Mark A Bellis

Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis.

Liver disease in the UK stands out as the one glaring exception to the vast improvements made during the past 30 years in health and life expectancy for chronic disorders such as stroke, heart disease, and many cancers. Mortality rates have increased 400% since 1970, and in people younger than 65 years have risen by almost five-times. Liver disease constitutes the third commonest cause of premature death in the UK and the rate of increase of liver disease is substantially higher in the UK than other countries in western Europe. More than 1 million admissions to hospital per year are the result of alcohol-related disorders, and both the number of admissions and the increase in mortality closely parallel the rise in alcohol consumption in the UK during the past three decades. The aim of this Commission is to provide the strongest evidence base through involvement of experts from a wide cross-section of disciplines, making firm recommendations to reduce the unacceptable premature mortality and disease burden from avoidable causes and to improve the standard of care for patients with liver disease in hospital. From the substantial number of recommendations given in our Commission, we selected those that will have the greatest effect and that need urgent implementation. Although the recommendations are based mostly on data from England, they have wider application to the UK as a whole, and are in accord with the present strategy for health-care policy by the Scottish Health Boards, the Health Department of Wales, and the Department of Health and Social Services in Northern Ireland.

The effect of multiple adverse childhood experiences on health: a systematic review and meta-analysis

BACKGROUND A growing body of research identifies the harmful effects that adverse childhood experiences (ACEs; occurring during childhood or adolescence; eg, child maltreatment or exposure to domestic violence) have on health throughout life. Studies have quantified such effects for individual ACEs. However, ACEs frequently co-occur and no synthesis of findings from studies measuring the effect of multiple ACE types has been done. METHODS In this systematic review and meta-analysis, we searched five electronic databases for cross-sectional, case-control, or cohort studies published up to May 6, 2016, reporting risks of health outcomes, consisting of substance use, sexual health, mental health, weight and physical exercise, violence, and physical health status and conditions, associated with multiple ACEs. We selected articles that presented risk estimates for individuals with at least four ACEs compared with those with none for outcomes with sufficient data for meta-analysis (at least four populations). Included studies also focused on adults aged at least 18 years with a sample size of at least 100. We excluded studies based on high-risk or clinical populations. We extracted data from published reports. We calculated pooled odds ratios (ORs) using a random-effects model. FINDINGS Of 11 621 references identified by the search, 37 included studies provided risk estimates for 23 outcomes, with a total of 253 719 participants. Individuals with at least four ACEs were at increased risk of all health outcomes compared with individuals with no ACEs. Associations were weak or modest for physical inactivity, overweight or obesity, and diabetes (ORs of less than two); moderate for smoking, heavy alcohol use, poor self-rated health, cancer, heart disease, and respiratory disease (ORs of two to three), strong for sexual risk taking, mental ill health, and problematic alcohol use (ORs of more than three to six), and strongest for problematic drug use and interpersonal and self-directed violence (ORs of more than seven). We identified considerable heterogeneity (I2 of >75%) between estimates for almost half of the outcomes. INTERPRETATION To have multiple ACEs is a major risk factor for many health conditions. The outcomes most strongly associated with multiple ACEs represent ACE risks for the next generation (eg, violence, mental illness, and substance use). To sustain improvements in public health requires a shift in focus to include prevention of ACEs, resilience building, and ACE-informed service provision. The Sustainable Development Goals provide a global platform to reduce ACEs and their life-course effect on health. FUNDING Public Health Wales.

Implementation of the Lancet Standing Commission on Liver Disease in the UK

Between 1980 and 2013, deaths from liver disease in the UK increased by four times, mainly attributable to alcohol consumption. Although the latest data from Public Health England (PHE) show some reduction in the number of hospital admissions for alcohol-related liver disease in those younger than 18 years and in the number drinking, the high mortality in adults continues with 50% of English local authorities seeing a rise in hospital admissions for alcohol-related illness. Obesity-related liver disease and prevalence of primary hepatocellular carcinoma (HCC) are both increasing, with ever increasing costs to the National Health Service (NHS). The ten major recommendations in the Lancet Commission report were selected as needing urgent implementation on the basis of strong evidence and are considered in terms of what has been achieved to date and where there is ongoing work.

The impact of adverse childhood experiences on health service use across the life course using a retrospective cohort study

Objectives The lifelong health impacts of adverse childhood experiences are increasingly being identified, including earlier and more frequent development of non-communicable disease. Our aim was to examine whether adverse childhood experiences are related to increased use of primary, emergency and in-patient care and at what ages such impact is apparent. Methods Household surveys were undertaken in 2015 with 7414 adults resident in Wales and England using random probability stratified sampling (age range 18–69 years). Nine adverse childhood experiences (covering childhood abuse and household stressors) and three types of health care use in the last 12 months were assessed: number of general practice (GP) visits, emergency department (ED) attendances and nights spent in hospital. Results Levels of use increased with increasing numbers of adverse childhood experiences experienced. Compared to those with no adverse childhood experiences, odds (±95% CIs) of frequent GP use (≥6 visits), any ED attendance or any overnight hospital stay were 2.34 (1.88–2.92), 2.32 (1.90–2.83) and 2.67 (2.06–3.47) in those with ≥ 4 adverse childhood experiences. Differences were independent of socio-economic measures of deprivation and other demographics. Higher health care use in those with ≥ 4 adverse childhood experiences (compared with no adverse childhood experiences) was evident at 18–29 years of age and continued through to 50–59 years. Demographically adjusted means for ED attendance rose from 12.2% of 18-29 year olds with no adverse childhood experiences to 28.8% of those with ≥ 4 adverse childhood experiences. At 60–69 years, only overnight hospital stay was significant (9.8% vs. 25.0%). Conclusions Along with the acute impacts of adverse childhood experiences on child health, a life course perspective provides a compelling case for investing in safe and nurturing childhoods. Disproportionate health expenditure in later life might be reduced through childhood interventions to prevent adverse childhood experiences.

Interpersonal Violence: Global Impact and Paths to Prevention

Interpersonal violence is a global public health problem that disproportionately impacts lowand middle income countries (LMICs). Children, adolescents and young adults, both males and females, are its primary victims. The consequences of experiencing interpersonal violence are pervasive and enduring, increasing the risk of injury, infectious diseases such as HIV, mental health problems, reproductive health problems, and non-communicable diseases. Given the high prevalence of interpersonal violence and its extensive consequences, the associated economic impact is substantial. The evidence base for preventing interpersonal violence is growing, but is largely based on research conducted in high-income countries. Key challenges moving forward include building the evidence base for cost effective programs and policies in LMICs as well as the infrastructure needed to support the dissemination, scaling up, and sustenance of effective programs and policies. Interpersonal violence can be prevented if governments, their citizens, and the global community start now, act wisely, and work together.

“I think we should all be singing from the same hymn sheet” – English and Swedish midwives’ views of advising pregnant women about alcohol

Abstract Many countries have adopted abstinence guidelines for pregnant women, due to uncertainty around the risk of harm caused by small amounts of alcohol. There is a lack of research exploring frontline midwives’ attitudes towards alcohol use during pregnancy and comparisons of practices in different countries. Sixteen semi-structured interviews were conducted with midwives working in Liverpool, England (n = 7) and Örebro County, Sweden (n = 9). Data were analysed inductively, using thematic analysis with thematic networks. The findings show that all midwives believed pregnant women should be advised not to consume any alcohol during pregnancy and there is a need to tailor their approach to the individual. A key concern among midwives in both countries was how to advise about alcohol exposure that occurs before the pregnancy is known to the woman. English midwives discussed the uncertainty around the risk of consuming small amounts of alcohol, whereas Swedish midwives believed any amount of alcohol was associated with risk. Discussing alcohol was viewed as part of the health professional’s role, but routine questions for all women were perceived to aid discussions about alcohol. Future research should further explore the impact of wider social and political environment on midwives’ attitudes around risks with prenatal alcohol use.

PW 0661 Estimating the financial costs of adverse childhood experiences (ACES) in europe

We present findings from a study to estimate the economic costs of adverse childhood experiences (ACEs, e.g. child abuse, neglect, exposure to domestic violence). By utilising international literature on the prevalence of ACEs and their association with increased risk of major health conditions we calculate ACE-attributable fractions for major health conditions and convert these into financial costs for countries using a DALY/GDP based model. Following our recent systematic review and meta-analysis on the health consequences of multiple ACEs, we expanded search criteria to allow calculations of relative risks of key health conditions (e.g. cardiovascular disease, diabetes, mental health disorders, cancers) in adulthood associated with exposure to no, one and two or more ACEs. Searches have retrieved over 3 800 unique studies of which more than 800 have been reviewed to identify data for inclusion in the analysis. From studies that meet the criteria, the most reliable estimates have been extracted for prevalence and health outcome risk estimates. We developed a model to calculate proportionate attributable fractions for each outcome based on retrieved estimates and subsequently estimate the DALYs lost. We use established health economics methods to convert DALYs into annual financial costs to countries. Results of the systematic review and attributable fractions for major health conditions identify that substantive proportions of each major non-communicable disease and other health condition are related to exposure to ACEs in childhood. Such relationships are consistent across a number of countries and suggest high financial costs to countries resulting from a legacy of ACEs. There is a strong and cost effective case for policy changes that invest more in safe and nurturing childhoods in order to reduce long term ill health and overall costs to the public purse.

PW 1787 Sources of childhood and adult resilience and their impact on harms associated with adverse childhood experiences

Background Adverse childhood experiences (ACEs; i.e. child maltreatment, household dysfunction) have wide-reaching impacts and are strong predictors of poor outcomes in adults. However, many individuals who experience ACEs avoid or overcome their associated problems. The factors which effectively promote resilience against ACEs are still largely unknown. Objective This research sought to understand what contributes to an individual’s resilience and how much resilience offers protection from the negative effects of ACEs. Methods A face-to-face household survey was conducted with 2 497 residents aged 18–69 in Wales, United Kingdom, from March-June 2017. The survey explored: exposure to 11 ACEs; access to childhood and adult resilience resources, health-related behaviours and health outcomes. Findings Half of all adults reported at least one ACE, 14% had four or more. ACEs were strongly associated with worse health outcomes, for example, individuals with 4+ACEs were four times more likely to report current mental illness, six times more likely to report lifetime mental illness and over nine times more likely to have ever felt suicidal or self-harmed. Childhood and adulthood resilience were associated with better health outcomes in those both with and without ACEs. Resilience resources associated with lower levels of mental illness included, in childhood: sports participation and having a trusted adult relationship; and as adults: sports/community group participation, enjoying culture/traditions, financial security, and higher perceived support from public services and employers. Conclusion and policy implications ACEs are common and represent a significantly increased risk of poor health across the life-course. Supporting individuals affected by childhood adversity is vital to improve population health. Building resilience can moderate the increased risk to health that ACEs pose. However, resilience resources do not entirely counter ACE-related harms, thus work should be directed at the prevention of ACEs to ensure the provision of positive childhood environments for future generations.

The Europe we want—a Transatlantic Health and Wellbeing Partnership?

‘ A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities …’ Article 152 of the Treaty establishing the European Community 1 Amongst the ten priority policy areas2 for the European Commission (EC) is the negotiation of ‘a reasonable and balanced free trade agreement with the US’-the Transatlantic Trade and Investment Partnership (TTIP). President Juncker has explicitly stated2 that he ‘will not sacrifice Europe’s safety, health, social and data protection standards … on the altar of free trade’. He has also promised2 the ‘jurisdiction of courts in the EU Member States’ not to be ‘limited by special regimes for investor disputes’ and that ‘the rule of law and the principle of equality before the law’ will apply in this context. The proposed TTIP is a comprehensive trade and investment agreement, focusing on European Union (EU)-United States (US) market liberalization. It is about to transform the EU regulatory setting with potentially serious and damaging implications for the public’s health and wellbeing, and healthcare.3 Is the Commission abiding by its own legal commitment to protect health in all its policies and activities? Is President Juncker going to keep his promises? TTIP represents potentially the largest regional free-trade agreement in history, accounting for nearly a half of the world Gross Domestic Product (GDP) and almost a third of world trade flows.4 It is predicted to deliver the EU 0.5% additional GDP growth (€119 billion per year or €545 for an average …