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

2. Aaron Antonovsky 1923-1994

4. “.....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....

5. 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

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

9. 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

10. Inflammation in plaques Inflammatory cells MMPs, IL-6, IL-15, IL-18, CRP Lumen Core Cap Thin Fibrous Cap InflammatoryCells SMCapoptosis Degradedmatrix Unstable cytokinesMMP

11. 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

12. 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

14. 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

15. “Serve and return” “ The ‘instruction’ to attend to the primary caregiver is genetic, the outcome depends on what happens” Balbernie, 2001

16. The stressed brain

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

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

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

21. 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

22. 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

23. 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