Associations between SARS-CoV-2 infection and subsequent economic inactivity and employment status: pooled analyses of five linked longitudinal surveys.

Introduction: Following the acute phase of the COVID-19 pandemic, record numbers of people became economically inactive (i.e., neither working nor looking for work), or non-employed (including unemployed job seekers and economically inactive people). A possible explanation is people leaving the workforce after contracting COVID-19. We investigated whether testing positive for SARS-CoV-2 is related to subsequent economic inactivity and non-employment, among people employed pre-pandemic. Methods: The data came from five UK longitudinal population studies held by both the UK Longitudinal Linkage Collaboration (UK LLC; primary analyses) and the UK Data Service (UKDS; secondary analyses). We pooled data from five long established studies (1970 British Cohort Study, English Longitudinal Study of Ageing, 1958 National Child Development Study, Next Steps, and Understanding Society). The study population were aged 25-65 years between March 2020 to March 2021 and employed pre-pandemic. Outcomes were economic inactivity and non-employment measured at the time of the last follow-up survey (November 2020 to March 2021, depending on study). For the UK LLC sample (n=8,174), COVID-19 infection was indicated by a positive SARS-CoV-2 test in NHS England records. For the UKDS sample we used self-reported measures of COVID-19 infection (n=13,881). Logistic regression models estimated odds ratios (ORs) with 95% confidence intervals (95%CIs) adjusting for potential confounders including sociodemographic variables, pre-pandemic health and occupational class. Results: Testing positive for SARS-CoV-2 was very weakly associated with economic inactivity (OR 1.08 95%CI 0.68-1.73) and non-employment status (OR 1.09. 95%CI 0.77-1.55) in the primary analyses. In secondary analyses, self-reported test-confirmed COVID-19 was not associated with either economic inactivity (OR 1.01 95%CI 0.70-1.44) or non-employment status (OR 1.03 95%CI 0.79-1.35). Conclusions: Among people employed pre-pandemic, testing positive for SARS-CoV-2 was either weakly or not associated with increased economic inactivity or non-employment. Research on the recent increases in economic inactivity should focus on other potential causes.

Changes in retirement plans in the English older population during the COVID-19 pandemic: The roles of health factors and financial insecurity.

Over the course of 2020 and 2021, the COVID-19 pandemic disrupted lives globally. In the UK, unemployment rate continued to increase during and post-lockdown periods, and job security and financial wellbeing deteriorated. It is important to understand whether individual decisions related to retirement plans have changed systematically as a result of the pandemic, especially among older adults who experienced greater rates of pandemic unemployment. Using the English Longitudinal Study of Ageing, this article examines changes in retirement plans of older adults during the COVID-19 pandemic and estimates the impact of health and financial circumstances on these changes. In June/July 2020, 5% of 2095 participants reported planning earlier retirement, while 9% reported planning later retirement. We found that poor self-rated health and financial insecurity were associated with intentions to postpone retirement. Additional risk of later retirement associated with poor health was detected among those experiencing financial insecurity. In November/December 2020, 7% of 1845 participants reported planning earlier retirement, while 12% reported planning later retirement. We found that poor health was predictive of a lower relative risk of later retirement, while depressive symptomology and financial insecurity predicted a higher relative risk of later retirement. The findings imply a contextual role of health factors in, and a persistent influence of financial insecurity on, retirement planning in the older population.

Is grandparental childcare socio-economically patterned? Evidence from the English longitudinal study of ageing.

Grandparents play a vital role in providing childcare to families. Qualitative research and evidence from parents raise concerns that it is grandparents who are socio-economically disadvantaged who provide grandchild care more regularly, perform more intensive tasks, and care out of financial necessity. However, no European studies have investigated these issues at population level. This study is based on grandparents aged 50+ who looked after grandchildren. Data are from wave 8 of the nationally representative English Longitudinal Study of Ageing (2016/2017). We exploit newly collected information on frequency of grandchild care, activities, and reasons for care. Using multinomial regressions, we first examined the extent to which grandparents' socio-economic characteristics (wealth and education) are associated with frequency of grandchild care. Second, using logistic regressions, we investigated whether wealth and education are associated with activities and reasons for grandchild care. Overall, grandparents from disadvantaged socio-economic backgrounds were more likely to provide more regular childcare. Similarly, grandparents in the lowest wealth quartile were more involved in hands-on activities (cooking, taking/collecting grandchildren to/from school), whereas highly educated grandparents were more likely to help grandchildren with homework. Finally, better-off grandparents were more likely to look after grandchildren to help parents and provide emotional support and less likely to report difficulty in refusing to provide care. Our findings show that grandparental childcare varies by socio-economic status with more intensive childcare activities falling disproportionately on those with fewer resources, and this may act to exacerbate existing socio-economic inequalities in later life. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-021-00675-x.

Mental health, financial, and social outcomes among older adults with probable COVID-19 infection: A longitudinal cohort study.

We investigated the immediate and longer-term impact (over 4-6 months) of probable COVID-19 infection on mental health, wellbeing, financial hardship, and social interactions among older people living in England. Data were analysed from 5146 older adults participating in the English Longitudinal Study of Ageing who provided data before the pandemic (2018-19) and at two COVID-19 assessments in 2020 (June-July and November-December). The associations of probable COVID-19 infection (first COVID-19 assessment) with depression, anxiety, poor quality of life (QoL), loneliness, financial hardship, and social contact with family/friends at the first and second COVID-19 assessments were tested using linear/logistic regression and were adjusted for pre-pandemic outcome measures. Participants with probable infection had higher levels of depression and anxiety, poorer QoL, and greater loneliness scores compared with those without probable infection at both the first (ORdepression = 1.62, P-value = 0.005; ORanxiety = 1.59, P-value = 0.049; bpoorQoL = 1.34, P < 0.001; bloneliness = 0.49, P < 0.001) and second (ORdepression = 1.56, P-value = 0.003; ORanxiety = 1.55, P-value = 0.041; bpoorQoL = 1.38, P-value < 0.001; bloneliness = 0.31, P-value = 0.024) COVID-19 assessments. Participants with probable infection also experienced greater financial difficulties than those without infection at the first assessment (OR = 1.50, P-value = 0.011). Probable COVID-19 infection is associated with longer-term deterioration of mental health and wellbeing and short-term increases in financial hardship among older adults. It is important to monitor the mental health of older people affected by COVID-19 and provide additional support to those in need.

Lower socioeconomic status and the acceleration of aging: An outcome-wide analysis.

Aging involves decline in a range of functional abilities and phenotypes, many of which are also associated with socioeconomic status (SES). Here we assessed whether lower SES is a determinant of the rate of decline over 8 y in six domains-physical capability, sensory function, physiological function, cognitive performance, emotional well-being, and social function-in a sample of 5,018 men and women aged 64.44 (SD 8.49) y on average at baseline. Wealth was used as the marker of SES, and all analyses controlled for age, gender, ethnicity, educational attainment, and long-term health conditions. Lower SES was associated with greater adverse changes in physical capability (grip strength, gait speed, and physical activity), sensory function (sight impairment), physiological function (plasma fibrinogen concentration and lung function), cognitive performance (memory, executive function, and processing speed), emotional well-being (enjoyment of life and depressive symptoms), and social function (organizational membership, number of close friends, volunteering, and cultural engagement). Effects were maintained when controlling statistically for other factors such as smoking, marital/partnership status, and self-rated health and were also present when analyses were limited to participants aged ≤75 y. We conclude that lower SES is related to accelerated aging across a broad range of functional abilities and phenotypes independently of the presence of health conditions and that social circumstances impinge on multiple aspects of aging.

Socioeconomic Inequalities in Disability-free Life Expectancy in Older People from England and the United States: A Cross-national Population-Based Study.

BACKGROUND: We examined socioeconomic inequalities in disability-free life expectancy in older men and women from England and the United States and explored whether people in England can expect to live longer and healthier lives than those in the United States. METHODS: We used harmonized data from the Gateway to Global Aging Data on 14,803 individuals aged 50+ from the U.S. Health and Retirement Study (HRS) and 10,754 from the English Longitudinal Study of Ageing (ELSA). Disability was measured in terms of impaired activities and instrumental activities of daily living. We used discrete-time multistate life table models to estimate total life expectancy and life expectancy free of disability. RESULTS: Socioeconomic inequalities in disability-free life expectancy were of a similar magnitude (in absolute terms) in England and the United States. The socioeconomic disadvantage in disability-free life expectancy was largest for wealth, in both countries: people in the poorest group could expect to live seven to nine fewer years without disability than those in the richest group at the age of 50. CONCLUSIONS: Inequalities in healthy life expectancy exist in both countries and are of similar magnitude. In both countries, efforts in reducing health inequalities should target people from disadvantaged socioeconomic groups.

Inequalities in time from stopping paid work to death: findings from the ONS Longitudinal Study, 2001-2011.

BACKGROUND: UK state pension eligibility ages are linked to average life expectancy, which ignores wide socioeconomic disparities in both healthy and overall life expectancy. OBJECTIVES: Investigate whether there are occupational social class differences in the amount of time older adults live after they stop work, and how much of these differences are due to health. METHODS: Participants were 76 485 members of the Office for National Statistics Longitudinal Study (LS), who were 50-75 years at the 2001 census and had stopped work by the 2011 census. Over 10 years of follow-up, we used censored linear regression to estimate mean differences in years between stopping work and death by occupational social class. RESULTS: After adjustment for age, both social class and health were independent predictors of postwork duration (mean difference (95% CI): unskilled class vs professional: 2.7 years (2.4 to 3.1); not good vs good health: 2.4 years (1.9 to 2.9)), with LS members in the three manual classes experiencing ~1 additional year of postwork duration than professional workers (interaction p values all <0.001). Further adjustment for gender and educational qualifications was reduced but did not eliminate social class and postwork duration associations. We estimate the difference in postwork years between professional classes in good health and unskilled workers not in good health as 5.1 years for women (21.0 vs 26.1) and 5.5 years for men (19.5 vs 25.0). CONCLUSIONS: Lower social class groups are negatively affected by uniform state pension ages, because they are more likely to stop work at younger ages due to health reasons.

Linking local labour market conditions across the life course to retirement age: Pathways of health, employment status, occupational class and educational achievement, using 60 years of the 1946 British Birth Cohort.

Several studies have documented that older workers who live in areas with higher unemployment rates are more likely to leave work for health and non-health reasons. Due to tracking of area disadvantage over the life course, and because negative individual health and socioeconomic factors are more likely to develop in individuals from disadvantaged areas, we do not know at what specific ages, and through which specific pathways, area unemployment may be influencing retirement age. Using data from the MRC National Survey of Health and Development, we use structural equation modelling to investigate pathways linking local authority unemployment at three ages (4y, 26y and 53y) to age of retirement (right-censored). We explored five hypothesized pathways: (1) residential tracking, (2) health, (3) employment status, (4) occupational class, and (5) education. Initially, pathways between life course area unemployment, each pathway and retirement age were assessed individually. Mediation pathways were tested in the full model. Our results showed that area unemployment tracked across the life course. Higher area unemployment at ages 4 and 53 were independently associated with earlier retirement age [1% increase = mean -0.64 (95% CI: -1.12, -0.16) and -0.25 (95% CI: -0.43, -0.06) years]. Both were explained by adjustment for individual employment status at ages 26 and 53 years. Higher area unemployment at age 26 was associated with poorer health and lower likelihood of employment at aged 53; and these 2 individual pathways were identified as the key mediators between area unemployment and retirement age. In conclusion, these results suggest that interventions designed to create local employment opportunities for young adults should lead to extended working through improved employment and health at mid-life.

Socioeconomic differences in healthy and disease-free life expectancy between ages 50 and 75: a multi-cohort study.

BACKGROUND: There are striking socioeconomic differences in life expectancy, but less is known about inequalities in healthy life expectancy and disease-free life expectancy. We estimated socioeconomic differences in health expectancies in four studies in England, Finland, France and Sweden. METHODS: We estimated socioeconomic differences in health expectancies using data drawn from repeated waves of the four cohorts for two indicators: (i) self-rated health and (ii) chronic diseases (cardiovascular, cancer, respiratory and diabetes). Socioeconomic position was measured by occupational position. Multistate life table models were used to estimate healthy and chronic disease-free life expectancy from ages 50 to 75. RESULTS: In all cohorts, we found inequalities in healthy life expectancy according to socioeconomic position. In England, both women and men in the higher positions could expect 82-83% of their life between ages 50 and 75 to be in good health compared to 68% for those in lower positions. The figures were 75% compared to 47-50% for Finland; 85-87% compared to 77-79% for France and 80-83% compared to 72-75% for Sweden. Those in higher occupational positions could expect more years in good health (2.1-6.8 years) and without chronic diseases (0.5-2.3 years) from ages 50 to 75. CONCLUSION: There are inequalities in healthy life expectancy between ages 50 and 75 according to occupational position. These results suggest that reducing socioeconomic inequalities would make an important contribution to extending healthy life expectancy and disease-free life expectancy.

Occupational and educational inequalities in exit from employment at older ages: evidence from seven prospective cohorts.

OBJECTIVES: Past studies have identified socioeconomic inequalities in the timing and route of labour market exit at older ages. However, few studies have compared these trends cross-nationally and existing evidence focuses on specific institutional outcomes (such as disability pension and sickness absence) in Nordic countries. We examined differences by education level and occupational grade in the risks of work exit and health-related work exit. METHODS: Prospective longitudinal data were drawn from seven studies (n=99 164). Participants were in paid work at least once around age 50. Labour market exit was derived based on reductions in working hours, changes in self-reported employment status or from administrative records. Health-related exit was ascertained by receipt of health-related benefit or pension or from the reported reason for stopping work. Cox regression models were estimated for each study, adjusted for baseline self-rated health and birth cohort. RESULTS: There were 50 003 work exits during follow-up, of which an average of 14% (range 2-32%) were health related. Low level education and low occupational grade were associated with increased risks of health-related exit in most studies. Low level education and occupational grade were also associated with an increased risk of any exit from work, although with less consistency across studies. CONCLUSIONS: Workers with low socioeconomic position have an increased risk of health-related exit from employment. Policies that extend working life may disadvantage such workers disproportionally, especially where institutional support for those exiting due to poor health is minimal.

Socio-economic trajectories and cardiovascular disease mortality in older people: the English Longitudinal Study of Ageing.

Background: Socio-economic status from early life has been linked to cardiovascular disease risk, but the impact of life-course socio-economic trajectories, as well as the mechanisms underlying social inequalities in cardiovascular disease risk, is uncertain. Objectives: We assessed the role of behavioural, psychosocial and physiological (including inflammatory) factors in the association between life-course socio-economic status and cardiovascular disease mortality in older adults. Methods: Participants were 7846 individuals (44% women) from the English Longitudinal Study of Ageing, a representative study of individuals aged ≥ 50 years, established in 2002-03. Comprising four indicators of socio-economic status (father's social class, own education, occupational position and wealth), we computed an index of socio-economic trajectory and a lifetime cumulative socio-economic score. Behavioural (smoking, physical activity, alcohol consumption, body mass index) and psychosocial (social relations, loneliness) factors, physiological (blood pressure, total cholesterol, triglycerides) and inflammatory markers (C-reactive protein, fibrinogen), measured repeatedly over time, were potential explanatory variables. Cardiovascular disease mortality was ascertained by linkage of study members to a national mortality register. Mediation was calculated using the traditional 'change-in-estimate method' and alternative approaches such as counterfactual mediation modelling could not be applied in this context. Results: During the 8.4-year follow-up, 1301 study members died (438 from cardiovascular disease). A stable low-social-class trajectory was associated with around double the risk of cardiovascular disease mortality (hazard ratio; 95% confidence interval: 1.94, 1.37; 2.75) compared with a stable high social class across the life course. Individuals in the lowest relative to the highest life-course cumulative socio-economic status group were also more than twice as likely to die of cardiovascular disease (2.57, 1.81; 3.65). Behavioural factors and inflammatory markers contributed most to explaining this gradient, whereas the role of psychosocial and other physiological risk factors was modest. Conclusions: In a population-based cohort of older individuals living in England, we provide evidence that disadvantage across the life course is linked to cardiovascular mortality. That behavioural factors and inflammatory markers partially explain this gradient may provide insights into the potential for intervention.

Sustained enjoyment of life and mortality at older ages: analysis of the English Longitudinal Study of Ageing.

OBJECTIVE:  To test whether the number of reports of enjoyment of life over a four year period is quantitatively associated with all cause mortality, and with death from cardiovascular disease and from other causes. DESIGN AND SETTING:  Longitudinal observational population study using the English Longitudinal Study of Ageing (ELSA), a nationally representative sample of older men and women living in England. PARTICIPANTS:  9365 men and women aged 50 years or older (mean 63, standard deviation 9.3) at recruitment. MAIN OUTCOME MEASURES:  Time to death, based on mortality between the third phase of data collection (wave 3 in 2006) and March 2013 (up to seven years). RESULTS:  Subjective wellbeing with measures of enjoyment of life were assessed in 2002 (wave 1), 2004 (wave 2), and 2006 (wave 3). 2264 (24%) respondents reported no enjoyment of life on any assessment, with 1833 (20%) reporting high enjoyment on one report of high enjoyment of life, 2063 (22%) on two reports, and 3205 (34%) on all three occasions. 1310 deaths were recorded during follow-up. Mortality was inversely associated with the number of occasions on which participants reported high enjoyment of life. Compared with the no high enjoyment group, the hazard ratio for all cause mortality was 0.83 (95% confidence interval 0.70 to 0.99) for two reports of enjoyment of life, and 0.76 (0.64 to 0.89) for three reports, after adjustment for demographic factors, baseline health, mobility impairment, and depressive symptoms. The same association was observed after deaths occurring within two years of the third enjoyment measure were excluded (0.90 (0.85 to 0.95) for every additional report of enjoyment), and in the complete case analysis (0.90 (0.83 to 0.96)). CONCLUSIONS:  This is an observational study, so causal conclusions cannot be drawn. Nonetheless, the results add a new dimension to understanding the significance of subjective wellbeing for health outcomes by documenting the importance of sustained wellbeing over time.

Lifecourse socioeconomic status and type 2 diabetes: the role of chronic inflammation in the English Longitudinal Study of Ageing.

We examined the association between lifecourse socioeconomic status (SES) and the risk of type 2 diabetes at older ages, ascertaining the extent to which adult lifestyle factors and systemic inflammation explain this relationship. Data were drawn from the English Longitudinal Study of Ageing (ELSA) which, established in 2002, is a representative cohort study of ≥50-year olds individuals living in England. SES indicators were paternal social class, participants' education, participants' wealth, and a lifecourse socioeconomic index. Inflammatory markers (C-reactive protein and fibrinogen) and lifestyle factors were measured repeatedly; diabetes incidence (new cases) was monitored over 7.5 years of follow-up. Of the 6218 individuals free from diabetes at baseline (44% women, mean aged 66 years), 423 developed diabetes during follow-up. Relative to the most advantaged people, those in the lowest lifecourse SES group experienced more than double the risk of diabetes (hazard ratio 2.59; 95% Confidence Interval (CI) = 1.81-3.71). Lifestyle factors explained 52% (95%CI:30-85) and inflammatory markers 22% (95%CI:13-37) of this gradient. Similar results were apparent with the separate SES indicators. In a general population sample, socioeconomic inequalities in the risk of type 2 diabetes extend to older ages and appear to partially originate from socioeconomic variations in modifiable factors which include lifestyle and inflammation.

Is Social Capital a Determinant of Oral Health among Older Adults? Findings from the English Longitudinal Study of Ageing.

There are a number of studies linking social capital to oral health among older adults, although the evidence base mainly relies on cross-sectional study designs. The possibility of reverse causality is seldom discussed, even though oral health problems could potentially lead to lower social participation. Furthermore, few studies clearly distinguish between the effects of different dimensions of social capital on oral health. The objective of the study was to examine the longitudinal associations between individual social capital and oral health among older adults. We analyzed longitudinal data from the 3rd and 5th waves of the English Longitudinal Study of Ageing (ELSA). Structural social capital was operationalized using measures of social participation, and volunteering. Number of close ties and perceived emotional support comprised the functional dimension of social capital. Oral health measures were having no natural teeth (edentate vs. dentate), self-rated oral health and oral health-related quality of life. Time-lag and autoregressive models were used to explore the longitudinal associations between social capital and oral health. We imputed all missing data, using multivariate imputation by chained equations. We found evidence of bi-directional longitudinal associations between self-rated oral health, volunteering and functional social capital. Functional social capital was a strong predictor of change in oral health-related quality of life - the adjusted odds ratio of reporting poor oral health-related quality of life was 1.75 (1.33-2.30) for older adults with low vs. high social support. However in the reverse direction, poor oral health-related quality of life was not associated with changes in social capital. This suggests that oral health may not be a determinant of social capital. In conclusion, social capital may be a determinant of subjective oral health among older adults rather than edentulousness, despite many cross-sectional studies on the latter.

Relationship between wealth and age trajectories of walking speed among older adults: evidence from the English Longitudinal Study of Ageing.

BACKGROUND: Slow walking speed is associated with higher risk of accidents, disability, and mortality in older adults, with people in more disadvantaged socioeconomic positions being at higher risk. We explore the relationship between wealth and age trajectories of walking speed among older adults. METHODS: Data come from three waves (2002-2003 to 2006-2007) of the English Longitudinal Study of Ageing. We use latent growth curve models and aging-vector graphs to explore individual changes and average population age trajectories of walking speed by wealth among 7,225 individuals aged 60 and older. RESULTS: For someone aged 71 in the poorest wealth quintile, the baseline mean walking speed was 0.75 m/s, which decreased to 0.71 m/s 4 years later, whereas that of a person in the richest wealth quintile was 0.91 m/s, which decreased to 0.82 m/s. Although the decline in walking speed was faster among people in the richest wealth (net of covariates), the gaps in walking speed between richest and poorest did not close. Even after accounting for covariates, people in the richest wealth only reached critical values (0.60 m/s) of walking speed at the age of 90, whereas people in the poorest wealth reached that level 6 years earlier. CONCLUSIONS: Our findings showed continuing gaps in physical functioning by wealth, even among people with the same health, psychosocial, and demographic conditions. As wealth reflects both past and current socioeconomic status, the implications of our findings are that reducing socioeconomic inequalities at all stages of the life course may have a positive impact on functioning in old age.

Cross national study of leisure-time physical activity in Dutch and English populations with ethnic group comparisons.

BACKGROUND: Variations between countries in leisure-time physical activity (LTPA) can be used to test the convergence thesis, which expects that ethnic minority groups change towards the LTPA levels of the native population of host countries. The aim of this study was to test whether similar differences in LTPA between the native populations of England and the Netherlands are also observed among the Indian and African descent groups living in these countries. METHODS: We used English and Dutch population-based health surveys that included participants aged 35-60 years of European (n(english) = 14,723, n(dutch) = 567), Indian (n(english) = 1264, n(dutch) = 370) and African-Caribbean (n(english) = 1112, n(dutch) = 689) descent. Levels of LTPA (30-minute walking, any reported cycling, gardening, dancing and playing sports) were estimated with age-sex-standardized prevalence rates. Comparisons among groups were made using adjusted Prevalence Ratios (PRs). RESULTS: Within both countries and compared with the European group, Indian and African groups had lower levels of gardening and cycling, whereas the African groups had higher levels of dancing. Between countries, among the European groups, the Netherlands showed higher prevalence of cycling than England, PR = 2.26 (95% CI: 2.06-2.48), and this was 2.85 (1.94-4.19) among Indian descent, and 2.77 (2.05-3.73) among African descent. For playing sports, this was PR = 1.30 (1.23-1.38), 1.43 (1.24-1.66) and 1.22 (1.10-1.34), whereas for gardening this was PR = 0.71 (0.65-0.78), 0.65 (0.52-0.81) and 0.75 (0.62-0.90), respectively. Walking and dancing showed inconsistent differences between the countries and ethnic groups. CONCLUSION: This cross-national comparison supports the expectation that LTPA of Indian and African descent groups converge towards the national levels of England and the Netherlands respectively.

What explains the American disadvantage in health compared with the English? The case of diabetes.

BACKGROUND: Middle-aged and older American men and women have almost twice the rate of diabetes of men and women in England. This differential was not explained by conventional risk factors including age, smoking, social position and body mass index (BMI). METHODS: This study used large and representative samples of non-minority adults aged 52-85 years taken from the 1999-2006 American National Health and Nutrition Examination Survey (NHANES) and the 2004 English Longitudinal Study of Aging. The surveys contain self-reported and objective biological disease markers of diabetes as well as indicators of major risk factors for diabetes including anthropometric measures of BMI, height and waist circumference. RESULTS: The older American population has much higher rates of diabetes than the English population-a differential not yet explained, but this population also has higher waist circumference at each level of BMI than does the equivalent group in England. By controlling for such waist circumference differences and allowing for different effects of waist on diabetes in each country, approximately three-quarters of the country differences for women and 38% among men can be explained. CONCLUSIONS: Higher rates of diabetes in the US old-age population than in England were largely accounted for by raised waist circumference and not BMI differences, especially among women. In addition, elevated diabetes risk associated with higher waist circumference in the USA as opposed to England could arise as a result of a number of different mechanisms. Investigation of the relative importance of such mechanisms is an important topic for further study.