1. Wellbeing and its determinants CSP Congress 2009 Liverpool 16 October 2009

2. Social circumstances and health

3. 20 th century trends in life expectancy in Scotland and 16 other Western European countries Males 30 40 50 60 70 80 19001910192019301940195019601970198019902000 Year of birth Life expectancy in years Scotland

4. Health Inequalities u Are they due to: –Poverty? –Diet ? –Tobacco?

5. Deprivation in 1981

6. Deprivation in 1991

7. Deprivation in 2001

8. Excess Standardised Mortality not explained by deprivation (Scotland v. E&W)

9. Coronary heart disease mortality Men aged 15-74 years Age-standardised mortality per 100,000

10. World Health Organization (1997 and 2003)www.heartstats.org

11. Smoking prevalence - Europe Males

12. Smoking prevalence - Europe Females

13. Comparison of lung cancer mortality in West of Scotland and 3 major cohorts West of Scotland UK doctors American Cancer Society volunteers US veterans Average annual death rate /100,000

14. Lung cancer mortality by social class 0 20 40 60 80 100 never 1-1415-2425+ daily cigarette consumption Rate per 10,000 manual non-manual

15. Risk of death - by level of hopelessness RHR Everson et al 1996

16. Carotid artery thickening

19. Aaron Antonovsky 1923-1994

20. “.....expresses the extent to which one has a feeling of confidence that the stimuli deriving from one's internal and external environments in the course of living are structured, predictable and explicable, that one has the internal resources to meet the demands posed by these stimuli and, finally, that these demands are seen as challenges, worthy of investment and engagement." Sense of coherence....

21. For the creation of health........the social and physical environment must be: u Comprehensible u Manageable u Meaningful

22. STRESS AND GRADE OF EMPLOYMENT: MEN Salivary Cortisol Time of Day Steptoe et al. 2003, Psychosomatic Medicine, 65, 461-470

24. Environmental determinants of inflammatory status CRP (median) mg/dl affluent deprived

25. P<0.001 P=0.03 Quartile of hs-CRP (Range, mg/dL) P Trend <0.001  0.055 0.056–0.114 0.056–0.114 0.115–0.210 0.115–0.210  0.211  0.211 Relative Risk of MI Ridker. N Engl J Med. 1997;336:973–979. 0 1 2 3 1234 hs-CRP and Risk of Future MI in Apparently Healthy Men

26. Inflammation in plaques Inflammatory cells MMPs, IL-6, IL-15, IL-18, CRP Lumen Core Cap Thin Fibrous Cap InflammatoryCells SMCapoptosis Degradedmatrix Unstable cytokinesMMP

27. 0 1 2 3 4 5 00.511.522.533.544.55 Q1 : <0.66 mg/l Q5: > 4.18 mg/l Years in study % diabetic CRP and cumulative risk of type 2 diabetes Freeman et al. Diabetes 2002,51;1596

28. Adipocyte programming insulin resistance, inflammation and ALP Adipose stores NEFAs liver CRP SAA IL-6/IL-6sR TNF-  TNF-  sR-I triglyceride Low HDL small LDL Atherogenic Lipoprotein Phenotype Pro-inflammatory state skeletal muscle Insulin resistance

29. Its all about the brain

30. All shapes and sizes!

39. Attachment theory “Infants develop the attachment behaviours that optimally enhance their survival in their own characteristic environments.” Crittenden, 2000

40. Attachment theory u Ainsworth –Deep emotional connection that infant develops with primary caregiver –Reflects an “internal working model”expressing the infant’s expectations of parental behaviour in meaningful situations –Basis for development of later relationships u Increasingly recognised as determinant of later emotional, cognitive and social outcomes

41. “Serve and return” “ The ‘instruction’ to attend to the primary caregiver is genetic, the outcome depends on what happens” Balbernie, 2001

42. Engaged to respond to danger Disengaged... Who needs to bother about differential calculus?

43. The Dunedin cohort u 1000 children recruited in late 1972/3 u At age 3, “at risk” children identified on the basis of chaotic circumstances, emotional behaviour, negativity and poor attentiveness u As adults, those “at risk” were more likely to : –be unemployed –have criminal convictions (especially for violence) –been pregnant as a teenager –have a substance abuse problem –exhibit signs of insulin resistance and metabolic syndrome

44. Telomeres u Ends of chromosomes u Sense and signal damage u Home of repair systems u Integrate energy production and utilisation u Anti-cancer  Telomere length predictive for mortality

45. Telomere length in twins by occupation

47. “Physical activity” or sweaty exercise? u Are we being too modest in our aspirations for fitness? u Should we make more use of sport as a means to get people active? u By embracing “physical activity”, are we admitting defeat?

48. Opportunity to escape poverty, decent housing, social networks, self esteem and sense of control Consistent parenting, safe, nurturing early years, supportive education Health related behaviours

49. Opportunity to escape poverty, decent housing, social networks, self esteem and sense of control Consistent parenting, safe, nurturing early years, supportive education Health related behaviours Comprehensible Manageable Meaningful