Midlife health in Britain and the United States: a comparison of two nationally representative cohorts.

BACKGROUND: Older adults in the USA have worse health and wider socioeconomic inequalities in health compared with those in Britain. Less is known about how health in the two countries compares in mid-life, a time of emerging health decline, including inequalities in health. METHODS: We compare measures of current regular smoking status, obesity, self-rated health, cholesterol, blood pressure and glycated haemoglobin using population-weighted modified Poisson regression in the 1970 British Cohort Study (BCS70) in Britain (N = 9665) and the National Longitudinal Study of Adolescent to Adult Health (Add Health) in the USA (N = 12 300), when cohort members were aged 34-46 and 33-43, respectively. We test whether associations vary by early- and mid-life socioeconomic position. RESULTS: US adults had higher levels of obesity, high blood pressure and high cholesterol. Prevalence of poor self-rated health and current regular smoking was worse in Britain. We found smaller socioeconomic inequalities in mid-life health in Britain compared with the USA. For some outcomes (e.g. smoking), the most socioeconomically advantaged group in the USA was healthier than the equivalent group in Britain. For other outcomes (hypertension and cholesterol), the most advantaged US group fared equal to or worse than the most disadvantaged groups in Britain. CONCLUSIONS: US adults have worse cardiometabolic health than British counterparts, even in early mid-life. The smaller socioeconomic inequalities and better overall health in Britain may reflect differences in access to health care, welfare systems or other environmental risk factors.

Clustering of adverse health and educational outcomes in adolescence following early childhood disadvantage: population-based retrospective UK cohort study.

BACKGROUND: Disadvantage in early childhood (ages 0-5 years) is associated with worse health and educational outcomes in adolescence. Evidence on the clustering of these adverse outcomes by household income is scarce in the generation of adolescents born since the turn of the millennium. We aimed to describe the association between household income in early childhood and physical health, psychological distress, smoking behaviour, obesity, and educational outcomes at age 17 years, including the patterning and clustering of these five outcomes by income quintiles. METHODS: In this population-based, retrospective cohort study, we used data from the Millennium Cohort Study in which individuals born in the UK between Sept 1, 2000, and Jan 1, 2002, were followed up. We collected data on five adverse health and social outcomes in adolescents aged 17 years known to limit life chances: psychological distress, self-assessed ill health, smoking, obesity, and poor educational achievement. We compared how single and multiple outcomes were distributed across early childhood quintile groups of income, as an indicator of disadvantage, and modelled the potential effect of three income-shifting scenarios in early childhood for reducing adverse outcomes in adolescence. FINDINGS: We included 15 245 adolescents aged 17 years, 7788 (51·1%) of whom were male and 7457 (48·9%) of whom were female. Adolescents in the lowest income quintile group in childhood were 12·7 (95% CI 6·4-25·1) times more likely than those in the highest quintile group to have four or five adverse adolescent outcomes, with poor educational achievement (risk ratio [RR] 4·6, 95% CI 4·2-5·0) and smoking (3·6, 3·0-4·2), showing the largest single risk ratios. Shifting up to the second lowest, middle, and highest income groups would reduce multiple adolescent adversities by 4·9% (95% CI -23·8 to 33·6), 32·3% (-2·7 to 67·3), and 83·9% (47·2 to 120·7), respectively. Adjusting for parental education and single parent status moderately attenuated these estimates. INTERPRETATION: Early childhood disadvantage is more strongly correlated with multiple adolescent adversities than any of the five single adverse outcomes. However, shifting children from the lowest income quintile group to the next lowest group is ineffective. Tackling multiple adolescent adversities requires managing early childhood disadvantage across the social gradient, with income redistribution as a central element of coordinated cross-sectoral action. FUNDING: UK Prevention Research Partnership.

Midlife Health in Britain and the US: A comparison of Two Nationally Representative Cohorts.

Background: Older adults in the United States (US) have worse health and wider socioeconomic inequalities in health compared to Britain. Less is known about how health in the two countries compares in midlife, a time of emerging health decline, including inequalities in health. Methods: We compare measures of smoking status, alcohol consumption, obesity, self-rated health, cholesterol, blood pressure, and glycated haemoglobin using population-weighted modified Poisson regression in the 1970 British Cohort Study (BCS70) in Britain (N= 9,665) and the National Longitudinal Study of Adolescent to Adult Health (Add Health) in the US (N=12,297), when cohort members were aged 34-46 and 33-43, respectively. We test whether associations vary by early- and mid-life socioeconomic position. Findings: US adults had higher levels of obesity, high blood pressure and high cholesterol. Prevalence of poor self-rated health, heavy drinking, and smoking was worse in Britain. We found smaller socioeconomic inequalities in midlife health in Britain compared to the US. For some outcomes (e.g., smoking), the most socioeconomically advantaged group in the US was healthier than the equivalent group in Britain. For other outcomes (hypertension and cholesterol), the most advantaged US group fared equal to or worse than the most disadvantaged groups in Britain. Interpretation: US adults have worse cardiometabolic health than British counterparts, even in early midlife. The smaller socioeconomic inequalities and better overall health in Britain may reflect differences in access to health care, welfare systems, or other environmental risk factors. Funding: ESRC, UKRI, MRC, NIH, European Research Council, Leverhulme Trust.

The UK Coronavirus Job Retention Scheme and smoking, alcohol consumption and vaping during the COVID-19 pandemic: evidence from eight longitudinal population surveys.

BACKGROUND: Employment disruptions can impact smoking and alcohol consumption. During the COVID-19 pandemic, many countries implemented furlough schemes to prevent job loss. We examine how furlough was associated with smoking, vaping and alcohol consumption in the UK. METHODS: Data from 27,841 participants in eight UK adult longitudinal surveys were analysed. Participants self-reported employment status and current smoking, current vaping and alcohol consumption (>4 days/week or 5+ drinks per typical occasion) both before and during the early stages of the pandemic (April-July 2020). Risk ratios were estimated within each study using modified Poisson regression, adjusting for a range of potential confounders, including pre-pandemic behaviour. Findings were synthesised using random effects meta-analysis. RESULTS: Compared to stable employment and after adjustment for pre-pandemic characteristics, furlough was not associated with smoking (ARR = 1.05; 95% CI: 0.95-1.16; I2: 10%), vaping (ARR = 0.89; 95% CI: 0.74-1.08; I2: 0%) or drinking (ARR = 1.03; 95% CI: 0.94-1.13; I2: 48%). There were similar findings for no longer being employed, and stable unemployment, though this varied by sex: stable unemployment was associated with smoking for women (ARR = 1.35; 95% CI: 1.00-1.82; I2: 47%) but not men (0.84; 95% CI: 0.67-1.05; I2: 0%). No longer being employed was associated with vaping among women (ARR = 2.74; 95% CI: 1.59-4.72; I2: 0%) but not men (ARR = 1.25; 95% CI: 0.83-1.87; I2: 0%). CONCLUSIONS: We found no clear evidence of furlough or unemployment having adverse impacts on smoking, vaping or drinking behaviours during the early stages of the COVID-19 pandemic in the UK. Differences in risk compared to those who remained employed were largely explained by pre-pandemic characteristics.

The UK Coronavirus Job Retention Scheme and diet, physical activity, and sleep during the COVID-19 pandemic: evidence from eight longitudinal population surveys.

BACKGROUND: In March 2020, the UK implemented the Coronavirus Job Retention Scheme (furlough) to minimise job losses. Our aim was to investigate associations between furlough and diet, physical activity, and sleep during the early stages of the COVID-19 pandemic. METHODS: We analysed data on 25,092 participants aged 16-66 years from eight UK longitudinal studies. Changes in employment, including being furloughed, were based on employment status before and during the first lockdown. Health behaviours included fruit and vegetable consumption, physical activity, and sleep. Study-specific estimates obtained using modified Poisson regression, adjusting for socio-demographic characteristics and pre-pandemic health and health behaviours, were statistically pooled using random effects meta-analysis. Associations were also stratified by sex, age, and education. RESULTS: Across studies, between 8 and 25% of participants were furloughed. Compared to those who remained working, furloughed workers were slightly less likely to be physically inactive (RR = 0.85; [95% CI 0.75-0.97]; I 2 = 59%) and did not differ overall with respect to low fruit and vegetable consumption or atypical sleep, although findings for sleep were heterogenous (I 2 = 85%). In stratified analyses, furlough was associated with lower fruit and vegetable consumption among males (RR = 1.11; [1.01-1.22]; I 2 = 0%) but not females (RR = 0.84; [0.68-1.04]; I 2 = 65%). Considering changes in quantity, furloughed workers were more likely than those who remained working to report increases in fruit and vegetable consumption, exercise, and hours of sleep. CONCLUSIONS: Those furloughed exhibited similar health behaviours to those who remained in employment during the initial stages of the pandemic. There was little evidence to suggest that adoption of such social protection policies in the post-pandemic recovery period and during future economic crises had adverse effects on population health behaviours.

SARS-CoV-2 infection in the first trimester and the risk of early miscarriage: a UK population-based prospective cohort study of 3041 pregnancies conceived during the pandemic.

STUDY QUESTION: Does maternal infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the first trimester affect the risk of miscarriage before 13 week's gestation? SUMMARY ANSWER: Pregnant women with self-reported diagnosis of SARS-CoV-2 in the first trimester had a higher risk of early miscarriage. WHAT IS KNOWN ALREADY: Viral infections during pregnancy have a broad spectrum of placental and neonatal pathology. Data on the effects of the SARS-CoV-2 infection in pregnancy are still emerging. Two systematic reviews and meta-analyses reported an increased risk of preterm birth, caesarean delivery, maternal morbidity and stillbirth. Data on the impact of first trimester infection on early pregnancy outcomes are scarce. This is the first study, to our knowledge, to investigate the rates of early pregnancy loss during the SARS-CoV-2 outbreak among women with self-reported infection. STUDY DESIGN, SIZE, DURATION: This was a nationwide prospective cohort study of pregnant women in the community recruited using social media between 21 May and 31 December 2020. We recruited 3545 women who conceived during the SARS-CoV-2 pandemic who were <13 week's gestation at the time of recruitment. PARTICIPANTS/MATERIALS, SETTING, METHODS: The COVID-19 Contraception and Pregnancy Study (CAP-COVID) was an on-line survey study collecting longitudinal data from pregnant women in the UK aged 18 years or older. Women who were pregnant during the pandemic were asked to complete on-line surveys at the end of each trimester. We collected data on current and past pregnancy complications, their medical history and whether they or anyone in their household had symptoms or been diagnosed with SARS-CoV-2 infection during each trimester of their pregnancy. RT-PCR-based SARS-CoV-2 RNA detection from respiratory samples (e.g. nasopharynx) is the standard practice for diagnosis of SARS-CoV-2 in the UK. We compared rate of self-reported miscarriage in three groups: 'presumed infected', i.e. those who reported a diagnosis with SARS-CoV-2 infection in the first trimester; 'uncertain', i.e. those who did not report a diagnosis but had symptoms/household contacts with symptoms/diagnosis; and 'presumed uninfected', i.e. those who did not report any symptoms/diagnosis and had no household contacts with symptoms/diagnosis of SARS-CoV-2. MAIN RESULTS AND THE ROLE OF CHANCE: A total of 3545 women registered for the CAP-COVID study at <13 weeks gestation and were eligible for this analysis. Data for the primary outcome were available from 3041 women (86%). In the overall sample, the rate of self-reported miscarriage was 7.8% (238/3041 [95% CI, 7-9]). The median gestational age (GA) at miscarriage was 9 weeks (interquartile range 8-11). Seventy-seven women were in the 'presumed infected' group (77/3041, 2.5% [95% CI 2-3]), 295/3041 were in the uncertain group (9.7% [95% CI 9-11]) and the rest in the 'presumed uninfected' (87.8%, 2669/3041 [95% CI 87-89]). The rate of early miscarriage was 14% in the 'presumed infected' group, 5% in the 'uncertain' and 8% in the 'presumed uninfected' (11/77 [95% CI 6-22] versus 15/295 [95% CI 3-8] versus 212/2669 [95% CI 7-9], P = 0.02). After adjusting for age, BMI, ethnicity, smoking status, GA at registration and the number of previous miscarriages, the risk of early miscarriage appears to be higher in the 'presumed infected' group (relative rate 1.7, 95% CI 1.0-3.0, P = 0.06). LIMITATIONS, REASONS FOR CAUTION: We relied on self-reported data on early pregnancy loss and SARS-CoV-2 infection without any means of checking validity. Some women in the 'presumed uninfected' and 'uncertain' groups may have had asymptomatic infections. The number of 'presumed infected' in our study was low and therefore the study was relatively underpowered. WIDER IMPLICATIONS OF THE FINDINGS: This was a national study from the UK, where infection rates were one of the highest in the world. Based on the evidence presented here, women who are infected with SARS-CoV-2 in their first trimester may be at an increased risk of a miscarriage. However, the overall rate of miscarriage in our study population was 8%. This is reassuring and suggests that if there is an effect of SARS-CoV-2 on the risk of miscarriage, this may be limited to those with symptoms substantial enough to lead to a diagnostic test. Further studies are warranted to evaluate a causal association between SARS-CoV-2 infection in early pregnancy and miscarriage risk. Although we did not see an overall increase in the risk of miscarriage, the observed comparative increase in the presumed infected group reinforces the message that pregnant women should continue to exercise social distancing measures and good hygiene throughout their pregnancy to limit their risk of infection. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by a grant from the Elizabeth Garrett Anderson Hospital Charity (G13-559194). The funders of the study had no role in study design, data collection, data analysis, data interpretation or writing of the report. J.A.H. is supported by an NIHR Advanced Fellowship. A.L.D. is supported by the National Institute for Health Research University College London Hospitals Biomedical Research Centre. All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: support to J.A.H. and A.L.D. as above; no financial relationships with any organizations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work. TRIAL REGISTRATION NUMBER: N/A.

The clustering of risk behaviours in adolescence and health consequences in middle age.

INTRODUCTION: There is increasing interest in the clustering of risk behaviours in adolescence. However, few studies have examined what clusters of risk behaviours exist among adolescents, their early-life predictors, and their associations with later health. METHODS: We analysed data derived from 8754 participants (women 53.3%) in the 1970 British Cohort Study. Latent class analysis was used to identify clusters of risk behaviours at age 16. Regression modelling was then used to examine predictors of clusters and their consequences of risk behaviours and health outcomes at age 42. RESULTS: We identified two latent classes: a risky-behaviour (men: 20.0%, women: 23.6%) and less-risky-behaviour class. Among men, those in the risky-behaviour class were more likely to report smoking, multiple binge drinking, sexual debut before 16, involvement in fights and delinquency than were women. Membership in risky-behaviour class was mainly predicted by sociodemographic and parental risk behaviours and monitoring. The risky-behaviour class at age 16 was associated with the following outcome age 42: smoking status (more strongly among women), excessive alcohol consumption (more strongly among men), worse self-rated health (more strongly among men), and psychological distress (only among women). CONCLUSIONS: Engagement in multiple risk behaviours in adolescence is an important driver of health inequalities later in life. Early life intervention, for example via school-based interventions, may be warranted for favourable lifelong health.

Light drinking during pregnancy: Social advantages explain positive correlates with child and early adolescent adjustment.

Maternal heavy alcohol use during pregnancy is harmful to offspring's health and adjustment. However, findings from studies on lower levels of prenatal drinking are mixed; a few even predict positive cognitive and psychosocial outcomes. Given that alcohol is a neurotoxin and teratogen, scholars question developmental benefits and point to residual confounding as a potential explanation, particularly as light drinkers are positively selected with respect to health and socioeconomic status. Using prospective, intergenerational data from the nationally-representative Millennium Cohort Study (MCS) in the United Kingdom, we studied associations between mother's drinking during pregnancy and children's cognitive and psychosocial outcomes at ages 3, 5, 7, 11, and 14 years (n = 10,454). We included early life confounders (e.g., maternal education, health, smoking) and mother's cognitive ability, and assessed robustness of relationships across outcomes and alternate drinking classifications. Results of a series of multivariable regression models found no association between light drinking and cognitive and psychosocial outcomes up to and including the age of 14, after controlling for key confounders. Light drinking during pregnancy was linked to higher socioeconomic advantages (e.g., mothers' higher education, professional/managerial occupation, home ownership, cognitive scores), which together accounted for positive associations between light drinking and children's outcomes. Mother's cognitive ability was an especially important confounder.

Risk factors associated with early smoking onset in two large birth cohorts.

We use prospective data from the ongoing British Cohort Study (BCS) and Millennium Cohort Study (MCS) to: 1) document changes in the prevalence of childhood smoking onset; 2) assess whether broad historic shifts in key risk factors, such as maternal education, parental smoking, and peer childhood smoking, explain observed cohort changes in childhood smoking; and 3) evaluate whether inequalities in onset have narrowed or widened during this period. The children in these two studies were born 31 years apart (i.e., BCS in 1970; MCS in 2001), and were followed from infancy through early adolescence (n = 23,506 children). Our outcome variable is child self-reports of smoking (ages 10, 11). Early life risk factors were assessed via parent reports in infancy and age 5. Findings reveal that the odds of childhood smoking were over 12 times greater among children born in 1970 versus 2001. The decline in childhood smoking by cohort was partly explained by increases in maternal education, decreases in mothers' and fathers' smoking, and declines in the number of children whose friends smoked. Results also show that childhood smoking is now more linked to early life disadvantages, as MCS children were especially likely to smoke if their mother had low education or used cigarettes, or if the child had a friend who smoked. Although the prevalence of child and adult smoking has dropped dramatically in the past three decades, policy efforts should focus on the increased social inequality resulting from the concentration of early life cigarette use among disadvantaged children.

Association of nursery and early school attendance with later health behaviours, biomedical risk factors, and mortality: evidence from four decades of follow-up of participants in the 1958 birth cohort study.

BACKGROUND: Although early life education for improved long-term health and the amelioration of socioeconomically generated inequalities in chronic disease is advocated in influential policy statements, the evidence base is very modest. AIMS: To address this dearth of evidence using data from a representative UK national birth cohort study. METHODS: The analytical sample comprised men and women in the 1958 birth cohort study with prospectively gathered data on attendance at nursery or primary school before the age of 5 years who had gone on to participate in social survey at 42 years (n=11 374), or a biomedical survey at 44/5 years of age (n=9210), or had data on vital status from 18 to 55 years (n=17 657). RESULTS: Relative to study members who had not attended nursery, in those who had, there was in fact a higher prevalence of smoking and high alcohol intake in middle age. Conversely, nursery attenders had more favourable levels of lung function and systolic blood pressure in middle age. This apparent association between nursery attendance and lower systolic blood pressure was confined to study members from more deprived social backgrounds of origin (P value for interaction 0.030). There was no apparent link between early school attendance and any behavioural or biological risk factor. Neither nursery nor early school attendance was clearly related to mortality risk. CONCLUSIONS: We found no clear evidence for an association of either attendance at nursery or primary school before the age of 5 years and health outcomes around four decades later.

Factors across the life course predict women's change in smoking behaviour during pregnancy and in midlife: results from the National Child Development Study.

BACKGROUND: Tobacco smoking before, during and after pregnancy remains one of the few preventable factors associated with poor health outcomes for mothers and their children. We investigate predictors across the life course for change in smoking behaviour during pregnancy and whether this change predicts smoking status in midlife. METHODS: Data were from the National Child Development Study (1958 British birth cohort). We included female cohort members who reported a first pregnancy up to age 33 years. Among 1468 women who smoked before pregnancy, we examined predictors reported in childhood (age 11 years), adolescence (age 16 years) and early adulthood (age 23 years) of change in smoking behaviour from 12 months before to during pregnancy using log-binomial regression. The association between change in smoking behaviour during pregnancy and smoking status in midlife (age 55 years) was examined while adjusting for predictors across the life course. RESULTS: Among prepregnancy smokers (39%), 26% reduced and 35% quit smoking during pregnancy. Parental smoking and lower social class during childhood, and early adulthood lower social class, depression, early smoking initiation, high smoking intensity, living with a smoker, no pregnancy planning and early motherhood were associated with lower probability of smoking reduction or cessation in pregnancy. Compared with women who smoked before and during pregnancy, women who reduced or quit were two times more likely to be non-smoker at age 55 years (95% CI 1.76 to 2.20). CONCLUSIONS: Findings from this population-based birth cohort study lend support for smoking cessation strategies that target those at risk at various stages across the life course.

Impact of Integrated Services on HIV Testing: A Nonrandomized Trial among Kenyan Family Planning Clients.

The impact of integrated reproductive health and HIV services on HIV testing and counseling (HTC) uptake was assessed among 882 Kenyan family planning clients using a nonrandomized cohort design within six intervention and six "comparison" facilities. The effect of integration on HTC goals (two tests over two years) was assessed using conditional logistic regression to test four "integration" exposures: a training and reorganization intervention; receipt of reproductive health and HIV services at recruitment; a functional measure of facility integration at recruitment; and a woman's cumulative exposure to functionally integrated care across different facilities over time. While recent receipt of HTC increased rapidly at intervention facilities, achievement of HTC goals was higher at comparison facilities. Only high cumulative exposure to integrated care over two years had a significant effect on HTC goals after adjustment (aOR 2.94, 95%CI 1.73-4.98), and programs should therefore make efforts to roll out integrated services to ensure repeated contact over time.

Is "Sexual Competence" at First Heterosexual Intercourse Associated With Subsequent Sexual Health Status?

The timing of first sexual intercourse is often defined in terms of chronological age, with particular focus on "early" first sex. Arguments can be made for a more nuanced concept of readiness and appropriateness of timing of first intercourse. Using data from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), conducted in 2010-2012, this study examined whether a context-based measure of first intercourse-termed sexual competence-was associated with subsequent sexual health in a population-based sample of 17-to 24-year-olds residing in Britain (n = 2,784). Participants were classified as "sexually competent" at first intercourse if they reported the following four criteria: contraceptive protection, autonomy of decision (not due to external influences), that both partners were "equally willing," and that it happened at the "right time." A lack of sexual competence at first intercourse was independently associated with testing positive for human papillomavirus (HPV) at interview; low sexual function in the past year; and among women only, reported sexually transmitted infection (STI) diagnosis ever; unplanned pregnancy in the past year; and having ever experienced nonvolitional sex. These findings provide empirical support for defining the nature of first intercourse with reference to contextual aspects of the experience, as opposed to a sole focus on chronological age at occurrence.

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.

Does an elite education benefit health? Findings from the 1970 British Cohort Study.

Background: Attending private school or a higher-status university is thought to benefit future earnings and occupational opportunities. We examined whether these measures were beneficially related to health and selected health-related behaviours in midlife. Methods: Data were from up to 9799 participants from the 1970 British birth Cohort Study. The high school attended (private, grammar or state) was ascertained at 16 years, and the university attended reported at 42 years [categorised as either higher (Russell Group) or normal-status institutions]. Self-reported health, limiting illness and body mass index (BMI) were reported at 42 years, along with television viewing, take-away meal consumption, physical inactivity, smoking and high risk alcohol drinking. Associations were examined using multiple regression models, adjusted for gender and childhood socioeconomic, health and cognitive measures. Results: Private school and higher status university attendance were associated with favourable self-rated health and lower BMI, and beneficially associated with health-related-behaviours. For example, private school attendance was associated with 0.56 [95% confidence interval (CI): 0.48, 0.65] odds of lower self-rated health [odds ratio (OR) for higher-status university: 0.32 (0.27, 0.37)]. Associations were largely attenuated by adjustment for potential confounders, except for those of private schooling and higher-status university attendance with lower BMI and television viewing, and less frequent take-away meal consumption. Conclusions: Private school and higher-status university attendance were related to better self-rated health, lower BMI and multiple favourable health behaviours in midlife. Findings suggest that type or status of education may be an important under-researched construct to consider when documenting and understanding socioeconomic inequalities in health.

Do routinely measured risk factors for obesity explain the sex gap in its prevalence? Observations from Saudi Arabia.

BACKGROUND: The prevalence of adult obesity is higher in women than men in most countries. However, the pathways that link female sex with excess obesity are still not fully understood. We examine whether socioeconomic and behavioural factors may mediate the association between sex and obesity in the Saudi Arabian setting where there is female excess in obesity. METHODS: We performed a mediation analysis using a cross-sectional, national household survey from Saudi Arabia with 4758 participants (51% female). A series of multivariable regression models were fitted to test if socioeconomic position, physical activity, sedentary behaviour, diet, and smoking mediate the association between sex and obesity (BMI >=30). The findings were confirmed using causal mediation analysis. RESULTS: Women in this sample were roughly twice as likely as men to be obese (crude OR 1.9; 95% CI 1.6-2.3). The odds ratio remained significantly higher for women compared to men in models testing for mediation (OR range 1.95-2.06). Our data suggest that indicators of socio-economic position, physical activity, sedentary behaviour, diet, and smoking do not mediate the sex differences in obesity. CONCLUSIONS: Our analysis shows that most commonly measured risk factors for obesity do not explain the sex differences in its prevalence in the Saudi context. Further research is needed to understand what might explain the female excess in obesity prevalence. We discuss how data related to the lived experience of Saudi men and women may tap into underlying mechanisms by which the sex difference in obesity prevalence are produced.

Intellectual development before and after the onset of infantile spasms: a controlled prospective longitudinal study in tuberous sclerosis.

OBJECTIVE: Infantile spasms (IS) have long been suspected to be a risk factor for impairment in intellectual development, but there are no controlled, prospective longitudinal data in well-characterized conditions to confirm this suspicion. We tested the hypothesis in a longitudinal study of children with tuberous sclerosis (TS), who have a high risk of developing IS. METHODS: Eleven infants with TS were recruited and studied longitudinally using the Mullen Scales of Early Learning. Seizure histories were assessed using a structured parent interview and by review of medical notes. Intellectual development was examined in relation to the onset and length of exposure to IS and other types of seizures. RESULTS: Six children developed IS and five children developed other types of seizure disorders. Among those that developed IS, estimated mean IQ dropped significantly (nonparametric test for trend p = 0.002) from 92 (prior to onset of spasms) to 73 (after exposure to IS for a month or less) and 62 (after exposure to IS for more than a month). By contrast, there was no significant drop in estimated IQ among the five infants exposed to other types of seizure disorders (nonparametric test for trend p = 0.9). All six children exposed to infantile spasms developed clinically significant intellectual impairment. SIGNIFICANCE: These data provide the first clear evidence of clinically significant, dose dependent, impairment in intellectual development following exposure to infantile spasms. The mechanisms underlying this developmental impairment and methods for preventing it require in depth study.

Hazardous alcohol consumption is associated with increased levels of B-type natriuretic peptide: evidence from two population-based studies.

Russia has very high mortality from cardiovascular disease (CVD), with evidence that heavy drinking may play a role. To throw further light on this association we have studied the association of alcohol with predictors of CVD risk including B-type natriuretic peptide (BNP). Levels of BNP increase primarily in response to abnormal cardiac chamber wall stretch which can occur both as a result of atherosclerosis as well as due to other types of damage to the myocardium. No previous population-based studies have investigated the association with alcohol. We analysed cross-sectional data on drinking behaviour in 993 men aged 25-60 years from the Izhevsk Family Study 2 (IFS2), conducted in the Russian city of Izhevsk in 2008-2009. Relative to non-drinkers, men who drank hazardously had an odds ratio (OR) of being in the top 20 % of the BNP distribution of 4.66 (95 % CI 2.13, 10.19) adjusted for age, obesity, waist-hip ratio, and smoking. Further adjustment for class of hypertension resulted in only slight attenuation of the effect, suggesting that this effect was not secondary to the influence of alcohol on blood pressure. In contrast hazardous drinking was associated with markedly raised ApoA1 and HDL cholesterol levels, but had little impact on levels of ApoB and LDL cholesterol. Similar but less pronounced associations were found in the Belfast (UK) component of the PRIME study conducted in 1991. These findings suggest that the association of heavy drinking with increased risk of cardiovascular disease may be partly due to alcohol-induced non-atherosclerotic damage to the myocardium.

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.

Social determinants of tuberculosis in Europe: a prospective ecological study.

Tuberculosis (TB) is considered to be a disease of poverty, since its incidence is exacerbated by socioeconomic factors, inconsistent or partial treatment practices, and immigration from endemic countries. A prospective country level study, using a comprehensive dataset of TB incidence and prevalence taken from countries within the World Health Organization (WHO) European region, was conducted. We employed quintile regression to investigate the prospective association between baseline (measured in 2000) and a nation's wealth, level of egalitarianism, migration rate, health-related lifestyle and social capital with TB incidence and prevalence over a 10-yr period (2000-2009). We found that ∼50% of TB variation is accounted for by a nation's wealth and level of egalitarianism. We observed a negative prospective association between logged gross domestic product and TB rates, and a positive prospective association between income inequality and TB. National income levels per capita and income inequality are important predictors for TB incidence and prevalence in the WHO European region. They account for 50% of country-level variation, indicating the importance of a combined absolute and relative socioeconomic disadvantage in the development of TB. These findings also provide a tool for forecasting potential fluctuations in the level of TB epidemics in the WHO European region, with respect to socioeconomic changes.