1. Social circumstances and health

2. Deprivation in 1981

3. Deprivation in 1991

4. Deprivation in 2001

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

6. Past experiences:Castlemilk  ≥ £244.5m spent over 10 yrs to 2000 u Major impact on physical environment u Population decline – but stabilised u 18% reduction of FTE jobs, though higher employment rate u Rise in % with LLT illness (from 21% in ’91 to 32% in ’01). Glasgow figs 19% to 26%.

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

8. Smoking prevalence - Europe Males

9. Smoking prevalence - Europe Females

10. 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

11. 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

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

13. PREDICTED HEART DISEASE DEATHS IN RENFREW PAISLEY (MIDSPAN)

14. PREDICTED AND OBSERVED HEART DEATHS IN RENFREW PAISLEY (MIDSPAN)

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

16. Carotid artery thickening

17. Cortisol levels in affluent and deprived Schoolchildren (Montreal)

19. 19 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

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

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

22. 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

23. 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

24. A classification of stress u Positive – tolerable and short lived. Caused by everyday experiences such as meeting new people, frustration and coping with normal discipline. - Concept of “Serve and return” u Tolerable – could affect brain structure but relieved by supportive relationships. Natural disasters, loss of a loved one u Toxic – prolonged, highly active stress response. Associated with abuse, enduring maternal depression, neglect. Absence of continuing supportive relationships fails to build resilience B S McEwen et al 2007

26. Psobid u Psychological u Sociological and u Biological u Indicators of u Disease

27. 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

28. Some early years programmes u Nurse Family Partnership u Infant health and development programme u Perry High/Scope project u Early training project u Carolina Abcderian project u Milwaukee project u The Experience Corps u Pedagogues in Scandinavia u Sure Start in England

29. Cost benefit of early intervention programmes A Sinclair The Work Foundation 2007

30. Conclusions u Clear evidence that adverse early life circumstances have distinct biological effects u Some evidence that some early life support projects can improve health, social and economic prospects for children u Successful projects foster engagement between children, their peers and adults in a way that is appropriate to their stage of development u Projects are often poorly evaluated and reports seldom published in peer reviewed literature u Evidence of effectiveness is crucial to influence policy

31. “We look to Scotland for all our ideas of civilisation.” Voltaire (Francois Marie Arouet, 1694–1778) was responding to the flowering of ideas in eighteenth century Scotland that has become known as ‘The Scottish Enlightenment’..