Improving oral health and related health behaviours (substance use, smoking, diet) in people with severe and multiple disadvantage: A systematic review of effectiveness and cost-effectiveness of interventions.

BACKGROUND: People experiencing homelessness co-occurring with substance use or offending ('severe and multiple disadvantage' SMD) often have high levels of poor oral health and related health behaviours (particularly, substance use, smoking, poor diet). This systematic review aimed to assess the effectiveness and cost-effectiveness of interventions in adults experiencing SMD to improve oral health and related health behaviours. METHODS AND FINDINGS: From inception to February 2023, five bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus) and grey literature were searched. Two researchers independently screened the search results. Randomized controlled trials (RCTs), comparative studies and economic evaluations were included that reported outcomes on oral health and the related health behaviours. Risk of bias was assessed and results narratively synthesized. Meta-analyses were performed where appropriate. This review was registered with PROSPERO (reg. no: CRD42020202416). Thirty-eight studies were included (published between 1991 and 2023) with 34 studies reporting about effectiveness. Most studies reported on substance use (n = 30). Interventions with a combination of housing support with substance use and mental health support such as contingent work therapy appeared to show some reduction in substance use in SMD groups. However, meta-analyses showed no statistically significant results. Most studies had short periods of follow-up and high attrition rates. Only one study reported on oral health; none reported on diet. Three RCTs reported on smoking, of which one comprising nicotine replacement with contingency management showed improved smoking abstinence at 4 weeks compared to control. Five studies with economic evaluations provided some evidence that interventions such as Housing First and enhanced support could be cost-effective in reducing substance use. CONCLUSION: This review found that services such as housing combined with other healthcare services could be effective in improving health behaviours, particularly substance use, among SMD groups. Gaps in evidence also remain on oral health improvement, smoking, and diet. High quality studies on effectiveness with adequate power and retention are needed to address these significant health challenges in SMD populations.

Factors influencing implementation and sustainability of interventions to improve oral health and related health behaviours in adults experiencing severe and multiple disadvantage: a mixed-methods systematic review.

OBJECTIVES: Among people experiencing severe and multiple disadvantage (SMD), poor oral health is common and linked to smoking, substance use and high sugar intake. Studies have explored interventions addressing oral health and related behaviours; however, factors related to the implementation of these interventions remain unclear. This mixed-methods systematic review aimed to synthesise evidence on the implementation and sustainability of interventions to improve oral health and related health behaviours among adults experiencing SMD. METHODS: Bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature were searched from inception to February 2023. Studies meeting the inclusion criteria were screened and extracted independently by two researchers. Quality appraisal was undertaken, and results were synthesised using narrative and thematic analyses. RESULTS: Seventeen papers were included (published between 1995 and 2022). Studies were mostly of moderate quality and included views from SMD groups and service providers. From the qualitative synthesis, most findings were related to aspects such as trust, resources and motivation levels of SMD groups and service providers. None of the studies reported on diet and none included repeated offending (one of the aspects of SMD). From the quantitative synthesis, no difference was observed in programme attendance between the interventions and usual care, although there was some indication of sustained improvements in participation in the intervention group. CONCLUSION: This review provides some evidence that trust, adequate resources and motivation levels are potentially important in implementing interventions to improve oral health and substance use among SMD groups. Further research is needed from high quality studies and focusing on diet in this population. PROSPERO REGISTRATION NUMBER: CRD42020202416.

Interventions to improve oral health and related health behaviours of substance use, smoking, and diet in people with severe and multiple disadvantage: a systematic review of effectiveness and cost-effectiveness.

BACKGROUND: Homelessness overlapping with substance use and offending is described as severe and multiple disadvantage (SMD). People experiencing SMD have poor oral health along with high levels of related behaviours such as substance use, smoking, and poor diet. Existing evidence largely describes the prevalence of oral health problems, substance use, and smoking in SMD groups. Little is known about interventions that can address these conditions in SMD groups. We aimed to review the effectiveness and cost-effectiveness of interventions on oral health and related health behaviours in adults experiencing SMD. METHODS: For this systematic review, we searched bibliographic databases (MEDLINE, EMBASE, PsycINFO, CINAHL, EBSCO, Scopus) and grey literature for papers published from inception to February 2023. Two researchers independently reviewed the searches. Randomised controlled trials (RCTs), comparative studies and economic evaluations were included. Risk of bias was assessed. Population included adults experiencing SMD (including homelessness and substance use or repeat offending). Outcomes included oral health, and related behaviours (substance use, smoking, poor diet). Results were narratively synthesised. This review was registered with PROSPERO, CRD42020202416. FINDINGS: The review included 38 studies (published between 1991 and 2023), with 34 reporting effectiveness. These studies comprised of 23 RCTs and 11 quasi-experimental studies conducted in the USA (25 studies), Canada (seven studies), France (one study), and Spain (one study). The interventions involving multiple components, such as housing services with substance use and mental health support, effectively reduced substance use in SMD groups; these were mostly individual-level interventions. However, these studies had short follow-up periods and high attrition rates. Only one study addressed oral health outcomes, none focused on diet, and three RCTs covered smoking, with one intervention showing smoking abstinence at 4 weeks. Some limited evidence suggested cost-effectiveness of substance use interventions. INTERPRETATION: This review found that integrating services such as housing with other health-care services together could be effective in improving health behaviours, especially substance use among SMD groups. More evidence is needed specifically on oral health, smoking, and diet-related interventions. The generalisability of findings of this review is limited to high-income countries and shorter-term outcomes. FUNDING: National Institute for Health and Care Research (NIHR) Policy Research Programme.

From Drugs to Dry Mouth: A Systematic Review Exploring Oral and Psychological Health Conditions Associated with Dry Mouth in Older Adults with Polypharmacy.

BACKGROUND: Approximately 60% of older adults complain of dry mouth, which may be associated with polypharmacy, common in this population. Existing studies have reported treatment approaches to dry mouth but do not address long-term preventative measures that would more positively benefit the health and well-being of older adults. OBJECTIVE: We aimed to explore the consequences of dry mouth, associated with polypharmacy, on the physical and psychological health of older adults in order to establish the importance of preventing dry mouth. METHODS: This systematic review was conducted of studies reporting health conditions of dry mouth, in relation to polypharmacy in older adults (aged ≥ 65 years). MEDLINE, EMBASE, PsycINFO and CINAHL databases were searched using keywords such as 'polypharmacy', 'dry mouth', 'oral health' and 'quality of life' (PROSPERO: CRD42021288945). Joanna Briggs Institute critical appraisal tools were used to assess study quality. RESULTS: Of the 6852 citations screened, nine studies (cross-sectional, n = 8; longitudinal, n = 1) were included that comprised 37,459 participants (mean age range 68.5-85.0 years). Studies were published between 2005 and 2019. Because of the heterogeneity of reported study outcomes, a narrative synthesis was undertaken. The health conditions identified in this review were categorised as 'physical' or 'psychological'. The main physical health conditions reported in the studies related to dental health, such as tooth loss, and functional impairments, such as swallowing difficulties. An increase in the number of medicines taken, from 0 to 5, decreased the number of natural teeth remaining from 16 (standard deviation [SD] ± 9) to 12 (SD ± 8), respectively. Additionally, the number of dental complications increased from 1 (SD ± 2) to 2 (SD ± 2) as the number of medicines increased from 1 to ≥ 3. There was a paucity of studies (n = 2) that investigated psychological health conditions of dry mouth among older adults, with depression identified as a significant issue among older adults with dry mouth (where the reported prevalence was as high as 64%). An additional six psychological health conditions were identified: self-consciousness, feeling tense, difficulty relaxing, irritability, difficulty completing tasks and feeling less satisfied in life. CONCLUSIONS: High levels of physical health conditions of dry mouth are observed in older adults and, to a lesser extent, psychological health conditions. These conditions can negatively affect quality of life. There remains a need to prevent dry mouth and the adverse health conditions associated with it in older adults. The modifiable nature of polypharmacy could be targeted to minimise, and potentially prevent, dry mouth. The optimisation of medication regimes to effectively treat chronic conditions, but also limit the likelihood of dry mouth, is a practical approach. Dry mouth prevention should be a priority and polypharmacy can pave the way for prevention strategies, avoiding the need to treat dry mouth.

Associations between inflammation, coagulation, cardiac strain and injury, and subclinical vascular disease with frailty in older men: a cross-sectional study.

BACKGROUND: Inflammation, coagulation activation, endothelial dysfunction and subclinical vascular disease are cross-sectionally associated with frailty. Cardiac-specific biomarkers are less-well characterised. We assessed associations between these and frailty, in men with, and without, cardiovascular disease (CVD). METHODS: Cross-sectional analysis of 1096 men without, and 303 with, CVD, aged 71-92, from the British Regional Heart Study. Multinominal logistic regression was performed to examine the associations between frailty status (robust/pre-frail/frail) and, separately, C-reactive protein (CRP), interleukin-6 (IL-6), tissue plasminogen activator (tPA), D-dimer, von Willebrand factor (vWF), high-sensitivity cardiac troponin-T (hs-cTnT), N-terminal pro B-type natriuretic peptide (NT-proBNP) (all natural log-transformed), and, in men without CVD, carotid intima-media thickness (CIMT), carotid-femoral pulse wave velocity (cfPWV), carotid distensibility coefficient (DC), and ankle-brachial pressure index (ABPI), adjusted for age, renal function, BMI, social class, smoking, polypharmacy, cognition, multimorbidity and systolic blood pressure. Explanatory variables with p < 0.05 were carried forward into mutually-adjusted analysis. RESULTS: In men without CVD, higher CRP, IL-6, vWF, tPA, hs-cTnT, NT-proBNP, cfPWV, and lower DC were significantly associated with frailty; mutually-adjusted, log IL-6 (OR for frailty = 2.02, 95%CI 1.38-2.95), log hs-cTnT (OR = 1.95, 95%CI 1.24-3.05) and DC (OR = 0.92, 95%CI 0.86-0.99) retained associations. In men with CVD, higher CRP, IL-6, and hs-cTnT, but not vWF, tPA, NT-proBNP or D-dimer, were significantly associated with frailty; mutually-adjusted, log hs-cTnT (OR 3.82, 95%CI 1.84-7.95) retained a significant association. CONCLUSIONS: In older men, biomarkers of myocardial injury are associated with frailty. Inflammation is associated with frailty in men without CVD. Carotid artery stiffness is associated with frailty in men without CVD, independently of these biomarkers.

Investigating the Effectiveness and Acceptability of Oral Health and Related Health Behaviour Interventions in Adults with Severe and Multiple Disadvantage: Protocol for a Mixed-Methods Systematic Review.

Increasing numbers of people in England experience homelessness, substance use, and repeated offending (known as 'severe and multiple disadvantage'; SMD). Populations experiencing SMD often have extremely poor oral health, which is closely inter-linked with high levels of substance use, smoking, and poor diet. This study aims to undertake an evidence synthesis to identify the effectiveness, resource requirements, and factors influencing the implementation and acceptability of oral health and related health behaviour interventions in adults experiencing SMD. Two systematic reviews will be conducted using mixed-methods. Review 1 will investigate the effectiveness and resource implications of oral health and related health behaviours (substance use, smoking, diet) interventions; Review 2 will investigate factors influencing the implementation of such interventions. The population includes adults (≥18 years) experiencing SMD. Standard review methods in terms of searches, screening, data extraction, and quality appraisal will be conducted. Narrative syntheses will be conducted. If feasible, a meta-analysis will be conducted for Review 1 and a thematic synthesis for Review 2. Evidence from the two reviews will then be synthesised together. Input from people with experience of SMD will be sought throughout to inform the reviews. An initial logic model will be iteratively refined during the review.

Exploring Interventions to Improve the Oral Health and Related Health Behaviours of Adults Experiencing Severe and Multiple Disadvantage: Protocol for a Qualitative Study with Stakeholders.

The number of individuals in England experiencing homelessness, substance use, and involvement with the criminal justice system is increasing. These issues, referred to as severe and multiple disadvantage (SMD), are often interlinked and co-occur. Health inequalities, particularly poor oral health, persist for those facing these inter-related issues and are closely linked with high levels of substance use, smoking, and poor diet. However, evidence for interventions that can improve these health outcomes for those experiencing these issues is limited. This paper outlines the design of a qualitative study which aims to explore the perspectives of stakeholders to understand what interventions can help to support SMD groups with their oral health and related health behaviours (i.e., substance use, smoking, diet). Interviews and focus groups will be undertaken with stakeholders comprising two groups: (1) individuals with experience of SMD, and (2) service providers (staff and volunteers), policy makers, and commissioners who support such individuals. Public involvement and engagement is central to the project. For example, stakeholders and research partners in policy and practice and people with lived experience of SMD will provide input at all stages of this study. Findings from the study will inform an 'evidence for practice' briefing outlining recommendations for policy. Dissemination will occur through presentations to a range of practice, policy and academic beneficiaries, and through peer-reviewed publications.

Subclinical cardiovascular disease and risk of incident frailty: The British Regional Heart Study.

BACKGROUND/OBJECTIVES: Subclinical cardiovascular disease (CVD) is cross-sectionally associated with frailty, but the relationship between subclinical CVD and incident frailty has not been reported. We aimed to assess this prospective association. DESIGN: Longitudinal analysis of data from the British Regional Heart Study, a prospective cohort study. PARTICIPANTS: 1057 men, aged 71-92 years, robust or pre-frail at baseline, and without a clinical diagnosis of CVD. MEASUREMENTS: Participants underwent baseline measurement of carotid-femoral pulse wave velocity (cfPWV), carotid intima-media thickness (CIMT), carotid distensibility coefficient (DC), and ankle-brachial pressure index (ABPI), and had questionnaire-based frailty assessment after three years. Frailty status was based on the Fried phenotype. Multivariate logistic regressions examined associations between incident frailty and tertile of cfPWV, CIMT, DC, and ABPI group (<0.9, 0.9-1.4, ≥1.4). RESULTS: 865 men were examined and completed the 3 year follow-up questionnaire, of whom 78 became frail. Adjusted for age, prefrailty, body mass index, diabetes, smoking, atrial fibrillation, blood pressure, renal function, and incident CVD, higher CIMT was associated with greater odds of incident frailty (2nd tertile OR 1.62, 95% CI 0.78-3.35, 3rd tertile OR 2.61, 95% CI 1.30-5.23, p = 0.007, trend p = 0.006). cfPWV showed a weaker, non-significant association (2nd tertile OR 1.79, 95% CI 0.85-3.78, 3rd tertile OR 1.73, OR 0.81-3.72, p = 0.16, trend p = 0.20). There was no clear association between incident frailty and DC or ABPI. In subgroup analyses, CIMT was significantly associated with incident frailty in men ≥80 years (3rd tertile OR 6.99, 95%CI 1.42-34.5), but not in men aged 75-80 or < 75 years. CONCLUSION: Subclinical CVD, as measured by CIMT, is associated with greater risk of incident frailty in older men over three year follow-up, independent of the development of clinically-apparent stroke, heart failure, or myocardial infarction, and may be a modifiable risk factor for frailty. This association may be stronger in very old age.

Associations between inflammation, cardiovascular biomarkers and incident frailty: the British Regional Heart Study.

INTRODUCTION: cardiovascular disease (CVD) and chronic inflammation are implicated in the development of frailty. Longitudinal analyses of inflammatory markers, biomarkers of cardiac dysfunction and incidence of frailty are limited. METHODS: in the British Regional Heart Study, 1,225 robust or pre-frail men aged 71-92 years underwent a baseline examination, with questionnaire-based frailty assessment after 3 years. Frailty definitions were based on the Fried phenotype. Associations between incident frailty and biomarkers of cardiac dysfunction (high-sensitivity cardiac troponin T (hs-cTnT), N-terminal pro B-type natriuretic peptide (NT-proBNP)) and inflammation (C-reactive protein (CRP) and interleukin-6 (IL-6)) were examined, by tertile, with the lowest as reference. RESULTS: follow-up data were available for 981 men. Ninety one became frail. Adjusted for age, pre-frailty, prevalent and incident CVD, comorbidity, polypharmacy and socioeconomic status, IL-6 (third tertile OR 2.36, 95% CI 1.07-5.17) and hs-cTnT (third tertile OR 2.24, 95% CI 1.03-4.90) were associated with increased odds of frailty. CRP (third tertile OR 1.83, 95% CI 0.97-4.08) and NT-proBNP (second tertile OR 0.48, 95% CI 0.23-1.01) showed no significant association with incident frailty. The top tertiles of CRP, IL-6, hscTnT and NT-proBNP were strongly associated with mortality prior to follow-up. CONCLUSION: IL-6 is associated with incident frailty, supporting the prevailing argument that inflammation is involved in the pathogenesis of frailty. Cardiomyocyte injury may be associated with frailty risk. Associations between elevated CRP and frailty cannot be fully discounted; NT-proBNP may have a non-linear relationship with incident frailty. CRP, IL-6, hs-cTnT and NT-proBNP are vulnerable to survivorship bias.

Poor Oral Health and Inflammatory, Hemostatic, and Cardiac Biomarkers in Older Age: Results From Two Studies in the UK and USA.

BACKGROUND: We examined the association of objective and subjective oral health markers with inflammatory, hemostatic, and cardiac biomarkers in older age. METHODS: Cross-sectional analyses were based on the British Regional Heart Study (BRHS) comprising British men aged 71-92 years (n = 2,147), and the Health, Aging and Body Composition (HABC) Study comprising American men and women aged 71-80 years (n = 3,075). Oral health markers included periodontal disease, tooth count, dry mouth. Inflammatory biomarkers included C-reactive protein (CRP), interleukin-6 (IL-6) in both studies, and tissue plasminogen activator (t-PA), von Willebrand Factor (vWF), fibrin D-dimer, high-sensitivity Troponin T (hsTnT), and N-terminal pro-brain natriuretic peptide (NTproBNP) only in the BRHS. RESULTS: In both studies, tooth loss, was associated with the top tertile of CRP-odds ratios (ORs) (95% confidence interval [CI]) are 1.31 (1.02-1.68) in BRHS; and 1.40 (1.13-1.75) in the HABC Study, after adjusting for confounders. In the HABC Study, cumulative (≥3) oral health problems were associated with higher levels of CRP (OR [95% CI] =1.42 [1.01-1.99]). In the BRHS, complete and partial tooth loss was associated with hemostatic factors, in particular with the top tertile of fibrin D-dimer (OR [95% CI] = 1.64 [1.16-2.30] and 1.37 [1.05-1.77], respectively). Tooth loss and periodontal disease were associated with increased levels of hsTnT. CONCLUSIONS: Poor oral health in older age, particularly tooth loss, was consistently associated with some inflammatory, hemostatic, and cardiac biomarkers. Prospective studies and intervention trials could help understand better if poor oral health is causally linked to inflammatory, hemostatic, and cardiac biomarkers.

Chronic kidney disease, cardiovascular risk markers and total mortality in older men: cystatin C versus creatinine.

BACKGROUND: It remains uncertain whether cystatin C is a superior marker of renal function than creatinine in older adults. We have investigated the association between estimated glomerular filtration rate (eGFR) using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations based on creatinine (CKD-EPIcr) and cystatin C (CKD-EPIcys), and cardiovascular risk markers and mortality in older adults. METHODS: This is a cross-sectional and prospective study of 1639 British men aged 71-92 years followed up for an average of 5 years for mortality. Cox survival model and receiving operating characteristic analysis were used to assess the associations. RESULTS: The prevalence of chronic kidney disease (CKD) was similar using the two CKD-EPI equations, although cystatin C reclassified 43.9% of those with stage 3a CKD (eGFR 45-59 mL/min/1.732, moderate damage) to no CKD. However, CKD stages assessed using both CKD-EPIcr and CKD-EPIcys were significantly associated with vascular risk markers and with all-cause and cardiovascular disease mortality. In all men with CKD (eGFR <60 mL/min/1.732), the HRs (95% CI) for all-cause mortality after adjustment for cardiovascular risk factors compared with those with no CKD were 1.53 (1.20 to 1.96) and 1.74 (1.35 to 2.23) using CKD-EPIcr and CKD-EPIcys, respectively. Comparisons of the two CKD equations showed no significant difference in their predictive ability for mortality (difference in area under the curve p=0.46). CONCLUSION: Despite reclassification of CKD stages, assessment of CKD using CKD-EPIcys did not improve prediction of mortality in older British men >70 years. Our data do not support the routine use of CKD-EPIcys for identifying CKD in the elderly British male population.

Healthier diet quality and dietary patterns are associated with lower risk of mobility limitation in older men.

PURPOSE: To investigate associations between diet quality, dietary patterns and mobility limitation 15 years later in a population-based sample of older British men. METHODS: We used longitudinal data from 1234 men from the British Regional Heart Study, mean age 66 years at baseline. Mobility limitation was defined as difficulty going up- or downstairs or walking 400 yards as a result of a long-term health problem. Dietary intake was measured using a food frequency questionnaire data from which the Healthy Diet Indicator (HDI), the Elderly Dietary Index (EDI), and three a posteriori dietary patterns were derived. The a posteriori dietary patterns were identified using principal components analysis: (1) high fat/low fibre, (2) prudent and (3) high sugar. RESULTS: Men with greater adherence to the EDI or HDI were less likely to have mobility limitation at follow-up, top vs bottom category odds ratio for the EDI OR 0.50, 95% CI 0.34, 0.75, and for the HDI OR 0.55, 95% CI 0.35, 0.85, after adjusting for age, social class, region of residence, smoking, alcohol consumption and energy intake. Men with a higher score for the high-fat/low-fibre pattern at baseline were more likely to have mobility limitation at follow-up, top vs bottom quartile odds ratio OR 3.28 95% CI 2.05, 5.24. These associations were little changed by adjusting for BMI and physical activity. CONCLUSION: Our study provides evidence that healthier eating patterns could contribute to prevention or delay of mobility limitation in older British men.

Influence of Poor Oral Health on Physical Frailty: A Population-Based Cohort Study of Older British Men.

OBJECTIVES: To investigate the associations between objective and subjective measures of oral health and incident physical frailty. DESIGN: Cross-sectional and longitudinal study with 3 years of follow-up using data from the British Regional Heart Study. SETTING: General practices in 24 British towns. PARTICIPANTS: Community-dwelling men aged 71 to 92 (N = 1,622). MEASUREMENTS: Objective assessments of oral health included tooth count and periodontal disease. Self-reported oral health measures included overall self-rated oral health; dry mouth symptoms; sensitivity to hot, cold, and sweet; and perceived difficulty eating. Frailty was defined using the Fried phenotype as having 3 or more of weight loss, grip strength, exhaustion, slow walking speed, and low physical activity. Incident frailty was assessed after 3 years of follow-up in 2014. RESULTS: Three hundred three (19%) men were frail at baseline (aged 71-92). Having fewer than 21 teeth, complete tooth loss, fair to poor self-rated oral health, difficulty eating, dry mouth, and more oral health problems were associated with greater likelihood of being frail. Of 1,284 men followed for 3 years, 107 (10%) became frail. The risk of incident frailty was higher in participants who were edentulous (odds ratio (OR) = 1.90, 95% confidence interval (CI) = 1.03-3.52); had 3 or more dry mouth symptoms (OR = 2.03, 95% CI = 1.18-3.48); and had 1 (OR = 2.34, 95% CI = 1.18-4.64), 2 (OR = 2.30, 95% CI = 1.09-4.84), or 3 or more (OR = 2.72, 95% CI = 1.11-6.64) oral health problems after adjustment for age, smoking, social class, history of cardiovascular disease or diabetes mellitus, and medications related to dry mouth. CONCLUSION: The presence of oral health problems was associated with greater risks of being frail and developing frailty in older age. The identification and management of poor oral health in older people could be important in preventing frailty.

The relationships between body composition characteristics and cognitive functioning in a population-based sample of older British men.

BACKGROUND: Current research has established obesity as one of the main modifiable risk factors for cognitive impairment. However, evidence on the relationships of total and regional body composition measures as well as sarcopenia with cognitive functioning in the older population remains inconsistent. METHODS: Data are based on 1,570 participants from the British Regional Heart Study (BRHS), a cohort of older British men from 24 British towns initiated in 1978-80, who were re-examined in 2010-12, aged 71-92 years. Cognitive functioning was assessed with the Test-Your-Memory cognitive screening tool. Body composition characteristics assessed using bioelectrical impedance analysis included total fat mass (FM), central FM, peripheral FM, and visceral fat level. Sarcopenia was defined using the European Working Group on Sarcopenia in Older People (EWGSOP) definition of severe sarcopenia and the Foundation for the National Institutes of Health (FNIH) sarcopenia project criteria. RESULTS: Among 1,570 men, 636 (41 %) were classified in the mild cognitive impairment (MCI) and 133 (8 %) in the severe cognitive impairment (SCI) groups. Age-adjusted multinomial logistic regressions showed that compared with participants in the normal cognitive ageing group, those with SCI were more likely to have waist circumference >102 cm, BMI >30 kg/m(2), to be in the upper quintile of total FM, central FM, peripheral FM and visceral fat level and to be sarcopenic. The relationships remained significant for total FM (RR = 2.16, 95 % CI 1.29-3.63), central FM (RR = 1.85, 95 % CI 1.09-3.14), peripheral FM (RR = 2.67, 95 % CI 1.59-4.48), visceral fat level (RR = 2.28, 95 % CI 1.32-3.94), BMI (RR = 2.25, 95 % CI 1.36-3.72) and waist circumference (RR = 1.63, 95 % CI 1.05-2.55) after adjustments for alcohol, smoking, social class, physical activity and history of cardiovascular diseases or diabetes. After further adjustments for interleukin-6 and insulin resistance, central FM, waist circumference and sarcopenia were no longer significantly associated with SCI. CONCLUSIONS: Increased levels of peripheral FM, visceral fat level, and BMI are associated with SCI among older people. Distinct pathophysiological mechanisms link regional adipose tissue deposition and cognitive functioning.

Time trends in socioeconomic inequalities in cancer mortality: results from a 35 year prospective study in British men.

BACKGROUND: Socioeconomic inequalities in cancer mortality in Britain have been shown to be present in the 1990s and early 2000s. Little is known about on-going patterns in such inequalities in cancer mortality. We examined time trends in socioeconomic inequalities in cancer mortality in Britain between 1978 and 2013. METHODS: A socially representative cohort of 7489 British men with data on longest-held occupational social class, followed up for 35 years, in whom 1484 cancer deaths occurred. RESULTS: The hazard ratio for cancer mortality for manual vs. non-manual social classes remained unchanged; among men aged 50-59 years it was 1.62 (95%CI 1.17-2.24) between 1980-1990 and 1.65 (95%CI 1.14-2.40) between 1990-2000. The absolute difference (non-manual minus manual) in probability of surviving death from cancer to 70 years remained at 3% over the follow-up. The consistency of risks over time was similar for both smoking-related and non-smoking related cancer mortality. CONCLUSION: Socioeconomic inequalities in cancer mortality in Britain remain unchanged over the last 35 years and need to be urgently addressed.

Inequalities in heart failure in older men: prospective associations between socioeconomic measures and heart failure incidence in a 10-year follow-up study.

AIMS: Socioeconomic position has been linked to incident heart failure (HF), but the underlying mechanisms are unclear. We examined the association of socioeconomic measures with incident HF in older adults and examined possible underlying pathways. METHODS AND RESULTS: A socially representative cohort of men aged 60-79 years in 1998-2000 from 24 British towns was followed-up for 10 years for incident HF. Adult socioeconomic position was based on a cumulative score, including occupation, education, housing tenure, pension, and amenities. Childhood socioeconomic measures included father's occupational social class and household amenities. Prevalent myocardial infarction and HF cases were excluded. Among 3836 men, 229 incident cases of HF occurred over 10 years. Heart failure risk increased with an increasing score of adverse adult socioeconomic measures (P for trend = < 0.0001). Compared with men with a score of 0, the hazard ratio for men with a score of ≥ 4 was 2.19 (95% confidence interval, CI, 1.34-3.55), which was attenuated to 1.87 (95% CI 1.12-3.11) after adjusting for systolic blood pressure, body mass index, smoking, HDL-cholesterol, diabetes, and lung function. Adjustment for left ventricular hypertrophy, atrial fibrillation, heart rate, and renal function made little difference. Further adjustment for C-reactive protein, von Willebrand Factor, N-terminal pro-brain natriuretic peptide, and plasma vitamin C also made little difference to the hazard ratio [1.89 (95% CI 1.10-3.24)]. Heart failure risk did not vary by childhood socioeconomic measures. CONCLUSION: Heart failure risk in older men was greater in the most deprived socioeconomic groups, which was only partly explained by established risk factors for HF. Novel risk factors contribute little to the associated risk.

Longitudinal associations of socioeconomic position in childhood and adulthood with decline in lung function over 20 years: results from a population-based cohort of British men.

BACKGROUND: Associations of socioeconomic position with lung function are reported mostly from cross-sectional studies. The aim of this study was to investigate the associations between socioeconomic position both in adulthood and childhood with changes in lung function over a 20-year period. METHODS: A socioeconomically representative cohort of 7735 British men aged 40-59 years was followed-up from 1978-1980 to 1998-2000. Lung function (height-standardised forced expiratory volume in 1 s (FEV(1)) and forced vital capacity (FVC)) was assessed at both time points in 4252 survivors. Adult socioeconomic position was derived from longest-held occupation in middle age and childhood socioeconomic position from father's longest-held occupation. RESULTS: Both FEV(1) and FVC declined over time; the decline increased progressively from social class I (highest) to V (lowest); p for trend ≤ 0.0001. The mean difference in decline comparing manual versus non-manual groups was -0.13 litres (95% CI -0.16 to -0.10) for FEV(1) and -0.09 litres (95% CI -0.13 to -0.05) for FVC. These differences remained after adjustment for age, cigarette smoking, body mass index, physical activity and history of bronchitis. Similar differences in lung function decline were observed comparing manual with non-manual childhood social classes, although the differences were reduced by adjustment for adult social class and risk factors. Men in manual social classes in both childhood and adulthood had the greatest decline in lung function compared to those in non-manual groups in childhood and adulthood. CONCLUSIONS: Socioeconomic position across the life course could have a significant impact on decline in lung function in later life. The role of environmental factors associated with socioeconomic position merits further exploration.

Social class differences in secular trends in established coronary risk factors over 20 years: a cohort study of British men from 1978-80 to 1998-2000.

BACKGROUND: Coronary heart disease (CHD) mortality in the UK since the late 1970s has declined more markedly among higher socioeconomic groups. However, little is known about changes in coronary risk factors in different socioeconomic groups. This study examined whether changes in established coronary risk factors in Britain over 20 years between 1978-80 and 1998-2000 differed between socioeconomic groups. METHODS AND FINDINGS: A socioeconomically representative cohort of 7735 British men aged 40-59 years was followed-up from 1978-80 to 1998-2000; data on blood pressure (BP), cholesterol, body mass index (BMI) and cigarette smoking were collected at both points in 4252 survivors. Social class was based on longest-held occupation in middle-age. Compared with men in non-manual occupations, men in manual occupations experienced a greater increase in BMI (mean difference = 0.33 kg/m(2); 95%CI 0.14-0.53; p for interaction = 0.001), a smaller decline in non-HDL cholesterol (difference in mean change = 0.18 mmol/l; 95%CI 0.11-0.25, p for interaction≤0.0001) and a smaller increase in HDL cholesterol (difference in mean change = 0.04 mmol/l; 95%CI 0.02-0.06, p for interaction≤0.0001). However, mean systolic BP declined more in manual than non-manual groups (difference in mean change = 3.6; 95%CI 2.1-5.1, p for interaction≤0.0001). The odds of being a current smoker in 1978-80 and 1998-2000 did not differ between non-manual and manual social classes (p for interaction = 0.51). CONCLUSION: Several key risk factors for CHD and type 2 diabetes showed less favourable changes in men in manual occupations. Continuing priority is needed to improve adverse cardiovascular risk profiles in socially disadvantaged groups in the UK.

Extent of social inequalities in disability in the elderly: results from a population-based study of British men.

PURPOSE: Little is known about social inequalities in disability in the elderly. We examined the extent and determinants of socioeconomic inequalities in disability and functional limitation in elderly men in Britain. METHODS: Disability was ascertained as problems with activities of daily living (ADLs) and instrumental ADL in a socioeconomically representative sample of 3,981 men from 24 British towns who were between 63 to 82 years of age in 2003. We also examined functional limitation. Measures of socioeconomic position were social class, age at leaving full-time education, and car and house ownership. RESULTS: Men in lower social classes had greater risks of both ADL and instrumental ADL disability and functional limitation compared with higher social classes; odds ratios (95% CI) for social class V compared with I were 3.13 (1.64-5.97), 2.87 (1.49-5.51), and 2.65 (1.31-5.35), respectively. Behavioral risk factors (smoking, body mass index, physical activity) and particularly co-morbidity attenuated these differences; together, they reduced relative risks to 1.11 (0.49-2.51), 1.01 (0.45-2.25), and 1.05 (0.46-2.42). Age at leaving full-time education had no relation to functional limitations after taking social class into account. Men who were not house or car owners had greater odds of functional limitation and ADL disability compared with house or car owners, independent of behavioural risk factors, comorbidities and social class. CONCLUSION: Strong socioeconomic inequalities in disability exist in the elderly, which were considerably explained by behavioral factors and comorbidity. Policy efforts are needed to reduce the social disparities in disability in the elderly.

Is socioeconomic position related to the prevalence of metabolic syndrome?: influence of social class across the life course in a population-based study of older men.

OBJECTIVE: To examine whether adult social class and childhood social class are related to metabolic syndrome in later life, independent of adult behavioral factors. RESEARCH DESIGN AND METHODS: This was a population-based cross-sectional study comprising 2,968 men aged 60-79 years. RESULTS: Adult social class and childhood social class were both inversely related to metabolic syndrome. Mutual adjustment attenuated the relation of metabolic syndrome with childhood social class; that with adult social class was little affected. However, the relation with adult social class was markedly attenuated by adjustment for smoking status, physical activity, and alcohol consumption. High waist circumference was independently associated with adult social class. CONCLUSIONS: The association between adult social class and metabolic syndrome was largely explained by behavioral factors. In addition, central adiposity, a component of metabolic syndrome, was associated with adult social class. Focusing on healthier behaviors and obesity, rather than specific efforts to reduce social inequalities surrounding metabolic syndrome, is likely to be particularly important in reducing social inequalities that affect people with coronary disease.