1. Social circumstances and health

2. 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

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

4. Deprivation in 1981

5. Deprivation in 1991

6. Deprivation in 2001

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

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

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

10. Smoking prevalence - Europe Males

11. Smoking prevalence - Europe Females

12. 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

13. 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

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

15. Carotid artery thickening

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

19. EFFECT OF JOB INSECURITY AND UNEMPLOYMENT ON HEALTH Source: Ferrie et al. BMJ,2001,322: 647-651

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

22. P<0.001 P=0.03 Quartile of hs-CRP (Range, mg/dL) P Trend <0.001 0.055 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

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

24. 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

25. 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

34. 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