Psychosocial factors and hospitalisations for COVID-19: Prospective cohort study based on a community sample

BACKGROUND

While certain infectious diseases have been linked to socioeconomic disadvantage, mental health problems, and lower cognitive function, relationships with COVID-19 are either uncertain or untested. Our objective was to examine the association of a range of psychosocial factors with hospitalisation for COVID-19.

METHODS

UK Biobank, a prospective cohort study, comprises around half a million people who were aged 40-69 years at study induction between 2006 and 2010 when information on psychosocial factors and covariates were captured. Hospitalisations for COVID-19 were ascertained between 16th March and 26th April 2020.

RESULTS

There were 908 hospitalisations for COVID-19 in an analytical sample of 431,051 England-based study members. In age- and sex-adjusted analyses, an elevated risk of COVID-19 was related to disadvantaged levels of education (odds ratio; 95% confidence interval: 2.05; 1.70, 2.47), income (2.00; 1.63, 2,47), area deprivation (2.20; 1.86, 2.59), occupation (1.39; 1.14, 1.69), psychological distress (1.58; 1.32, 1.89), mental health (1.50; 1.25, 1.79), neuroticism (1.19; 1.00, 1.42), and performance on two tests of cognitive function - verbal and numerical reasoning (2.66; 2.06, 3.34) and reaction speed (1.27; 1.08, 1.51). These associations were graded (p-value for trend ≤ 0.038) such that effects were apparent across the full psychosocial continua. After mutual adjustment for these characteristics plus ethnicity, comorbidity, and lifestyle factors, only the relationship between lower cognitive function as measured using the reasoning test and risk of the infection remained (1.98; 1.38, 2.85).

CONCLUSIONS

A range of psychosocial factors revealed associations with hospitalisation for COVID-19 of which the relation with cognitive function, a marker of health literacy, was most robust.

25 A Pilot Implementation of Providing Enhanced Support to Care Homes within A Primary Care Network

Introduction

People living with severe frailty in care homes are vulnerable to frequent non-elective hospital attendances. However provision of enhanced healthcare support to care home residents can reduce this risk and increase quality of life for residents.1 The framework for enhanced health in care homes (EHCH) summarises best practice in this area and provides guidance for implementing services.2

Methods

This study was a pilot implementation of the EHCH framework based on a Primary Care and Specialist Frailty Multidisciplinary Team (MDT) and delivered on a Primary Care Network (PCN) footprint. The MDT targeted five care homes in a PCN area with historically high levels of non-elective attendances. The model of care was based on the principle of anticipatory care planning, training and support for care home staff to understand and implement plans.

Results

Over the pilot period of 9 months, non-elective attendances from the 5 homes reduced by 27% compared to the previous year, which was a significant reduction (p<0.042). There was variation between the homes in the reduction in non-elective attendances with the greatest impact seen in the homes that had the highest level of attendance at training and engagement in the care planning process. Feedback received from the care home staff indicated that they felt more confident to refer to the care plans and had alternative options to calling 999. A quality audit of the care plans completed as part of the pilot revealed a number of additional training needs for clinicians completing the plans to ensure consistency of recoding. This training was delivered following the pilot period.

Conclusions

The pilot demonstrated that the EHCH framework could be successfully implemented on a PCN footprint. Analysis shows this implementation coincided with a reduction in non-elective attendances from the targeted homes. Further analysis is required to compare the impact in different homes and to understand contributing factors. The pilot implementation provides helpful information to inform PCN development.

References

1. Lloyd T, Wolters A and Steveton A (2014) The impact of providing enhanced support for care home residents in Rushcliffe: Health Foundation consideration of findings from the Improvement Analytics Unit. The Health Foundation.

2. NHS England (2016) The framework for enhanced health in care homes.

Does inflammation provide a link between psychosocial work characteristics and diabetes? Analysis of the role of interleukin-6 and C-reactive protein in the Whitehall II cohort study

OBJECTIVE

Inflammation may underlie the association between psychological stress and cardiometabolic diseases, but this proposition has not been tested longitudinally. We investigated whether the circulating inflammatory markers interleukin-6 (IL-6) and C-reactive protein (CRP) mediate the relationship between psychosocial work characteristics and diabetes.

METHODS

We used three phases of data at 5 years intervals from the Whitehall II cohort study, originally recruiting 10,308 civil service employees aged 35-55 years. The data included repeat self-reports of job demands, control and social support, IL-6 from plasma samples, CRP from serum samples, and diabetes, ascertained through oral glucose tolerance test, medications, and self-reports of doctor-diagnosed diabetes.

RESULTS

Structural equation models with age, sex and occupational position considering men and women combined, showed that low social support at work, but not high job demands or low job control, was prospectively associated with diabetes (standardized ß  =  0.05, 95% confidence interval (CI) 0.01-0.09) and higher levels of IL-6 (ß  =  0.03, CI 0.00-0.06). The inflammatory markers and diabetes were bidirectionally associated over time. A mediation model including workplace social support, IL-6 and diabetes further showed that 10% of the association between social support and diabetes over the three repeat examinations (total effect ß  =  0.08, CI 0.01-0.15) was attributable to a weak indirect effect through IL-6 (ß  =  0.01, CI 0.00-0.02). A similar indirect effect was observed for CRP in men only, while job control was prospectively associated with IL-6 among women.

CONCLUSIONS

This study indicates an association between poor workplace support and diabetes that is partially ascribed to an inflammatory response.

Association of objectively measured physical activity with brain structure: UK Biobank study

BACKGROUND

Physical activity may be beneficial for cognition but mechanisms are unclear. We examined the association between objectively assessed physical activity and brain volume, with a focus on the hippocampus region.

METHODS

We used data from UK Biobank (n = 5272; aged 55.4 ± 7.5 years; 45.6% men) collected through 2013-2016. Participants wore the Axivity AX3 wrist-worn triaxial accelerometer for 7 days to assess habitual physical activity. Structural magnetic resonance imaging was performed using a standard Siemens Skyra 3T running VD13A SP4 to obtain images of the brain.

RESULTS

There was an association between physical activity (per SD increase) and grey matter volume after adjustment for a range of covariates, although this association was only detected in older adults (>60 years old). We also observed associations of physical activity with both left (B = 0.52, 95% CI, 0.01, 1.03; P = 0.046) and right hippocampal volume (B = 0.59, 95% CI, 0.08, 1.10; P = 0.024) in covariate-adjusted models.

CONCLUSION

In summary, physical activity may play a role in the prevention of neurodegenerative diseases.

History, politics and vulnerability: explaining excess mortality in Scotland and Glasgow

OBJECTIVES

High levels of excess mortality (i.e. that not explained by deprivation) have been observed for Scotland compared with England & Wales, and especially for Glasgow in comparison with similar post-industrial cities such as Liverpool and Manchester. Many potential explanations have been suggested. Based on an assessment of these, the aim was to develop an understanding of the most likely underlying causes. Note that this paper distils a larger research report, with the aim of reaching wider audiences beyond Scotland, as the important lessons learnt are relevant to other populations.

STUDY DESIGN

Review and dialectical synthesis of evidence.

METHODS

Forty hypotheses were examined, including those identified from a systematic review. The relevance of each was assessed by means of Bradford Hill's criteria for causality alongside-for hypotheses deemed causally linked to mortality-comparisons of exposures between Glasgow and Liverpool/Manchester, and between Scotland and the rest of Great Britain. Where gaps in the evidence base were identified, new research was undertaken. Causal chains of relevant hypotheses were created, each tested in terms of its ability to explain the many different aspects of excess mortality. The models were further tested with key informants from public health and other disciplines.

RESULTS

In Glasgow's case, the city was made more vulnerable to important socioeconomic (deprivation, deindustrialisation) and political (detrimental economic and social policies) exposures, resulting in worse outcomes. This vulnerability was generated by a series of historical factors, processes and decisions: the lagged effects of historical overcrowding; post-war regional policy including the socially selective relocation of population to outside the city; more detrimental processes of urban change which impacted on living conditions; and differences in local government responses to UK government policy in the 1980s which both impacted in negative terms in Glasgow and also conferred protective effects on comparator cities. Further resulting protective factors were identified (e.g. greater 'social capital' in Liverpool) which placed Glasgow at a further relative disadvantage. Other contributory factors were highlighted, including the inadequate measurement of deprivation. A similar 'explanatory model' resulted for Scotland as a whole. This included: the components of the Glasgow model, given their impact on nationally measured outcomes; inadequate measurement of deprivation; the lagged effects of deprivation (in particular higher levels of overcrowding historically); and additional key vulnerabilities.

CONCLUSIONS

The work has helped to further understanding of the underlying causes of Glasgow's and Scotland's high levels of excess mortality. The implications for policy include the need to address three issues simultaneously: to protect against key exposures (e.g. poverty) which impact detrimentally across all parts of the UK; to address the existing consequences of Glasgow's and Scotland's vulnerability; and to mitigate against the effects of future vulnerabilities which are likely to emerge from policy responses to contemporary problems which fail sufficiently to consider and to prevent long-term, unintended social consequences.

Intelligence and neuroticism in relation to depression and psychological distress: Evidence from two large population cohorts

Background

Neuroticism is a risk factor for selected mental and physical illnesses and is inversely associated with intelligence. Intelligence appears to interact with neuroticism and mitigate its detrimental effects on physical health and mortality. However, the inter-relationships of neuroticism and intelligence for major depressive disorder (MDD) and psychological distress has not been well examined.

Methods

Associations and interactions between neuroticism and general intelligence (g) on MDD, self-reported depression, and psychological distress were examined in two population-based cohorts: Generation Scotland: Scottish Family Health Study (GS:SFHS, n = 19,200) and UK Biobank (n = 90,529). The Eysenck Personality Scale Short Form-Revised measured neuroticism and g was extracted from multiple cognitive ability tests in each cohort. Family structure was adjusted for in GS:SFHS.

Results

Neuroticism was strongly associated with increased risk for depression and higher psychological distress in both samples. Although intelligence conferred no consistent independent effects on depression, it did increase the risk for depression across samples once neuroticism was adjusted for. Results suggest that higher intelligence may ameliorate the association between neuroticism and self-reported depression although no significant interaction was found for clinical MDD. Intelligence was inversely associated with psychological distress across cohorts. A small interaction was found across samples such that lower psychological distress associates with higher intelligence and lower neuroticism, although effect sizes were small.

Conclusions

From two large cohort studies, our findings suggest intelligence acts a protective factor in mitigating the effects of neuroticism on psychological distress. Intelligence does not confer protection against diagnosis of depression in those high in neuroticism.

Insulin-like growth factor 1 and risk of depression in older people: the English Longitudinal Study of Ageing

Depressive disorders are a leading cause of disability in older age. Although the role of psychosocial and behavioural predictors has been well examined, little is known about the biological origins of depression. Findings from animal studies have implicated insulin-like growth factor 1 (IGF-1) in the aetiology of this disorder. A total of 6017 older adults (mean age of 65.7 years; 55% women) from the English Longitudinal Study of Ageing provided serum levels of IGF-1 (mean=15.9 nmol l(-1), s.d. 5.7) during a nurse visit in 2008. Depression symptoms were assessed in the same year and again in 2012 using the eight-item Center for Epidemiologic Studies Depression Scale. Self-reports of a physician-diagnosis of depression were also collected at both time points. In separate analyses for men and women, the results from both the cross-sectional and longitudinal analyses revealed a 'U'-shaped pattern of association, such that lower and higher levels of IGF-1 were associated with a slightly elevated risk of depression, whereas the lowest risk was seen around the median levels. Thus, in men, with the lowest quintile of IGF-1 as the referent, the age-adjusted odds ratios (95% confidence interval) of developing depression symptoms after 4 years of follow-up, for increasing quintiles of IGF-1, were: 0.51 (0.28-0.91), 0.50 (0.27-0.92), 0.63 (0.35-1.15) and 0.63 (0.35-1.13) (P-value for quadratic association 0.002). Some attenuation of these effects was apparent after adjustment for co-morbidity, socioeconomic status and health behaviours. In conclusion, in the present study of older adults, there was some evidence that moderate levels of IGF-1 levels conferred a reduced risk of depression.

Severity of depressive symptoms as a predictor of mortality: the English longitudinal study of ageing

BACKGROUND

Major depressive disorder and subthreshold depression have been associated with premature mortality. We investigated the association between depressive symptoms and mortality across the full continuum of severity.

METHOD

We used Cox proportional hazards models to examine the association between depressive symptom severity, assessed using the eight-item Center for Epidemiological Studies Depression Scale (CES-D; range 0-8), and the risk of all-cause mortality over a 9-year follow-up, in 11 104 members of the English Longitudinal Study of Ageing.

RESULTS

During follow-up, one fifth of study members died (N = 2267). Depressive symptoms were associated with increased mortality across the full range of severity (p trend < 0.001). Relative to study members with no symptoms, an increased risk of mortality was found in people with depressive symptoms of a low [hazard ratio (HR) for a score of 2 was 1.59, 95% confidence interval (CI) 1.40-1.82], moderate (score of 4: HR 1.80, 95% CI 1.52-2.13) and high (score of 8: HR 2.27, 95% CI 1.69-3.04) severity, suggesting risk emerges at low levels but plateaus thereafter. A third of participants (36.4%, 95% CI 35.5-37.3) reported depressive symptoms associated with an increased mortality risk. Adjustment for physical activity, physical illnesses, and impairments in physical and cognitive functioning attenuated this association (p trend = 0.25).

CONCLUSIONS

Depressive symptoms are associated with an increased mortality risk even at low levels of symptom severity. This association is explained by physical activity, physical illnesses, and impairments in physical and cognitive functioning.

Interleukin-6 as a predictor of symptom resolution in psychological distress: a cohort study

BACKGROUND

Elevated levels of interleukin-6 (IL-6) have been associated with the development of common mental disorders, such as depression, but its role in symptom resolution is unclear.

METHOD

We examined the association between IL-6 and symptom resolution in a non-clinical sample of participants with psychological distress.

RESULTS

Relative to high IL-6 levels, low levels at baseline were associated with symptom resolution at follow-up [age- and sex-adjusted risk ratio (RR) = 1.15, 95% confidence interval (CI) 1.06-1.25]. Further adjustment for covariates had little effect on the association. Symptomatic participants with repeated low IL-6 were more likely to be symptom-free at follow-up compared with those with repeated high IL-6 (RR = 1.21, 95% CI 1.03-1.41). Among the symptomatic participants with elevated IL-6 at baseline, IL-6 decreased along with symptom resolution.

CONCLUSIONS

IL-6 is potentially related to the mechanisms underlying recovery from symptoms of mental ill health. Further studies are needed to examine these mechanisms and to confirm the findings in relation to clinical depression.

Sarcopenic obesity and risk of new onset depressive symptoms in older adults: English Longitudinal Study of Ageing

Background:

We examined the role of sarcopenic obesity as a risk factor for new-onset depressive symptoms over 6-year follow-up in a large sample of older adults.

Methods:

The sample comprised 3862 community dwelling participants (1779 men, 2083 women; mean age 64.6±8.3 years) without depressive symptoms at baseline, recruited from the English Longitudinal Study of Ageing. At baseline and 4-year follow-up, handgrip strength (kg) of the dominant hand was assessed using a hand-held dynamometer, as a measure of sarcopenia. The outcome was new onset depressive symptoms at 6-year follow-up, defined as a score of ⩾4 on the 8-item Centre of Epidemiological Studies Depression scale. Sarcopenic obesity was defined as obese individuals (body mass index ⩾30 kg m⁻²) in the lowest tertile of sex-specific grip strength (<35.3 kg men; <19.6 kg women).

Results:

Using a multivariable logistic regression model, the risk of depressive symptoms was greatest in obese adults in the lowest tertile of handgrip strength (odds ratio (OR), 1.79, 95% confidence interval (CI), 1.10, 2.89) compared with non-obese individuals with high handgrip strength. Participants who were obese at baseline and had a decrease of more than 1 s.d. in grip strength over 4-year follow-up were at greatest risk of depressive symptoms (OR=1.97, 95% CI, 1.22, 3.17) compared with non-obese with stable grip strength.

Conclusions:

A reduction in grip strength was associated with higher risk of depressive symptoms in obese participants only, suggesting that sarcopenic obesity is a risk factor for depressive symptoms.

Physical activity patterns over 10 years in relation to body mass index and waist circumference: the Whitehall II cohort study

OBJECTIVE

Physical activity patterns over 10-years in relation to changes in body mass index (BMI) and waist circumference (WC) were examined.

DESIGN AND METHODS

Participants (4,880, mean age 49.3 years at baseline) from the Whitehall II cohort study were included. Self-reported physical activity and anthropometric data were collected at baseline (1991) and twice during follow-up (1997 and 2002).

RESULTS

At baseline, meeting established guidelines for physical activity, particularly through vigorous activity, was associated with lower WC (multivariable adjusted B compared to not meeting the guidelines -2.08 cm, 95% CI, -1.39, -0.75) and BMI (-0.34 kg/m(2) , -0.10, -0.59). Based on repeat data, "high adherence" to the guidelines compared to "rare adherence" over follow-up was associated with lower BMI (adjusted difference, -0.43 kg/m(2) , 95% CI, -0.79, -0.08) and WC (-2.50 cm, 95% CI, -3.46, -1.54) at follow-up. Compared to participants that remained stable between 1997 and 2002 (change of <2.5 h/week), those that reported an increase in moderate-vigorous physical activity of at least 2.5 h/week displayed lower BMI (-0.40 kg/m(2) , 95% CI, -0.71, -0.08) and WC (-1.10 cm, 95% CI, -1.95, -0.75).

CONCLUSION

Regular physical activity, confirmed by repeated assessments, is associated with relatively favorable levels of adiposity markers after 10 years follow-up.

Ageing and the prevalence and treatment of mental health problems

BACKGROUND

Ageing is an important factor in the development of mental health problems and their treatment. We assessed age trajectories of common mental disorders (CMDs) and psychotherapy utilization from adolescence to old age, and examined whether these trajectories were modified by time period or birth cohort effects.

METHOD

British Household Panel Survey (BHPS) with an 18-year follow-up between 1991 and 2009 (n=30 224 participants, aged 15–100 years, with an average 7.3 person-observations per person). CMDs were assessed with the 12-item version of the General Health Questionnaire (GHQ). Psychotherapy treatment utilization during the past year was self-reported by the participants. The modifying influences of time period and cohort effects were assessed in a cohort-sequential longitudinal setting.

RESULTS

Following a moderate decrease after age 50, the prevalence of GHQ caseness increased steeply from age 75. This increase was more marked in the 2000s (GHQ prevalence increasing from 24% to 43%) than in the 1990s (from 22% to 34%). Psychotherapy utilization decreased after age 55, with no time period or cohort effects modifying the age trajectory. These ageing patterns were replicated in within-individual longitudinal analysis.

CONCLUSIONS

Old age is associated with higher risk of CMDs, and this association has become more marked during the past two decades. Ageing is also associated with an increasing discrepancy between prevalence of mental disorders and provision of treatment, as indicated by lower use of psychotherapy in older individuals.

Association of personality with the development and persistence of obesity: a meta-analysis based on individual-participant data

Personality is thought to affect obesity risk but before such information can be incorporated into prevention and intervention plans, robust and converging evidence concerning the most relevant personality traits is needed. We performed a meta-analysis based on individual-participant data from nine cohort studies to examine whether broad-level personality traits predict the development and persistence of obesity (n = 78,931 men and women; mean age 50 years). Personality was assessed using inventories of the Five-Factor Model (extraversion, neuroticism, agreeableness, conscientiousness and openness to experience). High conscientiousness - reflecting high self-control, orderliness and adherence to social norms - was associated with lower obesity risk across studies (pooled odds ratio [OR] = 0.84; 95% confidence interval [CI] = 0.80-0.88 per 1 standard deviation increment in conscientiousness). Over a mean follow-up of 5.4 years, conscientiousness predicted lower obesity risk in initially non-obese individuals (OR = 0.88, 95% CI = 0.85-0.92; n = 33,981) and was associated with greater likelihood of reversion to non-obese among initially obese individuals (OR = 1.08, 95% CI = 1.01-1.14; n = 9,657). Other personality traits were not associated with obesity in the pooled analysis, and there was substantial heterogeneity in the associations between studies. The findings indicate that conscientiousness may be the only broad-level personality trait of the Five-Factor Model that is consistently associated with obesity across populations.

Job strain in relation to body mass index: pooled analysis of 160 000 adults from 13 cohort studies

BACKGROUND

Evidence of an association between job strain and obesity is inconsistent, mostly limited to small-scale studies, and does not distinguish between categories of underweight or obesity subclasses.

OBJECTIVES

To examine the association between job strain and body mass index (BMI) in a large adult population.

METHODS

We performed a pooled cross-sectional analysis based on individual-level data from 13 European studies resulting in a total of 161 746 participants (49% men, mean age, 43.7 years). Longitudinal analysis with a median follow-up of 4 years was possible for four cohort studies (n = 42 222).

RESULTS

A total of 86 429 participants were of normal weight (BMI 18.5-24.9 kg m(-2) ), 2149 were underweight (BMI < 18.5 kg m(-2) ), 56 572 overweight (BMI 25.0-29.9 kg m(-2) ) and 13 523 class I (BMI 30-34.9 kg m(-2) ) and 3073 classes II/III (BMI ≥ 35 kg m(-2) ) obese. In addition, 27 010 (17%) participants reported job strain. In cross-sectional analyses, we found increased odds of job strain amongst underweight [odds ratio 1.12, 95% confidence interval (CI) 1.00-1.25], obese class I (odds ratio 1.07, 95% CI 1.02-1.12) and obese classes II/III participants (odds ratio 1.14, 95% CI 1.01-1.28) as compared with participants of normal weight. In longitudinal analysis, both weight gain and weight loss were related to the onset of job strain during follow-up.

CONCLUSIONS

In an analysis of European data, we found both weight gain and weight loss to be associated with the onset of job strain, consistent with a 'U'-shaped cross-sectional association between job strain and BMI. These associations were relatively modest; therefore, it is unlikely that intervention to reduce job strain would be effective in combating obesity at a population level.

Why the Scots die younger: synthesizing the evidence

OBJECTIVE

To identify explanations for the higher mortality in Scotland relative to other European countries, and to synthesize those best supported by evidence into an overall explanatory framework.

STUDY DESIGN

Review and dialectical synthesis.

METHODS

Candidate hypotheses were identified based on a literature review and a series of research dissemination events. Each hypothesis was described and critically evaluated in relation to the Bradford-Hill criteria for causation in observational epidemiology. A synthesis of the more convincing hypotheses was then attempted using a broadly 'dialectical' approach.

RESULTS

Seventeen hypotheses were identified including: artefactual explanations (deprivation, migration); 'downstream explanations' (genetics, health behaviours, individual values); 'midstream' explanations (substance misuse; culture of boundlessness and alienation; family, gender relations and parenting differences; lower social capital; sectarianism; culture of limited social mobility; health service supply or demand; deprivation concentration); and 'upstream' explanations (climate, inequalities, de-industrialization, political attack). There is little evidence available to determine why mortality rates diverged between Scotland and other European countries between 1950 and 1980, but the most plausible explanations at present link to particular industrial, employment, housing and cultural patterns. From 1980 onwards, the higher mortality has been driven by unfavourable health behaviours, and it seems quite likely that these are linked to an intensifying climate of conflict, injustice and disempowerment. This is best explained by developing a synthesis beginning from the political attack hypothesis, which suggests that the neoliberal policies implemented from 1979 onwards across the UK disproportionately affected the Scottish population.

CONCLUSIONS

The reasons for the high Scottish mortality between 1950 and 1980 are unclear, but may be linked to particular industrial, employment, housing and cultural patterns. From 1980 onwards, the higher mortality is most likely to be accounted for by a synthesis which begins from the changed political context of the 1980s, and the consequent hopelessness and community disruption experienced. This may have relevance to faltering health improvement in other countries, such as the USA.

Childhood socioeconomic position, adult socioeconomic position and social mobility in relation to markers of adiposity in early adulthood: evidence of differential effects by gender in the 1978/79 Ribeirao Preto cohort study

Background:

Longitudinal studies drawn from high-income countries demonstrate long-term associations of early childhood socioeconomic deprivation with increased adiposity in adulthood. However, there are very few data from resource-poor countries where there are reasons to anticipate different gradients. Accordingly, we sought to characterise the nature of the socioeconomic status (SES)-adiposity association in Brazil.

Methods:

We use data from the Ribeirao Preto Cohort Study in Brazil in which 9067 newborns were recruited via their mothers in 1978/79 and one-in-three followed up in 2002/04 (23–25years). SES, based on family income (salaries, interest on savings, pensions and so on), was assessed at birth and early adulthood, and three different adiposity measures (body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR)) ascertained at follow-up. The association between childhood SES, adult SES and social mobility (defined as four permutations of SES in childhood and adulthood: low–low, low–high, high–low, high–high), and the adiposity measures was examined using linear regression.

Results:

There was evidence that the association between SES and the three markers of adiposity was modified by gender in both adulthood (P<0.02 for all outcomes) and childhood SES (P<0.02 for WC and WHR). Thus, in an unadjusted model, linear regression analyses showed that higher childhood SES was associated with lower adiposity in women (coefficient (95% confidence intervals) BMI: −1.49 (−2.29,−0.69); WC: −3.85 (−5.73,−1.97); WHR: −0.03 (−0.04,−0.02)). However, in men, higher childhood SES was related to higher adiposity (BMI: 1.03 (0.28,−1.78); WC: 3.15 (1.20, 5.09); WHR: 0.009 (−0.001, 0.019)) although statistical significance was not seen in all analyses. There was a suggestion that adult SES (but not adult health behaviours or birthweight) accounted for these relationships in women only. Upward mobility was associated with protection against greater adiposity in women but not men.

Conclusion:

In the present study, in men there was some evidence that both higher childhood and adulthood SES was related to a higher adiposity risk, while the reverse gradient was apparent in women.

Resting heart rate and the risk of death and cardiovascular complications in patients with type 2 diabetes mellitus

AIMS/HYPOTHESIS

An association between resting heart rate and mortality has been described in the general population and in patients with cardiovascular disease. There are, however, few data exploring this relationship in patients with type 2 diabetes mellitus. The current study addresses this issue.

METHODS

The relationship between baseline resting heart rate and all-cause mortality, cardiovascular death and major cardiovascular events (cardiovascular death, non-fatal myocardial infarction or non-fatal stroke) was examined in 11,140 patients who participated in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation (ADVANCE) Study.

RESULTS

A higher resting heart rate was associated with a significantly increased risk of all-cause mortality (fully adjusted HR 1.15 per 10 bpm [95% CI 1.08, 1.21], p<0.001), cardiovascular death and major cardiovascular outcomes without adjustment and after adjusting for age and sex and multiple covariates. The increased risk associated with a higher baseline resting heart rate was most obvious in patients with previous macrovascular complications (fully adjusted HR for death 1.79 for upper [mean 91 bpm] vs lowest [mean 58 bpm] fifth of resting heart rate in this subgroup [95% CI 1.28, 2.50], p = .001).

CONCLUSIONS/INTERPRETATION

Among patients with type 2 diabetes, a higher resting heart rate is associated with an increased risk of death and cardiovascular complications. It remains unclear whether a higher heart rate directly mediates the increased risk or is a marker for other factors that determine a poor outcome.

Influence of maternal and paternal IQ on offspring health and health behaviours: evidence for some trans-generational associations using the 1958 British birth cohort study

PURPOSE

Individuals scoring poorly on tests of intelligence (IQ) have been reported as having increased risk of morbidity, premature mortality, and risk factors such as obesity, high blood pressure, poor diet, alcohol and cigarette consumption. Very little is known about the impact of parental IQ on the health and health behaviours of their offspring.

METHODS

We explored associations of maternal and paternal IQ scores with offspring television viewing, injuries, hospitalisations, long standing illness, height and BMI at ages 4 to 18 using data from the National Child Development Study (1958 birth cohort).

RESULTS

Data were available for 1446 mother-offspring and 822 father-offspring pairs. After adjusting for potential confounding/mediating factors, the children of higher IQ parents were less likely to watch TV (odds ratio (95% confidence interval) for watching 3+ vs. less than 3hours per week associated with a standard deviation increase in maternal or paternal IQ: 0.75 (0.64, 0.88) or 0.78 (0.64, 0.95) respectively) and less likely to have one or more injuries requiring hospitalisation (0.77 (0.66, 0.90) or 0.72 (0.56, 0.91) respectively for maternal or paternal IQ).

CONCLUSIONS

Children whose parents have low IQ scores may have poorer selected health and health behaviours. Health education might usefully be targeted at these families.

Sex hormones and cause-specific mortality in the male veterans: the Vietnam Experience Study

BACKGROUND

Testosterone levels have been linked to life expectancy in men, less is known about the sex hormones follicular stimulating hormone and luteinizing hormone.

AIM

To examine the association of testosterone, follicular stimulating hormone, luteinizing hormone with mortality.

DESIGN

Prospective cohort analysis.

METHODS

Participants were 4255 Vietnam-era US army veterans with a mean age of 38.3 years. From military service files, telephone interviews and a medical examination, socio-demographic and health data were collected. Contemporary morning fasted hormone concentrations were determined. All-cause, cardiovascular, cancer, external and 'other' cause mortality was ascertained over the subsequent 15 years. Hazard ratios were calculated, first with adjustment for age and then, additionally, for a range of confounders.

RESULTS

Individuals within the highest tertiles of follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels were at increased risk of all-cause mortality following adjustment for a range of risk factors. However, with mutual adjustment, neither FSH nor LH significantly predicted mortality. Testosterone levels did not show an association with all-cause mortality, and none of the hormones were significantly associated with CVD, cancer, 'other' or external-cause mortality in fully adjusted models.

CONCLUSION

Greater FSH and LH levels are associated with all-cause mortality, but not independently of one another.

Association of body mass index in early adulthood and middle age with future site-specific cancer mortality: the Harvard Alumni Health Study

BACKGROUND

The association between adiposity in early adulthood and subsequent development of specific malignancies is unclear. Further, the potential for mediation by adiposity in middle age has not been well examined. In a rare study, we investigated the association of body mass index (BMI) in early adulthood with mortality from several site-specific cancers.

DESIGN

In the Harvard Alumni Health Study cohort, 19 593 males had a physical examination at the university between 1914 and 1952 (mean age: 18.4 years) and returned a questionnaire in 1962 or 1966 (mean age = 45.1 years). BMI was computed using weight (kg)/height(2) (m(2)) at both time points. Vital status follow up continued for a maximum of 82 years.

RESULTS

Positive early adulthood cancer mortality gradients by BMI were found for all malignancies combined (adjusted hazard ratio [HR] = 1.11; 95% confidence interval [CI]: 1.05-1.17 for a one standard deviation increase in early adulthood BMI), and for lung (HR = 1.24; 95% CI = 1.10-1.40) and skin (HR = 1.29; 95% CI = 0.96-1.75) cancers. There were also apparent associations for cancers of the oesophagus and urogenital sites. Mediation by BMI in middle age was found to be minimal.

CONCLUSION

Higher BMI in early adulthood appears to be a direct risk factor for selected malignancies several decades later.

Body mass index, waist circumference and waist-hip ratio: which is the better discriminator of cardiovascular disease mortality risk?: evidence from an individual-participant meta-analysis of 82 864 participants from nine cohort studies

Few studies have examined both the relative magnitude of association and the discriminative capability of multiple indicators of obesity with cardiovascular disease (CVD) mortality risk. We conducted an individual-participant meta-analysis of nine cohort studies of men and women drawn from the British general population resulting in sample of 82 864 individuals. Body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) were measured directly. There were 6641 deaths (1998 CVD) during a mean of 8.1 years of follow-up. After adjustment, a one SD higher in WHR and WC was related to a higher risk of CVD mortality (hazard ratio [95% CI]): 1.15 (1.05-1.25) and 1.15 (1.04-1.27), respectively. The risk of CVD mortality also increased linearly across quintiles of both these abdominal obesity markers with a 66% increased risk in the highest quintile of WHR. In age- and sex-adjusted models only, BMI was related to CVD mortality but not in any other analyses. No major differences were revealed in the discrimination capabilities of models with BMI, WC or WHR for cardiovascular or total mortality outcomes. In conclusion, measures of abdominal adiposity, but not BMI, were related to an increased risk of CVD mortality. No difference was observed in discrimination capacities between adiposity markers.

Haemoglobin A1c, fasting glucose and future risk of elevated depressive symptoms over 2 years of follow-up in the English Longitudinal Study of Ageing

BACKGROUND

The cross-sectional association between impaired glucose/diabetes and depression is inconsistent. We examined the longitudinal associations between diabetes, indicators of glucose metabolism and depressive symptoms over 2 years of follow-up.

METHOD

Participants were 4338 men and women from the English Longitudinal Study of Ageing, a prospective study of community-dwelling older adults [aged 62.9 (s.d.=9.0) years, 45.2% men]. Depressive symptoms were assessed at baseline and after 2 years of follow-up using the eight-item Centre of Epidemiological Studies--Depression (CES-D) scale. Glycated haemoglobin (HbA1c) levels, fasting glucose and other biological and behavioural risk factors were also assessed at baseline.

RESULTS

Approximately 11.5% of the sample were categorized with elevated depressive symptoms at follow-up (a score ≥ 4 on the CES-D). There was an association between HbA1c and depressive symptoms at follow-up [per unit increase, odds ratio (OR) 1.17, 95% confidence interval (CI) 1.03-1.33] after adjustment for age and baseline CES-D. Cross-sectionally, the probability of depressive symptoms increased with increasing HbA1c levels until the value of 8.0% after which there was a plateau [p(curve)=0.03]. Compared with those with normal fasting glucose, participants with diabetes (confirmed through self-report or elevated fasting blood glucose) at baseline had an elevated risk of depressive symptoms at follow-up (OR 1.52, 95% CI 1.01-2.30) after adjusting for depressive symptoms at baseline, behavioural and sociodemographic variables, adiposity and inflammation.

CONCLUSIONS

These data suggest that poor glucose metabolism and diabetes are risk factors for future depression in older adults. There was no evidence of a U-shaped association.

Interventions for the prevention of overweight and obesity in preschool children: a systematic review of randomized controlled trials

The objective of this study was to analyse interventions for the prevention of overweight and obesity in children under 5 years of age. We carried out a systematic review focusing exclusively on randomized controlled trials (RCTs). Data sources include Medline, Cochrane Library, EMBASE, CINHAL, PsychInfo and Web of Science. Data were extracted from seventeen articles describing seven RCTs identified through electronic search, screening of references in systematic reviews, own files and contact with authors. RCTs were assessed with the Jadad scale. Four trials were carried out in preschool settings, one with an exclusive educational component, two with an exclusive physical activity component and one with both. Two trials were family-based, with education and counselling for parents and children. The remaining trial was carried out in maternity hospitals, with a training intervention on breastfeeding. None of the interventions had an effect in preventing overweight and obesity. The failure to show an effect may be due to the choice of outcomes, the quality of the RCTs, the suboptimal implementation of the interventions, the lack of focus on social and environmental determinants. More rigorous research is needed on interventions and on social and environmental factors that could impact on lifestyle.

Temporal trends in diabetes prevalence and key diabetes risk factors in Scotland, 2003-2008

AIMS

We assessed temporal trends in diabetes prevalence and key diabetes risk factors (obesity, physical activity, smoking) over 5 years in a nationally representative sample.

METHODS

Participants were drawn from the Scottish Health Surveys, which recruited two separate, nationally representative samples in 2003 (n = 7229, aged 50.5 ± 17.2 years) and 2008 (n = 6313, aged 51.8 ± 17.6 years). Prevalent diabetes was assessed from a self-reported physician's diagnosis, and high diabetes risk or undiagnosed cases were defined from HbA(1c) ≥ 6.0% (≥ 42 mmol/mol) to < 6.5% (< 47.5 mmol/mol) and ≥ 6.5% (≥ 47.5 mmol/mol), respectively.

RESULTS

Over 5 years there was an increased prevalence of diabetes (5.2 vs. 9.4% in 2003 and 2008, respectively) and in the prevalence of high diabetes risk (2.9 vs. 12.4%). These differences were accentuated in participants aged 65 years and above; for diabetes, there was a prevalence of 12 and 17.3% in 2003 and 2008, respectively, and, for high risk, the prevalence was 7.8 and 24.7%, respectively. There was also an increase in diabetes risk factors, including obesity and lack of physical activity, although these factors did not explain the diabetes trend.

CONCLUSIONS

These results suggest nearly a doubling in the prevalence of diabetes over 5 years in Scotland.

Lymphocyte cell counts in middle age are positively associated with subsequent all-cause and cardiovascular mortality

BACKGROUND

There is an association between higher white blood cell counts and all-cause and cardiovascular disease (CVD) mortality. However, little is known about the prognostic significance of circulating lymphocyte and lymphocyte subset numbers.

AIMS

The present study examined the association between T-, CD4-, CD8- and B-cell numbers, and the CD4:CD8 ratio, and all-cause and CVD mortality.

METHODS

Lymphocyte and lymphocyte subset numbers were measured by flow cytometry in a cohort of 4256 male middle-aged Vietnam-era US veterans. Mortality was tracked for 15 years and cause of death was determined from death certificates.

RESULTS

In fully adjusted survival analyses, high circulating T-cells numbers were associated with increased risk of both all-cause [hazard ratio (HR)=1.75, 95% confidence interval (CI) 1.15-2.66] and cardiovascular (HR=3.57, 95% CI 1.53-8.33) mortality. The former association appeared to reflect an effect for high CD8-cells numbers, the latter an effect for high CD4-cell numbers. For all-cause mortality, a high CD4:CD8 ratio was protective (HR=0.58, 95% CI 0.41-0.81). Cardiovascular mortality was also predicted by high B-cells numbers (HR=1.87, 95% CI 1.10-3.17).

CONCLUSION

Circulating lymphocyte and lymphocyte subset numbers may have substantial prognostic significance for both all-cause and CVD mortality.

Cortisol, dehydroepiandrosterone sulphate, their ratio and hypertension: evidence of associations in male veterans from the Vietnam Experience Study

Although clinical observations implicate cortisol in hypertension, the epidemiological evidence is less compelling. Little is known about the relationship between dehydroepiandrosterone sulphate (DHEAS) and hypertension, and nothing about the association with the cortisol:DHEAS ratio. The present analyses of data obtained from Vietnam-era US veterans examined the associations between cortisol, DHEAS, their ratio and hypertension. Participants were 4180 male veterans. From military files, telephone interviews and a medical examination, sociodemographic and health data were collected. At medical examination, a fasted morning blood sample was collected to assay serum cortisol and DHEAS, blood pressure measured and body mass index (BMI) determined. Hypertension was defined by having one of the following: a reported physician diagnosis, taking antihypertensive medication, an average systolic blood pressure ≥ 140 mm Hg and an average diastolic blood pressure ≥ 90 mm Hg. Cortisol and the cortisol:DHEAS ratio were positively associated with hypertension (P < 0.001), whereas DHEAS was negatively associated; the latter relationship was attenuated to non-significance (P = 0.06) in models that adjusted for age, sociodemographics, place of service, health behaviours and BMI. The present analyses provide confirmation of a positive association between cortisol and the cortisol:DHEAS ratio and population hypertension.

Oral disease and subsequent cardiovascular disease in people with type 2 diabetes: a prospective cohort study based on the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) trial

AIMS/HYPOTHESIS

While there are plausible biological mechanisms linking oral health with cardiovascular disease (CVD) and mortality rates, no study, to our knowledge, has examined this association in a representative population of people with type 2 diabetes.

METHODS

We used the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) study, a large, detailed, randomised controlled trial among a general population of individuals with type 2 diabetes. For the purposes of the present analyses, data from the trial are used within a prospective cohort study design. A total of 10,958 men and women, aged 55 to 88 years and with type 2 diabetes, participated in a baseline medical examination, during which they counted their number of natural teeth and reported the number of days that their gums had bled over the preceding year. Study members were followed up for mortality and morbidity over 5 years.

RESULTS

After controlling for a range of potential confounding factors, the group with no teeth had a markedly increased risk of death due to all causes (HR 1.48, 95% CI 1.24-1.78), CVD (1.35, 1.05-1.74) and non-CVD (1.64, 1.26-2.13), relative to the group with the most teeth (≥22 teeth). Frequency of bleeding gums was not associated with any of the outcomes of interest. There was no suggestion that treatment group or sex modified these relationships.

CONCLUSIONS/INTERPRETATION

In people with type 2 diabetes, oral disease, as indexed by fewer teeth, was related to an increased risk of death from all causes and of death due to CVD and non-CVD.

Early-life determinants of overweight and obesity: a review of systematic reviews

The aim of this paper was to review the evidence for early-life (from conception to 5 years of age) determinants of obesity. The design is review of published systematic reviews. Data sources included Medline, Embase, Web of Science, Cochrane Library, CINAHL, PsycINFO. Identification of 22 eligible reviews from a database of 12,021 independent publications. Quality of selected reviews assessed using the Assessment of Multiple Systematic Reviews score. Articles published after the reviews were used to confirm results. No review was classified as high quality, 11 as moderate and 11 as low. Factors associated with later overweight and obesity: maternal diabetes, maternal smoking, rapid infant growth, no or short breastfeeding, obesity in infancy, short sleep duration, <30 min of daily physical activity, consumption of sugar-sweetened beverages. Other factors were identified as potentially relevant, although the size of their effect is difficult to estimate. Maternal smoking, breastfeeding, infant size and growth, short sleep duration and television viewing are supported by better-quality reviews. It is difficult to establish a causal association between possible determinants and obesity, and the relative importance of each determinant. Future research should focus on early-life interventions to confirm the role of protective and risk factors and to tackle the high burden obesity represents for present and future generations.

Associations of diabetes mellitus with site-specific cancer mortality in the Asia-Pacific region

BACKGROUND

Owing to the increasing prevalence of obesity and diabetes in Asia, and the paucity of studies, we examined the influence of raised blood glucose and diabetes on cancer mortality risk.

MATERIALS AND METHODS

Thirty-six cohort Asian and Australasian studies provided 367, 361 participants (74% from Asia); 6% had diabetes at baseline. Associations between diabetes and site-specific cancer mortality were estimated using time-dependent Cox models, stratified by study and sex, and adjusted for age.

RESULTS

During a median follow-up of 4.0 years, there were 5992 deaths due to cancer (74% Asian; 41% female). Participants with diabetes had 23% greater risk of mortality from all-cause cancer compared with those without: hazard ratio (HR) 1.23 [95% confidence interval (CI) 1.12, 1.35]. Diabetes was associated with mortality due to cancer of the liver (HR 1.51; 95% CI 1.19, 1.91), pancreas (HR 1.78; 95% CI 1.20, 2.65), and, less strongly, colorectum (HR 1.32; 95% CI 0.98, 1.78). There was no evidence of sex- or region-specific differences in these associations. The population attributable fractions for cancer mortality due to diabetes were generally higher for Asia compared with non-Asian populations.

CONCLUSION

Diabetes is associated with increased mortality from selected cancers in Asian and non-Asian populations.

Intelligence in early adulthood and subsequent risk of unintentional injury over two decades: cohort study of 1 109 475 Swedish men

BACKGROUND

There is growing evidence of an inverse association between intelligence (IQ) and unintentional injuries.

METHODS

Analyses are based on a cohort of 1 109 475 Swedish men with IQ measured in early adulthood. Men were followed up for an average 24 years, and hospital admissions for unintentional injury were recorded.

RESULTS

198 133 (17.9%) men had at least one hospital admission for any unintentional injury during follow-up. The most common cause of unintentional injury was falling, followed by road accidents, poisoning, fire and drowning. In addition, 14 637 (1.3%) men had at least one admission for complications of medical care. After adjusting for confounding variables, lower IQ scores were associated with an elevated risk of any unintentional injury (HR (95% CI) per SD decrease in IQ: 1.15 (1.14 to 1.15)) and of cause-specific injuries other than drowning (poisoning (1.53 (1.49 to 1.57)), fire (1.36 (1.31 to 1.41)), road traffic accidents (1.25 (1.23 to 1.26)), medical complications (1.20 (1.18 to 1.22)) and falling (1.17 (1.16 to 1.18))). These gradients were stepwise across the full IQ range.

CONCLUSIONS

Low IQ scores in early adulthood were associated with a subsequently increased risk of unintentional injury. A greater understanding of mechanisms underlying these associations may provide opportunities and strategies for prevention.

Adult height and cancer mortality in Asia: the Asia Pacific Cohort Studies Collaboration

BACKGROUND

The observation that taller people experience an increased risk of selected cancers is largely restricted to Caucasian cohorts. These associations may plausibly differ in Asian populations. For the first time, we make direct comparison in the same analyses of the associations between height and a series of malignancies in Australasian (Caucasian) and Asian populations.

METHODS

Analyses were based on the Asia Pacific Cohort Studies Collaboration of 506 648 study participants (408 381 Asia, 98 267 Australasia) drawn from 38 population-based cohort studies. Cox proportional hazards regression was used to estimate the relationship between height and cancer rates.

RESULTS

A total of 3 272 600 person-years of follow-up gave rise to 7497 cancer deaths (4415 in Asia; 3082 in Australasia). After multiple adjustments and left censoring, taller individuals experienced increased rates of carcinoma of the intestine (men and women); all cancers, liver, lung, breast, 'other' malignancies (all women); and cancers of the prostate and bladder (men). No consistent regional (Asia versus Australasia) or sex differences were observed.

CONCLUSIONS

In the present study, taller men and women had an elevated risk of selected malignancies. These associations did not differ appreciably between Asian and Caucasian populations.

Impact of resurvey non-response on the associations between baseline risk factors and cardiovascular disease mortality: prospective cohort study

BACKGROUND

Selection bias in observational epidemiology--the notion that people who participate in a study are fundamentally different from those who do not--is a perennial concern. In cohort studies, a potentially important but little investigated manifestation of selection bias is the distortion of the exposure-disease relationship according to participation status.

METHODS

Seven years after the original UK Health and Lifestyle Survey (HALS1; N = 6484), attempts were made to resurvey participants (HALS2). The baseline characteristics, mortality experience following the completion of HALS2 and, finally, the baseline risk factor-cardiovascular disease (CVD) mortality gradients in HALS2 non-participants (N = 1894) and participants (N = 4590) were compared.

RESULTS

Resurvey non-participants, based on data from HALS1, were younger, were of lower social class and had a lower prevalence of hypertension or self-reported limiting long-standing illness, but a higher prevalence of psychological distress (p < or = 0.027). The risk of death from future CVD was significantly higher in those baseline study members who did not participate in HALS2. However, the magnitude of the association between a series of risk factors and CVD mortality was essentially the same in the HALS2 non-participants and participants (p value for interaction > or = 0.108).

CONCLUSION

In the present cohort study, non-response at resurvey did not bias the observed associations between baseline risk factors and later CVD mortality. Future studies should also examine the impact of non-response to baseline surveys on these relationships.

Socioeconomic status and telomere length: the West of Scotland Coronary Prevention Study

BACKGROUND

It has been hypothesised that socioeconomically deprived people age more rapidly than their more advantaged counterparts and this is biologically manifest in shorter telomeres. However, in the very few studies conducted, substantial uncertainty exists regarding this relationship.

METHODS

In the present investigation, 1542 men in the West of Scotland Coronary Prevention Study responded to a series of enquiries about their socioeconomic position (educational attainment, employment status, area-based deprivation), had their physical stature measured (a proxy for early life social circumstances) and provided a blood specimen from which leucocyte DNA was extracted and telomere length derived.

RESULTS

There was no strong evidence that any of these four indices of socioeconomic position was robustly related to telomere length. The only exception was employment status: men who reported being out of work had significantly shorter telomeres than those who were employed (p = 0.007).

CONCLUSION

In this cross-sectional study-the largest to date to examine the relationship-we found little evidence of an association between socioeconomic status and telomere length.