Towards a consensus definition of allostatic load: a multi-cohort, multi-system, multi-biomarker individual participant data (IPD) meta-analysis.

BACKGROUND: Allostatic load (AL) is a multi-system composite index for quantifying physiological dysregulation caused by life course stressors. For over 30 years, an extensive body of research has drawn on the AL framework but has been hampered by the lack of a consistent definition. METHODS: This study analyses data for 67,126 individuals aged 40-111 years participating in 13 different cohort studies and 40 biomarkers across 12 physiological systems: hypothalamic-pituitary-adrenal (HPA) axis, sympathetic-adrenal-medullary (SAM) axis, parasympathetic nervous system functioning, oxidative stress, immunological/inflammatory, cardiovascular, respiratory, lipidemia, anthropometric, glucose metabolism, kidney, and liver. We use individual-participant-data meta-analysis and exploit natural heterogeneity in the number and type of biomarkers that have been used across studies, but a common set of health outcomes (grip strength, walking speed, and self-rated health), to determine the optimal configuration of parameters to define the concept. RESULTS: There was at least one biomarker within 9/12 physiological systems that was reliably and consistently associated in the hypothesised direction with the three health outcomes in the meta-analysis of these cohorts: dehydroepiandrosterone sulfate (DHEAS), low frequency-heart rate variability (LF-HRV), C-reactive protein (CRP), resting heart rate (RHR), peak expiratory flow (PEF), high density lipoprotein cholesterol (HDL-C), waist-to-height ratio (WtHR), HbA1c, and cystatin C. An index based on five biomarkers (CRP, RHR, HDL-C, WtHR and HbA1c) available in every study was found to predict an independent outcome - mortality - as well or better than more elaborate sets of biomarkers. DISCUSSION: This study has identified a brief 5-item measure of AL that arguably represents a universal and efficient set of biomarkers for capturing physiological 'wear and tear' and a further biomarker (PEF) that could usefully be included in future data collection.

A picture of health: determining the core population served by an urban NHS hospital trust and understanding the key health needs.

BACKGROUND: NHS hospitals do not have clearly defined geographic populations to whom they provide care, with patients able to attend any hospital. Identifying a core population for a hospital trust, particularly those in urban areas where there are multiple providers and high population churn, is essential to understanding local key health needs especially given the move to integrated care systems. This can enable effective planning and delivery of preventive interventions and community engagement, rather than simply treating those presenting to services. In this article we describe a practical method for identifying a hospital's catchment population based on where potential patients are most likely to reside, and describe that population's size, demographic and social profile, and the key health needs. METHODS: A 30% proportional flow method was used to identify a catchment population using an acute hospital trust in West London as an example. Records of all hospital attendances between 1st April 2017 and 31st March 2018 were analysed using Hospital Episode Statistics. Any Lower Layer Super Output Areas where 30% or more of residents who attended any hospital for care did so at the example trust were assigned to the catchment area. Publicly available local and national datasets were then applied to identify and describe the population's key health needs. RESULTS: A catchment comprising 617,709 people, of an equal gender-split (50.4% male) and predominantly working age (15 to 64 years) population was identified. Thirty nine point six percent of residents identified as being from Black and Minority Ethnic (BAME) groups, a similar proportion that reported being born abroad, with over 85 languages spoken. Health indicators were estimated, including: a healthy life expectancy difference of over twenty years; bowel cancer screening coverage of 48.8%; chlamydia diagnosis rates of 2,136 per 100,000; prevalence of visible dental decay among five-year-olds of 27.9%. CONCLUSIONS: We define a blueprint by which a catchment can be defined for a hospital trust and demonstrate the value a hospital-view of the local population could provide in understanding local health needs and enabling population-level health improvement interventions. While an individual approach allows tailoring to local context and need, there could be an efficiency saving were such public health information made routinely and regularly available for every NHS hospital.

Smoking, SARS-CoV-2 and COVID-19: A review of reviews considering implications for public health policy and practice.

INTRODUCTION: There has been significant speculation regarding the association between the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pathogen, coronavirus disease (COVID-19) and smoking. We provide an overview of the available literature regarding the association between smoking, risk of SARS-CoV-2 infection, and risk of severe COVID-19 and poor clinical outcomes, with the aim of informing public health policy and practice, particularly in England. METHODS: Publications were identified utilising a systematic search approach on PUBMED and Google Scholar. Publications presenting a systematic review or meta-analysis considering the association between smoking and SARS-COV-2 infection or COVID-19 outcomes were included. RESULTS: Eight studies were identified. One considered the relationship between smoking and the probability of SARS-CoV-2 infection, three considered the association between COVID-19 hospitalisation and smoking history, and six reviewed the association between smoking history and development of severe COVID-19. One study specifically investigated the risk of mortality. The studies considering risk of severe disease indicate that there is a significant association between COVID-19 and current or ever smoking. CONCLUSIONS: This is a rapidly evolving topic. Current analysis remains limited due to the quality of primary data, although, early results indicate an association between smoking and COVID-19 severity. We highly recommend public health messaging to continue focusing on smoking cessation efforts.

The association between parity, CVD mortality and CVD risk factors among Norwegian women and men.

BACKGROUND: Several studies have shown that women and men with two children have lower mortality than the childless, but there is less certainty about mortality, including CVD mortality, at higher parities and meagre knowledge about factors underlying the parity-mortality relationship. METHODS: The association between parity and CVD mortality was analyzed by estimating discrete-time hazard models for women and men aged 40-80 in 1975-2015. Register data covering the entire Norwegian population were used, and the models included a larger number of relevant sociodemographic control variables than in many previous studies. To analyze the relationship between parity and seven CVD risk factors, logistic models including the same variables as the mortality models were estimated from the CONOR collection of health surveys, linked to the register data. RESULTS: Men (but not women) who had four or more children had higher mortality from CVD than those with two, although this excess mortality was not observed for the heart disease sub-group. Overweight, possibly in part a result of less physical activity, seems to play a role in this. All CVD risk factors except smoking and alcohol may contribute to the relatively high CVD mortality among childless. CONCLUSIONS: Childbearing is related to a number of well-known CVD risk factors, and becoming a parent or having an additional child is, on the whole, associated with lower-or at least not higher-CVD mortality in Norway. However, for men family sizes beyond three children are associated with increased CVD mortality, with risks of overweight one possible pathway.

Fertility trajectories and later-life depression among parents in England.

We examine pathways between indicators of fertility tempo/quantum and depressive symptoms among parents aged 55+ with at least two children, using three waves of the English Longitudinal Study of Ageing. Using standard regression approaches and path analysis within the structural equation framework, we also investigate whether fertility trajectories mediated the association between childhood disadvantage and later-life depression. Results provide limited support for direct influences of fertility trajectories on depression, but indicate indirect linkages for both women and men. Associations are mediated by partnership history, social support, wealth, later-life smoking, and functional limitation. Associations between childhood disadvantage and later-life depression are partially mediated by fertility stressors. Results confirm the influence of life course experiences on depression at older ages and demonstrate the interlinked role of family and other life course pathways on later-life well-being.

Life-course partnership history and midlife health behaviours in a population-based birth cohort.

BACKGROUND: Marital and partnership history is strongly associated with health in midlife and later life. However, the role of health behaviours as an explanatory mechanism remains unclear. The aim of this study was to investigate prospective associations between life-course partnership trajectories (taking into account timing, non-marital cohabitation, remarriage and marital transitions) and health behaviours measured in midlife. METHODS: We analysed data from the British National Child Development Study, a prospective cohort study that includes all people born in 1 week of March 1958 (N=10 226). This study included men and women with prospective data on partnership history from age 23 to 42-44 and health behaviours collected at ages 42-46 (2000-2004). Latent class analysis was used to derive longitudinal trajectories of partnership history. We used multivariable regression models to estimate the association between midlife health behaviours and partnership trajectory, adjusting for various early and young adult characteristics. RESULTS: After adjustment for a range of potential selection factors in childhood and early adulthood, we found that problem drinking, heavy drinking and smoking were more common in men and women who experienced divorce or who had never married or cohabited. Women who married later had a lower prevalence of smoking and were less likely to be overweight than those who married earlier. Overall marriage was associated with a higher body mass index. Individuals who never married or cohabited spent less time exercising. CONCLUSIONS: Some aspects of partnership history such as remaining unpartnered and experiencing divorce are associated with more smoking and drinking in midlife, whereas marriage is associated with midlife weight gain. Despite these offsetting influences, differences in health behaviours probably account for much of the association between partnership trajectories and health found in previous studies.

Allostatic load and health in the older population of England: a crossed-lagged analysis.

OBJECTIVE: Allostatic load, a composite measure of accumulated physical wear and tear, has been proposed as an early sign of physiological dysregulation predictive of health problems, functional limitation, and disability. However, much previous research has been cross sectional and few studies consider repeated measures. We investigate the directionality of associations between allostatic load, self-rated health, and a measure of physical function (walking speed). METHODS: The sample included men and women 60 and older who participated in Wave 2 (2004) and Wave 4 (2008) of the English Longitudinal Study of Ageing (n = 6132 in Wave 2). Allostatic load was measured with nine biomarkers using a multisystem summary approach. Self-rated health was measured using a global 5 point summary indicator. Time to walk 8 ft was used as a measure of function. We fitted and tested autoregressive cross-lagged models between the allostatic load measure, self-rated health, and walking speed in Waves 2 and 4. Models were adjusted for age, sex, educational level, and smoking status at Wave 2 and for time-varying indicators of marital status, wealth, physical activity, and social support. RESULTS: Allostatic load predicted slower walking speed (standardized estimate = -0.08, 95% confidence interval [CI] = -0.10 to -0.05). Better self-rated health predicted faster walking speed (standardized estimate = 0.11, 95% CI = 0.08-0.13) as well as lower allostatic load (standardized estimate = -0.15, 95% CI = -0.22 to -0.09), whereas paths from allostatic load and walking speed to self-rated health were weaker (standardized estimates = -0.05 [95% CI = -0.07 to -0.02] and 0.06 [95% CI = 0.04-0.08]). CONCLUSIONS: Allostatic load can be a useful risk indicator of subsequent poor health or function.

Completeness and usability of ethnicity data in UK-based primary care and hospital databases.

BACKGROUND: Ethnicity recording across the National Health Service (NHS) has improved dramatically over the past decade. This study profiles the completeness, consistency and representativeness of routinely collected ethnicity data in both primary care and hospital settings. METHODS: Completeness and consistency of ethnicity recording was examined in the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES), and the ethnic breakdown of the CPRD was compared with that of the 2011 UK censuses. RESULTS: 27.1% of all patients in the CPRD (1990-2012) have ethnicity recorded. This proportion rises to 78.3% for patients registered since April 2006. The ethnic breakdown of the CPRD is comparable to the UK censuses. 79.4% of HES inpatients, 46.8% of outpatients and 26.8% of A&E patients had their ethnicity recorded. Amongst those with ethnicity recorded on >1 occasion, consistency was over 90% in all data sets except for HES inpatients. Combining CPRD and HES increased completeness to 97%, with 85% of patients having the same ethnicity recorded in both databases. CONCLUSIONS: Using CPRD ethnicity from 2006 onwards maximizes completeness and comparability with the UK population. High concordance within and across NHS sources suggests these data are of high value when examining the continuum of care. Poor completeness and consistency of A&E and outpatient data render these sources unreliable.

Socioeconomic position and later life prevalence of hypertension, diabetes and visual impairment in Nakuru, Kenya.

OBJECTIVES: We examined the extent to which the association between socioeconomic position (SEP) and later life prevalence of hypertension, diabetes and visual impairment in Nakuru, Kenya is mediated by health-related behaviour. METHODS: We used data from a community survey of 4,314 participants sampled from urban and rural areas in Nakuru, Kenya. Structural equation modelling was employed to estimate the direct and indirect--via health-related behaviour--effects of SEP on the three health outcomes. RESULTS: The accumulation of material resources was positively associated with hypertension and diabetes, whereas both education and material resources had a negative association with the prevalence of visual impairment. However, the observed health inequalities were not due to variation between SEP groups in health-related behaviour. CONCLUSIONS: The pattern of associations between education, material resources and the three health outcomes varied, suggesting that in Kenya, unlike the observed pattern of inequalities in high income countries, different dimensions of SEP provide different aspects of protection as well as risk. Smoking and alcohol use did not appear to mediate the observed associations, in contrast with countries past the epidemiologic transition.

Effect of a nutrition supplement and physical activity program on pneumonia and walking capacity in Chilean older people: a factorial cluster randomized trial.

BACKGROUND: Ageing is associated with increased risk of poor health and functional decline. Uncertainties about the health-related benefits of nutrition and physical activity for older people have precluded their widespread implementation. We investigated the effectiveness and cost-effectiveness of a national nutritional supplementation program and/or a physical activity intervention among older people in Chile. METHODS AND FINDINGS: We conducted a cluster randomized factorial trial among low to middle socioeconomic status adults aged 65-67.9 years living in Santiago, Chile. We randomized 28 clusters (health centers) into the study and recruited 2,799 individuals in 2005 (~100 per cluster). The interventions were a daily micronutrient-rich nutritional supplement, or two 1-hour physical activity classes per week, or both interventions, or neither, for 24 months. The primary outcomes, assessed blind to allocation, were incidence of pneumonia over 24 months, and physical function assessed by walking capacity 24 months after enrollment. Adherence was good for the nutritional supplement (~75%), and moderate for the physical activity intervention (~43%). Over 24 months the incidence rate of pneumonia did not differ between intervention and control clusters (32.5 versus 32.6 per 1,000 person years respectively; risk ratio = 1.00; 95% confidence interval 0.61-1.63; p = 0.99). In intention-to-treat analysis, after 24 months there was a significant difference in walking capacity between the intervention and control clusters (mean difference 33.8 meters; 95% confidence interval 13.9-53.8; p = 0.001). The overall cost of the physical activity intervention over 24 months was US$164/participant; equivalent to US$4.84/extra meter walked. The number of falls and fractures was balanced across physical activity intervention arms and no serious adverse events were reported for either intervention. CONCLUSIONS: Chile's nutritional supplementation program for older people is not effective in reducing the incidence of pneumonia. This trial suggests that the provision of locally accessible physical activity classes in a transition economy population can be a cost-effective means of enhancing physical function in later life. TRIAL REGISTRATION: Current Controlled Trials ISRCTN 48153354.

Health measurement in population surveys: combining information from self-reported and observer-measured health indicators.

Our primary aim is to develop and validate a population health metric for survey-based health assessment that combines information from both self-reported and observer-measured health indicators. A secondary objective is to use this index to examine gender and socioeconomic differentials in the health status of older people. We use data from the second wave of the English Longitudinal Study of Ageing (ELSA) conducted in 2004 (N = 8,870). Information from three observer-measured and three self-reported health indicators was combined, using a latent variable modeling approach. A model that decomposed the manifest health indicators to valid health, systematic error, and random error was found to fit the data best. The latent health dimension represented somatic health, and was tested against three external criteria: height, waist-hip ratio, and smoking status. We present the Latent Index of Somatic Health (LISH), as well as a procedure for deriving the LISH in surveys employing both self- and observer-measured health indicators. Observer-measured and self-reported indicators were found to be equally biased in indexing population somatic health, with the exception of self-reports of functional limitations, which was the most reliable somatic health indicator. As expected, results showed that women had worse health than men and that socioeconomic advantage is associated with better somatic health.

Fertility history and cause-specific mortality: a register-based analysis of complete cohorts of Norwegian women and men.

The relationship between women's reproductive histories and later all-cause mortality has been investigated in several studies, with mixed results. Some studies have also considered cause-specific mortality and some have included men, but none has done both. We analyse associations between parity and age of first birth for women and men across 11 cause-of-death groupings using Norwegian register data for complete cohorts born 1935-1968 whose mortality was observed 1980-2003 (i.e. at ages 45-68). Age, period, educational level, marital status, region of residence and population size of municipality were included as co-variates. In total, there were 63,000 deaths. Results showed that relative to parents of two children, childless men and women and those with one child had higher mortality risks for nearly all cause of death groupings. High parity (4+ children) was associated with raised male mortality from accidents and violence and higher mortality from cancer of the cervix among women. For other cause and gender groupings there was either little difference between those with two children and those of higher parities or an overall negative association between parity and mortality. Among men with the lowest level of education, however, high parity was positively associated with mortality from circulatory diseases. For all causes except female breast cancer, there was an inverse association between age at first birth and mortality risk. Similarities observed across cause groups and for women and men suggest that much of the fertility-mortality relationship is a result of selection or effects of reproductive behaviour on lifestyle. The latter may include both beneficial effects and harmful stress responses. However, physiological mechanisms are most probably important for some causes of death for women. Research on associations between parenting histories, health related behaviours, social support exchanges and reported or measured stress is needed to clarify mechanisms underlying the associations reported here.

The association of cancer survival with four socioeconomic indicators: a longitudinal study of the older population of England and Wales 1981-2000.

BACKGROUND: Many studies have found socioeconomic differentials in cancer survival. Previous studies have generally demonstrated poorer cancer survival with decreasing socioeconomic status but mostly used only ecological measures of status and analytical methods estimating simple survival. This study investigate socio-economic differentials in cancer survival using four indicators of socioeconomic status; three individual and one ecological. It uses a relative survival method which gives a measure of excess mortality due to cancer. METHODS: This study uses prospective record linkage data from The Office for National Statistics Longitudinal Study for England and Wales. The participants are Longitudinal Study members, recorded at census in 1971 and 1981 and with a primary malignant cancer diagnosed at age 45 or above, between 1981 and 1997, with follow-up until end 2000. The outcome measure is relative survival/excess mortality, compared with age and sex adjusted survival of the general population. Relative survival and Poisson regression analyses are presented, giving models of relative excess mortality, adjusted for covariates. RESULTS: Different socioeconomic indicators detect survival differentials of varying magnitude and definition. For all cancers combined, the four indicators show similar effects. For individual cancers there are differences between indicators. Where there is an association, all indicators show poorer survival with lower socioeconomic status. CONCLUSION: Cancer survival differs markedly by socio-economic status. The commonly used ecological measure, the Carstairs Index, is adequate at demonstrating socioeconomic differentials in survival for combined cancers and some individual cancers. A combination of car access and housing tenure is more sensitive than the ecological Carstairs measure at detecting socioeconomic effects on survival--confirming Carstairs effects where they occur but additionally identifying effects for other cancers. Social class is a relatively weak indicator of survival differentials.

Promoção da saúde, epidemiologia social e capital social: inter-relações e perspectivas para a saúde pública / Health promotion, social epidemiology, and social capital: associations and perspectives for public health

A idéia de promover saúde antecede o uso explícito do termo. No entanto, a incorporação dessa idéia e da prática no campo da saúde pública foi influenciado especialmente pela reforma de saúde iniciada no Canadá, em 1974, a qual refletiu os anseios de muitos outros preocupados com influência do meio físico e social na saúde. Essa reforma serviu de base para o lançamento de várias conferências desencadeados pela Organização Mundial da Saúde, começando pela de Alma Ata em 1977, e seguida pela Conferência de Ottawa, da qual resultou o primeiro documento internacional em promoção de saúde: a Carta de Ottawa. Embora promoção da saúde esteja presente em uma grande e variada literatura, seu conceito ainda não é bem entendido e sua prática dificultada. Parece que a importância dessas conferências tem servido para não deixar fenecer a idéia de eqüidade em saúde, uma vez que os esforços para reduzir a distância entre retórica e prática continuam longe de ser alcançados. Entretanto, o crescimento da epidemiologia social associado ao conceito de capital social para saúde podem complementar os preceitos da epidemiologia tradicional e, conseqüentemente, contribuir para a efetivação do modelo estruturalista para a promoção da saúde. O propósito desse artigo é elucidar esses conceitos e descrever o papel que eles desempenham no campo da saúde pública a fim de estimular debates futuros.

Health inequalities in the older population: the role of personal capital, social resources and socio-economic circumstances.

Older people now constitute the majority of those with health problems in developed countries so an understanding of health variations in later life is increasingly important. In this paper, we use data from three rounds of the Health Survey for England, a large nationally representative sample, to analyse variations in the health of adults aged 65-84 by indicators of attributes acquired in childhood and young adulthood, termed personal capital; and by current social resources and current socio-economic circumstances, while controlling for smoking behaviour and age. We used six indicators of health status in the analysis, four based on self-reports and two based on nurse collected data, which we hypothesised would identify different dimensions of health. Results showed that socio-economic indicators, particularly receipt of income support (a marker of poverty) were most consistently associated with raised odds of poor health outcomes. Associations between marital status and health were in some cases not in the expected direction. This may reflect bias arising from exclusion of the institutional population (although among those under 85 the proportion in institutions is very low) but merits further investigation, especially as the marital status composition of the older population is changing. Analysis of deviance showed that social resources (marital status and social support) had the greatest effect on the indicator of psychological health (GHQ) and also contributed significantly to variation in self-rated health, but among women not to variation in taking three or more medicines and among men not to self-reported long-standing illnesses. Smoking, in contrast, was much more strongly associated with these indicators than with self-rated health. These results are consistent with the view that self-rated health may provide a holistic indicator of health in the sense of well-being, whereas measures such as taking prescribed medications may be more indicative of specific morbidities. The results emphasise again the need to consider both socio-economic and socio-psychological influences on later life health.