text.

The UK Biobank (UKB) has been used widely to examine associations between lifestyle risk factors and mortality outcomes. It is unknown whether the extremely low UKB response rate (5.5%) and lack of representativeness materially affects the magnitude and direction of effect estimates.

A roadmap of six different pathways to improve survival in laryngeal cancer patients

PURPOSE OF REVIEW

Laryngeal cancer continues to require improvement in earlier stage diagnosis and better imaging delineation of disease, and hence 'more evidence-based' selection of treatment, as recent evidence suggests that related mortality, in the last decades, has not significantly decreased worldwide. Even though the reasons are not fully understood, there persists an urgency for a review and development of future strategies to embrace such clinical and diagnostic challenges from a political, societal, as well as scientific and clinical points of view.

RECENT FINDINGS

This review of the published literature suggests that survival improvement in laryngeal cancer may be achieved by fuelling and combining at least some or all of six targeted agendas: documentation of disease global incidence and national burden monitoring; development and implementation of high-quality cancer registries; education on risk factors and hazardous habits associated with laryngeal cancer for the general population; active modification of proven at-risk population lifestyles; centralization of treatment; and use of machine learning of gathered 'big data' and their integration into approaches for the optimization of prevention and treatments strategies.

SUMMARY

Laryngeal cancer should be tackled on several fronts, commencing with disease monitoring and prevention, up to treatment optimisation. Available modern resources offer the possibility to generate significant advances in laryngeal cancer management. However, each nation needs to develop a comprehensive approach, which is an essential prerequisite to obtain meaningful improvement on results.

Biomarker-assessed passive smoking in relation to cause-specific mortality: pooled data from 12 prospective cohort studies comprising 36 584 individuals

AIMS

While investigators have typically quantified the health risk of passive (secondhand) smoking by using self-reported data, these are liable to measurement error. By pooling data across studies, we examined the prospective relation of a biochemical assessment of passive smoking, salivary cotinine, with mortality from a range of causes.

METHODS

We combined data from 12 cohort studies from England and Scotland initiated between 1998 and 2008. A total of 36 584 men and women aged 16-85 years of age reported that they were non-smoking at baseline, provided baseline salivary cotinine and consented to mortality record linkage.

RESULTS

A mean of 8.1 years of mortality follow-up of 36 584 non-smokers (16 792 men and 19 792 women) gave rise to 2367 deaths (775 from cardiovascular disease, 779 from all cancers and 289 from smoking-related cancers). After controlling for a range of covariates, a 10 ng/mL increase in salivary cotinine was related to an elevated risk of total (HRs; 95% CI) (1.46; 1.16 to 1.83), cardiovascular disease (1.41; 0.96 to 2.09), cancer (1.49; 1.00 to 2.22) and smoking-related cancer mortality (2.92; 1.77 to 4.83).

CONCLUSIONS

Assessed biomedically, passive smoking was a risk factor for a range of health outcomes known to be causally linked to active smoking.

Comparison of risk factor associations in UK Biobank against representative, general population based studies with conventional response rates: prospective cohort study and individual participant meta-analysis

OBJECTIVE

To compare established associations between risk factors and mortality in UK Biobank, a study with an exceptionally low rate of response to its baseline survey, against those from representative studies that have conventional response rates.

DESIGN

Prospective cohort study alongside individual participant meta-analysis of other cohort studies.

SETTING

United Kingdom.

PARTICIPANTS

Analytical sample of 499 701 people (response rate 5.5%) in analyses in UK Biobank; pooled data from the Health Surveys for England (HSE) and the Scottish Health Surveys (SHS), including 18 studies and 89 895 people (mean response rate 68%). Both study populations were linked to the same nationwide mortality registries, and the baseline age range was aligned at 40-69 years.

MAIN OUTCOME MEASURE

Death from cardiovascular disease, selected malignancies, and suicide. To quantify the difference between hazard ratios in the two studies, a ratio of the hazard ratios was used with HSE-SHS as the referent.

RESULTS

Risk factor levels and mortality rates were typically more favourable in UK Biobank participants relative to the HSE-SHS consortium. For the associations between risk factors and mortality endpoints, however, close agreement was seen between studies. Based on 14 288 deaths during an average of 7.0 years of follow-up in UK Biobank and 7861 deaths over 10 years of mortality surveillance in HSE-SHS, for cardiovascular disease mortality, for instance, the age and sex adjusted hazard ratio for ever having smoked cigarettes (versus never) was 2.04 (95% confidence interval 1.87 to 2.24) in UK Biobank and 1.99 (1.78 to 2.23) in HSE-SHS, yielding a ratio of hazard ratios close to unity (1.02, 0.88 to 1.19). The overall pattern of agreement between studies was essentially unchanged when results were compared separately by sex and when baseline years and censoring dates were aligned.

CONCLUSION

Despite a very low response rate, risk factor associations in the UK Biobank seem to be generalisable.

Intensity-Weighted Physical Activity Volume and Risk of All-Cause and Cardiovascular Mortality: Does the Use of Absolute or Corrected Intensity Matter?

BACKGROUND

Previous epidemiological studies examining the association between physical activity (PA) and mortality risk have measured absolute PA intensity using standard resting metabolic rate reference values that fail to consider individual differences. This study compared the risk of all-cause and cardiovascular mortality between absolute and corrected estimates of PA volume.

METHODS

49,982 adults aged ≥40 years who participated in the Health Survey for England and Scottish Health Survey in 1994-2008 were included in our study. PA was classified as absolute or corrected metabolic equivalent (MET)-hours per week, taking participant's weight, height, age, and sex into account. Cox regression models were used to examine the association between absolute and corrected PA volumes and all-cause and cardiovascular mortality.

RESULTS

The authors found no difference in the association between levels of PA and risk of all-cause and cardiovascular mortality for absolute and corrected MET-hours per week, although there was a consistent decrease in mortality risk with increasing PA. There was no difference in mortality when analyses were stratified by sex, age, and body mass index.

CONCLUSIONS

The association between PA volume and risk of mortality was similar regardless of whether PA volume was estimated using absolute or corrected METs. There is no empirical justification against the use of absolute METs to estimate PA volume from questionnaires.

Associations of vigorous physical activity with all-cause, cardiovascular and cancer mortality among 64 913 adults

Background

Physical activity recommendations state that for the same energy expenditure, moderate-to-vigorous physical activities (MVPAs) produce similar health benefits. However, few epidemiological studies have tested this hypothesis.

Design

We examined whether, compared with moderate, vigorous activity was associated with larger mortality risk reductions.

Methods

Data from 11 cohorts of the Health Survey for England and the Scottish Health Survey, collected from 1994 to 2011 (mean (SD) follow-up, 9.0 (3.6) years). Adults aged ≥30 years reported MVPA and linkage to mortality records. Exposure was the proportion of self-reported weighted MVPA through vigorous activity. Outcomes were all-cause, cardiovascular disease (CVD) and cancer mortality.

Results

Among 64 913 adult respondents (44% men, 56% women, mean (SD) age, 49.8 (13.6) years), there were 5064 deaths from all-causes, 1393 from CVD and 1602 from cancer during 435 743 person-years of follow-up. Compared with those who reported no vigorous physical activity, and holding constant the volume of weighted MVPA, vigorous activity was associated with additional reductions in mortality risk. For all-cause mortality, the adjusted HR was HR=0.84 (95% CI 0.71, 0.99) and HR=0.84 (95% CI 0.76, 0.94) among those who reported between >0% and<30%, or ≥30% of their activity as vigorous, respectively. For CVD and cancer mortality, point estimates showed similar beneficial associations yet CIs were wider and crossed unity.

Conclusion

Vigorous activities were associated with larger reductions in mortality risk than activities of moderate intensity, but no evidence of dose–response effects was found.

Assessment of Relative Utility of Underlying vs Contributory Causes of Death

Importance

In etiological research, investigators using death certificate data have traditionally extracted underlying cause of mortality alone. With multimorbidity being increasingly common, more than one condition is often compatible with the manner of death. Using contributory cause plus underlying cause would also have some analytical advantages, but their combined utility is largely untested.

Objective

To compare the relative utility of cause of death data extracted from the underlying cause field vs any location on the death certificate (underlying and contributing combined).

Design, Setting, and Participants

This study compares the association of 3 known risk factors (cigarette smoking, low educational attainment, and hypertension) with health outcomes based on where cause of death data appears on the death certificate in 2 prospective cohort study collaborations (UK Biobank [N = 502 655] and the Health Survey for England [15 studies] and the Scottish Health Surveys [3 studies] [HSE-SHS; N = 193 873]). Data were collected in UK Biobank from March 2006 to October 2010 and in HSE-SHS from January 1994 to December 2008. Data analysis began in June 2018 and concluded in June 2019.

Main Outcomes and Measures

Death from cardiovascular disease, cancer, dementia, and injury. For each risk factor-mortality end point combination, a ratio of hazard ratios (RHR) was computed by dividing the effect estimate for the underlying cause by the effect estimate for any mention.

Results

In UK Biobank, there were 14 421 deaths (2.9%) during a mean (SD) of 6.99 (1.03) years of follow up; in HSE-SHS, there were 21 314 deaths (11.0%) during a mean (SD) of 9.61 (4.44) years of mortality surveillance. Established associations of risk factors with death outcomes were essentially the same irrespective of placement of cause on the death certificate. Results from each study were mutually supportive. For having ever smoked cigarettes (vs never having smoked) in the UK Biobank, the RHR for cardiovascular disease was 0.98 (95% CI, 0.87-1.10; P value for difference = .69); for cancer, the RHR was 0.99 (95% CI, 0.93-1.05; P value for difference = .69). In the HSE-SHS, the RHR for cardiovascular disease was 0.94 (95% CI, 0.87-1.01; P value for difference = .09); for cancer, it was 1.01 (95% CI, 0.94-1.10; P value for difference = .75).

Conclusions and Relevance

Risk factor-end point associations were not sensitive to the placement of data on the death certificate. This has implications for the examination of the association of risk factors with causes of death where there may be too few events to compute reliable effect estimates based on the underlying field alone.

Physical activity and chronic back conditions: A population-based pooled study of 60,134 adults

BACKGROUND

Little is known about the association between different types of physical activity (PA) and chronic back conditions (CBCs) at the population level. We investigated the association between levels of total and type-specific PA participation and CBCs.

METHODS

The sample comprised 60,134 adults aged ≥16 years who participated in the Health Survey for England and Scottish Health Survey from 1994 to 2008. Multiple logistic regression models, adjusted for potential confounders, were used to examine the association between total and type-specific PA volume (walking, domestic activity, sport/exercise, cycling, football/rugby, running/jogging, manual work, and housework) and the prevalence of CBCs.

RESULTS

We found an inverse association between total PA volume and prevalence of CBCs. Compared with inactive participants, the fully adjusted odds ratio (OR) for very active participants (≥15 metabolic equivalent h/week) was 0.77 (95% confidence interval (CI): 0.69-0.85). Participants reporting ≥300 min/week of moderate-intensity activity and ≥75 min/week of vigorous-intensity activity had 24% (95%CI: 6%-39%) and 21% (95%CI: 11%-30%) lower odds of CBCs, respectively. Higher odds of CBCs were observed for participation in high-level manual domestic activity (OR = 1.22; 95%CI: 1.00-1.48). Sport/exercise was associated with CBCs in a less consistent manner (e.g., OR = 1.18 (95%CI: 1.06-1.32) for low levels and OR = 0.82 (95%CI: 0.72-0.93) for high levels of sport/exercise).

CONCLUSION

PA volume is inversely associated with the prevalence of CBCs.

Correcting for non-participation bias in health surveys using record-linkage, synthetic observations and pattern mixture modelling

Surveys are key means of obtaining policy-relevant information not available from routine sources. Bias arising from non-participation is typically handled by applying weights derived from limited socio-demographic characteristics. This approach neither captures nor adjusts for differences in health and related behaviours between participants and non-participants within categories. We addressed non-participation bias in alcohol consumption estimates using novel methodology applied to 2003 Scottish Health Survey responses record-linked to prospective administrative data. Differences were identified in socio-demographic characteristics, alcohol-related harm (hospitalisation or mortality) and all-cause mortality between survey participants and, from unlinked administrative sources, the contemporaneous general population of Scotland. These were used to infer the number of non-participants within each subgroup defined by socio-demographics and health outcomes. Synthetic observations for non-participants were then generated, missing only alcohol consumption. Weekly alcohol consumption values among synthetic non-participants were multiply imputed under missing at random and missing not at random assumptions. Relative to estimates adjusted using previously derived weights, the obtained mean weekly alcohol intake estimates were up to 59% higher among men and 16% higher among women, depending on the assumptions imposed. This work demonstrates the universal value of multiple imputation-based methodological advancement incorporating administrative health data over routine weighting procedures.

Testing Differential Associations Between Smoking and Chronic Disease Across Socioeconomic Groups: Pooled Data From 15 Prospective Studies

BACKGROUND

For the same quantity of cigarettes smoked, relative to more affluent people, socioeconomically disadvantaged people have higher levels of smoking biomarkers. This may be ascribed to inhaling cigarette smoke more deeply and more frequently and/or choosing higher tar-containing brands. We investigated whether this increased tobacco load, as captured using cotinine measurements, is associated with a greater risk of mortality in lower social groups.

METHODS

We used Cox proportional hazards models stratified by socioeconomic position to calculate hazard ratios in a pooled sample of 15 English and Scottish prospective cohort studies (N = 81,476).

RESULTS

During a mean (SD) follow-up of 10.3 (4.4) years, 8234 deaths occurred. Risk of total mortality (hazard ratio; 95% confidence interval) for smokers relative to never-smokers in the high (2.5; 2.1, 3.1), intermediate (2.1; 1.8, 2.4), and low (2.0; 1.9, 2.2) educational groups did not differ markedly (P for interaction=0.61). Similar findings emerged when using cause-specific outcomes and occupational social class and housing tenure as socioeconomic indices.

CONCLUSION

Contrary to our hypothesis, we found no indication that chronic disease mortality associated with smoking was higher in disadvantaged people.

Association between physical activity and sub-types of cardiovascular disease death causes in a general population cohort

Physical activity is thought to be cardioprotective, but associations with different subtypes of cardiovascular disease (CVD) are poorly understood. We examined associations between physical activity and seven major CVD death causes. The sample comprised 65,093 adults (aged 58 ± 12 years, 45.4% men) followed up over mean [SD] 9.4 ± 4.5 years, recruited from The Health Survey for England and the Scottish Health Surveys. A CVD diagnosis was reported in 9.2% of the sample at baseline. Physical activity was self-reported. Outcomes were subtypes of CVD death; acute myocardial infarction; chronic ischaemic heart disease; pulmonary heart disease; a composite of cardiac arrest, arrhythmias, and sudden cardiac death; heart failure; cerebrovascular; composite of aortic aneurysm and other peripheral vascular diseases. There were 3050 CVD deaths (30.8% of all deaths). In Cox proportional hazards models adjusted for confounders, physical activity was associated with reduced relative risk of all CVD outcomes; compared with the lowest, the highest physical activity quintile was associated with reduced risk of acute myocardial infarction (Hazard ratio 0.66: 95% CI 0.50, 0.89), chronic ischaemic heart disease (0.49: 0.38, 0.64), pulmonary heart disease (0.48: 0.22, 1.07), arrhythmias (0.18: 0.04, 0.76); heart failure (0.35: 0.20, 0.63), cerebrovascular events (0.53: 0.38, 0.75); aneurysm and peripheral vascular diseases (0.54: 0.34, 0.93). Results were largely consistent across participants with and without existing CVD at baseline. Physical activity was associated with reduced risk of seven major CVD death causes. Protective benefits were apparent even at levels of activity below the current recommendations.

Long-term weight loss following a randomised controlled trial of a weight management programme for men delivered through professional football clubs: the Football Fans in Training follow-up study

Background

Rising levels of obesity require interventions that support people in long-term weight loss. The Football Fans in Training (FFIT) programme uses loyalty to football teams to engage men in weight loss. In 2011/12, a randomised controlled trial (RCT) found that the FFIT programme was effective in helping men lose weight up to 12 months.

Objectives

To investigate the long-term weight, and other physical, behavioural and psychological outcomes up to 3.5 years after the start of the RCT; the predictors, mediators and men’s qualitative experiences of long-term weight loss; cost-effectiveness; and the potential for long-term follow-up via men’s medical records.

Design

A mixed-methods, longitudinal cohort study.

Setting

Thirteen professional Scottish football clubs from the RCT and 16 additional Scottish football clubs that delivered the FFIT programme in 2015/16.

Participants

A total of 665 men who were aged 35–65 years at the RCT baseline measures and who consented to follow-up after the RCT (intervention group, n = 316; comparison group, n = 349), and 511 men who took part in the 2015/16 deliveries of the FFIT programme.

Interventions

None as part of this study.

Main outcome measures

Objectively measured weight change from the RCT baseline to 3.5 years.

Results

In total, 488 out of 665 men (73.4%) attended 3.5-year measurements. Participants in the FFIT follow-up intervention group sustained a mean weight loss from baseline of 2.90 kg [95% confidence interval (CI) 1.78 to 4.02 kg; p < 0.001], and 32.2% (75/233) weighed ≥ 5% less than at baseline. Participants in the FFIT follow-up comparison group (who participated in routine deliveries of the FFIT programme after the RCT) lost a mean of 2.71 kg (95% CI 1.65 to 3.77 kg; p < 0.001), and 31.8% (81/255) achieved ≥ 5% weight loss. Both groups showed long-term improvements in body mass index, waist circumference, percentage body fat, blood pressure, self-reported physical activity (PA) (including walking), the consumption of fatty and sugary foods, fruit and vegetables and alcohol, portion sizes, self-esteem, positive and negative affect, and physical and mental health-related quality of life (HRQoL). Mediators included self-reported PA (including walking) and sitting time, the consumption of fatty and sugary foods and fruit and vegetables, portion sizes, self-esteem, positive affect, physical HRQoL, self-monitoring of weight, autonomous regulation, internal locus of control, perceived competence, and relatedness to other FFIT programme participants and family members. In qualitative interviews, men described continuing to self-monitor weight and PA. Many felt that PA was important for weight control, and walking remained popular; most were still aware of portion sizes and tried to eat fewer snacks. The FFIT programme was associated with an incremental cost-effectiveness of £10,700–15,300 per quality-adjusted life-year (QALY) gained at 3.5 years, and around £2000 per QALY gained in the lifetime analysis. Medical record linkage provided rich information about the clinical health outcomes of the FFIT RCT participants, and 90% of men (459/511) who took part in the 2015/16 FFIT programme gave permission for future linkage.

Conclusions

Participation in the FFIT programme under both research (during the FFIT RCT) and routine (after the FFIT RCT) delivery conditions led to significant long-term weight loss. Further research should investigate (1) how to design programmes to improve long-term weight loss maintenance, (2) longer-term follow-up of FFIT RCT participants and (3) very long-term follow-up via medical record linkage.

Trial registration

Current Controlled Trials ISRCTN32677491.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 6, No. 9. See the NIHR Journals Library website for further project information. The Scottish Executive Health Department Chief Scientist Office (CSO) funded the feasibility pilot that preceded the FFIT RCT (CZG/2/504). The Medical Research Council (MRC) funded Kate Hunt and additional developmental research through the MRC/CSO Social and Public Health Sciences Unit Gender and Health programme (5TK50/25605200-68094).

Self-rated walking pace and all-cause, cardiovascular disease and cancer mortality: individual participant pooled analysis of 50 225 walkers from 11 population British cohorts

BACKGROUND/OBJECTIVES

Walking pace is associated with risk of premature mortality. However, whether this relationship is independent of total volume of physical activity and highest physical activity intensity remains unclear. We examined the associations between walking pace and cause-specific mortality, investigating the potential modifying effect of factors such as total physical activity volume, highest physical activity intensity, age, sex and body mass index (BMI).

METHODS

Prospective pooled analysis of 11 population-based baseline surveys in England and Scotland between 1994 and2008 that were linked with mortality records. Multivariate-adjusted Cox proportional hazards models examined associations between walking pace (slow, average, brisk/fast) and all-cause, cancer and cardiovascular disease (CVD) mortality.

RESULTS

50 225 walkers were entered in the core analyses. Among participants who did not experience an event in the first 2 years of follow-up (n=49 731), walking at an average or brisk/fast pace was associated with a reduced risk of all-cause (20% (95% CI 12% to 28%) and 24% (95% CI 13% to 33%), respectively) and CVD mortality (24% (95% CI 9% to 36%) and 21% (95% CI 1% to 38%), respectively), compared with reporting walking at a slow pace. In stratified analyses, such associations were evident among those over 50 years, those not meeting the physical activity recommendations and those who did not undertake vigorous-intensity activity. There were no interactions by sex or BMI. No associations were seen between pace and cancer mortality.

CONCLUSION

Walking benefits health. Assuming causality, these analyses suggest that increasing walking pace could reduce risk for all-cause and CVD mortality. Walking pace could be emphasised in public health messages, especially in situations when increase in walking volume or frequency is less feasible.

Does Strength-Promoting Exercise Confer Unique Health Benefits? A Pooled Analysis of Data on 11 Population Cohorts With All-Cause, Cancer, and Cardiovascular Mortality Endpoints

Public health guidance includes recommendations to engage in strength-promoting exercise (SPE), but there is little evidence on its links with mortality. Using data from the Health Survey for England and the Scottish Health Survey from 1994-2008, we examined the associations between SPE (gym-based and own-body-weight strength activities) and all-cause, cancer, and cardiovascular disease mortality. Multivariable-adjusted Cox regression was used to examine the associations between SPE (any, low-/high-volume, and adherence to the SPE guideline (≥2 sessions/week)) and mortality. The core sample comprised 80,306 adults aged ≥30 years, corresponding to 5,763 any-cause deaths (736,463 person-years). Following exclusions for prevalent disease/events occurring in the first 24 months, participation in any SPE was favorably associated with all-cause (hazard ratio (HR) = 0.77, 95% confidence interval (CI): 0.69, 0.87) and cancer (HR = 0.69, 95% CI: 0.56, 0.86) mortality. Adhering only to the SPE guideline was associated with all-cause (HR = 0.79, 95% CI: 0.66, 0.94) and cancer (HR = 0.66, 95% CI: 0.48, 0.92) mortality; adhering only to the aerobic activity guideline (equivalent to 150 minutes/week of moderate-intensity activity) was associated with all-cause (HR = 0.84, 95% CI: 0.78, 0.90) and cardiovascular disease (HR = 0.78, 95% CI: 0.68, 0.90) mortality. Adherence to both guidelines was associated with all-cause (HR = 0.71, 95% CI: 0.57, 0.87) and cancer (HR = 0.70, 95% CI: 0.50, 0.98) mortality. Our results support promoting adherence to the strength exercise guidelines over and above the generic physical activity targets.

Secondhand smoke exposure and risk of incident peripheral arterial disease and mortality: a Scotland-wide retrospective cohort study of 4045 non-smokers with cotinine measurement

BACKGROUND

Active smoking is an important risk factor for all-cause mortality and peripheral arterial disease (PAD). In contrast, published studies on the associations with secondhand smoke (SHS) are limited. The aim of this study was to examine the associations between SHS exposure and incident PAD, as well as mortality, among middle-aged non-smokers.

METHODS

We undertook a retrospective, cohort study using record linkage of the Scottish Health Surveys between 1998 and 2010 to hospital admissions and death certificates. Inclusion was restricted to participants aged > 45 years. Cox proportional hazard models were used to examine the association between SHS exposure and incident PAD (hospital admission or death) and all-cause mortality, with adjustment for potential confounders.

RESULTS

Of the 4045 confirmed non-smokers (self-reported non-smokers with salivary cotinine concentrations < 15 ng/mL), 1163 (28.8%) had either moderate or high exposure to SHS at baseline. In men, high exposure to SHS (cotinine ≥2.7 ng/mL) was associated with increased risk of all-cause mortality (fully adjusted hazard ratio [HR] 1.54, 95% CI 1.07-2.22, p = 0.020) with evidence of a dose-relationship (p for trend = 0.004). In men, high exposure to SHS was associated with increased risk of incident PAD over the first five years of follow-up (fully adjusted HR 4.29, 95% CI 1.14-16.10, p = 0.031) but the association became non-significant over longer term follow-up.

CONCLUSIONS

SHS exposure was independently associated with all-cause mortality and may be associated with PAD, but larger studies, or meta-analyses, are required to confirm the latter.

Integrating electronic healthcare records of armed forces personnel: Developing a framework for evaluating health outcomes in England, Scotland and Wales

•

A framework which integration national Electronic Healthcare Record datasets from England, Scotland and Wales is proposed.

•

Variable similarity is used to develop a schema which allows for variables to be linked and combined across the nations.

•

Evaluation of integration shows that it is possibly to perform data linkage across the nations.

Background

Electronic Healthcare Records (EHRs) are created to capture summaries of care and contact made to healthcare services. EHRs offer a means to analyse admissions to hospitals for epidemiological research. In the United Kingdom (UK), England, Scotland and Wales maintain separate data stores, which are administered and managed exclusively by devolved Government. This independence results in harmonisation challenges, not least lack of uniformity, making it difficult to evaluate care, diagnoses and treatment across the UK. To overcome this lack of uniformity, it is important to develop methods to integrate EHRs to provide a multi-nation dataset of health.

Objective

To develop and describe a method which integrates the EHRs of Armed Forces personnel in England, Scotland and Wales based on variable commonality to produce a multi-nation dataset of secondary health care.

Methods

An Armed Forces cohort was used to extract and integrate three EHR datasets, using commonality as the linkage point. This was achieved by evaluating and combining variables which shared the same characteristics. EHRs representing Accident and Emergency (A&E), Admitted Patient Care (APC) and Outpatient care were combined to create a patient-level history spanning three nations. Patient-level EHRs were examined to ascertain admission differences, common diagnoses and record completeness.

Results

A total of 6,336 Armed Forces personnel were matched, of which 5,460 personnel had 7,510 A&E visits, 9,316 APC episodes and 45,005 Outpatient appointments. We observed full completeness for diagnoses in APC, whereas Outpatient admissions were sparsely coded; with 88% of diagnoses coded as “Unknown/unspecified cause of morbidity”. In addition, A&E records were sporadically coded; we found five coding systems for identifying reason for admission.

Conclusion

At present, EHRs are designed to monitor the cost of treatment, enable administrative oversight, and are not currently suited to epidemiological research. However, only small changes may be needed to take advantage of what should be a highly cost-effective means of delivering important research for the benefit of the NHS.

Associations of total and type-specific physical activity with mortality in chronic obstructive pulmonary disease: a population-based cohort study

BACKGROUND

Regular physical activity is recommended for all people with chronic obstructive pulmonary disease (COPD), but the dose of physical activity required to gain mortality benefit in this population is not yet known. This aim of this study was to examine the associations of total and type-specific physical activity with mortality risk in people with COPD.

METHODS

People with COPD aged ≥40 years were identified from the 1997 Health Survey for England and the 1998 and 2003 Scottish Health Survey cohorts. Self-reported total physical activity, moderate-vigorous intensity physical activity (MVPA), walking, domestic physical activity, and sport/exercise were assessed at baseline. Cox proportional hazards models were used to examine the associations between physical activity and mortality risk.

RESULTS

Two thousand three hundred ninety-eight participants with COPD were included in the analysis and followed up for a mean 8.5 (SD 3.9) years. For both total physical activity and MVPA, we observed dose-response associations with all-cause and cardiovascular disease (CVD) mortality risk, and with respiratory mortality risk to a lesser extent. Compared to those who reported no physical activity, participants who met the physical activity guidelines demonstrated the greatest reductions in all-cause (HR 0.56, 95% CI 0.45-0.69), CVD (HR 0.48, 95% CI 0.32-0.71) and respiratory mortality risk (HR 0.40, 95% CI 0.24-0.67). Participants who reported a level of physical activity of at least half the dosage recommended by the guidelines also had a reduced risk of all-cause (HR 0.75, 95% CI 0.56-1.00) and CVD mortality (HR 0.48, 95% CI 0.26-0.88). Dose-response associations with mortality risk were demonstrated for walking and sport/exercise, but not domestic physical activity.

CONCLUSIONS

We found a dose-response association between physical activity and all-cause and CVD mortality risk in people with COPD, with protective effects appearing at levels considerably lower than the general physical activity recommendations. People with COPD may benefit from engagement in low levels of physical activity, particularly walking and structured exercise.

Psychosocial characteristics as potential predictors of suicide in adults: an overview of the evidence with new results from prospective cohort studies

In this narrative overview of the evidence linking psychosocial factors with future suicide risk, we collected results from published reports of prospective studies with verified suicide events (mortality or, less commonly, hospitalisation) alongside analyses of new data. There is abundant evidence indicating that low socioeconomic position, irrespective of the economic status of the country in question, is associated with an increased risk of suicide, including the suggestion that the recent global economic recession has been responsible for an increase in suicide deaths and, by proxy, attempts. Social isolation, low scores on tests of intelligence, serious mental illness (both particularly strongly), chronic psychological distress, and lower physical stature (a marker of childhood exposures) were also consistently related to elevated suicide rates. Although there is some circumstantial evidence for psychosocial stress, personality disposition, and early-life characteristics such as bullying being risk indices for suicide, the general paucity of studies means it is not currently possible to draw clear conclusions about their role. Most suicide intervention strategies have traditionally not explored the modification of psychosocial factors, partly because evidence linking psychosocial factors with suicide risk is, as shown herein, largely in its infancy, or, where is does exist, for instance for intelligence and personality disposition, the characteristics in question do not appear to be easily malleable.

A novel metadata management model to capture consent for record linkage in longitudinal research studies

Background: Informed consent is an important feature of longitudinal research studies as it enables the linking of the baseline participant information with administrative data. The lack of standardized models to capture consent elements can lead to substantial challenges. A structured approach to capturing consent-related metadata can address these. Objectives: a) Explore the state-of-the-art for recording consent; b) Identify key elements of consent required for record linkage; and c) Create and evaluate a novel metadata management model to capture consent-related metadata. Methods: The main methodological components of our work were: a) a systematic literature review and qualitative analysis of consent forms; b) the development and evaluation of a novel metadata model. Discussion: We qualitatively analyzed 61 manuscripts and 30 consent forms. We extracted data elements related to obtaining consent for linkage. We created a novel metadata management model for consent and evaluated it by comparison with the existing standards and by iteratively applying it to case studies. Conclusion: The developed model can facilitate the standardized recording of consent for linkage in longitudinal research studies and enable the linkage of external participant data. Furthermore, it can provide a structured way of recording consent-related metadata and facilitate the harmonization and streamlining of processes.

Comparison of Health Examination Survey Methods in Brazil, Chile, Colombia, Mexico, England, Scotland, and the United States

Comparability of population surveys across countries is key to appraising trends in population health. Achieving this requires deep understanding of the methods used in these surveys to examine the extent to which the measurements are comparable. In this study, we obtained detailed protocols of 8 nationally representative surveys from 2007-2013 from Brazil, Chile, Colombia, Mexico, the United Kingdom (England and Scotland), and the United States-countries that that differ in economic and inequity indicators. Data were collected on sampling frame, sample selection procedures, recruitment, data collection methods, content of interview and examination modules, and measurement protocols. We also assessed their adherence to the World Health Organization's "STEPwise Approach to Surveillance" framework for population health surveys. The surveys, which included half a million participants, were highly comparable on sampling methodology, survey questions, and anthropometric measurements. Heterogeneity was found for physical activity questionnaires and biological samples collection. The common age range included by the surveys was adults aged 18-64 years. The methods used in these surveys were similar enough to enable comparative analyses of the data across the 7 countries. This comparability is crucial in assessing and comparing national and subgroup population health, and to assisting the transfer of research and policy knowledge across countries.

Allostatic load as a predictor of all-cause and cause-specific mortality in the general population: Evidence from the Scottish Health Survey

Allostatic load is a multiple biomarker measure of physiological ‘wear and tear’ that has shown some promise as marker of overall physiological health, but its power as a risk predictor for mortality and morbidity is less well known. This study has used data from the 2003 Scottish Health Survey (SHeS) (nationally representative sample of Scottish population) linked to mortality records to assess how well allostatic load predicts all-cause and cause-specific mortality. From the sample, data from 4,488 men and women were available with mortality status at 5 and 9.5 (rounded to 10) years after sampling in 2003. Cox proportional hazard models estimated the risk of death (all-cause and the five major causes of death in the population) according to allostatic load score. Multiple imputation was used to address missing values in the dataset. Analyses were also adjusted for potential confounders (sex, age and deprivation). There were 258 and 618 deaths over the 5-year and 10-year follow-up period, respectively. In the fully-adjusted model, higher allostatic load (poorer physiological ‘health’) was not associated with an increased risk of all-cause mortality after 5 years (HR = 1.07, 95% CI 0.94 to 1.22; p = 0.269), but it was after 10 years (HR = 1.08, 95% CI 1.01 to 1.16; p = 0.026). Allostatic load was not associated with specific causes of death over the same follow-up period. In conclusions, greater physiological wear and tear across multiple physiological systems, as measured by allostatic load, is associated with an increased risk of death, but may not be as useful as a predictor for specific causes of death.

Oral Health and Risk of Arthritis in the Scottish Population: Results from the Scottish Health Survey

Objectives

To investigate the link between self-reported oral health and arthritis in the Scottish population using data from the Scottish Health Survey.

Material and Methods

Data were available from 2008 to 2013 on self-reported arthritis, oral health conditions and oral hygiene habits from the Scottish Health Survey. Arthritis was defined in this survey by self-reported long standing illness, those who reported having arthritis, rheumatism and/or fibrositis. Oral conditions were defined by self-reported bleeding gums, toothache, biting difficulties and/or edentulousness. Oral hygiene habits were defined by self-reported brushing teeth and/or using dental floss on daily basis. Logistic regression was used for statistical analysis adjusted for age, gender, qualification, smoking and body mass index.

Results

Prevalence of self-reported arthritis was 9.3% (95% confidence interval [CI] = 9.03 to 9.57). Those who reported having bleeding gums (adjusted odds ratio [OR] = 1.63; 95% CI = 1.35 to 1.96), toothache (OR = 1.32; 95% CI = 1.16 to 1.5), biting difficulties (OR = 1.95; 95% CI = 1.62 to 2.34), and being edentulous (OR = 1.22; 95% CI = 1.08 to 1.37) had an increased risk of arthritis. Brushing teeth (OR = 1.25; 95% CI = 0.74 to 2.12), and using dental floss (OR = 1.11; 95% CI = 0.89 to 1.39) were not associated with arthritis.

Conclusions

Self-reported oral conditions were associated with increased risk of self-reported arthritis. Oral hygiene habits were not associated with self-reported arthritis. Further investigation is required to assess the causal association between oral hygiene, oral disease and arthritis.

Unemployment and inflammatory markers in England, Wales and Scotland, 1998-2012: Meta-analysis of results from 12 studies

INTRODUCTION

Unemployment represents for many affected individuals a substantial source of psychosocial stress, and is linked to both increased risk of morbidity and mortality and adverse health-related behaviours. Few studies have examined the association of unemployment with systemic inflammation, a plausible mediator of the associations of psychosocial stress and health, and results are mixed and context dependent. This study examines the association of unemployment with C-reactive protein (CRP) and fibrinogen, two markers of systemic inflammation.

METHODS

A random-effects meta-analysis was performed using a multilevel modelling approach, including 12 national UK surveys of working-age participants in which CRP and fibrinogen were measured between 1998 and 2012 (N=30,037 economically active participants). The moderating impact of participant age and UK country was explored.

RESULTS

CRP and fibrinogen were elevated in unemployed compared to employed participants; jobseekers were also more likely (Odds Ratio: 1.39, p<0.001) to have CRP levels corresponding to high cardiovascular risk (>3mg/L), after adjustment for age, gender, education, long-term illness, smoking, and body mass index. Associations were not explained by mental health. Associations peaked in middle-age, and were stronger in Scotland and Wales than in England.

CONCLUSIONS

Our study demonstrates that systemic inflammation is associated with an important but little-studied aspect of the social environment, as it is elevated in unemployed compared to employed survey participants. Modifications suggest the association of unemployment and inflammation is substantially influenced by contextual factors, and may be especially strong in Wales, where further investigation of this relationship is needed.

Obesity in Scotland: a persistent inequality

BACKGROUND

Obesity is a health problem in its own right and a risk factor for other conditions such as cardiovascular disease. The prevalence of overweight and obesity increased in Scotland between 1995 and 2008 with socio-economic inequalities persisting in adults over time and increasing in children. This paper explores changes in the underlying distribution of body mass index (BMI) which is less well understood.

METHODS

Using data from the Scottish Health Survey (SHeS) between 1995 and 2014 for adults aged 18-64 years, we calculated population distributions for BMI for the population overall, and for age, sex and deprivation strata. We used SHeS data for children aged 2-15 years between 1998 and 2014, in addition to data from the Child Health Systems Programme (CHSP) collected from primary one (P1) children in participating local authorities, to describe the overall trends and to compare trends in inequalities by deprivation strata.

RESULTS

Amongst adults, the BMI distribution shifted upwards, with a large proportion of the population gaining a small amount of weight between 1995 and 2008 before subsequently stabilising across the distribution. In men the prevalence of obesity showed a linear deprivation gradient in 1995 but over time obesity declined in the least deprived quintile while the remaining four quintiles converged (and stabilised). In contrast, a persistent and generally linear gradient is evident among women for most of the 1995-2014 period. For those aged 2-15 years, obesity increased between 1998 and 2014 for the most deprived 40% of children contrasted with stable trends for the least deprived. The surveillance data for P1 children in Scotland showed a persistent inequality between 2005/06 and 2014/15 though it was less clear if this is widening.

CONCLUSIONS

The BMI distribution for adults increased between 1995 and 2008 with a large proportion of the population gaining a small amount of weight before stabilising across the distribution. Inequalities in obesity persist for adults (with different underlying patterns evident for men and women), and may be widening for children. Actions to reduce the obesogenic environment, including structural changes not dependent on individual agency, are urgently needed if the long-term health, social and inequality consequences of obesity are to be reduced.

Ventilatory function as a predictor of mortality in lifelong non-smokers: evidence from large British cohort studies

BACKGROUND

Reduced ventilatory function is an established predictor of all-cause mortality in general population cohorts. We sought to verify this in lifelong non-smokers, among whom confounding by active smoking can be excluded, and investigate associations with circulatory and cancer deaths.

METHODS

In UK Biobank, among 149 343 white never-smokers aged 40-69 years at entry, 2401 deaths occurred over a mean of 6.5-year follow-up. In the Health Surveys for England (HSE) 1995, 1996, 2001 and Scottish Health Surveys (SHS) 1998 and 2003 combined, there were 500 deaths among 6579 white never-smokers aged 40-69 years at entry, followed for a mean of 13.9 years. SD (z) scores for forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC) were derived using Global Lung Initiative 2012 reference equations. These z-scores were related to deaths from all causes, circulatory disease and cancers using proportional hazards models adjusted for age, sex, height, socioeconomic status, region and survey.

RESULTS

In the HSE-SHS data set, decreasing z-scores for FEV1 (zFEV1) and FVC (zFVC) were each associated to a similar degree with increased all-cause mortality (hazard ratios per unit decrement 1.17, 95% CI 1.09 to 1.25 for zFEV1 and 1.19, 95% CI 1.10 to 1.28 for zFVC). This was replicated in Biobank (HRs 1.21, 95% CI 1.17 to 1.26 and 1.24, 1.19 to 1.29, respectively). zFEV1 and zFVC were less strongly associated with mortality from circulatory diseases in HSE-SHS (HR 1.22, 95% CI 1.06 to 1.40 for zFVC) than in Biobank (HR 1.47, 95% CI 1.35 to 1.60 for zFVC). For cancer mortality, HRs were more consistent between cohorts (for zFVC: HRs 1.12, 95% CI 1.01 to 1.24 in HSE-SHS and 1.10, 1.05 to 1.15 in Biobank). The strongest associations were with respiratory mortality (for zFVC: HRs 1.61, 95% CI 1.25 to 2.08 in HSE-SHS and 2.15, 1.77 to 2.61 in Biobank).

CONCLUSIONS

Spirometric indices predicted mortality more strongly than systolic blood pressure or body mass index, emphasising the importance of promoting lung health in the general population, even among lifelong non-smokers.

The Scottish school leavers cohort: linkage of education data to routinely collected records for mortality, hospital discharge and offspring birth characteristics

PURPOSE

The Scottish school leavers cohort provides population-wide prospective follow-up of local authority secondary school leavers in Scotland through linkage of comprehensive education data with hospital and mortality records. It considers educational attainment as a proxy for socioeconomic position in young adulthood and enables the study of associations and causal relationships between educational attainment and health outcomes in young adulthood.

PARTICIPANTS

Education data for 284 621 individuals who left a local authority secondary school during 2006/2007-2010/2011 were linked with birth, death and hospital records, including general/acute and mental health inpatient and day case records. Individuals were followed up from date of school leaving until September 2012. Age range during follow-up was 15 years to 24 years.

FINDINGS TO DATE

Education data included all formal school qualifications attained by date of school leaving; sociodemographic information; indicators of student needs, educational or non-educational support received and special school unit attendance; attendance, absence and exclusions over time and school leaver destination. Area-based measures of school and home deprivation were provided. Health data included dates of admission/discharge from hospital; principal/secondary diagnoses; maternal-related, birth-related and baby-related variables and, where relevant, date and cause of death. This paper presents crude rates for all-cause and cause-specific deaths and general/acute and psychiatric hospital admissions as well as birth outcomes for children of female cohort members.

FUTURE PLANS

This study is the first in Scotland to link education and health data for the population of local authority secondary school leavers and provides access to a large, representative cohort with the ability to study rare health outcomes. There is the potential to study health outcomes over the life course through linkage with future hospital and death records for cohort members. The cohort may also be expanded by adding data from future school leavers. There is scope for linkage to the Prescribing Information System and the Scottish Primary Care Information Resource.

Adjustment for survey non-representativeness using record-linkage: refined estimates of alcohol consumption by deprivation in Scotland

BACKGROUND AND AIMS

Analytical approaches to addressing survey non-participation bias typically use only demographic information to improve estimates. We applied a novel methodology which uses health information from data linkage to adjust for non-representativeness. We illustrate the method by presenting adjusted alcohol consumption estimates for Scotland.

DESIGN

Data on consenting respondents to the Scottish Health Surveys (SHeSs) 1995-2010 were linked confidentially to routinely collected hospital admission and mortality records. Synthetic observations representing non-respondents were created using general population data. Multiple imputation was performed to compute adjusted alcohol estimates given a range of assumptions about the missing data. Adjusted estimates of mean weekly consumption were additionally calibrated to per-capita alcohol sales data.

SETTING

Scotland.

PARTICIPANTS

13 936 male and 18 021 female respondents to the SHeSs 1995-2010, aged 20-64 years.

MEASUREMENTS

Weekly alcohol consumption, non-, binge- and problem-drinking.

FINDINGS

Initial adjustment for non-response resulted in estimates of mean weekly consumption that were elevated by up to 17.8% [26.5 units (18.6-34.4)] compared with corrections based solely on socio-demographic data [22.5 (17.7-27.3)]; other drinking behaviour estimates were little changed. Under more extreme assumptions the overall difference was up to 53%, and calibrating to sales estimates resulted in up to 88% difference. Increases were especially pronounced among males in deprived areas.

CONCLUSIONS

The use of routinely collected health data to reduce bias arising from survey non-response resulted in higher alcohol consumption estimates among working-age males in Scotland, with less impact for females. This new method of bias reduction can be generalized to other surveys to improve estimates of alternative harmful behaviours.

Socioeconomic status as an effect modifier of alcohol consumption and harm: analysis of linked cohort data

Background

Alcohol-related mortality and morbidity are high in socioeconomically disadvantaged populations compared with individuals from advantaged areas. It is unclear if this increased harm reflects differences in alcohol consumption between these socioeconomic groups, reverse causation (ie, downward social selection for high-risk drinkers), or a greater risk of harm in individuals of low socioeconomic status compared with those of higher status after similar consumption. We aimed to investigate whether the harmful effects of alcohol differ by socioeconomic status, accounting for alcohol consumption and other health-related factors.

Methods

The Scottish Health Surveys are record-linked cross-sectional surveys representative of the adult population of Scotland. We obtained baseline demographics and data for alcohol consumption (units per week and binge drinking) from Scottish Health Surveys done in 1995, 1998, 2003, 2008, 2009, 2010, 2011, and 2012. We matched these data to records for deaths, admissions, and prescriptions. The primary outcome was alcohol-attributable admission or death. The relation between alcohol-attributable harm and socioeconomic status was investigated for four measures (education level, social class, household income, and area-based deprivation) using Cox proportional hazards models. The potential for alcohol consumption and other risk factors (including smoking and body-mass index [BMI]) mediating social patterning was explored in separate regression models. Reverse causation was tested by comparing change in area deprivation over time.

Findings

50 236 participants (21 777 men and 28 459 women) were included in the analytical sample, with 429 986 person-years of follow-up. Low socioeconomic status was associated consistently with strikingly raised alcohol-attributable harms, including after adjustment for weekly consumption, binge drinking, BMI, and smoking. Evidence was noted of effect modification; for example, relative to light drinkers living in advantaged areas, the risk of alcohol-attributable admission or death for excessive drinkers was increased (hazard ratio 6·12, 95% CI 4·45–8·41 in advantaged areas; and 10·22, 7·73–13·53 in deprived areas). We found little support for reverse causation.

Interpretation

Disadvantaged social groups have greater alcohol-attributable harms compared with individuals from advantaged areas for given levels of alcohol consumption, even after accounting for different drinking patterns, obesity, and smoking status at the individual level.

Funding

Medical Research Council, NHS Research Scotland, Scottish Government Chief Scientist Office.

Big data and data repurposing - using existing data to answer new questions in vascular dementia research

INTRODUCTION

Traditional approaches to clinical research have, as yet, failed to provide effective treatments for vascular dementia (VaD). Novel approaches to collation and synthesis of data may allow for time and cost efficient hypothesis generating and testing. These approaches may have particular utility in helping us understand and treat a complex condition such as VaD.

METHODS

We present an overview of new uses for existing data to progress VaD research. The overview is the result of consultation with various stakeholders, focused literature review and learning from the group's experience of successful approaches to data repurposing. In particular, we benefitted from the expert discussion and input of delegates at the 9th International Congress on Vascular Dementia (Ljubljana, 16-18th October 2015).

RESULTS

We agreed on key areas that could be of relevance to VaD research: systematic review of existing studies; individual patient level analyses of existing trials and cohorts and linking electronic health record data to other datasets. We illustrated each theme with a case-study of an existing project that has utilised this approach.

CONCLUSIONS

There are many opportunities for the VaD research community to make better use of existing data. The volume of potentially available data is increasing and the opportunities for using these resources to progress the VaD research agenda are exciting. Of course, these approaches come with inherent limitations and biases, as bigger datasets are not necessarily better datasets and maintaining rigour and critical analysis will be key to optimising data use.

Cancer-related health behaviours of young people not in education, employment or training ('NEET'): a cross-sectional study

BACKGROUND

Links between participating in unhealthy behaviours, e.g. smoking, and an increased risk of developing some cancers are well established. Unemployed adults are more likely to participate in cancer-related health behaviours than their employed counterparts. However, evidence of whether this is true in young adults not in education, employment or training (NEET) compared to their 'non-NEET' peers is either limited or inconclusive. Using cross-sectional health data from across the UK, this study aims to investigate whether participation in cancer-related health behaviours varies by NEET status.

METHODS

Data for 16-24 year olds were extracted from the 2010-12 Health Surveys for England (HSE) and Scottish Health Surveys (SHeS). Information on economic activity in the last week was used to determine NEET status. Data on whether respondents had been seeking employment within the last four weeks and availability to start within the next two weeks allowed NEETs to be further identified as unemployed (UE) or economically inactive (EI). Logistic regression modelled the effect of being NEET on odds of being a current smoker; heavy drinker; not participating in sport; having eaten less than five portions of fruit or vegetables the day before survey interview and having an unhealthy body mass index (BMI). Analyses were performed before and after exclusion of EI NEETs.

RESULTS

Data were extracted for 4272 individuals, of which 715 (17%) were defined as NEET with 371 (52%) and 342 (48%) further classified as UE and EI respectively. Two NEETs could not be further defined as UE or EI due to missing information. Relative to non-NEETs, NEETs were significantly more likely to be current smokers, not participate in sport and have an 'unhealthy' BMI. These results held after adjustment for socio-demographic characteristics both before and after exclusion of EI NEETs. Before exclusion of EI NEETs, NEETs were significantly less likely to be heavy drinkers than non-NEETs. There was no significant difference in likelihood of heavy drinking between NEETs and non-NEETs when excluding EI NEETs.

CONCLUSIONS

NEETs were generally at an increased risk of participating in cancer-related health behaviours than non-NEETs. As the likelihood of becoming NEET is greater in socioeconomically-disadvantaged groups, interventions to discourage unhealthy behaviours in NEETs may contribute to a reduction in health inequalities.

Psychological distress in relation to site specific cancer mortality: pooling of unpublished data from 16 prospective cohort studies

OBJECTIVE

 To examine the role of psychological distress (anxiety and depression) as a potential predictor of site specific cancer mortality.

DESIGN

 Pooling of individual participant data from 16 prospective cohort studies initiated 1994-2008.

SETTING

 Nationally representative samples drawn from the health survey for England (13 studies) and the Scottish health survey (three studies).

PARTICIPANTS

 163 363 men and women aged 16 or older at study induction, who were initially free of a cancer diagnosis, provided self reported psychological distress scores (based on the general health questionnaire, GHQ-12) and consented to health record linkage.

MAIN OUTCOME MEASURE

 Vital status records used to ascertain death from 16 site specific malignancies; the three Scottish studies also had information on cancer registration (incidence).

RESULTS

 The studies collectively contributed an average of 9.5 years of mortality surveillance during which there were 16 267 deaths (4353 from cancer). After adjustment for age, sex, education, socioeconomic status, body mass index (BMI), and smoking and alcohol intake, and with reverse causality (by left censoring) and missing data (by imputation) taken into account, relative to people in the least distressed group (GHQ-12 score 0-6), death rates in the most distressed group (score 7-12) were consistently raised for cancer of all sites combined (multivariable adjusted hazard ratio 1.32, 95% confidence interval 1.18 to 1.48) and cancers not related to smoking (1.45, 1.23 to 1.71), as well as carcinoma of the colorectum (1.84, 1.21 to 2.78), prostate (2.42, 1.29 to 4.54), pancreas (2.76, 1.47 to 5.19), oesophagus (2.59, 1.34 to 5.00), and for leukaemia (3.86, 1.42 to 10.5). Stepwise associations across the full range of distress scores were observed for colorectal and prostate cancer.

CONCLUSION

 This study contributes to the growing evidence that psychological distress might have some predictive capacity for selected cancer presentations, in addition to other somatic diseases.

Associations of specific types of sports and exercise with all-cause and cardiovascular-disease mortality: a cohort study of 80 306 British adults

BACKGROUND/AIM

Evidence for the long-term health effects of specific sport disciplines is scarce. Therefore, we examined the associations of six different types of sport/exercise with all-cause and cardiovascular disease (CVD) mortality risk in a large pooled Scottish and English population-based cohort.

METHODS

Cox proportional hazards regression was used to investigate the associations between each exposure and all-cause and CVD mortality with adjustment for potential confounders in 80 306 individuals (54% women; mean±SD age: 52±14 years).

RESULTS

Significant reductions in all-cause mortality were observed for participation in cycling (HR=0.85, 95% CI 0.76 to 0.95), swimming (HR=0.72, 95% CI 0.65 to 0.80), racquet sports (HR=0.53, 95% CI 0.40 to 0.69) and aerobics (HR=0.73, 95% CI 0.63 to 0.85). No significant associations were found for participation in football and running. A significant reduction in CVD mortality was observed for participation in swimming (HR=0.59, 95% CI 0.46 to 0.75), racquet sports (HR=0.44, 95% CI 0.24 to 0.83) and aerobics (HR=0.64, 95% CI 0.45 to 0.92), but there were no significant associations for cycling, running and football. Variable dose-response patterns between the exposure and the outcomes were found across the sport disciplines.

CONCLUSIONS

These findings demonstrate that participation in specific sports may have significant benefits for public health. Future research should aim to further strengthen the sport-specific epidemiological evidence base and understanding of how to promote greater sports participation.

Does physical activity moderate the association between alcohol drinking and all-cause, cancer and cardiovascular diseases mortality? A pooled analysis of eight British population cohorts

OBJECTIVE

To examine whether physical activity (PA) moderates the association between alcohol intake and all-cause mortality, cancer mortality and cardiovascular diseases (CVDs) mortality.

DESIGN

Prospective study using 8 British population-based surveys, each linked to cause-specific mortality: Health Survey for England (1994, 1998, 1999, 2003, 2004 and 2006) and Scottish Health Survey (1998 and 2003).

PARTICIPANTS

36 370 men and women aged 40 years and over were included with a corresponding 5735 deaths and a mean of 353 049 person-years of follow-up.

EXPOSURES

6 sex-specific categories of alcohol intake (UK units/week) were defined: (1) never drunk; (2) ex-drinkers; (3) occasional drinkers; (4) within guidelines (<14 (women); <21 (men)); (5) hazardous (14-35 (women); 21-49 (men)) and (6) harmful (>35 (women) >49 (men)). PA was categorised as inactive (≤7 MET-hour/week), active at the lower (>7.5 MET-hour/week) and upper (>15 MET-hour/week) of recommended levels.

MAIN OUTCOMES AND MEASURES

Cox proportional-hazard models were used to examine associations between alcohol consumption and all-cause, cancer and CVD mortality risk after adjusting for several confounders. Stratified analyses were performed to evaluate mortality risks within each PA stratum.

RESULTS

We found a direct association between alcohol consumption and cancer mortality risk starting from drinking within guidelines (HR (95% CI) hazardous drinking: 1.40 (1.11 to 1.78)). Stratified analyses showed that the association between alcohol intake and mortality risk was attenuated (all-cause) or nearly nullified (cancer) among individuals who met the PA recommendations (HR (95% CI)).

CONCLUSIONS

Meeting the current PA public health recommendations offsets some of the cancer and all-cause mortality risk associated with alcohol drinking.

Measuring Burden of Unhealthy Behaviours Using a Multivariable Predictive Approach: Life Expectancy Lost in Canada Attributable to Smoking, Alcohol, Physical Inactivity, and Diet

BACKGROUND

Behaviours such as smoking, poor diet, physical inactivity, and unhealthy alcohol consumption are leading risk factors for death. We assessed the Canadian burden attributable to these behaviours by developing, validating, and applying a multivariable predictive model for risk of all-cause death.

METHODS

A predictive algorithm for 5 y risk of death-the Mortality Population Risk Tool (MPoRT)-was developed and validated using the 2001 to 2008 Canadian Community Health Surveys. There were approximately 1 million person-years of follow-up and 9,900 deaths in the development and validation datasets. After validation, MPoRT was used to predict future mortality and estimate the burden of smoking, alcohol, physical inactivity, and poor diet in the presence of sociodemographic and other risk factors using the 2010 national survey (approximately 90,000 respondents). Canadian period life tables were generated using predicted risk of death from MPoRT. The burden of behavioural risk factors attributable to life expectancy was estimated using hazard ratios from the MPoRT risk model.

FINDINGS

The MPoRT 5 y mortality risk algorithms were discriminating (C-statistic: males 0.874 [95% CI: 0.867-0.881]; females 0.875 [0.868-0.882]) and well calibrated in all 58 predefined subgroups. Discrimination was maintained or improved in the validation cohorts. For the 2010 Canadian population, unhealthy behaviour attributable life expectancy lost was 6.0 years for both men and women (for men 95% CI: 5.8 to 6.3 for women 5.8 to 6.2). The Canadian life expectancy associated with health behaviour recommendations was 17.9 years (95% CI: 17.7 to 18.1) greater for people with the most favourable risk profile compared to those with the least favourable risk profile (88.2 years versus 70.3 years). Smoking, by itself, was associated with 32% to 39% of the difference in life expectancy across social groups (by education achieved or neighbourhood deprivation).

CONCLUSIONS

Multivariable predictive algorithms such as MPoRT can be used to assess health burdens for sociodemographic groups or for small changes in population exposure to risks, thereby addressing some limitations of more commonly used measurement approaches. Unhealthy behaviours have a substantial collective burden on the life expectancy of the Canadian population.

Dancing Participation and Cardiovascular Disease Mortality: A Pooled Analysis of 11 Population-Based British Cohorts

INTRODUCTION

Little is known about whether cardiovascular benefits vary by activity type. Dance is a multidimensional physical activity of psychosocial nature. The study aimed to examine the association between dancing and cardiovascular disease mortality.

METHODS

A cohort study pooled 11 independent population surveys in the United Kingdom from 1995 to 2007, analyzed in 2014. Participants were 48,390 adults aged ≥40 years who were free of cardiovascular disease at baseline and consented to be linked to the National Death Registry. Respondents reported participation in light- or moderate-intensity dancing and walking in the past 4 weeks. Physical activity amount was calculated based on frequency, duration, and intensity of participation in various types of exercise. The main outcome was cardiovascular disease mortality based on ICD-9 codes 390-459 or ICD-10 codes I01-I99.

RESULTS

During 444,045 person-years, 1,714 deaths caused by cardiovascular disease were documented. Moderate-intensity, but not light-intensity, dancing and walking were both inversely associated with cardiovascular disease mortality. In Cox regression models, the hazard ratios for cardiovascular disease mortality, adjusted for age, sex, SES, smoking, alcohol, BMI, chronic illness, psychosocial distress, and total physical activity amount, were 0.54 (95% CI=0.34, 0.87) for moderate-intensity dancing and 0.67 (95% CI=0.52, 0.87) for moderate-intensity walking.

CONCLUSIONS

Moderate-intensity dancing was associated with a reduced risk for cardiovascular disease mortality to a greater extent than walking. The association between dance and cardiovascular disease mortality may be explained by high-intensity bouts during dancing, lifelong adherence, or psychosocial benefits.

Predicting admissions and time spent in hospital over a decade in a population-based record linkage study: the EPIC-Norfolk cohort

OBJECTIVE

To quantify hospital use in a general population over 10 years follow-up and to examine related factors in a general population-based cohort.

DESIGN

A prospective population-based study of men and women.

SETTING

Norfolk, UK.

PARTICIPANTS

11,228 men and 13,786 women aged 40-79 years in 1993-1997 followed between 1999 and 2009.

MAIN OUTCOMES MEASURES

Number of hospital admissions and total bed days for individuals over a 10-year follow-up period identified using record linkage; five categories for admissions (from zero to highest ≥ 7) and hospital bed days (from zero to highest ≥ 20 nights).

RESULTS

Over a period of 10 years, 18,179 (72.7%) study participants had at least one admission to hospital, 13.8% with 7 or more admissions and 19.9% with 20 or more nights in hospital. In logistic regression models with outcome ≥ 7 admissions, low education level OR 1.14 (1.05 to 1.24), age OR per 10-year increase 1.75 (1.67 to 1.82), male sex OR 1.32 (1.22 to 1.42), manual social class 1.22 (1.13 to 1.32), current cigarette smoker OR 1.53 (1.37 to 1.71) and body mass index >30 kg/m² OR 1.41 (1.28 to 1.56) all independently predicted the outcome with p<0.0001. Results were similar for those with ≥ 20 hospital bed days. A risk score constructed using male sex, manual social class, no educational qualifications; current smoker and body mass index >30 kg/m², estimated percentages of the cohort in the categories of admission numbers and hospital bed days in stratified age bands with twofold to threefold differences in future hospital use between those with high-risk and low-risk scores.

CONCLUSIONS

The future probability of cumulative hospital admissions and bed days appears independently related to a range of simple demographic and behavioural indicators. The strongest of these is increasing age with high body mass index and smoking having similar magnitudes for predicting risk of future hospital usage.

Pre-notification letter type and response rate to a postal survey among women who have recently given birth

BACKGROUND

Surveys are commonly used in health research to assess patient satisfaction with hospital care. Achieving an adequate response rate, in the face of declining trends over time, threatens the quality and reliability of survey results. This paper evaluates a strategy to increase the response rate in a postal satisfaction survey with women who had recently given birth.

METHODS

A sample of 2048 Australian women who had recently given birth at seven maternity units in New South Wales were invited to participate in a postal survey about their recent experiences with maternity care. The study design included a randomised controlled trial that tested two types of pre-notification letter (with or without the option of opting out of the survey). The study also explored the acceptability of a request for consent to link survey data with existing routinely collected health data (omitting the latter data items from the survey reduced survey length and participant burden). This consent was requested of all women.

RESULTS

The survey had an overall response rate of 46% (913 completed surveys returned, total sample 1989). Women receiving the pre-notification letter with the option of opting out of the survey were more likely to actively decline to participate than women receiving the letter without this option, although the overall numbers of women declining were small (27 versus 12). Letter type was not significantly associated with the return of a completed survey. Among women who completed the survey, 97% gave consent to link their survey data with existing health data.

CONCLUSIONS

The two types of pre-notification letters used in our study did not influence the survey response rate. However, seeking consent for record linkage was highly acceptable to women who completed the survey, and represents an important strategy to add to the arsenal for designing and implementing effective surveys. In addition to aspects of survey design, future research should explore how to more effectively influence personal constructs that contribute to the decision to participate in surveys.

Sample selection, recruitment and participation rates in health examination surveys in Europe--experience from seven national surveys

Background

Health examination surveys (HESs), carried out in Europe since the 1950’s, provide valuable information about the general population’s health for health monitoring, policy making, and research. Survey participation rates, important for representativeness, have been falling. International comparisons are hampered by differing exclusion criteria and definitions for non-response.

Method

Information was collected about seven national HESs in Europe conducted in 2007–2012. These surveys can be classified into household and individual-based surveys, depending on the sampling frames used. Participation rates of randomly selected adult samples were calculated for four survey modules using standardised definitions and compared by sex, age-group, geographical areas within countries, and over time, where possible.

Results

All surveys covered residents not just citizens; three countries excluded those in institutions. In two surveys, physical examinations and blood sample collection were conducted at the participants’ home; the others occurred at examination clinics. Recruitment processes varied considerably between surveys. Monetary incentives were used in four surveys. Initial participation rates aged 35–64 were 45 % in the Netherlands (phase II), 54 % in Germany (new and previous participants combined), 55 % in Italy, and 65 % in Finland. In Ireland, England and Scotland, household participation rates were 66 %, 66 % and 63 % respectively. Participation rates were generally higher in women and increased with age. Almost all participants attending an examination centre agreed to all modules but surveys conducted in the participants’ home had falling responses to each stage. Participation rates in most primate cities were substantially lower than the national average. Age-standardized response rates to blood pressure measurement among those aged 35–64 in Finland, Germany and England fell by 0.7-1.5 percentage points p.a. between 1998–2002 and 2010–2012. Longer trends in some countries show a more marked fall.

Conclusions

The coverage of the general population in these seven national HESs was good, based on the sampling frames used and the sample sizes. Pre-notification and reminders were used effectively in those with highest participation rates. Participation rates varied by age, sex, geographical area, and survey design. They have fallen in most countries; the Netherlands data shows that they can be maintained at higher levels but at much higher cost.

Predictors of admission and readmission to hospital for major depression: A community cohort study of 52,990 individuals

BACKGROUND

Our current knowledge about predictors of admission and re-admission to hospital as a result of major depressive disorder (MDD) is limited. Here we present a descriptive analysis of factors which are associated with MDD hospitalisations within a large population cohort.

METHODS

We linked participants of the Scottish Health Survey (SHS) to historical and prospective hospital admission data. We combined information from the SHS baseline interview and historical hospitalisations to define a range of exposure variables. The main outcomes of interest were: (1) first time admission for MDD occurring after the SHS interview; and (2) readmission for MDD. We used Cox regression to determine the association between each predictor and each outcome, after adjusting for age, gender and deprivation quintile.

RESULTS

52,990 adult SHS participants were included. During a median follow-up of 4.5 years per participant, we observed 530 first-time admissions for MDD. A relatively wide range of factors - encompassing social, individual health status, and lifestyle-related exposures - were associated with this outcome (p<0.05). Among the 530 participants exhibiting a de novo admission for MDD during follow-up, 118 were later re-admitted. Only older age (over 70) and a prior non-depression related psychiatric admission were associated with readmission for MDD.

LIMTATIONS

MDD was defined using records of International Classification of Disease hospital discharge codes rather than formal diagnostic assessments.

CONCLUSION

These findings have implications for mental health service organisation and delivery and should stimulate future research on predictive factors for admission and readmission in MDD.

Temporal trends in socioeconomic inequalities in obesity prevalence among economically-active working-age adults in Scotland between 1995 and 2011: a population-based repeated cross-sectional study

OBJECTIVES

Obesity has been an alarming public health issue in the UK. Socioeconomic inequalities in obesity have been well-studied, however limited studies addressed inequality trends over time and none of them in Scotland.

METHODS

We used nationally-representative data from the Scottish Health Survey (SHeS) across four time points between 1995 and 2010/2011. Respondents were economically active adults aged 16-65 years (N=27,059, 12,218 men). Socioeconomic position (SEP) was assessed by highest educational qualification, occupational social class and household income (2003 and 2010/2011 only) as well as a composite SEP score. We carried out sex-stratified logistic regression analyses (adjusted for age, smoking status, alcohol consumption, self-rated general health and physical activity) and we computed the relative index of inequality (RII).

RESULTS

Between 1995 and 2010/2011, obesity prevalence increased in both men (from 17% in 1995 to 30.2% in 2010/2011, 2010/2011 OR of obesity compared with 1995=2.07; 95% CI 1.83 to 2.34) and women (from 18.4% to 30.2%; OR=1.85; 95% CI 1.66 to 2.07). Increase in obesity prevalence was observed across all socioeconomic strata, within which the most rapid increase was among males from the highest socioeconomic groups. RII showed that educational inequalities in obesity narrowed for both men (p=0.007) and women (p=0.008). Income inequalities in obesity between 2003 and 2010/2011 in women were also reduced (p=0.046) on the relative scale.

CONCLUSIONS

Obesity prevalence in Scotland increased substantially between 1995 and 2010/2011, although socioeconomic inequalities have decreased due to the more rapid increase in the higher socioeconomic strata.

Association Between Psychological Distress and Liver Disease Mortality: A Meta-analysis of Individual Study Participants

BACKGROUND & AIMS

Risk factors for cardiovascular disease, such as obesity and hypertension, have been associated with nonalcoholic fatty liver disease. Psychological distress (symptoms of anxiety and depression) is a risk factor for cardiovascular disease, so it might also be associated, directly or indirectly, with liver disease. We investigated the relationship between psychological distress (measured by the 12-item General Health Questionnaire [GHQ]) and liver disease mortality.

METHODS

We performed a meta-analysis of data from individual participants in 16 prospective studies of the general population in the United Kingdom, initiated from 1994 through 2008. Subjects were assigned to groups based on GHQ score: 0 (no distress), 1-3, 4-6, or 7-12.

RESULTS

We analyzed data from 166,631 individuals (55% women; mean ± SD age, 46.6 ± 18.4 years; range, 16-102 years). During a mean follow-up period of 9.5 years, 17,368 participants died (457 with liver disease). We found a significant increase in liver disease mortality with increase in GHQ score (Ptrend < .001). The age- and sex-adjusted hazard ratio for the highest GHQ score category (ie, 7-12), compared with the 0 score category, was 3.48 (95% confidence interval: 2.68-4.52). After adjustment for health behaviors, socioeconomic status, body mass index, and diabetes, this hazard ratio decreased to 2.59 (95% confidence interval: 1.82-3.68).

CONCLUSIONS

Based on a meta-analysis, psychological distress is associated with liver disease mortality, although this finding requires additional analysis. Although one is not likely to cause the other, we provide additional evidence for the deleterious effects of psychological problems on physical health.

Impaired glucose metabolism among those with and without diagnosed diabetes and mortality: a cohort study using Health Survey for England data

BACKGROUND

The extent that controlled diabetes impacts upon mortality, compared with uncontrolled diabetes, and how pre-diabetes alters mortality risk remain issues requiring clarification.

METHODS

We carried out a cohort study of 22,106 Health Survey for England participants with a HbA1C measurement linked with UK mortality records. We estimated hazard ratios (HRs) of all-cause, cancer and cardiovascular disease (CVD) mortality and 95% confidence intervals (CI) using Cox regression.

RESULTS

Average follow-up time was seven years and there were 1,509 deaths within the sample. Compared with the non-diabetic and normoglycaemic group (HbA1C <5.7% [<39 mmol/mol] and did not indicate diabetes), undiagnosed diabetes (HbA1C ≥6.5% [≥48 mmol/mol] and did not indicate diabetes) inferred an increased risk of mortality for all-causes (HR 1.40, 1.09-1.80) and CVD (1.99, 1.35-2.94), as did uncontrolled diabetes (diagnosed diabetes and HbA1C ≥6.5% [≥48 mmol/mol]) and diabetes with moderately raised HbA1C (diagnosed diabetes and HbA1C 5.7-<6.5% [39-<48 mmol/mol]). Those with controlled diabetes (diagnosed diabetes and HbA<5.7% [<39 mmol/mol]) had an increased HR in relation to mortality from CVD only. Pre-diabetes (those who did not indicate diagnosed diabetes and HbA1C 5.7-<6.5% [39-<48 mmol/mol]) was not associated with increased mortality, and raised HbA1C did not appear to have a statistically significant impact upon cancer mortality. Adjustment for BMI and socioeconomic status had a limited impact upon our results. We also found women had a higher all-cause and CVD mortality risk compared with men.

CONCLUSIONS

We found higher rates of all-cause and CVD mortality among those with raised HbA1C, but not for those with pre-diabetes, compared with those without diabetes. This excess differed by sex and diabetes status. The large number of deaths from cancer and CVD globally suggests that controlling blood glucose levels and policies to prevent hyperglycaemia should be considered public health priorities.

Life course trajectories of alcohol consumption in the United Kingdom using longitudinal data from nine cohort studies

BACKGROUND

Alcohol consumption patterns change across life and this is not fully captured in cross-sectional series data. Analysis of longitudinal data, with repeat alcohol measures, is necessary to reveal changes within the same individuals as they age. Such data are scarce and few studies are able to capture multiple decades of the life course. Therefore, we examined alcohol consumption trajectories, reporting both average weekly volume and frequency, using data from cohorts with repeated measures that cover different and overlapping periods of life.

METHODS

Data were from nine UK-based prospective cohorts with at least three repeated alcohol consumption measures on individuals (combined sample size of 59,397 with 174,666 alcohol observations), with data spanning from adolescence to very old age (90 years plus). Information on volume and frequency of drinking were harmonised across the cohorts. Predicted volume of alcohol by age was estimated using random effect multilevel models fitted to each cohort. Quadratic and cubic polynomial terms were used to describe non-linear age trajectories. Changes in drinking frequency by age were calculated from observed data within each cohort and then smoothed using locally weighted scatterplot smoothing. Models were fitted for men and women separately.

RESULTS

We found that, for men, mean consumption rose sharply during adolescence, peaked at around 25 years at 20 units per week, and then declined and plateaued during mid-life, before declining from around 60 years. A similar trajectory was seen for women, but with lower overall consumption (peak of around 7 to 8 units per week). Frequent drinking (daily or most days of the week) became more common during mid to older age, most notably among men, reaching above 50% of men.

CONCLUSIONS

This is the first attempt to synthesise longitudinal data on alcohol consumption from several overlapping cohorts to represent the entire life course and illustrates the importance of recognising that this behaviour is dynamic. The aetiological findings from epidemiological studies using just one exposure measure of alcohol, as is typically done, should be treated with caution. Having a better understanding of how drinking changes with age may help design intervention strategies.