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Wellbeing and its determinants CSP Congress 2009 Liverpool 16 October 2009.
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Transcript of Wellbeing and its determinants CSP Congress 2009 Liverpool 16 October 2009.
Wellbeing and its determinantsWellbeing and its determinants
CSP Congress 2009CSP Congress 2009
LiverpoolLiverpool
16 October 200916 October 2009
2020thth century trends in life expectancy in Scotland century trends in life expectancy in Scotland and 16 other Western European countriesand 16 other Western European countries
Males
30
40
50
60
70
80
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000Year of birth
Life
exp
ecta
ncy
in y
ears
Scotland
Health InequalitiesHealth Inequalities
Are they due to:Are they due to:
– Poverty?Poverty?
– Diet ?Diet ?
– Tobacco?Tobacco?
Excess Standardised Mortality not Excess Standardised Mortality not explained by deprivationexplained by deprivation(Scotland v. E&W)(Scotland v. E&W)
0
2
4
6
8
10
12
14
16
1981 1991 2001
Ex
ce
ss
Mo
rta
lity
(%
)
Age & Sex
Age, Sex & Deprivation
Coronary heart disease mortalityCoronary heart disease mortalityMen aged 15-74 yearsMen aged 15-74 years
100
200
300
400
500
600
1950 1960 1970 1980 1990
DenmarkFinlandNorwaySwedenScotland
Age
-sta
ndar
dise
d m
orta
lity
per
100
,000
World Health Organization (1997 and 2003)
www.heartstats.org
Prevalence of smoking by country, in 15 year olds by sex, 2000/01, Europe
0
5
10
15
20
25
30
35
40
45
50
Ukraine
Lith
uania
Ger
man
y
Eston
ia
Slove
nia
Czech
Repu
blic
Latvi
a
Finlan
d
Hungar
y
Russia
n Fede
ratio
n
Austri
a
Franc
e
Polan
d
Switzer
land
Spain
Belgiu
m -
Flemish
spe
aking
Croat
ia
Nether
land
s
Belgiu
m -
Frenc
h sp
eakin
gIta
ly
United
Kin
gdom
- Eng
land
Irelan
d
Norway
Portu
gal
Denm
arkIs
rael
Malt
a
United
Kin
gdom
- Sco
tland
United
Kin
gdom
- W
ales
Mac
edonia,
FYR
Gre
ece
Sweden
% r
egu
lar
smo
kers
Boys
Girls
Comparison of lung cancer mortality in West of Scotland
and 3 major cohorts
0
100
200
300
400
500
0 10 20 30 40
Average number of cigarettes smoked daily
West of Scotland
UK doctorsAmerican Cancer Society volunteers
US veterans
Average
annual
death rate
/100,000
Lung cancer mortality by social class
0
20
40
60
80
100
never 1-14 15-24 25+
daily cigarette consumption
Rate per 10,000
manual
non-manual
Risk of death Risk of death - by level of hopelessness- by level of hopelessness
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
All cause CVD Non CVD Cancer
Low
Moderate
HighRHRRHR
Everson et al 1996Everson et al 1996
00-046
-1.2
-1
-0.8
-0.6
-0.4
-0.2
0 10 20 30 40 50
Months of Orphanage Rearing
*linear trendline
Evening Cortisol Levels Increase withMonths of Orphanage Rearing *
The Founders’ Network
“.....expresses the extent to which one has a feeling of confidence that the stimuli deriving from one's internal and external environments in the course of living are structured, predictable and explicable, that one has the internal resources to meet the demands posed by these stimuli and, finally, that these demands are seen as challenges, worthy of investment and engagement."
Sense of coherence....Sense of coherence....
For the creation of health....For the creation of health....
....the social and physical environment must ....the social and physical environment must be:be:
ComprehensibleComprehensible ManageableManageable MeaningfulMeaningful
STRESS AND GRADE OF EMPLOYMENT: MEN
0
2
4
6
8
10
12
14
16
18
2008
-8.3
0
10-1
0.30
12-1
2.30
14-1
4.30
16-1
6.30
18-1
8.30
20-2
0.30
22-2
2.30
nmol
/l Higher GradeLower Grade
Salivary Cortisol
Time of DaySteptoe et al. 2003, Psychosomatic Medicine, 65, 461-470
Depcat % smokers Never-smokers Smokers
1 36.8 0.71 1.42
2 35.9 1.00 2.34
3 39.1 1.11 2.25
4 44.1 1.21 2.44
5 46.6 1.13 2.53
6 49.3 1.25 3.07
7 55.5 1.48 3.29
Environmental determinants of Environmental determinants of inflammatory status inflammatory status
CRP (median) mg/dl
affluent
deprived
PP<0.001<0.001
PP<0.001<0.001
PP=0.03=0.03
Quartile of hs-CRP (Range, mg/dL)Quartile of hs-CRP (Range, mg/dL)
P P Trend <0.001Trend <0.001
0.0550.055 0.056–0.1140.056–0.114 0.115–0.2100.115–0.210 0.2110.211
Rel
ativ
e R
isk
of
MI
Rel
ativ
e R
isk
of
MI
Ridker. N Engl J Med. 1997;336:973–979.
0
1
2
3
1 2 3 4
hs-CRP and Risk of Future MI hs-CRP and Risk of Future MI in Apparently Healthy Men in Apparently Healthy Men
Inflammation in plaquesInflammation in plaques
Inflammatory cellsInflammatory cells
MMPs, IL-6, MMPs, IL-6, IL-15, IL-18, CRPIL-15, IL-18, CRP
LumenLumen
CoreCore
CapCap
Thin Thin Fibrous CapFibrous Cap
InflammatoryInflammatoryCellsCells
SMCSMC apoptosisapoptosis
DegradedDegradedmatrixmatrix
UnstableUnstable
cytokinescytokines MMPMMP
0
1
2
3
4
5
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Q1 : <0.66 mg/l
Q5: > 4.18 mg/l
Years in study
% diabetic
CRP and cumulative risk of type 2 diabetes
Freeman et al. Diabetes 2002,51;1596
Adipocyte programmingAdipocyte programming insulin resistance, inflammation and ALPinsulin resistance, inflammation and ALP
Adipose stores
NEFAs
liver
CRPSAA
IL-6/IL-6sR
TNF-TNF-sR-I
triglyceride
Low HDLsmall LDL
AtherogenicLipoproteinPhenotype
Pro-inflammatorystate
skeletal muscleInsulin resistance
Attachment theory
“Infants develop the attachment behaviours that optimally enhance their survival in their own characteristic environments.”
Crittenden, 2000
Attachment theoryAttachment theory
AinsworthAinsworth– Deep emotional connection that infant develops with Deep emotional connection that infant develops with
primary caregiverprimary caregiver– Reflects an “internal working model”expressing the Reflects an “internal working model”expressing the
infant’s expectations of parental behaviour in infant’s expectations of parental behaviour in meaningful situationsmeaningful situations
– Basis for development of later relationshipsBasis for development of later relationships Increasingly recognised as determinant of later emotional, Increasingly recognised as determinant of later emotional,
cognitive and social outcomescognitive and social outcomes
“Serve and return”
“The ‘instruction’ to attend to the primary caregiver is genetic, the outcome depends on what happens”
Balbernie, 2001
The Dunedin cohortThe Dunedin cohort 1000 children recruited in late 1972/31000 children recruited in late 1972/3 At age 3, “at risk” children identified on the basis of chaotic At age 3, “at risk” children identified on the basis of chaotic
circumstances, emotional behaviour, negativity and poor circumstances, emotional behaviour, negativity and poor attentivenessattentiveness
As adults, those “at risk” were more likely to :As adults, those “at risk” were more likely to :– be unemployedbe unemployed– have criminal convictions (especially for violence) have criminal convictions (especially for violence) – been pregnant as a teenagerbeen pregnant as a teenager– have a substance abuse problemhave a substance abuse problem– exhibit signs of insulin resistance and metabolic syndromeexhibit signs of insulin resistance and metabolic syndrome
TelomeresTelomeres
Ends of chromosomesEnds of chromosomes Sense and signal damageSense and signal damage Home of repair systemsHome of repair systems Integrate energy production and utilisationIntegrate energy production and utilisation Anti-cancerAnti-cancer Telomere length predictive for mortalityTelomere length predictive for mortality
““Physical activity” or sweaty exercise?Physical activity” or sweaty exercise?
Are we being too modest in our Are we being too modest in our aspirations for fitness?aspirations for fitness?
Should we make more use of Should we make more use of sport as a means to get people sport as a means to get people active?active?
By embracing “physical activity”, By embracing “physical activity”, are we admitting defeat?are we admitting defeat?
Opportunity to escape Opportunity to escape poverty, decent housing, poverty, decent housing,
social networks, self esteem social networks, self esteem and sense of controland sense of control
Consistent parenting, safe, Consistent parenting, safe, nurturing early years, nurturing early years, supportive educationsupportive education
Health related Health related behavioursbehaviours
Opportunity to escape Opportunity to escape poverty, decent housing, poverty, decent housing,
social networks, self esteem social networks, self esteem and sense of controland sense of control
Consistent parenting, safe, Consistent parenting, safe, nurturing early years, nurturing early years, supportive educationsupportive education
Health related Health related behavioursbehaviours
Comprehensible
Manageable
Meaningful