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

Social circumstances and healthSocial circumstances and health

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?

Deprivation in 1981Deprivation in 1981

Deprivation in 1991Deprivation in 1991

Deprivation in 2001Deprivation in 2001

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

Smoking prevalence - EuropeSmoking prevalence - Europe

Males

Smoking prevalence - EuropeSmoking prevalence - Europe

Females

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

Carotid artery thickeningCarotid artery thickening

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

Aaron Antonovsky 1923-1994Aaron Antonovsky 1923-1994

“.....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

Its all about the brainIts all about the brain

All shapes and sizes!All shapes and sizes!

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

Engaged to respond to danger

Disengaged...Who needs to bother about differential calculus?

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

Telomere length in twins by occupationTelomere length in twins by occupation

““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