A secure start in life - why it is so important Dunblane 4 th May 2010

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 u Comprehensible u u Manageable u u Meaningful u u......or the individual would experience chronic stress

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

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

The stressed brain

pSoBid: Stroop test p<0.001 Age (years) Colour-word score

pSoBid: Verbal Learning p<0.001 Age (years) Word recall

pSoBid: Trails B p<0.001 Age (years) Seconds

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

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