Emanuela Falaschetti

Using the lower limit of normal for the FEV1/FVC ratio reduces the misclassification of airway obstruction.

Aim: The prevalence of airway obstruction varies widely with the definition used. Objectives: To study differences in the prevalence of airway obstruction when applying four international guidelines to three population samples using four regression equations. Methods: We collected predicted values for forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) and its lower limit of normal (LLN) from the literature. FEV1/FVC from 40 646 adults (including 13 136 asymptomatic never smokers) aged 17–90+years were available from American, English and Dutch population based surveys. The prevalence of airway obstruction was determined by the LLN for FEV1/FVC, and by using the Global Initiative for Chronic Obstructive Lung Disease (GOLD), American Thoracic Society/European Respiratory Society (ATS/ERS) or British Thoracic Society (BTS) guidelines, initially in the healthy subgroup and then in the entire population. Results: The LLN for FEV1/FVC varied between prediction equations (57 available for men and 55 for women), and demonstrated marked negative age dependency. Median age at which the LLN fell below 0.70 in healthy subjects was 42 and 48 years in men and women, respectively. When applying the reference equations (Health Survey for England 1995–1996, National Health and Nutrition Examination Survey (NHANES) III, European Community for Coal and Steel (ECCS)/ERS and a Dutch population study) to the selected population samples, the prevalence of airway obstruction in healthy never smokers aged over 60 years varied for each guideline: 17–45% of men and 7–26% of women for GOLD; 0–18% of men and 0–16% of women for ATS/ERS; and 0–9% of men and 0–11% of women for BTS. GOLD guidelines caused false positive rates of up to 60% when applied to entire populations. Conclusions: Airway obstruction should be defined by FEV1/FVC and FEV1 being below the LLN using appropriate reference equations.

Association Between Smoking and Blood Pressure: Evidence From the Health Survey for England

Cigarette smoking causes acute blood pressure (BP) elevation, although some studies have found similar or lower BPs in smokers compared with nonsmokers. Cross-sectional data from 3 years (1994 to 1996) of the annual Health Survey for England were used to investigate any difference in BP between smokers and nonsmokers in a nationally representative sample of adults (≥16 years old). Randomly selected adults (33 860; 47% men) with valid body mass index (BMI) and BP measurements provided data on smoking status (never, past, or current) and were stratified into younger (16 to 44 years old) and older (≥45 years old) age groups. Analyses provided between 89% and 94% power to detect a difference of 2 mm Hg systolic BP between smokers and nonsmokers in the 4 age/gender strata (&agr;=0.05). Older male smokers had higher systolic BP adjusted for age, BMI, social class, and alcohol intake than did nonsmoking men. No such differences were seen among younger men or for diastolic blood pressure in either age group. Among women, light smokers (1 to 9 cigarettes/d) tended to have lower BPs than heavier smokers and never smokers, significantly so for diastolic BP. Among men, a significant interaction between BMI and the BP-smoking association was observed. In women, BP differences between nonsmokers and light smokers were most marked in those who did not drink alcohol. These data show that any independent chronic effect of smoking on BP is small. Differences between men and women in this association are likely to be due to complex interrelations among smoking, alcohol intake, and BMI.

Continued Improvement in Hypertension Management in England. Results From the Health Survey for England 2006

This study evaluate whether blood pressure management has improved in England between 2003 and 2006, using cross-sectional, nationally representative, random samples of 8834 (in 2003) and 7478 (in 2006) noninstitutionalized adults (aged ≥16 years) of mean age 46 (in 2003) and 47 (in 2006) years. Overall mean blood pressure levels in 2006 were 130.8/74.2 mm Hg in men and 124.0/72.4 mm Hg in women. Awareness of hypertension increased significantly in the overall population (from 62% in 2003% to 66% in 2006; P<0.001), the increase being significant in women (from 64% in 2003% to 71% in 2006; P<0.001) but not in men (from 60% to 62%; P=0.26). Similarly, the proportion treated had risen significantly overall (from 48% to 54%; P<0.001) and in women (from 52% to 62%; P<0.001) but not in men (from 43% to 47%; P=0.05). Control rates (<140/90 mm Hg) were higher in 2006 than in 2003 (from 22% to 28%; P<0.001) and had increased more among women than men: from 23% to 32% in women (P<0.001) and from 21% to 24% in men (P=0.02). Among those on treatment, control rates increased from 46% to 52% (P<0.001; from 44% to 53% in women, P<0.001; and from 48% to 52% in men, P=0.18). The most common agents used for monotherapy have changed since 2003 and were angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Where ≥2 drugs were used, the most common antihypertensive class used varied by age and ethnicity. Awareness, treatment, and control of hypertension increased between 2003 and 2006, particularly in women, but opportunities for further improvement remain.

Hypertension prevalence, awareness, treatment and control in national surveys from England, the USA and Canada, and correlation with stroke and ischaemic heart disease mortality: a cross-sectional study.

Objective Comparison of recent national survey data on prevalence, awareness, treatment and control of hypertension in England, the USA and Canada, and correlation of these parameters with each country stroke and ischaemic heart disease (IHD) mortality. Design Non-institutionalised population surveys. Setting and participants England (2006 n=6873), the USA (2007–2010 n=10 003) and Canada (2007–2009 n=3485) aged 20–79 years. Outcomes Stroke and IHD mortality rates were plotted against countries’ specific prevalence data. Results Mean systolic blood pressure (SBP) was higher in England than in the USA and Canada in all age–gender groups. Mean diastolic blood pressure (DBP) was similar in the three countries before age 50 and then fell more rapidly in the USA, being the lowest in the USA. Only 34% had a BP under 140/90 mm Hg in England, compared with 50% in the USA and 66% in Canada. Prehypertension and stages 1 and 2 hypertension prevalence figures were the highest in England. Hypertension prevalence (≥140 mm Hg SBP and/or ≥90 mm Hg DBP) was lower in Canada (19·5%) than in the USA (29%) and England (30%). Hypertension awareness was higher in the USA (81%) and Canada (83%) than in England (65%). England also had lower levels of hypertension treatment (51%; USA 74%; Canada 80%) and control (<140/90 mm Hg; 27%; the USA 53%; Canada 66%). Canada had the lowest stroke and IHD mortality rates, England the highest and the rates were inversely related to the mean SBP in each country and strongly related to the blood pressure indicators, the strongest relationship being between low hypertension awareness and stroke mortality. Conclusions While the current prevention efforts in England should result in future-improved figures, especially at younger ages, these data still show important gaps in the management of hypertension in these countries, with consequences on stroke and IHD mortality.

Time trends in childhood and adolescent obesity in England from 1995 to 2007 and projections of prevalence to 2015

Background The aim was to examine the 1995–2007 childhood and adolescent obesity trends and project prevalence to 2015 by age group and social class. Methods Participants were children aged 2–10 and adolescents aged 11–18 years from general population households in England studied using repeated cross-sectional surveys. Obesity was computed using international standards. Prevalence projections to 2015 were based on extrapolation of linear and non-linear trends. Results Obesity prevalence increased from 1995 to 2007 from 3.1% to 6.9% among boys, and 5.2% to 7.4% among girls. There are signs of a levelling off trend past 2004/5. Assuming a linear trend, the 2015 projected obesity prevalence is 10.1% (95% CI 7.5 to 12.6) in boys and 8.9% (5.8 to 12.1) in girls, and 8.0% (4.5, 11.5) in male and 9.7% (6.0, 13.3) in female adolescents. Projected prevalence in manual social classes is markedly higher than in non-manual classes [boys: 10.7% (6.6 to 14.9) vs 7.9% (3.7 to 12.1); girls: 11.2% (7.0 to 15.3) vs 5.4% (1.3 to 9.4); male adolescents: 10.0% (5.2 to 14.8) vs 6.7% (3.4 to 10.0); female adolescents: 10.4% (5.0 to 15.8) vs 8.3% (4.3 to 12.4)]. Conclusion If the trends in young obesity continue, the percentage and numbers of obese young people in England will increase considerably by 2015 and the existing obesity gap between manual and non-manual classes will widen further. This highlights the need for public health action to reverse recent trends and narrow social inequalities in health.

Hypertension management in England: a serial cross-sectional study from 1994 to 2011

BACKGROUND Hypertension is the leading risk factor contributing to the global burden of disease. We aimed to assess the change in blood pressure management between 1994 and 2011 in England with a series of annual surveys. METHODS We did a serial cross-sectional study of five Health Survey for England surveys based on nationally representative samples of non-institutionalised adults (aged ≥16 years). Mean blood pressure levels and rates of awareness, treatment, and control of hypertension were assessed. Hypertension was defined as systolic blood pressure 140 mm Hg or higher, diastolic blood pressure 90 mm Hg or higher, or receiving treatment for high blood pressure. FINDINGS The mean blood pressure levels of men and women in the general population and among patients with treated hypertension progressively improved between 1994 and 2011. In patients with treated hypertension, blood pressure improved from 150·0 (SE 0·59)/80·2 (0·27) mm Hg to 135·4 (0·58)/73·5 (0·41) mm Hg. Awareness, treatment, and control rates among men and women combined also improved significantly across each stage of this 17-year period, with the prevalence of control among treated patients almost doubling from 33% (SE 1·4) in 1994 to 63% (1·7) in 2011. Nevertheless, of all adults with survey-defined hypertension in 2011, hypertension was controlled in only 37%. INTERPRETATION If the same systematic improvement in all aspects of hypertension management continues until 2022, 80% of patients with treated hypertension will have controlled blood pressure levels with a potential annual saving of about 50,000 major cardiovascular events. FUNDING None.

Adiposity and cardiovascular risk factors in a large contemporary population of pre-pubertal children

AIMS to examine the associations of several markers of adiposity and a wide range of cardiovascular risk factors and biomarkers in pre-pubertal children. METHODS AND RESULTS four measures of adiposity,body mass index (BMI), waist circumference, dual-energy X-ray absorptiometry (DXA)-determined fat mass, and leptin concentration, were available in up to 7589 children aged 8.8-11.7 (9.9 mean) years from the Avon Longitudinal Study of Parents and Children (ALSPAC). Thirteen per cent of boys and 18.8% of girls were overweight, and 5.3% of boys and 5% of girls were obese. Body mass index was highly correlated with waist circumference (r = 0.91), DXA fat mass (r = 0.87), and leptin concentration (r = 0.75), and all had similar associations with cardiovascular risk factors. A 1 kg/m(2) greater BMI was associated with 1.4 mmHg (95% CI 1.25-1.44) higher systolic blood pressure (BP). In 5002 children, a 1 kg/m(2) greater BMI was associated with a 0.05 mmol/L (95% CI 0.036-0.055) higher non-high-density lipoprotein (HDL) cholesterol and 0.03 mmol/L (95% CI -0.034 to -0.025) lower HDL cholesterol. There were also graded associations with apolipoproteins A1 and B, interleukin-6, and C-reactive protein. Comparing children who were obese with those who were normal weight, the odds ratio for hypertension was 10.7 (95% CI 7.2-15.9) for boys and 13.5 (95% CI 9.4-19.5) for girls. CONCLUSION in pre-pubertal UK children, overweight/obesity is common and has broadly similar associations with BP, HDL cholesterol, and non-HDL cholesterol to those observed in adults. Future research should evaluate whether effective interventions to maintain healthy weight in childhood could have important benefits for adult cardiovascular risk.

Age trajectories of quality of life among older adults: results from the English Longitudinal Study of Ageing.

PurposeTo explore age-trajectories of quality of life (QoL) and influences on them in a 4-year period among older adults living in England.MethodsData come from three waves (2002–2003 and 2006–2007) of the English Longitudinal Study of Ageing, a large panel study of 11,392 individuals aged 50 and over. We used Latent Growth Curve models and ageing-vector graphs to describe both individual differences and average population age-trajectories in QoL (measured by the CASP19 questionnaire).ResultsQoL at baseline was poorer for older than younger respondents, with the differences widening with age. QoL also declined more rapidly for older individuals. Gender, education, depression, limiting long-standing illness, difficulty with ADL-s, lack of wealth, non-employment, decreased number of friends and low positive support had a negative impact on QoL. Living with a partner had a positive effect on the QoL of men but not of women. The ageing-vector graphs revealed a clear gradient in age-trajectories of QoL for those in the best to the worst psychosocial, socioeconomic and health conditions.ConclusionsYounger old adults can be prepared for further ageing by increasing their network of friends and engaging with the wider community while they are able.

Changes in the FEV1/FVC ratio during childhood and adolescence: an intercontinental study

In children, the ratio of forced expiratory volume in 1 s (FEV1) to forced vital capacity (FVC) is reportedly constant or falls linearly with age, whereas the ratio of residual volume (RV) to total lung capacity (TLC) remains constant. This seems counter-intuitive given the changes in airway properties, body proportions, thoracic shape and respiratory muscle function that occur during growth. The age dependence of lung volumes, FEV1/FVC and RV/TLC were studied in children worldwide. Spirometric data were available for 22,412 healthy youths (51.4% male) aged 4–20 yrs from 15 centres, and RV and TLC data for 2,253 youths (56.7% male) from four centres; three sets included sitting height (SH). Data were fitted as a function of age, height and SH. In childhood, FVC outgrows TLC and FEV1, leading to falls in FEV1/FVC and RV/TLC; these trends are reversed in adolescence. Taking into account SH materially reduces differences in pulmonary function within and between ethnic groups. The highest FEV1/FVC ratios occur in those shortest for their age. When interpreting lung function test results, the changing pattern in FEV1/FVC and RV/TLC should be considered. Prediction equations for children and adolescents should take into account sex, height, age, ethnic group, and, ideally, also SH.

Most older pedestrians are unable to cross the road in time: a cross-sectional study

OBJECTIVES to compare walking speed in the UK older population with the speed required to utilise pedestrian crossings (≥1.2 m/s), and determine health and socio-demographic associations with walking impairment. DESIGN cross-sectional study using Health Survey for England 2005 data. SETTING private households in England. PARTICIPANTS random population sample of 3,145 adults (1,444 men) aged ≥65 years. MAIN OUTCOME MEASURES walking speed was assessed by timing a walk of 8 feet at normal pace. Walking impairment was defined as walking speed <1.2 m/s or non-participation in the test due to being unsafe or unable. RESULTS the mean walking speed was 0.9 m/s in men and 0.8 m/s in women; 84% of men and 93% of women ≥65 years had walking impairment. Female gender, increasing age, lower socio-economic status, poorer health and lower grip strength were predictors of walking impairment. CONCLUSION most older adults either cannot walk 8 feet safely or cannot walk fast enough to use a pedestrian crossing in the UK. The health impacts on older adults include limited independence and reduced opportunities for physical activity and social interaction. An assumed normal walking speed for pedestrian crossings of 1.2 m/s is inappropriate for older adults and revision of these timings should be considered.