1. LONGVIEW: COGNITIVE CAPITAL OVER THE LAST 50 YEARS SEMINAR 5 ADULT LIFE CHANCES: HEALTH Based on work led by David Batty, Catherine Gale, Stephani Hatch, Barbara Jefferis, Diana Kuh, and Marcus Richards

2. PATHWAYS FROM COGNITIVE CAPITAL TO HEALTH Mediation Cognition may mediate early circumstances that influence health: material home conditions (wealth) family interaction (psychosocial) developing health itself

3. PATHWAYS FROM COGNITIVE CAPITAL TO HEALTH Social causation Cognition can determine the acquisition of factors that influence health: material resources (wealth) psychosocial capital (status, control, wellbeing) self-care/health literacy (lifestyle, health service use)

4. PATHWAYS FROM COGNITIVE CAPITAL TO HEALTH Cognition as a biomarker Cognition may mark underlying physiological processes that regulate health: central nervous system autonomic nervous system endocrine axes (growth, thyroid, HPA, HPG) oxidative biochemistry immune function genetic pleiotropy

5. British 1946 birth cohort: cumulative male death rate 9 to 54 years for the highest and lowest quarters of the cognitive score at age 8 years. 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 Highest quartile Lowest quartile Kuh, Richards, Hardy, Butterworth & Wadsworth Int J Epidemiol 2004; 33: 408-413

6. Cognitive ability tests ____________________________________________________ 1946 cohort1970 cohort ____________________________________________________ Non-Verbal intelligenceNon-verbal (BAS) Verbal intelligence - Recall of digits Vocabulary - Matrices PronunciationVerbal (BAS) Arithmetic - Word definitions - Word similarities ___________________________________________________________

7. LIFESTYLE: HEALTH-RELATED BEHAVIOURS

8. Ever smoked cigarettes ___________________________________________________________ 1946 cohort (36 y) 1970 cohort (30 y) (63.8%) (55.4%) ___________________________________________________________ Unadjusted 0.83 (0.76, 0.92) p < 0.001 ----- Gender 0.84 (0.76, 0.92) p < 0.001 0.92 (0.88, 0.96) Parental SC 0.86 (0.77, 0.95) p = 0.003 0.93 (0.89, 0.97) Own education 1.07 (0.95, 1.22) p = 0.26 1.08 (1.03, 1.14) Adult SC 0.90 (0.80, 1.00) p = 0.05 1.01 (0.96, 1.06) Adult earnings 0.80 (0.72, 0.88) p < 0.001 0.93 (0.88, 0.98) All 1.09 (0.96, 1.24) p = 0.19 1.08 (1.02, 1.15) ____ ________________________________________________________ Batty D, Deary I, Schoon I, Gale C. In press: Journal of Epidemiology and Community Health

9. Quit smoking cigarettes ___________________________________________________________ 1946 cohort (36 y) 1970 cohort (30 y) (33.4%) (34.2%) ___________________________________________________________ Unadjusted 1.31 (1.16, 1.48) p < 0.001 ----- Gender 1.31 (1.16, 1.48) p < 0.001 1.25 (1.18, 1.34) Parental SC 1.29 (1.13, 1.47) p < 0.001 1.18 (1.10, 1.26) Own education 1.13 (0.97, 1.32) p = 0.11 1.10 (1.02, 1.18) Adult SC 1.22 (1.06, 1.40) p = 0.005 1.15 (1.07, 1.23) Adult earnings 1.30 (1.15, 1.48) p < 0.001 1.16 (1.07, 1.25) All 1.11 (0.95, 1.31) p = 0.19 1.02 (0.93, 1.11) ____ ________________________________________________________ Batty D, Deary I, Schoon I, Gale C. In press: Journal of Epidemiology and Community Health

10. 1946 cohort: odds of being CAGE positive at 53 years per point increase in childhood cognition at 8 years Odds = 1.04 (1.01 – 1.07) p = 0.02 Adjusting for: Gender SES origin and early adversity (fathers social class, mothers education, parental divorce, suboptimal maternal management and poor material home conditions) Highest educational qualifications by 26 years) Adult SES (social class and household income) Adult stressors (unemployment and economic hardship) Adult health behaviours (exercise and smoking) Hatch, Jones, Kuh, Hardy, Wadsworth & Richards Soc Sci Med 2007; 64: 2285-2296

11. Ever CAGE positive (men) ___________________________________________________________ 1946 cohort (43 y) 1970 cohort (30 y) (13.7%) (20.4%) ___________________________________________________________ Unadjusted 0.99 (0.84, 1.18) p = 0.93 ----- Parental SC 1.00 (0.83, 1.21) p = 0.98 1.13 (1.04, 1.24) Own education 1.03 (0.82, 1.29) p = 0.79 1.13 (1.04, 1.24) Adult SC 1.00 (0.82, 1.22) p = 0.99 1.18 (1.07, 1.30) Adult earnings 0.99 (0.82, 1.19) p = 0.90 1.15 (1.03, 1.26) Has children 0.99 (0.83, 1.18) p = 0.92 1.11 (1.02, 1.22) All 1.03 (0.81, 1.30) p = 0.82 1.16 (1.04, 1.28) ____ ________________________________________________________ Batty D, Deary I, Schoon I, Gale C. In press: American Journal of Public Health

12. Ever CAGE positive (women) ___________________________________________________________ 1946 cohort (43 y) 1970 cohort (30 y) (9.3%) (8.1%) ___________________________________________________________ Unadjusted 1.43 (1.06, 1.94) p = 0.02 1.44 (1.24, 1.67) Parental SC 1.37 (0.99, 1.91) p = 0.06 1.42 (1.22, 1.65) Own education 1.09 (0.74, 1.62) p = 0.67 1.46 (1.24, 1.71) Adult SC 1.24 (0.89, 1.74) p = 0.20 1.35 (1.16, 1.59) Adult earnings 1.16 (0.84, 1.59) p = 0.37 1.44 (1.24, 1.67) Has children 1.41 (1.04, 1.91) p = 0.03 1.36 (1.18, 1.58) All 1.02 (0.68, 1.53) p = 0.92 1.38 (1.17, 1.64) ____ ________________________________________________________ Batty D, Deary I, Schoon I, Gale C. In press: American Journal of Public Health

13. Any physical exercise ___________________________________________________________ 1946 cohort (36 y) 1970 cohort (30 y) (65.4%) ___________________________________________________________ Unadjusted 1.40 (1.28, 1.54) p < 0.001 1.21 (1.14, 1.27) Gender 1.42 (1.29, 1.56) p < 0.001 1.20 (1.14, 1.27) Parental SC 1.35 (1.22, 1.49) p < 0.001 1.16 (1.10, 1.23) Own education 1.23 (1.09, 1.39) p = 0.001 1.06 (1.00, 1.12) Adult SC 1.26 (1.13, 1.40) p < 0.001 1.15 (1.09, 1.22) Adult earnings 1.30 (1.18, 1.43) p < 0.001 1.16 (1.09, 1.24) All 1.19 (1.05, 1.35) p = 0.006 1.02 (0.94, 1.09) ____ ________________________________________________________ Batty D, Deary I, Schoon I, Gale C. Pediatrics 2007 (www.pediatrics.org)

14. Intense physical exercise ___________________________________________________________ 1946 cohort (53 y) 1970 cohort (30 y) (37%) ___________________________________________________________ Unadjusted 1.80 (1.60, 2.02) p < 0.001 1.35 (1.29, 1.41) Gender 1.81 (1.61, 2.04) p < 0.001 1.30 (1.24, 1.36) Parental SC 1.71 (1.51, 1.94) p < 0.001 1.31 (1.25, 1.37) Own education 1.43 (1.23, 1.65) p < 0.001 1.25 (1.19, 1.31) Adult SC 1.60 (1.40, 1.82) p < 0.001 1.22 (1.16, 1.28) Adult earnings 1.69 (1.50, 1.90) p < 0.001 1.20 (1.14, 1.27) All 1.39 (1.19, 1.62) p < 0.001 1.15 (1.08, 1.22) ____ ________________________________________________________ Batty D, Deary I, Schoon I, Gale C. Pediatrics 2007 (www.pediatrics.org)

15. Healthy food choice at 53 years (1946 cohort) _________________________________________________ Unadjusted 1.53 (1.35, 1.73) p < 0.001 Gender 1.52 (1.35, 1.72) p < 0.001 Parental SC 1.46 (1.28, 1.66) p < 0.001 Own education 1.14 (0.98, 1.34) p = 0.09 Adult SC 1.44 (1.25, 1.65) p < 0.001 Adult earnings 1.57 (1.38, 1.78) p < 0.001 All 1.14 (0.97, 1.34) p = 0.11 _________________________________________________ Based on forthcoming work in collaboration with the MRC Human Nutrition Research Centre, Elsie Widdowson Laboratories, Cambridge Healthy food choice representing 1. frequency of breakfast, 2. type of milk, 3. type of bread, 4. proportion of energy derived from fat, and 5. number of daily portions of fruit and vegetables (odds of > median total score)

16. Odds of being a vegetarian at 30 years (1970 cohort) _______________________ Unadjusted 1.38 (1.24, 1.53) Gender1.42 (1.28, 1.59) Parental SC 1.35 (1.21, 1.51) Own education1.16 (1.03, 1.30) Adult SC 1.29 (1.15, 1.45) All1.20 (1.06, 1.36) _______________________ Gale C, Deary I, Schoon I, Batty D. British Medical Journal 2007;334:245.

17. Health behaviours: summary Childhood IQ is mainly protective of harmful health- related behaviours, although it appears to be associated with increased risk of potential alcohol abuse These effects were often explained by educational attainment or adult SES, although there were independent effects of IQ on on risk of alcohol abuse and being a vegetarian in the 1970 and on likelihood of undertaking physical exercise in both cohorts There were few obvious cohort effects, although positive associations between IQ and potential alcohol abuse appeared to be stronger in the 1958 cohort

18. CHRONIC PHYSICAL DISEASE

19. Hypertension (self reported) ___________________________________________________________ 1946 cohort (36 y) 1970 cohort (30 y) (3.1%) (7.7%) ___________________________________________________________ Unadjusted 0.75 (0.59, 0.95) p = 0.02 ----- Gender 0.74 (0.58, 0.95) p = 0.02 0.90 (0.83, 0.98) Parental SC 0.75 (0.57, 0.97) p = 0.03 0.92 (0.84, 0.99) Own education 0.69 (0.51, 0.95) p = 0.02 0.93 (0.85, 1.01) Adult SC 0.77 (0.58, 1.02) p = 0.07 0.91 (0.83, 0.99) Adult earnings 0.78 (0.61, 1.01) p = 0.06 0.89 (0.80, 0.98) All 0.70 (0.51, 0.98) p = 0.04 0.94 (0.84, 1.06) ____ ________________________________________________________ Batty D, Deary I, Schoon I, Gale C. In press: Journal of Epidemiology and Community Health

20. Obesity (BMI > 30 kg/m 2 : WHO) ___________________________________________________________ 1946 cohort (36 y) 1970 cohort (30 y) (5.6%) (11.3%) ___________________________________________________________ Unadjusted 0.73 (0.61, 0.88) p = 0.001 ----- Gender 0.73 (0.61, 0.88) p = 0.001 0.84 (0.79, 0.91) Parental SC 0.78 (0.94, 0.95) p = 0.02 0.89 (0.83, 0.96) Own education 0.79 (0.62, 1.00) p = 0.05 0.93 (0.86, 1.00) Adult SC 0.78 (0.63, 0.97) p = 0.02 0.88 (0.81, 0.95) Adult earnings 0.76 (0.63, 0.92) p = 0.005 0.86 (0.79, 0.94) All 0.82 (0.64, 1.05) p = 0.12 0.97 (0.88, 1.07) ____ ________________________________________________________ Batty D, Deary I, Schoon I, Gale C. In press: Journal of Epidemiology and Community Health

21. Metabolic syndrome at 53 years (1946 cohort) _________________________________________________ Unadjusted 0.82 (0.72, 0.94) p = 0.004 Gender 0.82 (0.72, 0.94) p = 0.004 Parental SC 0.86 (0.74, 0.99) p = 0.04 Own education 0.96 (0.80, 1.14) p = 0.64 Adult SC 0.85 (0.73, 1.00) p = 0.04 Adult earnings 0.79 (0.69, 0.91) p = 0.001 All 0.98 (0.82, 1.18) p = 0.84 _________________________________________________ Metabolic syndrome identified in the 1946 cohort by Claudia Langenberg (American Journal of Public Health 2006; 96: 2216-2221) National Cholesterol Education Program Adult Treatment Panel III (ATPIII) definition (21.9%)

22. TIMING OF THE NATURAL MENOPAUSE Mediation: Cognition may mediate early circumstances that influence reproductive ageing Social causation: Education and cognition determine health behaviours (e.g. smoking) that trigger early menopause Cognition as a biomarker: oestrogen facilitates neural growth, prevents neuronal damage and death, and increases cerebral blood flow

23. Survivor functions for age at menopause by cognitive ability score at age 8 years 0.00 0.25 0.50 0.75 1.00 34363840424446485052545658 Age (years) Lowest thirdHighest third Proportion pre/peri menopausal Richards et al. Neurology 1999; Kuh et al. Menopause 2005

24. Effect of one standard deviation change in cognitive ability at 8 years on age at menopause Hazard Ratio (95%CI) Unadjusted0.89 (0.82,0.96) Adjusted for been breastfed0.88 (0.81,0.96) Adjusted for fathers social class0.91 (0.83,0.99) Adjusted for parental divorce (by 15)0.89 (0.82,0.96) Adjusted for parity0.88 (0.80,0.95) Adjusted for smoking0.91 (0.83,0.99) Fully adjusted0.90 (0.82,0.98) Kuh et al. Menopause 2005; 12: 475-82

25. COX PROPORTIONAL HAZARDS FOR COGNITION AND AGE AT MENOPAUSE ___________________________________________________________ Age of testHazard ratio (95% CI)p value ___________________________________________________________ 8 years0.73 (0.62 - 0.86)<0.001 11 years0.78 (0.67 - 0.91) 0.002 15 years0.80 (0.67 - 0.94) 0.007 26 years0.85 (0.72 - 1.00) 0.048 __________________________________________________________________

26. Chronic physical disease: summary Childhood IQ is associated with reduced risk of chronic physical disease As with health behaviours, this was mostly explained by educational attainment or adult SES, although there is an independent inverse association between IQ and risk of early natural menopause, possibly reflecting early programming of the reproductive hormonal axis There were few obvious cohort effects, although associations between IQ and self-reported hypertension appeared to be stronger in the 1946 cohort

27. MENTAL HEALTH

28. 1946 cohort: total GHQ-28 score at 53 years per point increase in childhood cognition at 8 years Regression coefficient (men) = -0.04 (-0.22, -0.15) p = 0.70 Regression coefficient (women) = -0.29 (-0.52, -0.06) p = 0.01 Adjusting for: SES origin and early adversity (fathers social class, mothers education, parental divorce, suboptimal maternal management and poor material home conditions) Highest educational qualifications by 26 years) Adult SES (social class and household income) Adult stressors (unemployment and economic hardship) Adult health behaviours (exercise and smoking) Hatch, Jones, Kuh, Hardy, Wadsworth & Richards Soc Sci Med 2007; 64: 2285-2296

29. LITERACY, COGNITIVE RESERVE, AND COGNITIVE DECLINE

30. Fathers occupation Cognitive ability at 8 years Education by 26 years Own occupation at 43 years literacy at 53 years 0.33 0.18 0.50 0.05 0.07 0.47 0.60 0.24 0.14 1946 cohort1958 cohort Fathers occupation Cognitive ability at 7 years Education by 23 years Own occupation at 33 years literacy at 43 years 0.31 0.54 0.43 0.01 0.08 0.11 0.21 0.41 Richards, Power & Sacker (In press: J Epidemiol Community Health)

31. Prior ability Age Cognitive decline (1946 cohort) Richards M, Shipley B, Fuhrer F & Wadsworth M British Medical Journal 2005; 328: 552-554

32. Age specific prevalence of Alzheimers disease

33. Clinical expression of disease Other influences on disease expression: Personality Health service delivery and uptake Cultural norms BRAIN LESIONS INFLUENCING FACTORS Genes Early social and material environment Educational and occupational attainment Physical health Health behaviours and lifestyle PREMORBID BRAIN SIZE COGNITIVE AND FUNCTION ABILITY (RESERVE) Richards M & Deary I. A life course approach to cognitive reserve: a model for cognitive aging and development? Annals of Neurology 2005; 58: 617-620

34. But what about wisdom? The development of expertise The development of contextualisation Relativism of values and priorities Recognition and management of uncertainty