Dr Emily Williams

International migration has increased rapidly over the past 20 years, with an estimated 281 million people living outside their country of birth. Similarly, migration to the UK has continued to rise over this period; current annual migration is estimated to be over 700,000 per year (net migration of over 300,000). With migration comes linguistic diversity, and in healthcare, this often translates into linguistic discordance between patients and healthcare professionals. This can result in communication difficulties that lead to lower quality of care and poor outcomes. COVID-19 has heightened inequalities in relation to language: communication barriers, defined as barriers in understanding or accessing key information on healthcare and challenges in reporting on health conditions, are known to have compounded risks for migrants in the context of COVID-19. Digitalisation of healthcare has further amplified inequalities in primary care for migrant groups.

This study aims to describe the prevalence of depression and anxiety among a population sample of people at high risk for type 2 diabetes in Kerala, India, and examine the relationship between depressive symptoms, anxiety, and incident Type 2 Diabetes Mellitus (T2DM) over a two-year period. We used data from the Kerala Diabetes Prevention Program, a cluster-randomized controlled trial for diabetes prevention among 1007 high-risk individuals. The prevalence of depression and anxiety were estimated using the 9-item Patient Health Questionnaire and the Generalized Anxiety Disorder 7-item scale, respectively. We calculated proportions for depression and anxiety and performed generalized estimating equations (GEE) to examine the relationship between baseline mental health status and incident T2DM. The prevalence of depression and anxiety at baseline were 7.5% and 5.5%, respectively. Compared with those reporting none/low symptoms, the odds ratio for incident diabetes was 1.07 (95% CI 0.54-2.12) for participants with moderate to severe depression and 0.73 (95% CI 0.23-2.28) for participants with moderate to severe anxiety, after adjusting for potential confounders. Our findings suggest that the prevalence of depression and anxiety were higher than those previously reported in the general population in India. However, among this sample of community-based adults at high risk of developing T2DM, the presence of moderate to severe depression and/or anxiety symptoms was not significantly associated with the risk of developing T2DM.

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.

Introduction: Initiation of injectable therapies in type 2 diabetes (T2D) is often delayed, however the reasons why are not fully understood. Methods: A mixed methods study performed in sequential phases. Phase 1: focus groups with people with T2D (injectable naı¨venaı¨ve [n = 12] and experienced [n = 5]) and healthcare professionals (HCPs; nurses [n = 5] and general practitioners (GPs) [n = 7]) to understand their

Background: Cross-cultural evidence on the factorial structure and invariance of the PHQ-9 and the GAD-7 is lacking for South Asia. Recommendations on the use of unit-weighted scores of these scales (the sum of items' scores) are not well-founded. This study aims to address these contextual and methodological gaps using data from a rural Indian population. Methods: The study surveyed 1,209 participants of the Kerala Diabetes Prevention Program aged 30-60 years (n at risk of diabetes = 1,007 and n with diabetes = 202). 1,007 participants were surveyed over 2 years using the PHQ-9 and the GAD-7. Bifactor-(S - 1) modeling and multigroup confirmatory factor analysis were used. Results: Factor analysis supported the existence of a somatic and cognitive/affective subcomponent for both scales, but less explicitly for the GAD-7. Hierarchical omega values were 0.72 for the PHQ-9 and 0.76 for the GAD-7. Both scales showed full scalar invariance and full or partial residual invariance across age, gender, education, status of diabetes and over time. Effect sizes between categories measured by unit-weighted scores versus latent means followed a similar trend but were systematically higher for the latent means. For both disorders, female gender and lower education were associated with higher symptom severity scores, which corresponds with regional and global trends. Conclusions: For both scales, psychometric properties were comparable to studies in western settings. Distinct clinical profiles (somatic-cognitive) were supported for depression, and to a lesser extent for anxiety. Unit-weighted scores of the full scales should be used with caution, while scoring subscales is not recommended. The stability of these scales supports their use and allows for meaningful comparison across tested subgroups.

The impact of lifestyle interventions on diabetes and mental health conditions have been documented among people with diabetes. However, the mental health benefits of lifestyle interventions designed for diabetes prevention have not been systematically investigated among people at high risk of diabetes, particularly in low- and middle-income countries. We examined the effects of a 12-month peer support lifestyle intervention designed for diabetes prevention on depression and anxiety symptomology in the sample population of the Kerala Diabetes Prevention Program. Mixed-effects linear regression models were used to examine the effect of the intervention on depression and anxiety scores at 12 and 24 months in the total sample of 1007 adults at risk for diabetes and among those with mild-severe depressive or anxiety symptoms at baseline (n = 326 for depression; n = 203 for anxiety). Among all participants, the intervention group had a significantly higher reduction of depressive symptoms as compared to the control group at 12 months (mean diff score = −0.51; 95% CI: −0.95, −0.07; P = 0.02). This effect was not sustained at 24 months. There were no significant intervention effects for anxiety. Among those with mild-severe symptoms at baseline, the intervention group had a significantly higher reduction of depressive symptoms (mean diff score = −1.55; 95% CI -2.50, −0.6; P = 0.001) and anxiety symptoms (mean diff score = −1.64; 95% CI -2.76, −0.52; P = 0.004) at 12 months. The effect was sustained at 24 months for depression, but not anxiety. Lifestyle interventions designed for prevention of diabetes might improve depressive and anxiety symptoms in the short-term, particularly among those with mild-severe symptoms.

Background There is an under-representation of Black, Asian and minority ethnic nurses in senior positions within the UK's national healthcare system. Objectives To understand student nurses' perspectives on the role of race and ethnicity on career expectations, course learning and delivery, and areas for additional training and skill development for all nurses in understanding structural inequalities in healthcare. Design Qualitative study involving semi-structured interviews. Settings University in south-east England, UK. Participants 15 nursing students (14 women, one man) from a range of ethnic backgrounds, age-groups and nationalities. Methods Interviews lasting 30–60 min were conducted with nursing students and thematic analyses undertaken. Results Four inter-related themes were constructed: altered career expectations, lack of understanding, absent discussion of racism and missing representation. Experiences of racism were not uncommon for students from Black, Asian and minority ethnic backgrounds and these experiences affected these students' career expectations. Students described a lack of understanding about racism and that it was a taboo topic on their course and in placements. Conclusions Findings highlight an urgent need for universities to challenge existing nursing curricula to ensure inclusive, anti-racist educational provision that works equitably for all future nurses. The importance of representation was highlighted among those who deliver courses, in the content of nursing curriculum through inclusive education, decolonised curricula and with student voices embedded to enable the development of culturally-competent nursing graduates.

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.

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

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.

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 < .001), but reactivity (change scores) for C-reactive protein, von Willebrand factor, cortisol, and platelet activation were not significantly correlated. Our results demonstrate that the stress-induced responses did not habituate between sessions, though the small magnitude of acute inflammatory, cortisol, and platelet responses limits the test–retest reliability of stress reactivity assessments.

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.

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 ≥60 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.

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.

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) ≥60 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 (≥5 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

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 (p˂0.001, 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' (p˂0.001, except Bangladeshi women) and 'using traditional remedies' (p˂0.001,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.

There has been little previous research regarding the effectiveness of ethics education interventions for residential care‐givers. The Researching Interventions to Promote Ethics in social care project responded to the question: Which is the most effective ethics education intervention for care‐givers in residential social care? A pragmatic cluster trial explored the impact of three ethics education interventions for: (a) interactive face‐to‐face ethics teaching; (b) reflective ethics discussion groups; and (c) an immersive simulation experience. There was also a control arm (d). 144 trial participants were recruited from 39 residential care homes for older people in southern England. Change scores compared across intervention arms showed a significant reduction in work‐related moral stress in the teaching arm compared with control group (p = .03); there were no significant differences between control and intervention arms in change scores for moral sensitivity, interpersonal reactivity (empathy) or ethical leadership. Qualitative data themes were as follows: ethical care; care challenges; and ethical care inhibitors. Overall findings stimulate reflection on the value of three different ethics education interventions and the most appropriate means to evaluate their impact. Findings suggest the complexity and diverse nature of ethical competence in care. We suggest a way forward for research evaluating ethics education.

Background The evidence supporting a relationship between stress and diabetes has been inconsistent. Purpose This study examined the effects of stress on abnormal glucose metabolism, using a population-based sample of 3,759, with normoglycemia at baseline, from the Australian Diabetes, Obesity and Lifestyle study. Methods Perceived stress and stressful life events were measured at baseline, with health behavior and anthropometric information also collected. Oral glucose tolerance tests were undertaken at baseline and 5-year follow-up. The primary outcome was the development of abnormal glucose metabolism (impaired fasting glucose, impaired glucose tolerance, and type 2 diabetes), according to WHO 1999 criteria. Results Perceived stress predicted incident abnormal glucose metabolism in women but not men, after multivariate adjustment. Life events showed an inconsistent relationship with abnormal glucose metabolism. Conclusions Perceived stress predicted abnormal glucose metabolism in women. Healthcare professionals should consider psychosocial adversity when assessing risk factor profiles for the development of diabetes.

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.

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.

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.

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 < .001). Multiple linear regression analysis adjusted for age, body mass index, and baseline levels revealed that men with higher effort-reward imbalance demonstrated greater CRP and vWF responses to the stress tasks but blunted cardiovascular responses. Inflammatory and cardiovascular responses to stress appeared to be unrelated. 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.

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.

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

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.

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

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 < .001), but reactivity (change scores) for C-reactive protein, von Willebrand factor, cortisol, and platelet activation were not significantly correlated. Our results demonstrate that the stress-induced responses did not habituate between sessions, though the small magnitude of acute inflammatory, cortisol, and platelet responses limits the test–retest reliability of stress reactivity assessments.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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

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.

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.

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 ≥25 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.

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.

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 ≥3 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

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 ≥35 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.

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.

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.

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.

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.

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.

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.

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