Excess Standardised Mortality not explained by deprivation (Scotland v. E&W)
Past experiences:Castlemilk ≥ £244.5m spent over 10 yrs to 2000 u Major impact on physical environment u Population decline – but stabilised u 18% reduction of FTE jobs, though higher employment rate u Rise in % with LLT illness (from 21% in ’91 to 32% in ’01). Glasgow figs 19% to 26%.
World Health Organization (1997 and 2003)www.heartstats.org
19 P<0.001 P=0.03 Quartile of hs-CRP (Range, mg/dL) P Trend <0.001 0.055 0.056–0.114 0.056–0.114 0.115–0.210 0.115–0.210 0.211 0.211 Relative Risk of MI Ridker. N Engl J Med. 1997;336:973–979. 0 1 2 3 1234 hs-CRP and Risk of Future MI in Apparently Healthy Men
Inflammation in plaques Inflammatory cells MMPs, IL-6, IL-15, IL-18, CRP Lumen Core Cap Thin Fibrous Cap InflammatoryCells SMCapoptosis Degradedmatrix Unstable cytokinesMMP
Environmental determinants of inflammatory status CRP (median) mg/dl affluent deprived
0 1 2 3 4 5 00.511.522.533.544.55 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 programming insulin resistance, inflammation and ALP Adipose stores NEFAs liver CRP SAA IL-6/IL-6sR TNF- TNF- sR-I triglyceride Low HDL small LDL Atherogenic Lipoprotein Phenotype Pro-inflammatory state skeletal muscle Insulin resistance
A classification of stress u Positive – tolerable and short lived. Caused by everyday experiences such as meeting new people, frustration and coping with normal discipline. - Concept of “Serve and return” u Tolerable – could affect brain structure but relieved by supportive relationships. Natural disasters, loss of a loved one u Toxic – prolonged, highly active stress response. Associated with abuse, enduring maternal depression, neglect. Absence of continuing supportive relationships fails to build resilience B S McEwen et al 2007
Psobid u Psychological u Sociological and u Biological u Indicators of u Disease
The Dunedin cohort u 1000 children recruited in late 1972/3 u At age 3, “at risk” children identified on the basis of chaotic circumstances, emotional behaviour, negativity and poor attentiveness u As adults, those “at risk” were more likely to : –be unemployed –have criminal convictions (especially for violence) –been pregnant as a teenager –have a substance abuse problem –exhibit signs of insulin resistance and metabolic syndrome
Some early years programmes u Nurse Family Partnership u Infant health and development programme u Perry High/Scope project u Early training project u Carolina Abcderian project u Milwaukee project u The Experience Corps u Pedagogues in Scandinavia u Sure Start in England
Cost benefit of early intervention programmes A Sinclair The Work Foundation 2007
Conclusions u Clear evidence that adverse early life circumstances have distinct biological effects u Some evidence that some early life support projects can improve health, social and economic prospects for children u Successful projects foster engagement between children, their peers and adults in a way that is appropriate to their stage of development u Projects are often poorly evaluated and reports seldom published in peer reviewed literature u Evidence of effectiveness is crucial to influence policy
“We look to Scotland for all our ideas of civilisation.” Voltaire (Francois Marie Arouet, 1694–1778) was responding to the flowering of ideas in eighteenth century Scotland that has become known as ‘The Scottish Enlightenment’..