Dr Emily Williams


Academic Lead for Equality, Diversity and Inclusion; Reader in Health Inequalities and Chronic Disease
B.Sc., Ph.D.
+44 (0)1483 688545
14 DK 04
Monday - Thursday

Biography

Areas of specialism

Equality, Diversity and Inclusion; Ethnic inequalities in chronic disease; Social epidemiology; Psychosocial risk factors for diabetes

University roles and responsibilities

  • Academic Lead for Equality, Diversity and Inclusion

    My qualifications

    2007
    Ph.D. Health Psychology
    University College London
    2002
    B.Sc. Joint Honours Psychology/Sports and Exercise Science (First class)
    University of Birmingham

    Previous roles

    01 October 2013 - 01 April 2017
    Senior Research Fellow
    University College London
    01 January 2010 - 30 September 2013
    Research Fellow
    Imperial College London/ Monash University
    01 June 2007 - 31 December 2009
    Research Fellow
    University College London

    Affiliations and memberships

    European Association for the Study of Diabetes
    Member
    Diabetes UK
    Member

    Research

    Research interests

    Research projects

    Research collaborations

    My teaching

    My publications

    Publications

    Madjid I, Backholer K, Williams ED, Magliano D, Shaw J, Peeters A (2014) The effect of educational status on the relationship between obesity and risk of type 2 diabetes,Obesity Research & Clinical Practice 8 (2) pp. e172-e177 Elsevier
    Objective: Obesity trends are likely to increase social disparities in diabetes. Themagnitude of this effect depends on the strength of the relationship between obesity and diabetes across categories of disadvantage. This study aims to test the hypothesis that education level moderates the association between obesity and fasting plasma glucose (FPG), 2-h plasma glucose (2hPG), HbA1c level, and diabetes prevalence.
    Methods: We used the baseline data from the Australian Obesity, Diabetes, and Lifestyle study in 2000 (n = 8646). We performed multiple linear regression analysis
    adjusted for confounding factors and stratified by education level. Body mass index (BMI) and waist circumference (WC) were positively associated with FPG, 2hPG,HbA1c and prevalence of diabetes.
    Results: No moderating effect of education on these relationships was observed in the total population. In never smokers free of diagnosed diabetes at baseline the
    association of WC with 2hPG and HbA1c and of BMI with HbA1c was stronger in those with a lower level of education.
    Conclusions: Overall, these results suggest that the association between obesity and diabetes risk is independent of educational status. However, inconsistent results suggest that further analyses of an adequately powered longitudinal study of never smokers free of diabetes would be useful to further explore this hypothesis.
    O?Neil A, Stevenson C, Williams ED, Mortimer D, Oldenburg B, Sanderson K (2013) The health-related quality of life burden of co-morbid
    cardiovascular disease and major depressive disorder
    in Australia: findings from a population-based,
    cross-sectional study
    ,
    Quality of Life Research 22 (1) pp. 37-44 Springer Link
    Purpose

    Health-related quality of life (HRQOL) can be significantly impaired by the presence of chronic conditions such as cardiovascular disease (CVD) and major depressive disorder (MDD). The aim of this paper was to (1) identify differences in HRQOL between individuals with CVD, MDD, or both, compared to a healthy reference group, (2) establish whether the influence of co-morbid MDD and CVD on HRQOL is additive or synergistic and (3) determine the way in which depression severity interacts with CVD to influence overall HRQOL.

    Methods

    Population-based data from the 2007 Australian National Survey of Mental Health and Well-being (NSMHWB) (n = 8841) were used to compare HRQOL of individuals with MDD and CVD, MDD but not CVD, CVD but not MDD, with a healthy reference group. HRQOL was measured using the Assessment of Quality of Life (AQOL). MDD was identified using the Composite International Diagnostic Interview (CIDI 3.0).

    Results

    Of all four groups, individuals with co-morbid CVD and depression reported the greatest deficits in AQOL utility scores (Coef: ?0.32, 95% CI: ?0.40, ?0.23), after adjusting for covariates. Those with MDD only (Coef: ?0.27, 95% CI: ?0.30, ?0.24) and CVD only (Coef: ?0.08, 95% CI: ?0.11, ?0.05) also reported reduced AQOL utility scores. Second, the influence of MDD and CVD on HRQOL was shown to be additive, rather than synergistic. Third, a significant dose?response relationship was observed between depression severity and HRQOL. However, CVD and depression severity appeared to act independently of each other in impacting HRQOL.

    Conclusions

    HRQOL is greatly impaired in individuals with co-morbid MDD and CVD; these conditions appear to influence HRQOL in an additive fashion. HRQOL alters with depression severity, therefore treating depression and improving HRQOL is of clinical importance.

    Williams E, Tillin T, Chaturvedi N (2012) OP31 Ethnic Differences in the Development of Disability Over 20 Years: Results from the Sabre Study,Journal of Epidemiology and Community Health 66 (Sup. 1) pp. A12.2-A13 BMJ Publishing Group
    Background As life expectancy increases, healthy ageing becomes more salient, and therefore it is important to understand how conditions such as disability may affect the later years of our extended lives. Ethnic differences in disability have been observed in some countries, however there is a lack of evidence from British ethnic groups.

    Methods Follow-up data over 20 years from 1789 White, Indian Asian and African Caribbean men and women were examined from a community-based study in West London. Disability was measured using the performance-based test of locomotor function and self-reported functional limitation, instrumental and basic activities of daily living (IADL/ADL) questionnaires. Logistic regression analyses examined ethnic group differences in disability, adjusting for socioeconomic, behavioural, adiposity and chronic disease risk factors.

    Results After full adjustment, Indian Asian people were significantly more likely to have developed all of the disability outcomes, compared with UK Whites (locomotor dysfunction: OR 2.20, 95% CI 1.56?3.11; functional limitation: OR 2.77, 2.01?3.81; IADL impairment: OR 3.12, 2.20?4.41; ADL impairment: OR 1.56, 1.11?2.24). Health behaviours, central adiposity, and chronic disease burden explained only a proportion of this excess risk. There were no ethnic group differences in locomotor dysfunction, functional limitation and IADL impairment between African Caribbean and White participants, however African Caribbean people showed a reduced risk of ADL impairment (OR 0.59, 0.38?0.93), after multivariate adjustment.

    Conclusion These findings demonstrate dramatic ethnic group differences in performance-based and self-reported disability between White, Indian Asian, and African Caribbean people in the UK. The excessive risk experienced by Indian Asian people was partly explained by health behaviours, adiposity, and chronic disease, however considerable inequalities remained. Other possible explanations for this vulnerability to disability among Indian Asian people will be discussed. Such inequalities are likely to have a detrimental impact on quality of life and morbidity in later years, and therefore, more research is urgently needed to understand these large ethnic inequalities in disability.

    Sathish Thirunavukkarasu, Williams Emily, Pasricha Naanki, Absetz Pilvikki, Lorgelly Paula, Wolfe Rory, Mathews Elezebeth, Aziz Zahra, Thankappan Kavumpurathu Raman, Zimmet Paul, Fisher Edwin, Tapp Robyn, Hollingsworth Bruce, Mahal Ajay, Shaw Jonathan, Jolley Damien, Daivadanam Meena, Oldenburg Brian (2013) Cluster randomised controlled trial of a peer-led lifestyle intervention program: study protocol for the Kerala diabetes prevention program,BMC Public Health 13 (1) BioMed Central
    Background: India currently has more than 60 million people with Type 2 Diabetes Mellitus (T2DM) and this is
    predicted to increase by nearly two-thirds by 2030. While management of those with T2DM is important, preventing or
    delaying the onset of the disease, especially in those individuals at ?high risk? of developing T2DM, is urgently needed,
    particularly in resource-constrained settings. This paper describes the protocol for a cluster randomised controlled trial
    of a peer-led lifestyle intervention program to prevent diabetes in Kerala, India.
    Methods/design: A total of 60 polling booths are randomised to the intervention arm or control arm in rural Kerala,
    India. Data collection is conducted in two steps. Step 1 (Home screening): Participants aged 30?60 years are
    administered a screening questionnaire. Those having no history of T2DM and other chronic illnesses with an Indian
    Diabetes Risk Score value of e60 are invited to attend a mobile clinic (Step 2). At the mobile clinic, participants
    complete questionnaires, undergo physical measurements, and provide blood samples for biochemical analysis.
    Participants identified with T2DM at Step 2 are excluded from further study participation. Participants in the control arm
    are provided with a health education booklet containing information on symptoms, complications, and risk factors of
    T2DM with the recommended levels for primary prevention. Participants in the intervention arm receive: (1) eleven
    peer-led small group sessions to motivate, guide and support in planning, initiation and maintenance of lifestyle
    changes; (2) two diabetes prevention education sessions led by experts to raise awareness on T2DM risk factors,
    prevention and management; (3) a participant handbook containing information primarily on peer support and its role
    in assisting with lifestyle modification; (4) a participant workbook to guide self-monitoring of lifestyle behaviours, goal
    setting and goal review; (5) the health education booklet that is given to the control arm. Follow-up assessments are
    conducted at 12 and 24 months. The primary outcome is incidence of T2DM. Secondary outcomes include behavioural,
    psychosocial, clinical, and biochemical measures. An economic evaluation is planned.
    Discussion: Results from this trial will contribute to improved policy and practice regarding lifestyle intervention
    programs to prevent diabetes in India and other resource-constrained settings.

    Trial registration: Australia and New Zealand Clinical

    Trials Registry: ACTRN12611000262909.

    Harding J, Backholer K K, Williams ED, Peeters A, Cameron A, Hare M, Shaw J, Magliano D (2014) Psychosocial stress is positively associated with body mass index gain over 5 years: Evidence from the longitudinal AusDiab study,Obesity 22 (1) pp. 277-286 John Wiley & Sons
    Objective

    Emerging evidence suggests that psychosocial stress may influence weight gain. The relationship between stress and weight change and whether this was influenced by demographic and behavioral factors was explored.
    Design and Methods

    A total of 5,118 participants of AusDiab were prospectively followed from 2000 to 2005. The relationship between stress at baseline and BMI change was assessed using linear regression.
    Results

    Among those who maintained/gained weight, individuals with high levels of perceived stress at baseline experienced a 0.20 kg/m2 (95% CI: 0.07-0.33) greater mean change in BMI compared with those with low stress. Additionally, individuals who experienced 2 or e3 stressful life events had a 0.13 kg/m2 (0.00-0.26) and 0.26 kg/m2 (0.14-0.38) greater increase in BMI compared with people with none. These relationships differed by age, smoking, and baseline BMI. Further, those with multiple sources of stressors were at the greatest risk of weight gain.
    Conclusion

    Psychosocial stress, including both perceived stress and life events stress, was positively associated with weight gain but not weight loss. These associations varied by age, smoking, obesity, and multiple sources of stressors. Future treatment and interventions for overweight and obese people should consider the psychosocial factors that may influence weight gain

    Williams ED, Eastwood SV S, Tillin T, Hughes A, Chaturvedi N (2014) The effects of weight and physical activity change over 20 years on later-life objective and self-reported disability,International Journal of Epidemiology 43 (3) pp. 856-865 Oxford University Press
    Background: Weight and health behaviours are known to affect physical disability; however the evidence exploring the impact of changes to these lifestyle factors over the life course on disability is inconsistent. We aimed to explore the roles of weight and activity change between mid and later life on physical disability.
    Methods: Baseline and 20-year clinical follow-up data were collected from 1418 men and women, aged 58?88 years at follow-up, as part of a population-based observational study based in north-west London. At clinic, behavioural data were collected by questionnaire and anthropometry measured. Disability was assessed using a performance-based locomotor function test and self-reported questionnaires on functional limitation and basic activities of daily living (ADLs).
    Results: At follow-up, 39% experienced a locomotor dysfunction, 24% a functional limitation and 17% an impairment of ADLs. Weight gain of 10?20% or >20% of baseline, but not weight loss, were associated with increased odds of a functional limitation [odds ratio (OR) 1.69, 95% confidence interval (CI) 1.14-2.49 and OR 2.74, 1.55-4.83, respectively], after full adjustment for covariates. The same patterns were seen for the other disability outcomes. Increased physical activity reduced, and decreased physical activity enhanced the likelihood of disability, independent of baseline behaviours and adiposity. The adverse effects of weight gain appeared to be lessened in the presence of increased later-life physical activity.
    Conclusion: Weight and activity changes between mid and later life have strong implications for physical functioning in older groups. These findings reinforce the importance of the maintenance of healthy weight and behaviour throughout the life course, and the need to promote healthy lifestyles across population groups.
    Williams ED, Eastwood S, Tillin T, Stewart, R, Chaturvedi N, Hughes A (2015) Statin use is associated with reduced depressive symptoms in Europeans, but increased symptoms in ethnic minorities in the UK: an observational study,British Journal of Clinical Pharmacology 80 (1) pp. 172-173 John Wiley & Sons
    O'Neil A, Williams ED, Browne J, Horne R, Pouwer F, Speight J (2014) Associations between economic hardship and markers of self-management in adults with type 2 diabetes: results from Diabetes MILES ? Australia,Australian and New Zealand Journal of Public Health 38 (5) pp. 466-472 John Wiley & Sons
    Objective: A socioeconomic gradient exists in Australia for type 2 diabetes mellitus (T2DM). It remains unclear whether economic hardship is associated with T2DM self?management behaviours.

    Methods: Cross-sectional data from a subset of the Diabetes MILES ? Australia study were used (n=915). The Economic Hardship Questionnaire was used to assess hardship. Outcomes included: healthy eating and physical activity (Diabetes Self-Care Inventory ? Revised), medication-taking behaviour (Medication Adherence Rating Scales) and frequency of self-monitoring of blood glucose (SMBG). Regression modelling was used to explore the respective relationships.

    Results: Greater economic hardship was significantly associated with sub-optimal medication-taking (Coefficient: ?0.86, 95%CI ?1.54, ?0.18), and decreased likelihood of regular physical activity (Odds Ratio: 0.47, 0.29, 0.77). However, after adjustments for a range of variables, these relationships did not hold. Being employed and higher depression levels were significantly associated with less-frequent SMBG, sub-optimal medication-taking and less-regular healthy eating. Engaging in physical activity was strongly associated with healthy eating.

    Conclusions: Employment, older age and depressive symptoms, not economic hardship, were commonly associated with diabetes self-management.

    Implications: Work-based interventions that promote T2DM self-management in younger, working populations that focus on negative emotions may be beneficial.

    Despite elevated risk profiles for depression among South Asian and Black Caribbean people in the UK, prevalences of late-life depressive symptoms across the UK's three major ethnic groups have not been well characterized.
    Data were collected at baseline and 20-year follow-up from 632 European, 476 South Asian and 181 Black Caribbean men and women (aged 58?88 years), of a community-based cohort study from north-west London. The 10-item Geriatric Depression Scale was interviewer-administered during a clinic visit (depressive symptoms defined as a score of ~4 out of 10), with clinical data (adiposity, diabetes, cardiovascular disease, cognitive function) also collected. Sociodemographic, psychosocial, behavioural, disability, and medical history information was obtained by questionnaire.
    Prevalence of depressive symptoms varied by ethnic group, affecting 9.7% of White European, 15.5% of South Asian, and 17.7% of Black Caribbean participants. Compared with White Europeans, South Asian and Black Caribbean participants were significantly more likely to have depressive symptoms (odds ratio 1.79, 95% confidence interval 1.24?2.58 and 1.80, 1.11?2.92, respectively). Adjustment for co-morbidities had most effect on the excess South Asian odds, and adjustment for socioeconomic position had most effect on the elevated Black Caribbean odds.
    Higher prevalence of depressive symptoms observed among South Asian people were attenuated after adjustment for physical health, whereas the Black Caribbean increased prevalence was most explained by socioeconomic disadvantage. It is important to understand the reasons for these ethnic differences to identify opportunities for interventions to address inequalities.
    Williams ED, Rawal L, Oldenburg B, Renwick C, Shaw J, Tapp R (2012) Risk of Cardiovascular and All-Cause Mortality: Impact of Impaired Health-Related Functioning and Diabetes
    The Australian Diabetes, Obesity and Lifestyle (AusDiab) study
    ,
    Diabetes Care 35 (5) pp. 1067-1073 American Diabetes Association
    OBJECTIVE
    There is an established link between health-related functioning (HRF) and
    cardiovascular disease (CVD) mortality, and it is known that those with diabetes predominantly
    die of CVD. However, few studies have determined the combined impact of diabetes and impaired
    HRF on CVD mortality. We investigated whether this combination carries a higher CVD
    risk than either component alone.

    RESEARCH DESIGN AND METHODS
    The Australian Diabetes, Obesity and Lifestyle
    (AusDiab) study included 11,247 adults aged $25 years from 42 randomly selected areas of
    Australia. At baseline (1999?2000), diabetes status was defined using the World Health Organization
    criteria and HRF was assessed using the SF-36 questionnaire.

    RESULTS
    Overall, after 7.4 years of follow-up, 57 persons with diabetes and 105 without
    diabetes had died from CVD. In individuals with and without diabetes, HRF measures were
    significant predictors of increased CVD mortality. The CVD mortality risks among those with
    diabetes or impaired physical health component summary (PCS) alone were similar (diabetes
    only: hazard ratio 1.4 [95% CI 0.7?2.7]; impaired PCS alone: 1.5 [1.0?2.4]), while those with
    both diabetes and impaired PCS had a much higher CVD mortality (2.8 [1.6?4.7]) compared
    with those without diabetes and normal PCS (after adjustment for multiple covariates). Similar
    results were found for the mental health component summary.

    CONCLUSIONS
    This study demonstrates that the combination of diabetes and impaired
    HRF is associated with substantially higher CVD mortality. This suggests that, among those with
    diabetes, impaired HRF is likely to be important in the identification of individuals at increased
    risk of CVD mortality.

    Williams ED, Magliano D, Zimmet P, Kavanagh A, Stevenson C, Oldenburg B, Shaw J (2012) Area-Level Socioeconomic Status and Incidence of Abnormal Glucose Metabolism
    The Australian Diabetes, Obesity and Lifestyle (AusDiab) study
    ,
    Diabetes Care 35 (7) pp. 1455-1461 American Diabetes Association
    OBJECTIVE To examine the role of area-level socioeconomic status (SES) on the development of abnormal glucose metabolism (AGM) using national, population-based data.

    RESEARCH DESIGN AND METHODS The Australian Diabetes, Obesity and Lifestyle (AusDiab) study is a national, population-based, longitudinal study of adults aged e25 years. A sample of 4,572 people provided complete baseline (1999 to 2000) and 5-year follow-up (2004 to 2005) data relevant for these analyses. Incident AGM was assessed using fasting plasma glucose and 2-h plasma glucose from oral glucose tolerance tests, and demographic, socioeconomic, and behavioral data were collected by interview and questionnaire. Area SES was defined using the Index of Relative Socioeconomic Disadvantage. Generalized linear mixed models were used to examine the relationship between area SES and incident AGM, with adjustment for covariates and correction for cluster design effects.

    RESULTS Area SES predicted the development of AGM, after adjustment for age, sex, and individual SES. People living in areas with the most disadvantage were significantly more likely to develop AGM, compared with those living in the least deprived areas (odds ratio 1.53; 95% CI 1.07?2.18). Health behaviors (in particular, physical activity) and central adiposity appeared to partially mediate this relationship.

    CONCLUSIONS Our findings suggest that characteristics of the physical, social, and economic aspects of local areas influence diabetes risk. Future research should focus on identifying the aspects of local environment that are associated with diabetes risk and how they might be modified.

    Chamberlain C, McNamara B, Williams ED, Yore D, Oldenburg B, Oats J, Eades S (2013) Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States: a systematic review of the evidence for screening in early pregnancy,Diabetes/Metabolism Research and Reviews 29 (4) pp. 241-256 John Wiley & Sons
    Recently proposed international guidelines for screening for gestational diabetes mellitus (GDM) recommend additional screening in early pregnancy for sub-populations at a high risk of type 2 diabetes mellitus (T2DM), such as indigenous women. However, there are criteria that should be met to ensure the benefits outweigh the risks of population-based screening. This review examines the published evidence for early screening for indigenous women as related to these criteria. Any publications were included that referred to diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand and the United States (n = 145). The risk of bias was appraised. There is sufficient evidence describing the epidemiology of diabetes in pregnancy, demonstrating that it imposes a significant disease burden on indigenous women and their infants at birth and across the lifecourse (n = 120 studies). Women with pre-existing T2DM have a higher risk than women who develop GDM during pregnancy. However, there was insufficient evidence to address the remaining five criteria, including the following: understanding current screening practice and rates (n = 7); acceptability of GDM screening (n = 0); efficacy and cost of screening for GDM (n = 3); availability of effective treatment after diagnosis (n = 6); and effective systems for follow-up after pregnancy (n = 5). Given the impact of diabetes in pregnancy, particularly undiagnosed T2DM, GDM screening in early pregnancy offers potential benefits for indigenous women. However, researchers, policy makers and clinicians must work together with communities to develop effective strategies for implementation and minimizing the potential risks. Evidence of effective strategies for primary prevention, GDM treatment and follow-up after pregnancy are urgently needed
    Background: Co-morbid major depressive disorder (MDD) and cardiovascular disease (CVD) is associated with poor
    clinical and psychological outcomes. However, the full extent of the burden of, and interaction between, this comorbidity
    on important vocational outcomes remains less clear, particularly at the population level. We examine
    the association of co-morbid MDD with work outcomes in persons with and without CVD.
    Methods: This study utilised cross-sectional, population-based data from the 2007 Australian National Survey of
    Mental Health and Wellbeing (n = 8841) to compare work outcomes of individuals with diagnostically-defined
    MDD and CVD, MDD but not CVD, CVD but not MDD, with a reference group of ?healthy? Australians. Workforce
    participation was defined as being in full- or part-time employment. Work functioning was measured using a WHO
    Disability Assessment Schedule item. Absenteeism was assessed using the ?days out of role? item.
    Results: Of the four groups, those with co-morbid MDD and CVD were least likely to report workforce
    participation (adj OR:0.4, 95% CI: 0.3-0.6). Those with MDD only (adj OR:0.8, 95% CI:0.7-0.9) and CVD only (adj OR:0.8,
    95% CI: 0.6-0.9) also reported significantly reduced odds of participation. Employed individuals with co-morbid
    MDD and CVD were 8 times as likely to experience impairments in work functioning (adj OR:8.1, 95% CI: 3.8- 17.3)
    compared with the reference group. MDD was associated with a four-fold increase in impaired functioning.
    Further, individuals with co-morbid MDD and CVD reported greatest likelihood of workplace absenteeism (adj.
    OR:3.0, 95% CI: 1.4-6.6). Simultaneous exposure to MDD and CVD conferred an even greater likelihood of poorer
    work functioning.
    Conclusions: Co-morbid MDD and CVD is associated with significantly poorer work outcomes. Specifically, the
    effects of these conditions on work functioning are synergistic. The development of specialised treatment
    programs for those with co-morbid MDD and CVD is required.
    Rawal L, Tapp R, Williams ED, Carina C, Yasin S, Oldenburg B (2012) Prevention of Type 2 Diabetes and Its Complications in Developing Countries: A Review,International Journal of Behavioral Medicine 19 (2) pp. 121-133 Springer Verlag
    Background

    Type 2 diabetes mellitus (T2DM) is a significant global public health problem affecting more than 285 million people worldwide. Over 70% of those with T2DM live in developing countries, and this proportion is increasing annually. Evidence suggests that lifestyle and other nonpharmacological interventions can delay and even prevent the development of T2DM and its complications; however, to date, programs that have been specifically adapted to the needs and circumstances of developing countries have not been well developed or evaluated.

    Purpose

    The purpose of this article is to review published studies that evaluate lifestyle and other non-pharmacological interventions aimed at preventing T2DM and its complications in developing countries.

    Methods

    We undertook an electronic search of MEDLINE, PubMed, and EMBASE with the English language restriction and published until 30 September 2009.

    Results

    Nine relevant publications from seven studies were identified. The reported interventions predominantly used counseling and educational methods to improve diet and physical activity levels. Each intervention was found to be effective in reducing the risk of developing T2DM in people with impaired glucose tolerance, and improving glycemic control in people with T2DM.

    Conclusions

    The current evidence concerning the prevention of T2DM and its complications in developing countries has shown reasonably consistent and positive results; however, the small number of studies creates some significant limitations. More research is needed to evaluate the benefits of low-cost screening tools, as well as the efficacy, cost-effectiveness, and sustainability of culturally appropriate interventions in such countries.

    Williams ED, Bird D, Forbes A, Russell A, Ash S, Friedman R, Scuffham P, Oldenburg B (2012) Randomised controlled trial of an automated, interactive telephone intervention (TLC Diabetes) to improve type 2 diabetes management: baseline findings and six-month outcomes.,BMC Public Health 12:602 pp. 1-11 BioMed Central
    Background
    Effective self-management of diabetes is essential for the reduction of diabetes-related complications, as global rates of diabetes escalate.

    Methods
    Randomised controlled trial. Adults with type 2 diabetes (n = 120), with HbA1c greater than or equal to 7.5 %, were randomly allocated (4 × 4 block randomised block design) to receive an automated, interactive telephone-delivered management intervention or usual routine care. Baseline sociodemographic, behavioural and medical history data were collected by self-administered questionnaires and biological data were obtained during hospital appointments. Health-related quality of life (HRQL) was measured using the SF-36.

    Results
    The mean age of participants was 57.4 (SD 8.3), 63% of whom were male. There were no differences in demographic, socioeconomic and behavioural variables between the study arms at baseline. Over the six-month period from baseline, participants receiving the Australian TLC (Telephone-Linked Care) Diabetes program showed a 0.8% decrease in geometric mean HbA1c from 8.7% to 7.9%, compared with a 0.2% HbA1c reduction (8.9% to 8.7%) in the usual care arm (p = 0.002). There was also a significant improvement in mental HRQL, with a mean increase of 1.9 in the intervention arm, while the usual care arm decreased by 0.8 (p = 0.007). No significant improvements in physical HRQL were observed.

    Conclusions
    These analyses indicate the efficacy of the Australian TLC Diabetes program with clinically significant post-intervention improvements in both glycaemic control and mental HRQL. These observed improvements, if supported and maintained by an ongoing program such as this, could significantly reduce diabetes-related complications in the longer term. Given the accessibility and feasibility of this kind of program, it has strong potential for providing effective, ongoing support to many individuals with diabetes in the future.

    Chamberlain C, Yore D, Li H, Williams ED, Oldenburg B, Oats J, McNamara B, Eades S (2011) Diabetes in pregnancy among indigenous women in Australia, Canada, New Zealand, and the United States: a method for systematic review of studies with different designs,BMC Pregnancy and Childbirth 11:104 (1) pp. 1-8 BioMed Central
    Background
    Diabetes in pregnancy, which includes gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM), is associated with poor outcomes for both mother and infant during pregnancy, at birth and in the longer term. Recent international guidelines recommend changes to the current GDM screening criteria. While some controversy remains, there appears to be consensus that women at high risk of T2DM, including indigenous women, should be offered screening for GDM early in pregnancy, rather than waiting until 24-28 weeks as is current practice. A range of criteria should be considered before changing screening practice in a population sub-group, including: prevalence, current practice, acceptability and whether adequate treatment pathways and follow-up systems are available. There are also specific issues related to screening in pregnancy and indigenous populations. The evidence that these criteria are met for indigenous populations is yet to be reported. A range of study designs can be considered to generate relevant evidence for these issues, including epidemiological, observational, qualitative, and intervention studies, which are not usually included within a single systematic review. The aim of this paper is to describe the methods we used to systematically review studies of different designs and present the evidence in a pragmatic format for policy discussion.

    Methods/Design
    The inclusion criteria will be broad to ensure inclusion of the critical perspectives of indigenous women. Abstracts of the search results will be reviewed by two persons; the full texts of all potentially eligible papers will be reviewed by one person, and 10% will be checked by a second person for validation. Data extraction will be standardised, using existing tools to identify risks for bias in intervention, measurement, qualitative studies and reviews; and adapting criteria for appraising risk for bias in descriptive studies. External validity (generalisability) will also be appraised. The main findings will be synthesised according to the criteria for population-based screening and summarised in an adapted "GRADE" tool.

    Discussion
    This will be the first systematic review of all the published literature on diabetes in pregnancy among indigenous women. The method provides a pragmatic approach for synthesizing relevant evidence from a range of study designs to inform the current policy discussion.

    Williams ED, Stamatakis E, Chandola T, Hamer M (2010) Assessment of physical activity levels in South Asians in the UK: findings from the Health Survey for England,JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH 65 (6) pp. 517-521 BMJ Publishing Group
    Background South Asians in the UK experience high rates of coronary heart disease compared with other ethnic groups. Behavioural risk factors such as physical inactivity have been explored as possible explanations for this trend. However, there have been few comprehensive accounts describing physical activity levels of this ethnic group.

    Methods Data from the Health Survey for England (1999?2004) on 5421 South Asians and 8974 white participants aged 18?55?years were used to compare physical activity levels. Analyses of covariance tested the association between ethnicity and self-reported total physical activity metabolic equivalents of task (MET) scores, adjusting for age, sex, self-reported health, adiposity and socioeconomic status.

    Results Total MET-min/week were consistently lower in UK South Asians than in white participants (973 vs 1465?MET-min, p

    Conclusions Physical activity levels are very low in UK South Asians; this is consistent across all examined population subsets. Physical inactivity is likely to contribute to their high risk of coronary heart disease. Increasing physical activity in all UK South Asians should be a public health priority for health professionals.

    Williams ED, Steptoe A, Chambers J, Kooner J (2011) Ethnic and gender differences in the relationship between hostility and metabolic and autonomic risk factors for coronary heart disease,Psychosomatic Medicine 73 (1) pp. 53-58 Wolters Kluwer
    Objective: To examine the relationship between hostility and biological risk factors for coronary heart disease (CHD) in a population of white European and South Asian men and women living in the United Kingdom.

    Methods: This cross-sectional study involved a community-based sample of 1,757 healthy white and South Asian men and women aged between 35 years and 75 years from West London. Participants completed the Cook-Medley Hostility Scale, together with measures of standard biological risk factors and heart rate variability. Associations between hostility and CHD risk factors were evaluated, controlling for age, education, smoking, physical activity, body mass index, and waist/hip ratio, using regression models.

    Results: In white men, hostility was associated positively with fasting glucose, glycosylated hemoglobin, and negatively with high-density lipoprotein cholesterol. High levels of hostility were also related to increased prevalence of diabetes and the metabolic syndrome in white men. Hostility in South Asian men was associated with impaired autonomic function. Hostility was not related to any biological CHD risk factors in South Asian or white women.

    Conclusions: Our results showed that hostility was independently associated with glucose metabolism and dyslipidemia in white men, and with autonomic dysfunction in South Asian men. Hostility was found not to be relevant for measured CHD risk factors in females. Longitudinal data are required to establish whether the impact of hostility on CHD risk in men is mediated through metabolic and autonomic processes.

    CHD = coronary heart disease; LOLIPOP = London Life Sciences Prospective Population; HRV = heart rate variability; BMI = body mass index; WHR = waist/hip ratio; AF = autonomic function; HF = high-frequency; HDL = high-density lipoprotein; LDL = low-density lipoprotein

    Williams ED, Stamatakis E, Chandola T, Hamer M (2011) Physical activity behaviour and coronary heart disease mortality among South Asian people in the UK: an observational longitudinal study,Heart 97 (8) pp. 655-659 BMJ Publishing Group
    Objective The aim of this study was to investigate the contribution of physical inactivity to the excess mortality from coronary heart disease (CHD) observed in the UK South Asian population.

    Design An observational longitudinal study with follow-up mortality data from NHS registries.

    Setting Data from the Health Survey for England, 1999 and 2004.

    Participants 13?293 White and 2120 South Asian participants aged e35?years consented to the mortality follow-up.

    Main outcome measures Deaths from CHD.

    Results South Asian participants were more likely to be physically inactive than white participants (47.0% vs 28.1%). Deaths from CHD were more common in UK South Asian participants, particularly among Pakistani and Bangladeshi groups (HR 2.87, 95% CI 1.74 to 4.73), than in UK white participants, and South Asian people experienced an event at an age on average 10?years younger than white people. Physical inactivity explained >20% of the excess CHD mortality in the South Asian sample, even after adjustment for potential confounding variables (including socioeconomic position, smoking, diabetes and existing cardiovascular disease).

    Conclusions Physical inactivity makes a significant contribution to the excess CHD mortality observed in the South Asian population in the UK. This highlights the importance of prioritising the promotion of physical activity in this high-risk population.

    Williams ED, Tapp R, Magliano D, Shaw J, Zimmet P, Oldenburg B (2010) Health behaviours, socioeconomic status and diabetes incidence: the Australian Diabetes Obesity and Lifestyle Study (AusDiab),Diabetologia 53 (12) pp. 2538-2545 Springer Verlag
    Aims/hypothesis

    To identify the impact of socioeconomic status on incident impaired glucose metabolism and type 2 diabetes and to investigate the mediating role of health behaviours on this relationship using national, population-based data.

    Methods

    The Australian Diabetes Obesity and Lifestyle (AusDiab) Study is a national, population-based, longitudinal study of adults aged 25 years and above. A total sample of 4,405 people provided complete baseline (1999?2000) and 5 year follow-up (2004?2005) data relevant for these analyses. Fasting plasma glucose and 2 h plasma glucose were obtained from an OGTT, and demographic, socioeconomic and behavioural data were collected by interview and questionnaire. Multinomial logistic regression examined the role of socioeconomic position in the development of diabetes and mediation analyses tested the contribution of health behaviours in this relationship.

    Results

    Highest level of education was a stronger predictor of incident impaired glucose tolerance and type 2 diabetes (p = 0.002), compared with household income (p = 0.103), and occupational grade (p = 0.202). Education remained a significant independent predictor of diabetes in fully adjusted models. However, the relationship was attenuated by the health behaviours (smoking and physical activity). Mediation analyses indicated that these behaviours were partial mediators (explaining 27%) of the socioeconomic status?diabetes relationship.

    Conclusion/interpretation

    Smoking and physical activity partly mediate the relationship between low education and type 2 diabetes. Identification of these modifiable behavioural mediators should facilitate the development of effective health promotion campaigns to target those at high risk of developing type 2 diabetes.

    Williams ED, Nazroo J, Kooner J, Steptoe A (2010) Subgroup differences in psychosocial factors relating to coronary heart disease in the UK South Asian population,Journal of Psychosomatic Research 69 (4) pp. 379-387 Elsevier
    Objectives

    To explore the differences in psychosocial risk factors related to coronary heart disease (CHD) between South Asian subgroups in the UK. South Asian people suffer significantly higher rates of CHD than other ethnic groups, but vulnerability varies between South Asian subgroups, in terms of both CHD rates and risk profiles. Psychosocial factors may contribute to the excess CHD propensity that is observed; however, subgroup heterogeneity in psychosocial disadvantage has not previously been systematically explored.

    Methods

    With a cross-sectional design, 1065 healthy South Asian and 818 white men and women from West London, UK, completed psychosocial questionnaires. Psychosocial profiles were compared between South Asian religious groups and the white sample, using analyses of covariance and post hoc tests.

    Results

    Of the South Asian sample, 50.5% was Sikh, 28.0% was Hindu, and 15.8% was Muslim. Muslim participants were more socioeconomically deprived and experienced higher levels of chronic stress, including financial strain, low social cohesion, and racial discrimination, compared with other South Asian religious groups. In terms of health behaviors, Muslim men smoked more than Sikhs and Hindus, and Muslims also reported lower alcohol consumption and were less physically active than other groups.

    Conclusion

    This study found that Muslims were exposed to more psychosocial and behavioral adversity than Sikhs and Hindus, and highlights the importance of investigating subgroup heterogeneity in South Asian CHD risk.

    O'Neil A, Williams ED, Stevenson C, Oldenburg B, Berk M, Sanderson K (2012) Co-morbid cardiovascular disease and depression: sequence of disease onset is linked to mental but not physical self-rated health. Results from a cross-sectional, population-based study,SOCIAL PSYCHIATRY AND PSYCHIATRIC EPIDEMIOLOGY 47 (7) pp. 1145-1151 Springer Verlag
    Purpose

    Self-rated health has been linked to important health and survival outcomes in individuals with co-morbid depression and cardiovascular disease (CVD). It is not clear how the timing of depression onset relative to CVD onset affects this relationship. We aimed to first identify the prevalence of major depressive disorder (MDD) preceding CVD and secondly determine whether sequence of disease onset is associated with mental and physical self-rated health.

    Methods

    This study utilised cross-sectional, population-based data from 224 respondents of the 2007 Australian National Survey of Mental Health and Wellbeing (NSMHWB). Participants were those diagnosed with MDD and reported ever having a heart/circulatory condition over their lifetime. Age of onset was reported for each condition. Logistic regression was used to explore differences in self-rated mental and physical health for those reporting pre-cardiac and post-cardiac depression.

    Results

    The proportion of individuals in whom MDD preceded CVD was 80.36% (CI: 72.57?88.15). One-fifth (19.64%, CI: 11.85?27.42) reported MDD onset at the time of, or following, CVD. After controlling for covariates, the final model demonstrated that those reporting post-cardiac depression were significantly less likely to report poor self-rated mental health (OR:0.36, CI: 0.14?0.93) than those with pre-existing depression. No significant differences were found in self-rated physical health between groups (OR:0.90 CI: 0.38?2.14).

    Conclusions

    MDD is most common prior to the onset of CVD. Further, there is an association between pre-morbid MDD and poorer self-rated mental health. To our knowledge, this is the first time this has been demonstrated in a national, population-based survey. As self-rated health has been shown to predict important outcomes such as survival, we recommend that those with MDD be identified as vulnerable to CVD onset and poorer health outcomes.

    Williams ED, Steptoe A (2007) The Role of Depression in the Etiology of Acute Coronary Syndrome.,Current Psychiatry Reports 9 (6) pp. 486-492 Current Medicine Group
    Recent research has confirmed that depression is a risk factor for the development and prognosis of coronary heart disease (CHD). Depressive symptoms are associated with the progression of underlying coronary atherosclerosis and clinical events such as acute coronary syndrome (ACS). Depression is poorly recognized and undertreated in patients following ACS, but progress is being made in developing abbreviated measurement tools that can be used in clinical cardiologic practice. Depressive symptoms emerging at various stages of CHD presentation may have different effects on CHD prognosis. The mechanisms mediating the relationship between depression and CHD include vascular inflammation, autonomic and endothelial dysfunction, and behavior patterns such as poor adherence to medication and advice. The optimal methods of managing depression following ACS have not yet been established.
    Williams ED, Kooner I, Steptoe A, Kooner J (2007) Psychosocial factors related to cardiovascular disease risk in UK South Asian men: A preliminary study.,British Journal of Health Psychology 12 (4) pp. 559-570 Wiley
    Objective. To compare the exposure to psychosocial factors associated with cardiovascular risk in UK South Asian and white European men.

    Design. Interview study of 63 healthy UK South Asian and 42 white European men aged 35?75 years, randomly selected from a larger study group in West London. Interviews were administered in Punjabi and English. Measures of psychosocial and cardiovascular risk factors were obtained.

    Setting. Ealing Hospital, West London.

    Results. The South Asian men had lived in the UK for an average of 27.9 (SD 11.6) years, and had higher educational attainment than the white Europeans. Compared with the white Europeans, the South Asian men lived in significantly more crowded homes, experienced lower job control, greater financial strain, lower neighbourhood social cohesion and more racial harassment. They received less emotional support, and were more depressed and less optimistic on standard questionnaires. These men also had higher waist/hip ratios and were more sedentary, but there were no significant ethnic differences in biological risk factors.

    Conclusions. South Asian men living in London showed a higher risk profile in psychosocial factors thought to contribute to cardiovascular disease risk. This preliminary investigation is consistent with the possibility that psychosocial adversity contributes to increased vulnerability to coronary heart disease in South Asians resident in the UK.

    Steptoe A, Gibson E, Vuononvirta R, Williams ED, Hamer M, Rycroft J, Erusalimsky J, Wardle J (2007) The effects of tea on psychophysiological stress responsivity and post-stress recovery: a randomised double-blind trial,Psychopharmacology 190 (1) pp. 81-89 Springer Verlag
    Rationale
    Tea has anecdotally been associated with stress
    relief, but this has seldom been tested scientifically.
    Objectives To investigate the effects of 6 weeks of black
    tea consumption, compared with matched placebo, on
    subjective, cardiovascular, cortisol and platelet responses to acute stress, in a parallel group double blind randomised design.

    Materials and methods
    Seventy-five healthy nonsmoking men were withdrawn from tea, coffee and caffeinated beverages for a 4-week wash-out phase during which they
    drank four cups per day of a caffeinated placebo. A
    pretreatment laboratory test session was carried out,
    followed by either placebo (n=38) or active tea treatment
    (n=37) for 6 weeks, then, a final test session.

    Cardiovascular measures were obtained before, during and after two challenging behavioural tasks, while cortisol, platelet and subjective measures were assessed before and after tasks.

    Results
    The tasks induced substantial increases in blood
    pressure, heart rate and subjective stress ratings, but
    responses did not differ between tea and placebo treatments.
    Platelet activation (assessed using flow cytometry)
    was lower following tea than placebo treatment in both
    baseline and post-stress samples (P

    Conclusions
    Compared with placebo, 6 weeks of tea consumption leads to lower post-stress cortisol and greater
    subjective relaxation, together with reduced platelet activation.
    Black tea may have health benefits in part by aiding
    stress recovery.

    Williams ED, Steptoe A, Chambers J, Kooner J (2009) Psychosocial risk factors for coronary heart disease in UK South Asian men and women.,Journal of Epidemiology and Community Health 63 (12) pp. 986-991 BMJ Publishing Group
    Background: South Asian people in the UK and other western countries have elevated rates of coronary heart disease (CHD). Psychosocial factors contribute to CHD risk, but information about psychosocial risk profiles in UK South Asians is limited. This study aimed to examine the profile of conventional and novel psychosocial risk factors in South Asian compared with white men and women.

    Methods: Using a cross-sectional population study design, psychosocial profiles were assessed in 1130 South Asian and 818 white European healthy men and women aged between 35 and 75 years, who had previously participated in a cardiovascular risk assessment programme in West London. Psychosocial factors potentially contributing to CHD risk were assessed using standardised questionnaires.

    Results: UK South Asians reported significantly higher psychosocial adversity compared with UK whites. South Asian men and women experienced greater chronic stress, in the form of financial strain, residential crowding, family conflict, social deprivation and discrimination, than white Europeans. They had larger social networks, but reported lower social support and greater depression and hostility. These effects were largely independent of socioeconomic status.

    Conclusion: UK South Asians experience significant psychosocial adversity compared with UK white Europeans. This is consistent with the heightened vulnerability to CHD observed in this population.

    Williams ED, Magid K, Steptoe A (2005) The impact of time of waking and concurrent
    subjective stress on the cortisol response
    to awakening.
    ,
    Psychoneuroendocrinology 30 (2) pp. 139-148 Elsevier
    Both time of awakening and stress are thought to influence the
    magnitude of the cortisol awakening response (CAR), but the relative importance
    of these factors is unclear. This study assessed these influences in a combined within and
    between-subject design. Data were collected from 32 men and women working
    as station staff in the London underground railway system in three conditions: earlyshift
    days, day-shift days, and control days. Saliva samples were obtained on waking,
    30 and 60 min later, together with measures of concurrent subjective stress, sleep
    quality the night before, and accumulated stress at the end of the day. Participants
    woke up more than 3.5 h earlier on average on early-shift than day-shift or control
    days, and cortisol levels on waking were lower in the early-shift condition. The CAR
    (assessed both with increases from waking to 30 min and with area under the curve
    measures) was greater on early-shift days. However, respondents were more stressed
    over the hour after waking and reported more sleep disturbance on early-shift days;
    when these factors were taken into account, the difference in CAR related to
    experimental condition was no longer significant. Comparisons were also made
    between individuals who started their day-shifts in the morning and afternoon. The
    morning shift group woke an average of 2 h earlier than did the afternoon shift group,
    but did not differ on stress, sleep quality, or CAR. Stress assessed retrospectively at
    the end of the day was not associated with the CAR. We conclude that early waking,
    stress early in the day, and sleep disturbance often coincide, but need to be
    distinguished in order accurately to interpret differences in CAR magnitude.
    Hamer M, Williams ED, Vuonovirta R, Giacobazzi P (2006) The effects of effort-reward imbalance on inflammatory and cardiovascular responses to mental stress.,Psychosomatic Medicine 68 (3) pp. 408-413 Lippincott, Williams & Wilkins
    Objective: We examined the influence of effort-reward imbalance, a stressful feature of the work environment, on cardiovascular and inflammatory responses to acute mental stress.

    Methods: Ninety-two healthy men (mean age, 33.1 yeasr) in full-time employment were recruited. Effort-reward imbalance was measured using a self-administered questionnaire. Blood, for the analysis of C-reactive protein (CRP) and von Willebrand factor (vWF) antigen, was sampled at baseline and 10 minutes after two mental stress tasks, whereas cardiovascular activity was measured throughout.

    Results: Plasma CRP and vWF were significantly elevated following the stress period, and cardiovascular activity was increased during and after both tasks (p

    Conclusions: These findings suggest that the association between chronic work stress and cardiovascular disease risk may be mediated in part by heightened acute inflammatory responsivity. These responses appear not to result from differences in sympathoadrenal activation.

    ERI = effort-reward imbalance; CHD = coronary heart disease; IL = interleukin; CRP = C-reactive protein; vWF = von Willebrand factor; BMI = body mass index.

    Williams ED, Tillin T, Chaturvedi N (2012) Ethnic Differences in the Development of Disability Over 20 Years:Results from the Sabre Study,Journal of Epidemiology and Community Health 66 (1) pp. A12-A13 BMJ Publishing Group
    Background As life expectancy increases, healthy ageing becomes more salient, and therefore it is important to understand how conditions such as disability may affect the later years of our extended lives. Ethnic differences in disability have been observed in some countries, however there is a lack of evidence from British ethnic groups.

    Methods Follow-up data over 20 years from 1789 White, Indian Asian and African Caribbean men and women were examined from a community-based study in West London. Disability was measured using the performance-based test of locomotor function and self-reported functional limitation, instrumental and basic activities of daily living (IADL/ADL) questionnaires. Logistic regression analyses examined ethnic group differences in disability, adjusting for socioeconomic, behavioural, adiposity and chronic disease risk factors.

    Results After full adjustment, Indian Asian people were significantly more likely to have developed all of the disability outcomes, compared with UK Whites (locomotor dysfunction: OR 2.20, 95% CI 1.56?3.11; functional limitation: OR 2.77, 2.01?3.81; IADL impairment: OR 3.12, 2.20?4.41; ADL impairment: OR 1.56, 1.11?2.24). Health behaviours, central adiposity, and chronic disease burden explained only a proportion of this excess risk. There were no ethnic group differences in locomotor dysfunction, functional limitation and IADL impairment between African Caribbean and White participants, however African Caribbean people showed a reduced risk of ADL impairment (OR 0.59, 0.38?0.93), after multivariate adjustment.

    Conclusion These findings demonstrate dramatic ethnic group differences in performance-based and self-reported disability between White, Indian Asian, and African Caribbean people in the UK. The excessive risk experienced by Indian Asian people was partly explained by health behaviours, adiposity, and chronic disease, however considerable inequalities remained. Other possible explanations for this vulnerability to disability among Indian Asian people will be discussed. Such inequalities are likely to have a detrimental impact on quality of life and morbidity in later years, and therefore, more research is urgently needed to understand these large ethnic inequalities in disability.

    Peeters A, Savitri I, Backholer K, Williams ED, Magliano D, Shaw J (2012) Does the relationship between excess body weight and risk of Type 2 diabetes differ according to educational status?,Obesity Research and Clinical Practice 6 (1) Elsevier
    Aim: To examine whether the association between overweight and obesity with 2-h plasma glucose (2hPG) and HbA1c levels differs according to educational attainment.

    Method: Using cross-sectional baseline data from the Australian Obesity, Diabetes, and Lifestyle study in 2000 (n?=?8576), we performed multivariable linear regression analysis adjusted for confounding factors and stratified by education. We performed a log-likelihood test to see whether the model including the interaction between education and body mass index (BMI)/waist circumference (WC) predicted the outcome better than the model without the interaction. Analyses were repeated stratified by sex and in never smokers.

    Results: Increased BMI/WC was associated with increased 2hPG and HbA1c levels. No moderating effect of education on the relationship between BMI with 2hPG and HbA1c was observed in the total population, or in males or females. However, in a subpopulation of never smokers, effect modification by education was observed, particularly when WC was used as the exposure. The association between obesity with 2hPG and HbA1c was stronger in people with a lower level of education. For example, the increase in HbA1C associated with very increased risk WC was 1.1 (95% CI 0.81?1.29) in the secondary only group compared to 0.61 (95% CI 0.25?0.96) in the degree group.

    Conclusions: To confirm these results, this analysis should be repeated using a longitudinal design in a population of non smokers. If the impact of obesity on the risk of diabetes is worse in those with lower education, obesity trends are likely to cause further inequalities in diabetes than currently expected.

    Hamer Mark, Williams Emily, Vuononvirta Raisa, Gibson E Leigh, Steptoe Andrew (2006) Association between coffee consumption and markers of inflammation and cardiovascular function during mental stress,Journal of Hypertension 24 (11) pp. 2191-2197 Lippincott, Williams & Wilkins
    Background: Coffee is widely consumed in the Western diet and therefore has important implications for public health. Research findings pertaining to the effects of coffee consumption on cardiovascular health are conflicting, and the role of caffeine is not clear.

    Objective: To examine the relationship between coffee intake, inflammation and cardiovascular function at baseline and during mental stress, both cross-sectionally and after a 4-week period of withdrawal of coffee during which intake of caffeine was maintained.

    Methods: Eighty-five healthy, non-smoking men with varying coffee-drinking habits were recruited. Blood pressure, heart rate, and markers of inflammation [C-reactive protein (CRP), von Willebrand factor antigen (vWF)], were measured at baseline and during mental stress. These measures were repeated after a 4-week period of withdrawal of coffee, during which intake of caffeine was maintained. Habitual levels of coffee and caffeine consumption were assessed from a self-reported questionnaire, and saliva samples for the analysis of caffeine concentrations were collected regularly throughout the period of withdrawal, to confirm compliance.

    Results: Multiple linear regression analysis of pre-withdrawal data, adjusted for age, body mass index and intake of tea, red wine, fruit, vegetables, oily fish and dietary supplements revealed that coffee consumption was positively related to baseline systolic blood pressure, and increased heart rate and vWF responses to mental stress. Four weeks after withdrawal of coffee, the heightened vWF and heart rate responses to stress in habitual coffee drinkers persisted, whereas baseline systolic blood pressure had decreased. Total caffeine intake was unrelated to any measures of physiological function.

    Conclusions: Habitual coffee consumption is associated with heightened acute vascular inflammatory responses to mental stress, although these effects are not affected by short-term abstinence from coffee. These findings suggest that the relationship between coffee and markers of cardiovascular risk may be explained by residual or unmeasured confounding factors.

    Park C, Williams E, Tillin T, Stuart R, Chaturvedi N, Hughes A (2015) Subclinical left ventricular dysfunction is associated with reduced brain structure and function.,Journal of Human Hypertension 29 pp. 623-650 Nature Publishing Group
    Background: Subclinical left ventricle (LV) dysfunction has been associated with early cognitive impairment; however findings are inconsistent. We investigated the association between LV function and both functional and structural measures of thebrain.

    Methods: A community-based sample 1207 individuals (69±6 yrs) underwent echocardiography and cognitive function assessment using the Community Screening Instrument for Dementia score (CSID).Hippocampal volume was measured by MRI. Fast-ing bloods including NT-pro BNP levels were measured. Measures of LV systolic and diastolic function included peak shortening velocity in systole (s?), and LA diameter (indexed to height2.7(LADI)).

    Results: After adjusting for age, sex and ethnicity, hippocampal volume was associated with all measures of LV function (Table 1: Model 1). CSID was significantly associated with diastolic but not systolic function. After further adjusting for diabetes, stroke, education and hypertension all significant associations remained (Table 1: Model 2).

    Conclusion: In a community-based sample of older people, measures of LV function were associated with functional and structural measures of cognitive impairment. These associations were not explained by concomitant risk factors.

    Williams ED, Tillin T, Hughes A, Chaturvedi N Risk of cardiovascular disease: impact of Type 2 diabetes and socioeconomic disadvantage by ethnic group,Diabetic Medicine 32 Wiley
    Objectives: Low socioeconomic position (SEP) and Type 2
    diabetes are cardiovascular disease (CVD) risk factors; however,
    whether they interact to increase CVD risk further is unknown.
    SEP, diabetes and CVD vary across ethnic groups; it is important to
    understand how these relationships differ across groups.
    Methods: Longitudinal data were collected from 2,028 White
    European and 1,475 South Asian adults from a community based
    cohort study in northwest London. At baseline (1989), manual
    occupation defined low SEP and Type 2 diabetes was determined
    based on participant/GP record. Fatal/non-fatal CVD events were
    assessed at 20-year follow-up using participant/GP/hospital records.
    Results: Of those with diabetes, 61% of low and 62% of high SEP
    Europeans and 75% of low and 56% of high SEP South Asians had
    experienced a CVD event by follow-up. Among South Asians, in
    age-, sex- and baseline CVD-adjusted Cox regression models, there
    was a significant diabetes?SEP interaction (p=0.021); low SEP
    South Asians with diabetes had nearly double the CVD risk of their
    high SEP counterparts [hazard ratio (HR) 1.80, 95% confidence
    interval 1.15?2.82) (in South Asians without diabetes, SEP was not
    associated with CVD, HR 1.05, 0.86?1.28). In contrast, in
    Europeans, the risk of CVD did not differ between high and low
    SEP individuals, with or without diabetes (HR 1.15, 0.58?2.27 and
    HR 1.17, 0.99?1.39, respectively).
    Conclusions: This study demonstrates that the combination of
    diabetes and socioeconomic disadvantage is associated with higher
    CVD risk in South Asian people. Among South Asians with Type 2
    diabetes, socioeconomic adversity may be important in the
    identification of individuals at increased risk of CVD.
    Park C, Williams E, Chaturvedi N, Tillin T, Stewart R, Richards M, Shibata D, Mayet J, Hughes A (2017) Associations Between Left Ventricular Dysfunction and Brain Structure and Function: Findings From the SABRE (Southall and Brent Revisited) Study,Journal of the American Heart Association 6 (4) Wiley Open Access
    Background Subclinical left ventricular (LV) dysfunction has been inconsistently associated with early cognitive impairment, and mechanistic pathways have been poorly considered. We investigated the cross?sectional relationship between LV dysfunction and structural/functional measures of the brain and explored the role of potential mechanisms.

    Method and Results A total of 1338 individuals (69±6 years) from the Southall and Brent Revisited study underwent echocardiography for systolic (tissue Doppler imaging peak systolic wave) and diastolic (left atrial diameter) assessment. Cognitive function was assessed and total and hippocampal brain volumes were measured by magnetic resonance imaging. Global LV function was assessed by circulating N?terminal pro?brain natriuretic peptide. The role of potential mechanistic pathways of arterial stiffness, atherosclerosis, microvascular disease, and inflammation were explored. After adjusting for age, sex, and ethnicity, lower systolic function was associated with lower total brain (beta±standard error, 14.9±3.2 cm3; P

    Conclusions In a community?based sample of older people, measures of LV function were associated with structural/functional measures of the brain. These associations were not wholly explained by concomitant risk factors or potential mechanistic pathways.

    Hamer Mark, Gibson EL, Vuononvirta Raisa, Williams Emily, Steptoe Andrew (2006) Inflammatory and hemostatic responses to repeated mental stress:
    Individual stability and habituation over time.
    ,
    Brain, Behavior, and Immunity 20 (5) pp. 456-459 Elsevier
    An important assumption underlying psychobiological studies relating stress reactivity with disease risk is that individuals are characterized by stable response profiles that can be reliably assessed using acute psychophysiological stress testing. Previous research has mainly focused on the stability of cardiovascular, neuroendocrine, and cellular immune responses to repeated stressors, and less attention has been given to inflammatory and platelet responses. We therefore examined both average stability and individual test?retest stability of cardiovascular, neuroendocrine, hemostatic, inflammatory, and subjective responses to mental stress over two repeated stress sessions, four weeks apart. Ninety-one healthy, non-smoking men (mean age 33.2 years) completed a 3-min speech task followed by a 5-min mirror tracing task on two separate occasions. Blood samples were taken at baseline and 10 min after the stress tasks while cardiovascular activity, saliva samples, and subjective ratings were measured repeatedly. There was significant cardiovascular and cortisol activation to the stressors and stress-induced increases in plasma C-reactive protein, von Willebrand factor antigen, and platelet activation indexed by leukocyte?platelet aggregates. The magnitude of stress responses did not differ between sessions in any variable. Significant test?retest correlations between sessions were observed for baseline and stress values of all variables (r = 0.47?0.74, p
    Jain P, Chambers J, Elliott P, Williams ED, Kraly B, Muscat S, Lahiri A, Kooner J (2008) Coronary artery calcification as a predictor of increased coronary heart disease risk in UK Indian Asians.,Heart 94 (2) pp. A77-A77 BMJ Publishing Group
    Background: Coronary heart disease (CHD) mortality is 70% higher among UK Indian Asian than white Europeans. Currently available risk stratification tools and biomarkers do not allow the accurate identification of Indian Asians at increased risk of CHD. Coronary artery calcification (CAC) is highly correlated with coronary plaque burden and is an independent predictor of future CHD events in north American and European white populations. We hypothesised that CAC is increased in Indian Asians compared with white Europeans and may provide a non-invasive tool for the assessment of CHD risk in Indian Asians.

    Methods: We investigated 2398 Indian Asian and white European men and women, aged 35?75 years (Indian Asians: 837 men, 530 women; white European: 722 men, 309 women). Participants were recruited from the practice lists of 58 general practitioners in west London, as part of the London Life Sciences Population (LOLIPOP) study and all were free form clinical cardiovascular disease. CAC was measured for all participants using an electron beam computed tomography scanner (Imatron C-150 (modified), General Electric). Participants were also characterised for cardiovascular risk factors.

    Results: In comparison with Europeans, Indian Asians had an approximately twofold higher prevalence of hypertension and type 2 diabetes, higher waist?hip ratio and triglycerides, and lower high-density lipoprotein cholesterol (table). Cigarette smoking and cholesterol levels were lower in Indian Asians compared with white Europeans. CAC was more common in men than women, and CAC scores were closely associated with cardiovascular risk factors including age, cigarette smoking, hypertension, diabetes, total cholesterol and metabolic syndrome (all p

    Summary: CAC is not increased in Indian Asians compared with white Europeans, in any age group or in either gender. Similar CAC in Indian Asians and Europeans contrasts with an almost twofold higher risk of myocardial infarction and CHD mortality in Asians. CAC does not predict or identify the excess CHD risk in Indian Asians.

    Baradaran H, Williams E, Tillin T, Whincup P, Forouhi N, Chaturvedi N (2012) Ethnic Differences in Disability Prevalence and Their Determinants Studied over a 20-Year Period: A Cohort Study,PLoS ONE 7 (9) Public Library of Science
    Background

    To compare disability prevalence rates in the major ethnic groups in the UK and understand the risk factors contributing to differences identified. It was hypothesised that Indian Asian and African Caribbean people would experience higher rates of disability compared with Europeans.

    Methods

    Data was collected from 888 European, 636 Indian Asian and 265 African Caribbean men and women, aged 58?88 years at 20-year follow-up of community-based cohort study, based in West London. Disability was measured using a performance-based locomotor function test and self-reported questionnaires on functional limitation, and instrumental (IADL) and basic activities of daily living (ADL).

    Results

    The mean (SD) age of participants at follow-up was 69.6 (6.2) years. Compared with Europeans, Indian Asian people were significantly more likely to experience all of the disability outcomes than Europeans; this persisted after adjustment for socioeconomic, behavioural, adiposity and chronic disease risk factors measured at baseline (locomotor dysfunction: adjusted odds ratio (OR) 2.20, 95% CI 1.56?3.11; functional limitation: OR 2.77, 2.01?3.81; IADL impairment: OR 3.12, 2.20?4.41; ADL impairment: OR 1.58, 1.11?2.24). In contrast, a modest excess risk of disability was observed in African Caribbeans, which was abolished after adjustment (e.g. locomotor dysfunction: OR 1.37, 0.90?1.91); indeed a reduced risk of ADL impairment appeared after multivariable adjustment (OR from 0.99, 0.68?1.45 to 0.59, 0.38?0.93), compared with Europeans.

    Conclusions

    Substantially elevated risk of disability was observed among Indian Asian participants, unexplained by known factors. A greater understanding of determinants of disability and normative functional beliefs of healthy aging is required in this population to inform intervention efforts to prevent disability.

    Hamer Mark, Gibson E. Leigh, Vuononvirta Raisa, Williams Emily, Steptoe Andrew (2006) Inflammatory and hemostatic responses to repeated mental stress: Individual stability and habituation over time,Brain, Behavior, and Immunity 20 (5) pp. 456-459 Elsevier
    An important assumption underlying psychobiological studies relating stress reactivity with disease risk is that individuals are characterized by stable response profiles that can be reliably assessed using acute psychophysiological stress testing. Previous research has mainly focused on the stability of cardiovascular, neuroendocrine, and cellular immune responses to repeated stressors, and less attention has been given to inflammatory and platelet responses. We therefore examined both average stability and individual test?retest stability of cardiovascular, neuroendocrine, hemostatic, inflammatory, and subjective responses to mental stress over two repeated stress sessions, four weeks apart. Ninety-one healthy, non-smoking men (mean age 33.2 years) completed a 3-min speech task followed by a 5-min mirror tracing task on two separate occasions. Blood samples were taken at baseline and 10 min after the stress tasks while cardiovascular activity, saliva samples, and subjective ratings were measured repeatedly. There was significant cardiovascular and cortisol activation to the stressors and stress-induced increases in plasma C-reactive protein, von Willebrand factor antigen, and platelet activation indexed by leukocyte?platelet aggregates. The magnitude of stress responses did not differ between sessions in any variable. Significant test?retest correlations between sessions were observed for baseline and stress values of all variables (r = 0.47?0.74, p
    Hamer M, Williams Emily, Vuononvirta R, Gibson EL, Steptoe A (2006) Association between coffee consumption and markers of inflammation and cardiovascular function during mental stress.,Journal of Hypertension 24 (11) pp. 2191-2197 Lippincott, Williams & Wilkins
    Background: Coffee is widely consumed in the Western diet and therefore has important implications for public health. Research findings pertaining to the effects of coffee consumption on cardiovascular health are conflicting, and the role of caffeine is not clear.

    Objective: To examine the relationship between coffee intake, inflammation and cardiovascular function at baseline and during mental stress, both cross-sectionally and after a 4-week period of withdrawal of coffee during which intake of caffeine was maintained.

    Methods: Eighty-five healthy, non-smoking men with varying coffee-drinking habits were recruited. Blood pressure, heart rate, and markers of inflammation [C-reactive protein (CRP), von Willebrand factor antigen (vWF)], were measured at baseline and during mental stress. These measures were repeated after a 4-week period of withdrawal of coffee, during which intake of caffeine was maintained. Habitual levels of coffee and caffeine consumption were assessed from a self-reported questionnaire, and saliva samples for the analysis of caffeine concentrations were collected regularly throughout the period of withdrawal, to confirm compliance.

    Results: Multiple linear regression analysis of pre-withdrawal data, adjusted for age, body mass index and intake of tea, red wine, fruit, vegetables, oily fish and dietary supplements revealed that coffee consumption was positively related to baseline systolic blood pressure, and increased heart rate and vWF responses to mental stress. Four weeks after withdrawal of coffee, the heightened vWF and heart rate responses to stress in habitual coffee drinkers persisted, whereas baseline systolic blood pressure had decreased. Total caffeine intake was unrelated to any measures of physiological function.

    Conclusions: Habitual coffee consumption is associated with heightened acute vascular inflammatory responses to mental stress, although these effects are not affected by short-term abstinence from coffee. These findings suggest that the relationship between coffee and markers of cardiovascular risk may be explained by residual or unmeasured confounding factors.

    Gregg Ed, Thankappan Kavumpurathu R., Sathish Thirunavukkarasu, Tapp Robyn J., Shaw Jonathan E., Lotfaliany Mojtaba, Wolfe Rory, Absetz Pilvikki, Mathews Elezebeth, Aziz Zahra, Williams Emily, Fisher Edwin B., Zimmet Paul Z., Mahal Ajay, Balachandran Sajitha, D'Esposito Fabrizio, Sajeev Priyanka, Thomas Emma, Oldenburg Brian (2018) A peer-support lifestyle intervention for preventing type 2 diabetes in India: A cluster-randomized controlled trial of the Kerala Diabetes Prevention Program,PLOS Medicine 15 (6) e1002575 Public Library of Science
    The major efficacy trials on diabetes prevention have used resource-intensive approaches to identify high-risk individuals and deliver lifestyle interventions. Such strategies are not feasible for wider implementation in low- and middle-income countries (LMICs). We aimed to evaluate the effectiveness of a peer-support lifestyle intervention in preventing type 2 diabetes among high-risk individuals identified on the basis of a simple diabetes risk score.

    Methods and findings:

    The Kerala Diabetes Prevention Program was a cluster-randomized controlled trial conducted in 60 polling areas (clusters) of Neyyattinkara taluk (subdistrict) in Trivandrum district, Kerala state, India. Participants (age 30?60 years) were those with an Indian Diabetes Risk Score (IDRS) e60 and were free of diabetes on an oral glucose tolerance test (OGTT). A total of 1,007 participants (47.2% female) were enrolled (507 in the control group and 500 in the intervention group). Participants from intervention clusters participated in a 12-month community-based peer-support program comprising 15 group sessions (12 of which were led by trained lay peer leaders) and a range of community activities to support lifestyle change. Participants from control clusters received an education booklet with lifestyle change advice. The primary outcome was the incidence of diabetes at 24 months, diagnosed by an annual OGTT. Secondary outcomes were behavioral, clinical, and biochemical characteristics and health-related quality of life (HRQoL). A total of 964 (95.7%) participants were followed up at 24 months. Baseline characteristics of clusters and participants were similar between the study groups. After a median follow-up of 24 months, diabetes developed in 17.1% (79/463) of control participants and 14.9% (68/456) of intervention participants (relative risk [RR] 0.88, 95% CI 0.66?1.16, p = 0.36). At 24 months, compared with the control group, intervention participants had a greater reduction in IDRS score (mean difference: ?1.50 points, p = 0.022) and alcohol use (RR 0.77, p = 0.018) and a greater increase in fruit and vegetable intake (e5 servings/day) (RR 1.83, p = 0.008) and physical functioning score of the HRQoL scale (mean difference: 3.9 score, p = 0.016). The cost of delivering the peer-support intervention was US$22.5 per participant. There were no adverse events related to the intervention. We did not adjust for multiple comparisons, which may have increased the overall type I error rate.

    Conclusions:

    A low-cost community-based peer-support lifestyle intervention resulted in a nonsignificant reduction in diabetes incidence in this high-risk population at 24 months. However, there were significant improvements in some cardiovascular risk factors and physical functioning score of the HRQoL scale

    Williams Emily D., Whitaker Katriina L., Piano Marianne, Marlow Laura A.V. (2019) Ethnic differences in barriers to symptomatic presentation in primary care: A survey of women in England,Psycho-Oncology Wiley

    Objective

    The majority of cancers are diagnosed following a decision to access medical help for symptoms. People from ethnic minority backgrounds have longer patient intervals following identification of cancer symptoms. This study quantified ethnic differences in barriers to symptomatic presentation including culturally?specific barriers. Correlates of barriers (e.g. migration status, health literacy and fatalism) were also explored.

    Methods

    A cross?sectional survey of 720 White British, Caribbean, African, Indian, Pakistani and Bangladeshi women aged 30?60 (n=120/group) was carried out in England. Barrier items were taken from the widely?used Cancer Awareness Measure; additional culturally?specific barriers to symptomatic presentation were included following qualitative work (11 in total). Migration status, health literacy and fatalism were included as correlates to help?seeking barriers.

    Results

    Ethnic minority women reported a higher number of barriers (pÂ0.001, 2.6?3.8 more than White British women). Emotional barriers were particularly prominent. Women from ethnic minority groups were more likely to report 'praying about a symptom' (pÂ0.001, except Bangladeshi women) and 'using traditional remedies' (pÂ0.001,except Caribbean women). Among ethnic minority women, adult migration to the UK, low health literacy and high fatalistic beliefs increased likelihood of reporting barriers to symptomatic presentation. For example, women who migrated as adults were more likely to be embarrassed (OR=1.83,CI:1.06?3.15), worry what GP might find (OR=1.91,CI:1.12?3.26) and be low on body vigilance (OR=4.44,CI:2.72?7.23).

    Conclusions

    Campaigns addressing barriers to symptomatic presentation among ethnic minority women should be designed to reach low health literacy populations and include messages challenging fatalistic views. These would be valuable for reducing ethnic inequalities in cancer outcomes.

    Williams Emily D, Cox Anna, Cooper Rachel (2019) Ethnic differences in functional limitations by age across the adult life course,The Journals of Gerontology Series A: Biological Sciences and Medical Sciences Oxford University Press (OUP)

    Background: Despite compelling evidence from the US of ethnic inequalities in physical functioning and ethnic differences in risk factors for poor physical functioning, very little is known about ethnic differences in the UK. Furthermore, the life stage at which these ethnic differentials are first observed has not been examined.

    Methods: Using cross-sectional data from Wave 1 of the UK Household Longitudinal Study (UKHLS), we compared self-reported physical functioning among 35,816 White British, 4450 South Asian and 2512 African Caribbean men and women across different stages of adulthood (young adulthood, early middle age, late middle age, older age). Regression analyses examined ethnic differences in functional limitations, with adjustment for socioeconomic and clinical covariates. Ethnicity by sex and ethnicity by age-group interactions were examined, and subgroup heterogeneity was explored.

    Results: Compared with White British adults over the age of 60, older South Asian men and women reported higher odds of functional limitations (OR 2.77 (95% CI: 2.00-3.89) and OR 3.99 (2.61-6.10) respectively); these ethnic differentials were observed as early as young adulthood. Young African Caribbean men had lower odds of functional limitations than White British men (OR 0.56 (0.34-0.94)), yet African Caribbean women reported higher odds of functional limitations in older age (OR 1.84 (1.21-2.79)).

    Conclusions: There is an elevated risk of functional limitations relating to ethnicity, even in young adulthood where the impact on future health and socioeconomic position is considerable. When planning and delivering health care services to reduce ethnic inequalities in functional health, the intersectionality with age and sex should be considered.

    Baptista S., Wadley G., Bird D., Oldenburg B., Speight J., Russell Anna, Scuffham P., Riddell MA, Williams Emily Acceptability of an embodied conversational agent for type 2 diabetes self-management education and support via a smartphone app: a mixed-methods study.,JMIR mHealth and uHealth JMIR Publications
    Background: Embodied conversational agents (ECAs) are increasingly used in healthcare applications (apps) however their acceptability in type 2 diabetes (T2D) self-management apps has not yet been investigated.

    Objective: To evaluate the acceptability of the ECA (Laura), used to deliver diabetes self-management education and support in the My Diabetes Coach (MDC) app.

    Methods: A sequential mixed methods design was applied. Adults with T2D allocated to the intervention arm of the MDC trial used the MDC app over a 12- month period. At 6 months, they completed questions assessing their interaction with, and attitudes to, the ECA. In-depth qualitative interviews were conducted with a sub-sample of intervention arm participants to explore their experiences of the ECA. Interview questions included participant perceptions of Laura, including their initial impression of her (and how this changed over time), her personality and ?human? character. Quantitative and qualitative data were interpreted through integrated synthesis.

    Results: Of the 93 intervention participants, 44 (47.3%) were women, mean±SD age was 55±10 years and baseline HbA1c was 7.3±1.5%. Sixty-six (71%) provided survey responses. Of these, most described Laura as being helpful (85%), friendly (85%), competent (84%), trustworthy (72%), and likable (60%). Some described Laura as not real (39%), boring (39%) and annoying (30%). Participants reported that interacting with Laura made them feel more motivated (43%), comfortable (36%), confident (21%), happy (16%) and hopeful (12%). Nineteen percent were frustrated by their interaction with Laura and 16% of participants reported that interacting with Laura made them feel guilty. Four themes emerged from the qualitative data (N=19): 1) Perceived role: a friendly coach rather than a health professional; 2) Perceived support: emotional and motivational; 3) Embodiment preference: a human-like character is acceptable; and 4) Room for improvement: greater congruence needed between Laura?s words and actions.

    Conclusions:
    These findings suggest an ECA is an acceptable means to deliver T2D self-management education and support. A human-like character providing ongoing friendly, non-judgemental, emotional and motivational support is well-received. Nevertheless, the ECA can be improved, by increasing congruence between its verbal and non-verbal communication and accommodating user preferences.

    Baptista S., Wadley G., Bird D., Oldenburg B., Speight J., Russell Anna, Harris M., Scuffham P., Riddell M.A, Williams Emily (2020) User experiences with a type 2 diabetes coaching app: a qualitative study,JMIR Diabetes JMIR Publications
    Background: Diabetes self-management apps have the potential to improve self-management by people with type 2 diabetes. Although efficacy trials provide evidence of health benefits, premature disengagement from apps is common. Therefore, it is important to understand factors that influence engagement in real-world settings.
    Objective: To explore users? real-world experiences with the ?My Diabetes Coach? self-management app.

    Methods: We conducted telephone-based interviews with participants who had accessed the ?My Diabetes Coach? self-management app via their own smartphone for up to 12 months. Interviews focused on the users? characteristics, the context within which the app was used, barriers and facilitators of app use, and on the design, content and delivery of support within the app.

    Results: Nineteen interviewees were aged 60 (SD=14) years. Eight (42%) were women. Eight (42%) participants had type 2 diabetes for less than five years, eight (42%) for five-ten years and three (16%) for more than ten years. Two themes were constructed from interview data: 1) the moderating effect of diabetes self-management styles on needs, preferences and expectations and 2) factors influencing users? engagement with the app: one size does not fit all.

    Conclusions: User characteristics, context of use and features of the app interact and influence engagement. Promoting engagement is vital if diabetes self-management apps are to become a useful complement to clinical care in supporting optimal self-management.