Wellbeing and its determinants CSP Congress 2009 Liverpool 16 October 2009

Social circumstances and health

20 th century trends in life expectancy in Scotland and 16 other Western European countries Males Year of birth Life expectancy in years Scotland

Health Inequalities u Are they due to: –Poverty? –Diet ? –Tobacco?

Deprivation in 1981

Deprivation in 1991

Deprivation in 2001

Excess Standardised Mortality not explained by deprivation (Scotland v. E&W)

Coronary heart disease mortality Men aged years Age-standardised mortality per 100,000

World Health Organization (1997 and 2003)

Smoking prevalence - Europe Males

Smoking prevalence - Europe Females

Comparison of lung cancer mortality in West of Scotland and 3 major cohorts West of Scotland UK doctors American Cancer Society volunteers US veterans Average annual death rate /100,000

Lung cancer mortality by social class never daily cigarette consumption Rate per 10,000 manual non-manual

Risk of death - by level of hopelessness RHR Everson et al 1996

Carotid artery thickening

Aaron Antonovsky

“.....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....

For the creation of health the social and physical environment must be: u Comprehensible u Manageable u Meaningful

STRESS AND GRADE OF EMPLOYMENT: MEN Salivary Cortisol Time of Day Steptoe et al. 2003, Psychosomatic Medicine, 65,

Environmental determinants of inflammatory status CRP (median) mg/dl affluent deprived

P<0.001 P=0.03 Quartile of hs-CRP (Range, mg/dL) P Trend <0.001  – – – –0.210   Relative Risk of MI Ridker. N Engl J Med. 1997;336:973– 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

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

Its all about the brain

All shapes and sizes!

Attachment theory “Infants develop the attachment behaviours that optimally enhance their survival in their own characteristic environments.” Crittenden, 2000

Attachment theory u Ainsworth –Deep emotional connection that infant develops with primary caregiver –Reflects an “internal working model”expressing the infant’s expectations of parental behaviour in meaningful situations –Basis for development of later relationships u Increasingly recognised as determinant of later emotional, cognitive 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 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

Telomeres u Ends of chromosomes u Sense and signal damage u Home of repair systems u Integrate energy production and utilisation u Anti-cancer  Telomere length predictive for mortality

Telomere length in twins by occupation

“Physical activity” or sweaty exercise? u Are we being too modest in our aspirations for fitness? u Should we make more use of sport as a means to get people active? u By embracing “physical activity”, are we admitting defeat?

Opportunity to escape poverty, decent housing, social networks, self esteem and sense of control Consistent parenting, safe, nurturing early years, supportive education Health related behaviours

Opportunity to escape poverty, decent housing, social networks, self esteem and sense of control Consistent parenting, safe, nurturing early years, supportive education Health related behaviours Comprehensible Manageable Meaningful