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This chapter shows that the main classical cardiovascular risk factors have the same effects in women as they do in men and preventive treatments that lower risk factors—antihypertensive drugs, aspirin, and cholesterol lowering drugs—work equally well in both sexes. Diabetes and the insulin resistance syndrome may confer greater risk to women than men. Women may be protected from coronary heart disease by a number of interacting factors including a more favourable fat distribution, a less adverse response to dietary saturated fats, and endogenous oestrogens. Low birthweight, poor infant nutrition, and accelerated postnatal growth are all associated with CHD and stroke risk in both women and men.

Objective: To test two methods of providing low cost information on the later health status of survivors of neonatal intensive care. Design: Cluster randomised comparison. Setting: Nine hospitals distributed across two UK health regions. Each hospital was randomised to use one of two methods of follow up. Participants: All infants born ≤32 weeks9 gestation during 1997 in the study hospitals. Method: Families were recruited at the time of discharge. In one method of follow up families were asked to complete a questionnaire about their child9s health at the age of 2 years (corrected for gestation). In the other method the children9s progress was followed by clerks in the local community child health department by using sources of routine information. Results: 236 infants were recruited to each method of follow up. Questionnaires were returned by 214 parents (91%; 95% confidence interval 84% to 97%) and 223 clerks (95%; 86% to 100%). Completed questionnaires were returned by 201 parents (85%; 76% to 94%) and 158 clerks (67%; 43% to 91%). Most parents found the forms easy to complete, but some had trouble understanding the concept of “corrected age” and hence when to return the form. Community clerks often had to rely on information that was out of date and difficult to interpret. Conclusion: Neither questionnaires from parents nor routinely collected health data are adequate methods of providing complete follow up data on children who were born preterm and required neonatal intensive care, though both methods show potential. What is already known on this topic Outcome of neonatal intensive care should include later health status not just early mortality Although these data are commonly sought, for various reasons no existing routine system currently delivers the information for ≥95% of the population (95% representing the minimum acceptable standard) Running one-off studies to gain later follow up data is difficult and costly What this study adds Potentially these data could come from parents but to reach 95% ascertainment perhaps 5-10% of parents would require help and support to provide information Existing data flows may be able to provide the required information if the timing of routine reviews and methods of data recording were harmonised across the United Kingdom The costs attached to introducing such a system seem to be low

The aim of this study was to evaluate the Dinamap 8100 and the Omron M1 (the test devices) against standard criteria for use in children in a fieldwork setting. Device calibration and validation were carried out in accordance with the British Hypertension Society protocol for special groups such as children. A total of 102 children, recruited from infant and junior schools in Southampton, had six sequential measurements made of their blood pressure-four measurements with a mercury sphygmomanometer and two with one of two test devices, 55 children with the Dinamap 8100 and 47 with the Omron M1. Systolic and diastolic readings with the Dinamap 8100 were on average 11 mmHg higher (95% confidence interval [CI] +9, +12 mmHg) and 3 mmHg lower (95% CI -5, -1 mmHg), respectively, than measurements with the mercury sphygmomanometer, overestimating systolic pressures and underestimating diastolic pressures across the whole range observed. The Omron M1 gave readings lower by 1 mmHg on average for systolic pressures and 2 mmHg for diastolic pressures compared with the sphygmomanometer (95% CIs -4, +1 mmHg and -5, +1 mmHg respectively), specifically overestimating higher pressures and underestimating lower pressures. According to the criteria of the British Hypertension Society, neither the Dinamap 8100 nor the Omron M1 can be recommended for use in children in clinical situations in which accuracy of the absolute measurement is required. In epidemiological surveys, in which differences in blood pressure between groups of people are more important than absolute levels, it may be more appropriate to use these devices. Of the two, its more consistent performance supports the Dinamap 8100 as the instrument of choice in such studies of children.

Background Promoting healthier lifestyles is at the heart of England’s public health strategy. The dominant focus has been on single health behaviours; however, most adults engage in multiple risk behaviours. Very few studies have investigated patterns among parents and children. This paper focuses on four health behaviours among mothers; part of a broader project examining multiple risk behaviours among parents and children. Methods Data from the Health Survey for England (years 2006 and 2008) identified 4,218 mothers living with children under the age of 16. Latent Class Analysis classified mothers into groups with differing combinations of cigarette smoking, alcohol, fruit and vegetable consumption and physical activity engagement. Logistic regression identified the characteristics associated with membership of each group. Results Six mutually exclusive groups of mothers were identified. The first (31% of mothers) had average fruit, vegetable and alcohol consumption, average physical activity engagement and were non-smokers. This group had higher income levels than other mothers. The second group had lower levels of alcohol consumption, were non-smokers with lower physical activity levels. They were from lower income groups. The third group drank alcohol most regularly, were cigarette smokers and had lower physical activity engagement and fruit and vegetable consumption. These women were more likely to be single and to be in employment. The fourth group were frequent consumers of alcohol but had high levels of fruit and vegetable consumption and higher engagement in physical activity. They had higher levels of educational attainment than other mothers. The fifth group were either ex or current smokers, infrequent drinkers, average engagers in sports physical activity but had higher fruit and vegetable consumption. They were more likely to live in rented accommodation. The sixth group were current cigarette smokers with lower physical activity engagement, lower fruit and vegetable consumption and were infrequent drinkers. A higher proportion of this group lived in more deprived areas. Discussion This analysis shows for the first time for mothers in England, how risk behaviours cluster and the differential social patterning associated with the clusters. It indicates how targeted interventions aimed at different ‘risk’ groups may be appropriate. These implications will be discussed.

Background Obesity is associated with increased mortality, cardiovascular disease (CVD), type 2 diabetes (T2D) and associated biomarkers. A key priority is to minimise such obesity-related consequences for the substantial proportion of adults now at risk. Potential modifiable factors, such as physical activity (PA) and sedentary lifestyles could mediate or moderate the obesity - ill-health association. However, research is scant on whether benefits of activity vary by obesity status across multiple biomarkers and whether there are corresponding patterns for sedentary behaviour. To establish whether the obesity −CVD and T2D risk associations can be lessened by PA or lower sedentary behaviour we aimed to assess whether (i) obesity, PA and sedentary behaviour are independently associated with biomarkers for CVD and T2D, and (ii) PA or sedentary behaviour moderate the obesity-biomarker associations. Methods In the 1958 British birth cohort (N = 9377) we examined associations between early adulthood obesity (33y) with subsequent biomarkers (45y) together with PA and sedentary behaviour (indicated by TV-viewing) recorded before or at 45y. The temporal sequence follows the ordering of potential interventions to reduce health burdens associated with obesity. Analyses were sex-specific, adjusted for covariates and used multiple imputation to account for missing data. Results Obesity was associated with lower HDL-cholesterol and higher systolic (SBP), diastolic (DBP) blood pressure, glycosylated haemoglobin (HbA1c) and triglycerides in both sexes (LDL-cholesterol in women only) by 4.30% (95% CI 3.19, 5.41) for SBP to 24.7% (18.8, 30.4) for triglycerides. Men active at least weekly had 1.09% (0.28, 1.90) lower DBP than less active men; triglycerides were 2.08% (0.52, 3.64) lower per unit higher PA (on 4-point scale). TV-viewing was independently associated with several biomarkers, e.g. per unit higher TV-viewing (on 4-point scale) DBP was raised by 0.50% (0.09, 0.90) and triglycerides by 3.61% (1.58, 5.64). For both TV-viewing and PA, associations with HbA1c were greatest for the obese (p-interaction≤0.04): compared to a reference value of 5.20 HbA1c% in non-obese men viewing 0–1h/day, HbA1c% differed little for those viewing >3 h/day; however, among obese men HbA1c% was 5.36 (5.22, 5.51) and 5.65 (5.53, 5.76), for 0–1 and >3 h/day respectively. For PA in non-obese men, the reduction associated with activity at least weekly was negligible compared to a reference value of 5.20 HbA1c% for those less active; but there was a benefit among obese men, HbA1c% was 5.50 (5.40, 5.59) vs 5.66 (5.55, 5.77) respectively. Conclusion Reduced sedentary behaviour and prevention of infrequent activity has greatest benefit among obese groups, particularly for glucose metabolism.

OBJECTIVE The mechanisms underlying the association between reduced size at birth and cardiovascular disease and non-insulin-dependent diabetes mellitus in adult life are not known. One possibility is that the intra-uterine environment has permanent effects on the function or activity of the hypothalamo-pituitary-adrenal axis. We tested this by relating size at birth to the urinary excretion of adrenal androgen and glucocorticoid metabolites in a population sample of 9-year-old children. SUBJECTS AND METHODS One hundred and ninety children (89 boys and 101 girls) of known present height, weight and size at birth collected a 24-hour urine sample. The urinary breakdown products of dehydroepiandrosterone sulphate and of cortisol and cortisone were measured by gas chromatography and their respective breakdown products summed (‘adrenal androgen metabolites’ and ‘glucocorticoid metabolites’). Excretion was expressed in μg/day. RESULTS Urinary adrenal androgen metabolite excretion was higher in children who had been light at birth. A 1-kg decrease in birthweight was associated with a 40% (95% CI 9–79%) increase in metabolite excretion. Excretion was positively associated with current weight and age, but the relation with birth weight was independent of weight, age or sex. Urinary glucocorticoid metabolite excretion was positively associated with current weight, but not independently with age. The urinary excretion of total glucocorticoid metabolites was higher in children who had been light at birth, but the relation was best described as U-shaped, with the highest average urinary glucocorticoid metabolite excretion being found in children who had been either light or heavy at birth. The U-shaped (quadratic) relation persisted after adjustment for sex and current weight (P for quadratic term 0.006). CONCLUSION These findings suggests that the intra-uterine environment, as measured by fetal size at birth, has long-lasting effects on the function of the hypothalamo-pituitary-adrenal axis.

Studies of population samples of adults and children consistently show a relation between lower birthweight and higher subsequent blood pressure (BP). This relation is not present in the neonatal period or in adolescence, which may reflect the unusual dynamics of growth at these times. We suggest that the inverse relation of BP with birthweight is a result of fetal adaptations to an adverse environment, particularly undernutrition. In making these adaptations, long-term physiology or metabolism is changed in a way that leads to subsequent higher BP. Such changes may be in the structure of blood vessels, or the re-programming of influential hormonal axes, such as the pituitary adrenal axis.

Background There is growing evidence of the health benefits of physical activity for young people, including reduced risk of obesity and improved psychological wellbeing. Conversely, sedentary behaviour is now recognised to increase the risk of later poor health. Patterns of physical activity and sedentary behaviour are established in early childhood. In July, 2011, the UK Chief Medical Officers released new guidelines for all young people, recommending engagement in moderate to vigorous intensity physical activity for at least 60 min every day, incorporation of vigorous intensity activities on at least 3 days each week, and minimising time spent being sedentary for extended periods. Information about the extent to which UK children of primary school age are meeting these recommendations is sparse. We measured time spent in different intensities of physical activity, and assessed adherence to guidelines, in a UK-wide representative sample of children of primary school age taking part in a longitudinal cohort study. We used accelerometer-based activity monitors because this approach allowed the frequency, intensity, and duration of free-living activity to be objectively measured. Methods Nearly 13 000 7-year-old children taking part in the UK Millennium Cohort Study consented to wear an Actigraph activity monitor during all waking hours for 7 days, apart from during bathing or other aquatic activities (eg, swimming). Valid accelerometer data (≥2 days, ≥6 h wear each day) were obtained from nearly 7000 singletons. For each child several variables were produced: mean daily min of sedentary (defined as 3841 cpm) activity. Time spent in moderate and vigorous activity was combined to establish adherence to activity guidelines. We fitted logistic regression models to compare adherence to guidelines according to individual (sex, ethnicity) and family (maternal social class, numbers of children in household, lone parenthood) factors, and country or region of residence. Findings On average, children accumulated 27 and 11 min per day of moderate and vigorous activity, respectively, and were sedentary for 5 h per day. Only 15% of all children achieved 60 min or more of daily moderate to vigorous intensity physical activity. Activity varied by ethnic group, with those of Indian and Bangladeshi origin the least active and black children the most active. Within adjusted analyses, significant differences were reported in adherence to activity guidelines between girls and boys (p Interpretation Only a small proportion of children of primary school age in the UK meet guidelines and are sufficiently active. A substantial part of their day is spent in sedentary behaviour and striking differences in activity are evident between boys and girls, different ethnic or social groups, and UK countries. Although we recognise the importance of some sedentary pursuits, such as reading and homework, measures to increase children's engagement in physical activity are needed for social and health benefits. Funding The Wellcome Trust (grant 084686/Z/08/A).

Background Maternal employment in the UK has increased significantly in recent years, but evidence of its relationship with child socio-emotional behaviour is mixed. Given the policy importance of both family employment and children’s wellbeing, this relationship needs to be better understood. This study seeks to investigate whether cumulative exposure to maternal employment is associated with socio-emotional behaviour at age 7. Methods The study comprises a longitudinal analysis of the United Kingdom Millennium Cohort Study (MCS), based on 10,723 singleton children who participated in all four sweeps of the study (at ages 9 months, 3, 5 and 7 years). Socio-emotional behaviour was measured using total Strengths and Difficulties Questionnaire (SDQ) scores, dichotomised using an established cut-off for borderline / abnormal behaviour. Risk ratios (RR) were estimated using Poisson regression for borderline / abnormal SDQ scores at age 7 according to cumulative maternal employment over four sweeps of the MCS (at 9 months, 3, 5 and 7 years), unadjusted (uRR) and adjusted (aRR) for confounders (age at first live birth, ethnicity, family size, lone parenthood, and maternal psychological distress, all recorded at 9 months). In order to disentangle whether there was a differential impact of earlier and current employment, additional analyses estimated the risk associated with employment up to age 5 years, adjusting for employment at age 7. Results The risk of borderline/abnormal scores decreased linearly by number of MCS sweeps that mothers were in employment; after adjustment for confounders the gradient attenuated but remained significant. Children growing up in households where mothers were employed in all MCS sweeps were significantly less likely to display borderline / abnormal behaviour at age 7 (compared to never in paid employment): uRR=0.37 (0.32–0.44); aRR=0.68 (0.56–0.81). Analyses differentiating early employment (between ages 9 months and 5 years) and current employment (at age 7) suggest that the cumulative impact of prior non-employment may be ameliorated once a mother gains employment. After adjusting for current employment and confounders, there was no increased risk of borderline / abnormal socio-emotional behaviour associated with non-employment in all earlier sweeps up to age 5 compared to being in paid employment continuously (baseline): aRR=1.01 (0.82–1.23). Conclusion This longitudinal analysis supports an association between maternal employment and child socio-emotional behaviour. Possible explanations and implications will be discussed.

Background Both physical activity levels and dietary behaviours have consistently been linked with the development of chronic disease, obesity and ill-health in both adult and youth samples. Nationally there are established recommendations of minimum levels of physical activity and fruit and vegetable consumption necessary to promote good health. Developing healthy behaviour is particularly important for young people, as adult behaviours that are detrimental or positive for health and well-being are often established in childhood and adolescence. This paper aims to investigate the prevalence of physical activity and fruit and vegetable consumption and to explore the co-occurrence of these behaviours among young people in the UK, using the newly available Understanding Society study. Methods This study is part of an ongoing secondary analysis of Understanding Society: The UK Household Longitudinal Study . The analysis sample consisted of 4,395 young people aged 10 - 15 living in the UK in 2009/2010 who participated in the first wave of the study. The prevalence of physical activity and fruit and vegetable consumption within the sample, and patterns of co-occurrence across the two behaviours, were explored descriptively. Multinomial regression models were estimated to investigate the social patterning of the health behaviour co-occurrence patterns, using socio-demographic characteristics of the young person and mother. Results 85.2% of young people did not meet the government recommendation for fruit and vegetable consumption, reporting less than 5 portions of fruit and vegetable daily. 70.6% of young people did not meet the recommendation for participation in daily physical activity. A small minority did not consume any fruits and vegetables (5.0%); and 6.4% reported participating in physical activity less often than weekly. On examining the patterns across combinations of the two behaviours, most young people did not meet both recommendations (62%), while only 6.1% of young people met both recommendations. Multinomial regression models indicated that gender, ethnicity and religion and socio-economic status were significantly associated with health behaviour patterns. Conclusion This paper presents an analysis of the most recently available health-risk behaviour data on children from all four countries of the UK. The results indicate that a high proportion of young people do not achieve levels of fruit and vegetable consumption or levels of participation in physical activity considered to be a minimum for good health, and these two behaviours tend to co-occur. The implications of these behaviour patterns and the associations with socio-demographic characteristics are discussed.

Background The evidence base for effective interventions to manage childhood overweight and obesity is growing. However, results from research may not generalise to service delivery settings, and scaled-up interventions may not reduce health inequalities. We examine a scaled–up childhood weight management intervention, examining variations in body mass index by person, family, place and programme. Methods MEND 7–13 (Mind, Exercise, Nutrition, Do It!) is a multi-component family-based community weight management intervention shown to be effective in a randomised controlled trial (RCT). We used MEND service data from 10,080 children attending MEND programmes from 2007–10. Outcomes were: Change in Body Mass Index (BMI) change over the programme (10 weeks). Anthropometry is measured by trained staff following standardised procedures. We estimated associations between BMI change and participant, family, neighbourhood and programme factors – including pre-specified interactions and random slopes. Multilevel multivariate regression models were used with multiple imputation for missing values. We described participants by BMI at programme start (pre-BMI), age, sex and ethnicity; families by parent-reported employment, lone parent and housing tenure status; places by residential neighbourhood income deprivation, urbanicity, food and built environments; and programmes by the percentage of sessions attended and variables describing programme composition (e.g. group size). Results BMI was reduced by similar amounts in the RCT and service delivery (RCT BMI change = –0.91 [95%CI: –1.13 to –0.68]), service BMI change = –0.75 [–0.78 to –0.73]. Service BMI reductions were clinically significant in all socio-demographic groups analysed. However, in multilevel models, pre-BMI, age, ethnicity, unemployment status and programme attendance were independently associated with BMI change. For example, in comparison to white children, reductions in BMI were statistically significantly smaller for black and minority ethnic group children (Asian b=0.29, p Conclusion Clinically significant BMI changes, similar to those achieved under research conditions, may be replicable in service delivery settings for children of all socio-demographic groups analysed. However, at the population level, scaled up programmes may work better for some groups than others. Public health implications of these results for health inequalities will be discussed.

Over half of all adults in the United States and the United Kingdom are overweight, and developing countries are increasingly facing the public health problems of overnutrition as well as undernutrition.1 In the past 20 years or so, the prevalence of obesity and overweight in both adults and children has increased dramatically.2 These time and geographical trends argue against a primarily genetic cause of obesity, and both behavioural and pharmaceutical interventions in obesity have limited effectiveness.3 Prevention through environmental, social, or behavioural interventions is a logical focus for tackling this epidemic. The possibility of preventing adult obesity by taking action in infancy and childhood is attractive. Several studies have shown a weak relation between being heavy at birth and becoming overweight in later life. Others have found that faster growth in childhood predicts obesity in adulthood.4 In this week's issue (p 1331) Parsons et al replicate these findings in a large British birth cohort study followed to age …

We would like to correct the inaccurate comments made in the commentary in STI .1 The paper states that the draft guidance misses out under 25 year olds as reflected in the paper’s title and in further references …

Background Reduced birthweight is associated with increased risk for the insulin resistance syndrome. Part of this risk is hypothesized to originate from undernutrition in utero. The prevalence of the insulin resistance syndrome increases in countries that undergo the transition from chronic malnutrition to adequate nutrition, when postnatal nutrition improves more rapidly than prenatal nutrition. Objective To determine whether the components of the insulin resistance syndrome are associated with reduced fetal growth and maternal undernutrition. Design A nonconcurrent, prospective study of men and women whose mothers' heights and weights were recorded during pregnancy. Setting Beijing, China. Participants 627 men and women (mean age, 45 years) whose mothers' obstetric records were preserved. Measurements Adult offspring's blood pressure, plasma glucose levels, insulin levels, and lipid concentrations during an oral glucose tolerance test. The main explanatory measurements were mothers' body mass index during pregnancy and offspring's birthweight and adult size. Results After adjustment for sex and current body mass index, low birthweight was associated with elevated plasma glucose levels, insulin levels, triglyceride concentrations, and blood pressure. For every 1-kg increase in birthweight, systolic blood pressure decreased by 2.9 mm Hg (95% CI, 0.3 to 5.4 mm Hg) and the 2-hour plasma glucose level decreased by 5.1% (CI, 0.7% to 9.3%). Low maternal body mass index in early and late pregnancy was associated with elevated levels of plasma glucose, insulin, and triglycerides in adult offspring but was not associated with elevated blood pressure. Conclusions Risk for the insulin resistance syndrome may be partially established through low maternal body mass before pregnancy and consequent fetal undernutrition. This risk is independent of that associated with adult obesity. In developing countries such as China, improved nutrition in girls and young women may offer long-term benefits to offspring.

EDITOR,—In their study of men in Uppsala, David A Leon and colleagues found that the highest blood pressures were in men who had been small babies but grew to be tall adults.1 They argue that these babies failed to achieve their growth potential in utero. We replicated their analysis in three studies of men born in England (in Hertfordshire (in 1920-30, n = 841), Preston (1935-43, n = 239), and Sheffield (1939-41, …

It has been shown recently that men and women who were thin at birth have a high prevalence of impaired glucose tolerance and insulin resistance. These associations may reflect impaired development of skeletal muscle during gestation. To determine whether the relations can be detected in children, we have studied a population sample of 249 British children aged 7 years. Blood was taken for glucose and insulin in the fasting state and 30 minutes after an oral glucose challenge. Plasma insulin, proinsulin, and 32-33 split proinsulin concentrations were determined by two site immunoreactive assays. Mean birthweight was 3359 (sd 510) grams. Glucose at 30 minutes was significantly inversely related to thinness at birth, as measured by the ponderal index (weight/height3). For a given insulin response to the glucose challenge, children who had been thin at birth had high glucose levels at 30 minutes. A high level of 32-33 split proinsulin, a measure of islet cell dysfunction, was related to shortness at birth. Those findings are further evidence that reduced growth in utero is followed by permanent dysfunction of the endocrine pancreas and resistance of peripheral tissues to insulin.

Birthweight is inversely related to blood pressure, but there is debate over whether this depends on influences acting during prenatal life, or adverse experiences in postnatal life which are associated with low birthweight. We have examined the relations of prenatal growth and growth in the first year of life to blood pressure in children and adults. The Brompton study measured growth and blood pressure annually from birth to 10 years in a population sample of 1797 children. The Hertfordshire study measured blood pressure at mean age 64 years in a population sample of 841 men whose birthweight and weight at one year were known. In children and adults blood pressure was negatively related to birthweight. The strength of this negative relation increased with age: the increase in systolic pressure (mm Hg) per kilogram decrease in birthweight was 1.0 (standard error 0.7) at 3 years, 1.6 (standard error 0.6) at 8 years and 4.0 (standard error 1.4) at 64 years. After taking account of birthweight, blood pressure was not related to growth during the first year of life. These analyses suggest that the relation of birthweight with blood pressure reflects prenatal rather than postnatal influences. Augmentation of blood pressure, described in secondary hypertension, may explain the increasing effect of birthweight on blood pressure as age increases.

Geographical differences in mortality from cardiovascular disease and chronic bronchitis within England and Wales are closely related to past differences in infant mortality. This paper examines the separate relations of mortality during 1968-78 with neonatal and post-neonatal mortality during 1911-25. These divisions of infant mortality are indicators of the intrauterine and early postnatal environments respectively. Stroke is related to neonatal mortality and therefore to the intrauterine environment. Prenatal determinants of blood pressure levels may be one mechanism underlying this. Bronchitis is related to postnatal mortality and therefore to the postnatal environment. This may reflect the long term effects of lower respiratory tract infection in early childhood. Ischaemic heart disease is related to both neonatal and post-neonatal mortality and therefore to the intrauterine and postnatal environments. The links may include blood pressure and as yet unknown processes established in early postnatal life.