t t HRB Centre for Health and Diet Research Research in Irish Primary Care The Cork & Kerry Study Ivan J Perry, Dept. of Epidemiology and Public Health, University College Cork. Inaugural National Primary Care Conference Livinghealth Clinic Mitchelstown, County Cork Thursday, November 17 th , 2011
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HRB Centre for Health and Diet Research
Research in Irish Primary CareThe Cork & Kerry Study
Ivan J Perry,
Dept. of Epidemiology and Public Health,
University College Cork.
Inaugural National Primary Care ConferenceLivinghealth Clinic
Mitchelstown, County CorkThursday, November 17th , 2011
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Overview• Background & context
• Cork & Kerry study sampling & methods
• Selection of key findings – CVD risk factor prevalence– Modelling of secular trends in CHD mortality in Ireland
• Data management issues
• Suggestions for further development of primary care research infrastructure
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Background & context• HRB funding for Population Health Sciences,
and Health Services Research (HSR)
• Costs and limitations of household surveys and telephone surveys for population health surveillance
• Primary care centres which serve a defined relatively large population with good links and outreach to the local community provide a potentially excellent sampling frame for population health research and HSR
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Biomedical perspective on nutrition-related diseases
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Sociological/ marketing perspective on nutrition transition
Source: Adapted from Cova and Cova, 2001, p.601; Desjeux, 19966
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0
200
400
600
800Per 100,000Per 100,000
Ireland
UK
USA
Netherlands
Finland
ItalyFrance
International mortality trends in CHD in men aged 35 to 74 years from 1968 to 2003
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Sick individuals and sick populations:Total cholesterol in three populations
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Cork & Kerry Diabetes and Heart Disease Study
• Linked cross-sectional and longitudinal studies involving representative samples of middle-aged men and women.
• Cork & Kerry Phase I and Phase II studies
» Phase I: 1998 (N=1018)
» Phase I Follow up: year 2008-2009
» Phase ll: 2010-11 (N=2000)
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Cork & Kerry Phase I Study Methods
• Cross sectional study in primary care carried out in 1998
• 17 General Practices linked to the Cork Vocational Training programme for general Practice
• 1018 participants and response rate of 69%.• Data on diet (FFQ), lifestyle, and anthropometric
measures including height, weight, waist circumference and blood pressure were obtained using standard, internationally validated questionnaires instruments and methods
• Detailed Standard Operating Procedure (SOP) and rigorous training of field survey staff
• Fasting blood samples and morning urine samples were obtained for estimation of glucose, insulin, lipids, homocysteine, microalbumin and other established biological CVD risk factors.
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Cork & Kerry Phase I-follow-up study
1018 men and women aged 50-69 years screened in 1998
156 deaths to Dec 2008
180 lost to follow-up & 43 unable to
participate
Contacted 639
362 (57%) responded
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Cork & Kerry Phase II Study Methods
• Cross sectional study in primary care carried out in 2010-2011
• Based in a single large primary care centre (LivingHealth Clinic) in Mitchelstown, Co Cork
• 2047 participants and response rate of 67%.• Dietary, lifestyle, and anthropometric
measures as in Phase I study• Addition of ACE (adverse childhood
experiences) instrument• Addition of 24 hour ambulatory BP in over
50% of participants and triaxial accelerometry data over 7-days from a sub-sample of over 400 participants
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Cork & Kerry Phase II Study Methods Contd
• Detailed SOP and rigorous training of field survey staff
• Fasting blood sample for measurement of full blood count (FBC), Glycosylated haemoglobin, glucose, estimated GFR, iron, Gamma GT, liver, renal, lipoprotein and bone profiles, serum B12, folate and ferritin.
• Blood samples are centrifuged on site and two serum bottles are stored in microlettes (1.3ml x2) in an onsite -80 degree freezer.
• Morning urine samples for estimation of electyrolytes and microalbumin
Cork & Kerry Phase 2 StudyLiving Health Clinic Mitchelstown
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Cork and Kerry 2010
• Study timelines =26th April 2010 to 21st April 2011 (44 weeks in total)
• Response rate =67% (2047/3043)
• Response rate for ABPM =58% (1179/2047)
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'Food Choices in Sickness and in Health
• While Irish adults may be generally aware of a link between nutrition and health, this is not reflected in everyday food choices. Food decisions may be influenced by myriad individual, social, cultural and environmental factors.
• This research explores socially- and culturally-mediated drivers of food choice decisions in sub-sets of the Cork and Kerry cohort.
• Contextualised understanding of food and eating can help to inform the design and planning of tailored public health interventions and communication strategies.
(Mary Delaney & Dr Mary McCarthy, Department of Food Business and Development UCC)
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'Food Choices in Sickness and in Health'
Study 1: Qualitative interview study on food choice influences in participants with different health and dietary profiles
Aim: To explore drivers of current eating habits in the context of everyday lives, health status, attitudes, values, beliefs, priorities and past experiences.
Method: In-depth interviews were carried out with 50 Cork and Kerry participants with varying dietary and health profiles (healthy participants with prudent and non-prudent diets and participants with diabetes and CVD). Analysis of the data will explore how the discourse on healthy eating and risk perception is situated within the wider role and meaning of food in everyday life.
Study 2: Questionnaire study on social-psychological correlates of healthy eating
Aim: To identify motivational determinants of healthy eating and behaviour change
Method: 700 Cork and Kerry participants completed a postal questionnaire on social psychological correlates of healthy eating including attitudes towards healthy eating, risk perception, normative beliefs and self-efficacy. This data will be combined with epidemiological data to identify particular group profiles and target issues for intervention.
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Prevalence of overweight and obesity by age and gender: Cork & Kerry Study 1998
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Prevalence of hypertension by age and gender Cork & Kerry Study 1998
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20
30
40
50
60
%
50-54 55-59 60-64 65-69
Male Female
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Prevalence of diabetes and impaired fasting glucose (combined) by age and gender
Cork & Kerry Study 1998
0
2
4
6
8
10
12
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%
50-54 55-59 60-64 65-69
Male Female
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Prevalence of the metabolic syndrome -US Adult Treatment Panel (ATP) III definition
23Eckel et al. Lancet 2005; 365: 1415–28 23
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Estimates of absolute risk of CVDEuropean Cardiac Society Risk Score
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The prevalence of pre-exisiting disease and the proportions identified "at risk" of a CHD event for three risk threshold, 30%,
20%, 15% over 10 years in the Cork & Kerry Study 1998
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CVD risk factors in men aged 50 to 69 years in 1998 and 2010 Cork & Kerry studies
Variables Cork & Kerry 1998 N=1018
Cork & Kerry 2010 N=2047
Weight Kg (mean (std)) 83.3 (13.4) 87.5(13.8)
BMI (kg/m2) Mean (std) 27.9 (4.1) 29.2(4.2)
Overweight % 52.1 (250) 49.2(493)
Obese I % 25.7 36.7(368)
Waist Circumference Mean cm (std) 99.3 (11.6) 102.8(11.1)
Central obesity % 68.8 (338) 78.6(789)(over 94 cms)
BP(those not on medication)
Mean SBP 136.8 (19.1) 129.3(15.1)
Mean DBP 81.6 (10.3) 79.5(9.2)
Cholesterol(those not on medication)
Mean mmol/L (std) 5.6 (0.9) 5.3(0.9)
% >5mmol/L 72.4 (297) 42.9(416)
HBA1C Mean 5.1 (0.98) 5.9(0.8)
% >6.5 2.2 (11) 8.3(81)
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24-hour ambulatory BP measurement
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24-hour ambulatory BP measurementHeadline findings
Wrist worn,light, water resistant
accelerometerwith capacity to
measure physical activity over 7
days
• 1030 individuals had measurements available for clinic, study and ambulatory blood pressure.
• Approximately 50% of individuals with hypertension based on previous GP readings and 44% of those with hypertension at the study visit had normal ABP.
• However, 21% of those with normal clinic blood pressure and 20% of those with normal study blood pressure had hypertension according to ABPM.
• Data relevant to recent NICE guidelines on use of ABPM in the diagnosis of hypertension.
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0
200
400
600
800Per 100,000Per 100,000
Ireland
UK
USA
Netherlands
Finland
ItalyFrance
International mortality trends in CHD in men aged 35 to 74 years from 1968 to 2003
Fig 2. CHD mortality fall in Ireland 1985 Fig 2. CHD mortality fall in Ireland 1985 -- 2000 explained by 2000 explained by a) treatments in CHD patients & b) population risk factora) treatments in CHD patients & b) population risk factorss
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-4000
-3000
-2000
-1000
0
37633763fewer deathsfewer deaths
Risk Factors worse +14%Risk Factors worse +14%
Risk Factors better Risk Factors better ––61%61%
Treatments Treatments -- 43.6%43.6%
2000200019851985
Fig 2. CHD mortality fall in Ireland 1985 Fig 2. CHD mortality fall in Ireland 1985 -- 2000 explained by 2000 explained by a) treatments in CHD patients & b) population risk factora) treatments in CHD patients & b) population risk factorss