Maternal separation in childhood and diurnal cortisol patterns in mid-life: findings from the Whitehall II study.

BACKGROUND: Animal studies suggest that maternal separation is associated with alterations in the hypothalamic-pituitary-adrenal (HPA) axis through effects that occur in a critical period following birth. Evidence for an association of the diurnal cortisol rhythm with maternal separation in humans is equivocal. METHOD: We examined whether maternal separation in childhood is associated with diurnal cortisol pattern in 3712 middle-aged men and women. Two aspects of cortisol release were examined: the cortisol awakening response (CAR) and the diurnal slope in cortisol throughout the day. RESULTS: Maternal separation in childhood was reported by 12% of participants. Those participants who reported maternal separation had a larger CAR and flatter slopes in cortisol levels compared to those who did not report maternal separation [adjusted mean CAR in those reporting no separation versus separation: 7.1, 95% confidence interval (CI) 6.7-7.5 v. 8.4, 95% CI 7.3-9.5, p = 0.02, corresponding to adjusted mean diurnal slope: -0.129 (95% CI -0.130 to -0.128) v. -0.126 (95% CI -0.128 to -0.124), p = 0.01]. In participants who reported maternal separation, the age of separation was not associated with either cortisol measure (p = 0.11). The association between maternal separation and slope in cortisol secretion was largely explained by smoking behaviour and marital status at the time of sample collection whereas that of the CAR was explained by childhood psychosocial, material factors and adult health behaviours. CONCLUSIONS: Our findings suggest that maternal separation in childhood is associated with alterations in the diurnal cortisol pattern in middle age. These associations are predominantly accounted for by adult circumstances and behaviours.

Social Determinants of Health among Older Adults with Dementia in Urban and Rural Areas.

BACKGROUND: Social determinants of health (SDOH) may influence health in people living with dementia. Little is known about SDOH differences in urban compared to rural dwelling people living with dementia. OBJECTIVES: To explore urban-rural differences in SDOH in people living with mild cognitive impairment (MCI) and dementia. DESIGN: Descriptive study. SETTING/PARTICIPANTS: People ≥55 years with MCI or dementia empaneled to Community Internal Medicine at Mayo Clinic (Rochester, MN, USA) who completed SDOH questions between June 1, 2019 and June 30, 2021 were included. MEASUREMENTS: SDOH questions addressed education, depression, alcohol use, financial strain, food insecurity, physical activity, social connections, stress and transportation. SDOH data were compared by location based on Rural-Urban Commuting Areas Codes. RESULTS: Of 3552 persons with MCI (n=1495) or dementia (n=2057), 62% lived in urban areas, 19% in large rural, 10% in small rural and 9% in isolated areas. Approximately 60% were physically inactive, 20% socially isolated and 30% had stress concerns. Rural patients experienced greater financial strain (p=0.003). CONCLUSION: Social isolation, stress and physical inactivity are common in people living with MCI and dementia across urban and rural areas. Targeted interventions to improve physical and psychosocial health could have great impact in this population.

Subjective memory complaints in community dwelling healthy older people: the influence of brain and psychopathology.

OBJECTIVES: Subjective memory complaints (SMC) are common. We aimed to characterize the relationship between psychiatric illness and white matter disease to SMC in a sample of healthy older people. MEASUREMENTS: Cognitively normal subjects between 55 and 90 years had age-adjusted and education-adjusted Consortium to Establish a Registry for Alzheimer's disease (CERAD) scores ≤1.5 SD from standard mean. ApoE genotyping was performed using polymerase chain reaction. Sixty subjects (30 SMC, 30 controls) underwent 3T MRI, which was rated by two raters blinded to the diagnosis, for periventricular (PVH) and deep white matter hyperintensities (DWMH) using the Fazekas scale. Subjective memory was assessed by asking the participant, Do you feel like your memory or thinking is becoming worse? RESULTS: Two hundred and fifteen volunteers were assessed. Ninety-six were cognitively normal (mean age 62.5 years). SMC were reported by 52/96 subjects (54%). These were compared with subjects who denied SMC. Participants with a history of depression or anxiety were more likely to have SMC (p = 0.02). The frequency distribution of ApoE4 allele and CERAD scores were similar. White matter load was similar (p ≤ 0.47), with a high prevalence of PVH and DWMH seen (100% and 88% of scans, respectively). CONCLUSION: Both SMC and white matter disease were common. SMC were associated with a history of depression or anxiety but not with white matter disease. Evaluation for a history of depression and anxiety in people with SMC is supported by these findings.

Command, control and communication (C3) during the COVID-19 pandemic; adapting a military framework to crisis response in a tertiary UK critical care centre.

The COVID-19 pandemic of 2020 imposed significant strain on critical care services worldwide. The South London region experienced the largest numbers of critical care admissions in the United Kingdom with King's College Hospital one of the busiest centres. This article outlines, using a descriptive narrative, the significant changes that occurred within King's Critical Care as a result of the pandemic and the decisions that were taken to provide effective co-ordination and control to the expanded service, in part drawing on the military experience of two of the authors. The wider context of crisis and major incident leadership and management is also discussed contrasting different approaches used in civilian and military settings.

Why does birthweight vary among ethnic groups in the UK? Findings from the Millennium Cohort Study.

BACKGROUND: Birthweight varies according to ethnic group, but it is not clear why such differences exist. We examine the contribution of socioeconomic, maternal and behavioural factors to differences in mean birthweight and the prevalence of low birthweight across ethnic groups. METHODS: Data from the nationally representative UK Millennium Cohort Study (n = 16,157) on White, Indian, Pakistani, Bangladeshi, Black Caribbean and Black African infants were analysed. Cohort members were born in 2000-02, and data on birthweight, maternal, infant, behavioural and socioeconomic factors were collected by home interviews. RESULTS: Indian, Pakistani and Bangladeshi infants were 280-350 g lighter, and 2.5 times more likely to be low birthweight compared with White infants. Black Caribbean infants were 150 g and Black African infants 70 g lighter compared with White infants, and Black Caribbean and Black African infants were 60% more likely to be low birthweight compared with White infants. For Black Caribbean, Black African, Bangladeshi and Pakistani infants, socioeconomic factors were important in explaining birthweight differences and, for Indian and Bangladeshi infants, maternal and infant factors were important in explaining birthweight differences. CONCLUSION: Future policies aimed at reducing inequalities in birthweight must pay attention to the different socioeconomic and culturally-related profiles of ethnic minority groups in the UK.

Unemployment pre-dates symptoms of depression and anxiety resulting in medical consultation in young men.

BACKGROUND: There is evidence to support a link between unemployment and lower levels of psychological well-being, but debate continues as to whether unemployment results in psychological morbidity, or whether the association is due to those who are more vulnerable to mental illness becoming unemployed. Here we assess the effect of recent and accumulated unemployment in young men on the risk of developing depression and anxiety leading to medical consultation. Adjustment was made for a measure of pre-existing tendency to depression, behavioural maladjustment, social class, qualifications and region of residence. METHODS: Some 3241 men from the National Child Development Study (the 1958 British birth cohort) with data from birth to age 33 years, collected at birth and ages 7, 11, 16, 23 and 33 years were used in these analyses. The outcome measure was onset age of anxiety or depression between ages 24 and 33 years, that resulted in consultation with a GP or a specialist. This was used in Cox proportional hazards models where two measures of unemployment were modelled as time varying covariates. Pre-existing tendency to depression was measured by the Malaise Inventory prior to the experience of unemployment at age 23 years. Two measures of unemployment were investigated: any unemployment in the year prior to onset (recent unemployment) and all accumulated unemployment prior to onset (divided into four categories: 0, 1-12, 13-36 and 37+ months of unemployment). RESULTS: After adjustment for potential confounding factors including pre-existing tendency to depression, the relative risk (RR) for developing symptoms resulting in consultation was 2.10 (95% CI: 1.21-3.63), when those who were unemployed in the year prior to onset were compared with those who were not. Accumulated unemployment was not statistically significantly related to onset of symptoms in all men after adjustment for the potential confounding factors: an RR of 1.63 (95% CI: 0.95-2.79) for men with 37+ months of accumulated unemployment when compared with none. However, exclusion of men with a pre-existing tendency to depression indicated by the Malaise Inventory score, increased the RR to 2.30 (95% CI: 1.44-3.65) for recent unemployment and 2.04 (95% CI: 1.17-3.54) for 37+ months of accumulated unemployment when compared with none. CONCLUSIONS: Unemployment is a risk factor for psychological symptoms of depression requiring medical attention, even in those men without previous psychological vulnerability.

Unemployment and ill health: understanding the relationship.

OBJECTIVE: To review research relevant to understanding the psychological, social, and biological pathways by which unemployment may affect health risk; to consider the importance of four specific mechanisms; and to indicate some directions for future research. CRITERIA FOR INCLUSION AND EXCLUSION OF PUBLISHED STUDIES: Studies were chosen to illustrate the development of four major hypotheses regarding the relationship between unemployment and ill health, as well as the present state of knowledge. The review therefore includes some much-cited "classics" drawn from a long time span. Where recent reviews already exist relevant to individual mechanisms, these are referred to. Recent (since 1987) reports were sought by searching the BIDS data base. Particular effort was made to locate studies which enabled alternative hypotheses to be evaluated, and to point out where existing evidence is inconsistent or incomplete, indicating the need for further research. CONCLUSIONS: To understand the relationship between unemployment and ill health and mortality, four mechanisms need to be considered: the role of relative poverty; social isolation and loss of self esteem; health related behaviour (including that associated with membership of certain types of "subculture"); and the effect that a spell of unemployment has on subsequent employment patterns.

The "inverse housing law" and respiratory health.

STUDY OBJECTIVE: To investigate whether there is a mismatch within Britain between climate severity and housing quality ("inverse housing law") and whether this mismatch is associated with respiratory health. DESIGN, SETTING AND PARTICIPANTS: Cross sectional observational study. Britain (Scotland, Wales and England). The 3023 male and 3694 female Health and Lifestyle Survey participants with valid data available on all relevant items. MAIN RESULTS: Geographical mapping shows a mismatch between climate severity and housing quality. Individual level analysis shows that lung function is associated with climate and housing, and their interaction, independently of cigarette smoking status. The physical quality of the housing seems to be most important to respiratory health in areas with harsh climate. CONCLUSIONS: Interpretation must be cautious because cross sectional data have been used to investigate processes that are longitudinal and, possibly, selective. Nevertheless, there does seem to be an "inverse housing law", such that some of the worst quality housing is found in areas with severe climate; and, on the balance of probabilities, this inverse housing law affects respiratory health.

Employment status, employment conditions, and limiting illness: prospective evidence from the British household panel survey 1991-2001.

OBJECTIVES: To assess the relation of the incidence of, and recovery from, limiting illness to employment status, occupational social class, and income over time in an initially healthy sample of working age men and women. METHODS: Cox proportional hazards models. RESULTS: There were large differences in the risk of limiting illness according to occupational social class, with men and women in the least favourable employment conditions nearly four times more likely to become ill than those in the most favourable. Unemployment and economic inactivity also had a powerful effect on illness incidence. Limiting illness was not a permanent state for most participants in the study. Employment status was also related to recovery. CONCLUSIONS: Having secure employment in favourable working conditions greatly reduces the risk of healthy people developing limiting illness. Secure employment increases the likelihood of recovery. These findings have considerable implications for both health inequality and economic policies.

Social distribution of cardiovascular disease risk factors: change among men in England 1984-1993.

OBJECTIVE: To investigate change in the social distribution of some of the main risk factors for cardiovascular disease in men in England during a period when inequality in cardiovascular disease mortality widened DESIGN: Age standardised comparison of the social distribution of seven known risk factors for cardiovascular disease (body mass index, waist to hip ratio, systolic and diastolic blood pressure, consumption of fresh green vegetables, leisure time exercise, cigarette smoking and levels of social support) in two large cross sectional representative samples of the English population. SUBJECTS: Men aged 20-64 years in the 1984 Health and Lifestyle Survey (excluding Scotland and Wales) first sweep and the 1993 Health Survey for England. MAIN OUTCOME MEASURES: Mean values of continuous variables; age adjusted proportions of categorical variables; change in the relative index of inequality for each risk factor. RESULTS: The overall prevalence of cardiovascular disease risk factors improved during the period in which cardiovascular disease mortality was falling. The social distribution of cardiovascular disease risk factors, in contrast, did not become more extreme. Increases in the relative index of inequality for angina from 1.75 to 1.86, for eating vegetables less than once a day from 1.76 in 1984 to 1.96 in 1993, and an apparently larger increase in inequality of social support, from 1.92 to 2.53 were not statistically significant. In most cases the degree of inequality in risk factors tended to narrow non-significantly: for example the relative index of inequality fell from 5.02 in 1984 to 3.07 in 1993 for systolic blood pressure, from 5.60 to 4.29 for current smoking and from 6.24 to 4.19 for eating other than wholemeal bread as the main form of bread in the diet. The two statistically significant changes in inequality were in the direction of narrowing inequality: from a relative index of inequality of 2.12 to 0.90 for diastolic blood pressure (p<0.01) and from 19.3 to 0.87 (p<0.01) for psychological distress as indicated by the General Health Questionnaire. CONCLUSIONS: Healthier lifestyle options have not been adopted at a significantly faster rate by middle class than working class people over this time period. At the population level the change in risk factors is consistent with falling cardiovascular mortality. The change in the social distribution of risk factors within the population, however, shows little or no relation to the pattern of widening inequality in cardiovascular mortality. This may be because the effect is lagged, or because the adoption of healthier behaviour confers greater benefits on those in higher socioeconomic status groups.

Social inequalities in health by individual and household measures of social position in a cohort of healthy people.

STUDY OBJECTIVE: It is increasingly recognised that different dimensions of social inequality may be linked to health by different pathways. Furthermore, factors operating at the individual level such as employment conditions may affect health in a different way from household level factors. The paper examines the associations between self rated health and four measures of social position- occupational class, household social advantage, personal and household income. DESIGN: Multilevel logistic regression models were used to predict self rated health using longitudinal data from the British Household panel survey (BHPS) with respondents nested within households. Separate analyses were carried out for economically active and inactive respondents. SETTING: Interview based surveys of adults living within households that are representative of British households. PARTICIPANTS: Adult respondents from the BHPS. MAIN RESULTS: Occupational class has relatively strong effects on the self rated health of the economically active, although household level factors also seem to influence their health. Household social advantage has relatively strong effects on the self rated health of the economically inactive. CONCLUSIONS: The paper found evidence in support of the view that different dimensions of social inequality have different pathways to self rated health. There are unexplained similarities in health between household members, which require further investigation.

Social position and minor psychiatric morbidity over time in the British Household Panel Survey 1991-1998.

STUDY OBJECTIVE: To examine social inequalities in minor psychiatric morbidity as measured by the GHQ-12 using lagged models of psychiatric morbidity and changing job status. DESIGN: GHQ scores were modelled using two level hierarchical regression models with measurement occasions nested within individuals. The paper compares and contrasts three different ways of describing social position: income, social advantage and lifestyle (the Cambridge scale), and social class (the new National Statistics Socio-Economic Classification), and adjusts for attrition. SETTING: Survey interviews for a nationally representative sample of adults of working age living in Britain. PARTICIPANTS: 8091 original adult respondents in 1991 who remain of working age during 1991-1998 from the British Household Panel Survey (BHPS). MAIN RESULTS: There was a relation of GHQ-12 to social position when social position was combined with employment status. This relation itself varied according to a person's psychological health in the previous year. CONCLUSIONS: The relation between social position and minor psychiatric morbidity depended on whether or not a person was employed, unemployed, or economically inactive. It was stronger in those with previously less good psychological health. Among employed men and women in good health, GHQ-12 varied little according to social class, status, or income. There was a "classic" social gradient in psychiatric morbidity, with worse health in less advantaged groups, among the economically inactive. Among the unemployed, a "reverse" gradient was found: the impact of unemployment on minor psychiatric morbidity was higher for those who were previously in a more advantaged social class position.

Health and social precursors of unemployment in young men in Great Britain.

OBJECTIVE: To identify health and socioeconomic factors in childhood that are precursors of unemployment in early adult life and to examine the hypothesis that young men who become unemployed are more likely to have accumulated risks to health during childhood. DESIGN: Longitudinal birth cohort study. The amount of unemployment experienced in early adult life up to age 32 years was the outcome measure used. Exposure measures to indicate vulnerability to future ill health were: height at age 7 years and the Bristol social adjustment guide (BSAG) at age 11 years, a measure of behavioural maladjustment. Socioeconomic measures were: social class at birth, crowding at age 7, qualifications attained before labour market entry, and region of residence. SETTING: Great Britain. SUBJECTS: Altogether 2256 men with complete data from the national child development study (NCDS). The NCDS has collected data on all men and women born in one week in 1958 and has followed them up using interviews, self completion questionnaires, and medical examinations at birth and at ages 7, 11, 16, 23 and 33 years. RESULTS: A total of 269 men (11.9%) experienced more than one year of unemployment between ages 22 and 32 years. Poor socioeconomic conditions in childhood and a lack of qualifications were associated with an increased risk of unemployment. Geographical region was also significant in determining the risk of unemployment. Men with short stature and poor social adjustment in childhood were more likely to experience unemployment in adult life, even after controlling for socioeconomic background, education, and parental height. These differences remained when those with chronic childhood illnesses were excluded from the analysis. The adjusted relative odds for experiencing more than one year of unemployment between ages 22 and 32 years for men who were in the top fifth of the BSAG distribution (most maladjusted) compared with those in the bottom fifth were 2.36 (95% CI 1.49, 3.73). The adjusted relative odds for experiencing more than one year of unemployment between ages 22 and 32 years for men who were in the bottom fifth of the distribution of height at age 7 years (indicating slowest growth) compared with those in the top fifth, were 2.41 (95% CI 1.43, 4.04). Adult height was not significantly associated with unemployment. CONCLUSION: The relationship between unemployment and poor health arises, in part, because men who become unemployed are more likely to have accumulated risks to health during childhood, reflected by slower growth and a greater tendency to behavioural maladjustment. Short stature in childhood is a significant indicator of poor socioeconomic circumstances in childhood and reflects earlier poor development.

Gender inequalities in health: social position, affective disorders and minor physical morbidity.

Research has consistently reported a female excess of minor physical morbidity and affective disorders compared to men. Using data from a national cross sectional survey of British women and men aged 18-59, this paper explores three prominent explanations for these patterns: that the female excess is due to problems associated with menstruation and the menopause; that it is 'caused' by the social positions which women occupy in contemporary western societies; and that the excess of affective disorders is 'caused' by women's social positions but that their higher rate of physical illness is psychosomatic in origin. The analysis presented here suggests that problems with menstruation and the menopause cannot explain gender inequalities in minor illness. Similarly the argument that the female excess of minor physical illness is psychosomatic is not supported, indeed, there is evidence that women's experience of minor physical illness may 'cause' their higher rates of affective disorders. Finally, with a few exceptions, the relationship between minor illness and four dimensions of social positions--marital status, employment status, social class and income--were broadly the same for women and men but in each social position category, women report higher rates of both types of ill health than men. It is concluded that present measures of these social positions do not capture the differing experiences of women and men and that more gender sensitive measures are needed if gender inequalities in minor illness are to be understood.

Gender differences in the relationship of partner's social class to behavioural risk factors and social support in the Whitehall II study.

In most countries health inequality in women appears to be greater when their socio-economic position is measured according to the occupation of male partners or spouses than the women's own occupations. Very few studies show social gradients in men's health according to the occupation of their female partners. This paper aims to explore the reasons for the differences in social inequality in cardiovascular disease between men and women by analysing the associations between own or spouses (or partners) socio-economic position and a set of risk factors for prevalent chronic diseases. Study participants were married or cohabiting London based civil servants included in the Whitehall II study. Socio-economic position of study participants was measured according to civil service grade; socio-economic position of the spouses and partners according to the Registrar General's social class schema. Risk factors were smoking, diet, exercise, alcohol consumption, and measures of social support. In no case was risk factor exposure more affected by the socio-economic position of a female partner than that of a male study participant. Wives' social class membership made no difference at all to the likelihood that male Whitehall participants were smokers, or took little exercise. Female participants' exercise and particularly smoking habit was, in contrast, related to their spouse's social class independently of their own grade of employment. Diet quality was affected equally by the socio-economic position of both male and female partners. Unlike the behavioural risk factors, the degree of social support reported by women participants was in general not strongly negatively affected by their husband or partner being in a less advantaged social class. However, non-employment in the husband or partner was associated with relatively lower levels of positive, and higher negative social support, while men with non-working wives or partners were unaffected. Studying gender differences in health inequality highlights some of the problems in health inequality research more broadly. We are brought face to face with the fact that the development of conceptual models that can be applied consistently to aetiology in both men and women are still at an early stage of development. Closer attention is needed to the different processes behind material power and 'emotional power' within the household when investigating gender differences in health and risk factors.

Understanding social variation in cardiovascular risk factors in women and men: the advantage of theoretically based measures.

Many studies have attempted to understand observed social variations in cardiovascular disease in terms of sets of intermediate or confounding risk factors. Tests of these models have tended to produce inconsistent evidence. This paper examines the relationships to cardiovascular risk factors or two theoretically based measures of social position. It shows that the strength of the relationships between social position and cardiovascular risk factors varies according to the definition of social position which is used: there is a closer relationship between most health behaviours and the Cambridge scale, an indicator of 'general social advantage and lifestyle', whereas the Erikson-Goldthorpe schema, which is based on employment relations and conditions, is more strongly related to work control and breathlessness. The implications of these findings for understanding the conflicting evidence in other studies of health inequalities are then discussed. The paper concludes that inconsistencies between studies may be in part due to unexamined differences between the conceptual bases of the measures of social position they use, combined with a failure to make explicit the hypothetical mechanisms of effect. If neither the conceptual basis of the measure of social position, nor the links between social position and health outcome tested in each study are clear, inconsistencies between studies will be difficult to interpret, making policy recommendations highly problematic.

Social position, social roles and women's health in England: changing relationships 1984-1993.

The aim of this study is to investigate the relationships between social roles, social position and health in English women using theoretically derived measures of social position. Data are taken from the Health and Lifestyle Survey, carried out between 1984-1985, and the Health Survey for England of 1993. First the paper asks whether health inequality in women is still evident when theoretically derived measures (the Erikson-Goldthorpe schema and the Cambridge scale) are used. It goes on to explore the extent to which different combinations of family roles and employment circumstances might affect social variations in health. Finally, the paper shows that health differences between women in different combinations of social roles were not the same in 1993 as in 1984 and examines some reasons why this change may have occurred.

Dimensions of social inequality in the health of women in England: occupational, material and behavioural pathways.

This paper examines the role of behavioural and psychosocial risk and protective factors in explaining social inequalities in the general self-assessed health of women. Using path analysis, data from the Health Survey for England (1993) are used to demonstrate how different dimensions of social position (working conditions, general social advantage and material deprivation) have distinct pathways to ill-health. Smoking, diet, alcohol consumption, exercise, social support and job strain were all related to poorer health, but not always in the predicted direction. The effects of social position on health were not fully mediated through these risk and protective factors. Each dimension of social position had unique pathways to ill-health via other unidentified mechanisms. Furthermore, the salience of the three dimensions of social position differed according to the level of labour market attachment. Different path models are required to fit the data for women at home or in full-time or part-time work.

The persisting effect of unemployment on health and social well-being in men early in working life.

In our studies of the effects of unemployment in the early working life of men in a British national birth cohort we have shown elsewhere that this experience was part of a longer term accumulation of social and health disadvantage. This present study asks whether men's unemployment also inflicted potential longterm damage to future socio-economic chances and health. We therefore constructed indicators of socio-economic circumstances and health at 33 years from factors already shown to be associated with health in later life. For the socio-economic indicator we used a combination of income, occupational status and home ownership and described this as socio-economic capital. For the health indicator we combined scores of body mass index, leisure time exercise, frequency of eating fresh fruit and of smoking, and described this as health capital. After controlling for pre-labour market socio-economic and health factors, prolonged unemployment is shown here to reduce significantly both socio-economic and health capital by age 33 years. We conclude that the experience of prolonged unemployment early in the working life of this population of young men looks likely to have a persisting effect on their future health and socio-economic circumstances.