Inequalities in health : social, biological, ethnic and life-course perspectives

There is an unmistakable consistency in differences in risks for morbidity and mortality between social groups. The more advantaged, whether measured in terms of income, education, class, status or ethnicity in general fare better when compared to others, emphasizing the importance of the social environment in determining health in all stages of life. The early stages of life; infancy, childhood, and adolescence are particularly vulnerable – exposures and health in these and later periods of life are dependent on both concurrent social environments and on previous parental life experiences and intergenerational influences. This stresses the need to investigate the development of risk factors and disease across the life course. Affluent and high-income countries are increasingly characterized by widening inequalities in health. Less is known about health differences in ethnic minorities in Sweden compared to similar high- income countries with large immigrant and ethnic minority groups. The importance of intergenerational mechanisms and the psychosocial environment in predicting childhood health was highlighted in studies in this thesis. Children (aged 5-14 years) of parents with lower reported levels of physical activity, higher smoking and alcohol consumption had higher mean BMI and cholesterol levels, independent of parental socioeconomic indicators. Overweight/obese parents also had substantially higher risks for having overweight/obese children (compared to parents of normal BMI, an obese mother had an OR of 4.53 (95% CI 1.98–10.38) for having an overweight/obese child. Similarly, OR for obese fathers was 5.07 (95% CI 2.11–12.20)). Results from studies included in this thesis show that some immigrant groups are at higher risk for health outcomes seen in different stages of the life course. Immigrant parents from Poland, Yugoslavia, Iran, South Asia, East Asia and Sub-Saharan Africa had higher risk for early preterm birth (adjusted RR (95% CI) 1.76, (1.24-2.50), 1.57, (1.31-1.87), 1.67, (1.30-2.14), 1.52, (1.07-2.16), 1.51, (1.08-2.10) and 2.03, (1.32-3.12)) respectively). South Asian, Sub-Saharan African and East Asian immigrant groups had a higher risk for late preterm birth (adjusted RR 1.62 (1.42-1.84), 1.31 (1.08-1.60) and 1.20 (1.06-1.36) respectively). North African/Middle eastern, Somali, and Ethiopian/Eritrean groups had increased RR for postterm birth (adjusted RR 1.31, (1.16-1.47), 2.57 (2.31-2.86), 1.85 (1.67-2.04) respectively). Children aged 4-5 years old, with immigrant parents from Turkey, North Africa, Iran and South America had a higher risk for overweight or obesity compared to children of Swedish born parents. In both studies, socioeconomic indicators did not explain the observed increased risk for either non-term birth or overweight/obesity indicating that other factors that constitute ethnicity may play a role. On the other hand, young Swedish males (ages 18 years) of immigrant parents had lower systolic blood pressure when compared to ethnic Swedish males. The established inverse association between foetal growth and adulthood blood pressure while observed in European-origin men was not seen in non-Europeans. While evidence exists to support that certain ethnic groups suffer disproportionately in risk for some of the adverse health outcomes studied in this thesis, there is also an indication that some ethnic groups are protected from the same. Contrary to expectation, variation in socioeconomic indicators did not explain the observed differences in risk. More studies are needed to understand these observed differences in health and guide better public health intervention for reducing inequalities seen in ethnic minorities

Adverse childhood experiences and the development of multimorbidity across adulthood—a national 70-year cohort study

AIM: To examine impact of adverse childhood experiences (ACE) on rates and development of multimorbidity across three decades in adulthood. METHODS: Sample: Participants from the 1946 National Survey of Health and Development, who attended the age 36 assessment in 1982 and follow-up assessments (ages 43, 53, 63, 69; N = 3,264, 51% males). Prospectively collected data on nine ACEs was grouped into (i) psychosocial, (ii) parental health and (iii) childhood health. For each group, we calculated cumulative ACE scores, categorised into 0, 1 and ≥2 ACEs. Multimorbidity was estimated as the total score of 18 health disorders.Serial cross-sectional linear regression was used to estimate associations between grouped ACEs and multimorbidity during follow-up. Longitudinal analysis of ACE-associated changes in multimorbidity trajectories across follow-up was estimated using linear mixed-effects modelling for ACE groups (adjusted for sex and childhood socioeconomic circumstances). FINDINGS: Accumulation of psychosocial and childhood health ACEs were associated with progressively higher multimorbidity scores throughout follow-up. For example, those with ≥2 psychosocial ACEs experienced 0.20(95% CI 0.07, 0.34) more disorders at age 36 than those with none, rising to 0.61(0.18, 1.04) disorders at age 69.All three grouped ACEs were associated with greater rates of accumulation and higher multimorbidity trajectories across adulthood. For example, individuals with ≥2 psychosocial ACEs developed 0.13(-0.09, 0.34) more disorders between ages 36 and 43, 0.29(0.06, 0.52) disorders between ages 53 and 63, and 0.30(0.09, 0.52) disorders between ages 63 and 69 compared with no psychosocial ACEs. INTERPRETATIONS: ACEs are associated with widening inequalities in multimorbidity development in adulthood and early old age. Public health policies should aim to reduce these disparities through individual and population-level interventions

Diabetic Ketoacidosis Severity at Diagnosis and Glycaemic Control in the First Year of Childhood Onset Type 1 DiabetesA Longitudinal Cohort Study

It is unclear whether diabetic ketoacidosis (DKA) severity at diagnosis affects the natural history of type 1 diabetes (T1D). We analysed associations between DKA severity at diagnosis and glycaemic control during the first year post-diagnosis. We followed 341 children with T1D, <19 years (64% non-white) attending paediatric diabetes clinics in East London. Data were extracted from routine medical registers. Subjects were categorized with normal, mild, moderate, or severe DKA. Linear mixed-effects modelling was used to assess differences in longitudinal HbA1c trajectories (glycaemic control) during 12 months post-diagnosis (1288 HbA1c data-points) based on DKA, adjusting for sex, age, ethnicity, SES (Socioeconomic Status) and treatment type. Females (OR 1.6, 95% CI 1.1–2.4) and younger age, 0–6 vs. 13–18 years (OR 2.9, 95% CI 1.5–5.6) had increased risk for DKA at diagnosis. Moderate or severe DKA was associated with higher HbA1c at diagnosis (adjusted estimates 8 mmol/mol, 2–14, and 10 mmol/mol, 4–15, respectively, compared to normal DKA). Differences in HbA1c trajectories by DKA were no longer apparent at six months post-diagnosis. All subjects experienced a steep decrease in HbA1c during the first three months followed by a gradual increase. While, DKA severity was not associated with glycaemic control at 12 months post-diagnosis, age at diagnosis, ethnicity, gender, and treatment type were significantly associated. For example, Black and mixed ethnicity children had increased risk for poor glycaemic control compared to White children (adjusted RRR 5.4, 95% CI 1.7–17.3 and RRR 2.5, 95% CI 1.2–6.0, respectively). DKA severity at diagnosis is associated with higher initial HbA1c but not glycaemic control from six months post-diagnosis. Age at diagnosis, ethnicity, gender, and insulin pump are associated with glycaemic control at one year post-diagnosis

Ethnic differences in early glycemic control in childhood-onset type 1 diabetes

Some ethnic minorities with type 1 diabetes (T1D) have worse glycemic control (higher glycated hemoglobin (HbA1c)) and increased risk for vascular complications. There is limited evidence on the impact of ethnicity on early glycemic control when most patients experience transient remission postdiagnosis. We examined associations between ethnicity and longitudinal HbA1c trajectories during the first 6 months postdiagnosis in a multiethnic cohort in East London. RESEARCH DESIGN AND METHODS: Data on 443 (50% female) children <19 years of age, with T1D and attending one of three clinics in East London between January 2005 and December 2015 were included. Linear mixed-effects modeling was used to assess ethnic differences in longitudinal HbA1c trajectories during the first 6 months postdiagnosis (1,028 HbA1c data points), adjusting for sex, age at diagnosis, socioeconomic status and pH at diagnosis. Growth curve modeling was used to plot discrete HbA1c trajectories by ethnicity. RESULTS: Longitudinal modeling revealed that all ethnic minorities had higher mean HbA1c at diagnosis compared with White children and highest in Bangladeshi (9.7 mmol/mol, 95% CI 5.1 to 14.3), Asian-Other (5.8 mmol/mol, 95% CI 2.2 to 9.3) and Somali (5.2 mmol/mol, 95% CI 0.1 to 10.2) children, and these differences persisted over the 6-month period after diagnosis. During the first month, HbA1c decreased on average by 19.6 mmol/mol (95% CI -21 to -18) for all children. Population averaged HbA1c decreased between diagnosis and 4 months, followed by a gradual increase in HbA1c levels (mean difference of -30 mmol/mol between diagnosis and 6 months). CONCLUSIONS: Ethnic minorities present with higher HbA1c at diagnosis, with the largest mean differences observed in Bangladeshi, Asian-Other and Somali children. These higher levels (indicating poorer glycemic control) track into the first 6 months postdiagnosis

Inequalities in glycemic control in childhood onset type 2 diabetes in England and Wales—A national population-based longitudinal study

Background Not much is known about glycaemic‐control trajectories in childhood‐onset type 2 diabetes (T2D). We investigated characteristics of children and young people (CYP) with T2D and inequalities in glycemic control. Methods We studied 747 CYP with T2D, 95% diabetes cases in England/Wales]). Linear mixed‐effects modeling was used to assess socioeconomic and ethnic differences in longitudinal glycated hemoglobin (HbA1c) trajectories during 4 years post‐diagnosis (3326 HbA1c data points, mean 4.5 data points/subject). Self‐identified ethnicity was grouped into six categories. Index of Multiple Deprivation (a small geographical area‐level deprivation measure) was grouped into SES quintiles for analysis. Results Fifty‐eight percent were non‐White, 66% were female, and 41% were in the most disadvantaged SES quintile. Mean age and HbA1c at diagnosis were 13.4 years and 68 mmol/mol, respectively. Following an initial decrease between diagnosis and end of year 1 (−15.2 mmol/mol 95%CI, −19.2, −11.2), HbA1c trajectories increased between years 1 and 3 (10 mmol/mol, 7.6, 12.4), followed by slight gradual decrease subsequently (−1.6 mmol/mol, −2, −1.1). Compared to White CYP, Pakistani children had higher HbA1c at diagnosis (13.2 mmol/mol, 5.6‐20.9). During follow‐up, mixed‐ethnicity and Pakistani CYP had poorer glycemic control. Compared to children in the most disadvantaged quintile, those in the most advantaged had lower HbA1c at diagnosis (−6.3 mmol, −12.6, −0.1). Differences by SES remained during follow‐up. Mutual adjustment for SES and ethnicity did not substantially alter the above estimates. Conclusions About two‐thirds of children with childhood‐onset T2D were non‐White, female adolescents, just under half of whom live in the most disadvantaged areas of England and Wales. Additionally, there are substantial socioeconomic and ethnic inequalities in diabetes control

Sexual minority health inequalities — why are we unable to do more?

Sexual and gender minority (SGM) individuals report worse mental and physical health compared to heterosexual and cisgender peers. Growing evidence, positive legislation and interventions have helped reduce sexual and gender-related discrimination. Nevertheless, a lack of SGM relevant data and research infrastructure impedes development in this research area

Socioeconomic inequalities in co-morbidity of overweight, obesity and mental ill-health from adolescence to mid-adulthood in two national birth cohort studies

Aim: To examine socioeconomic inequalities in comorbidity risk for overweight (including obesity) and mental ill-health in two national cohorts. We investigated independent effects of childhood and adulthood socioeconomic disadvantage on comorbidity from childhood to mid-adulthood, and differences by sex and cohort. Methods: Data were from 1958 National Child Development Study (NCDS58) and 1970 British Cohort Study (BCS70) [total N=30,868, 51% males] assessed at ages 10, 16, 23/26, 34 and 42 years. Socioeconomic indicators included childhood and adulthood social class and educational level. Risk for i. having healthy BMI and mental ill-health, ii. overweight and good mental health, and iii. overweight and mental ill-health was analysed using multinomial logistic regression. Findings: Socioeconomic disadvantage was consistently associated with greater risk for overweight-mental ill-health comorbidity at all ages (RRR 1.43, 2.04, 2.38, 1.64 and 1.71 at ages 10, 16, 23, 34 and 42 respectively for unskilled/skilled vs. professional/managerial class). The observed inequalities in co-morbidity were greater than those observed for either condition alone (overweight; RRR 1.39 and 1.25, mental ill-health; 1.36 and 1.22 at ages 16 and 42 respectively, for unskilled/skilled vs. professional/managerial class). In adulthood, both childhood and adulthood socioeconomic disadvantage were independently associated with comorbid overweight-mental ill-health, with a clear inverse gradient between educational level and risk for comorbidity. For instance, for the no education group (compared to university education) the RRR is 6.11 (95% CI 4.31-8.65) at age 34 and 4.42 (3.28-5.96) at age 42. There were no differences observed in the extent of inequalities by sex and differences between cohorts were limited. Interpretation: While socioeconomic disadvantage in childhood and adulthood are consistently and independently associated with greater risk for mental ill-health and being overweight separately, these associations are even larger for their comorbidity across the lifecourse. These findings are significant given the increasing global prevalence of obesity and mental ill-health, and their implications for lifelong health and mortality. Funding: This research was supported by grants from the Wellcome Trust (ISSF3/ H17RCO/NG1) and Medical Research Council (MRC) [MC_UU_00019/3]

Parental influences on cardiovascular risk factors in Swedish children aged 5-14 years

Background: Precursors of cardiovascular diseases (CVD) originate in childhood. We investigated relationships of children’s CVD risk factors with parent’s socio-economic position (SEP) and lifestyle and how CVD risk factors correlate within families. Methods: We studied 602 families with 2141 individuals comprising two full sibs; aged 5–14 years, and their biological parents (Uppsala Family Study). Parental SEP (occupational class and education) and lifestyle habits [smoking, physical activity (PA), alcohol consumption] were taken from questionnaires. Associations with cholesterol, ApoB/ApoA1, leptin, adiponectin, blood pressure, body mass index (BMI) and overweight/obesity (OW/OB) were analysed by linear/logistic regression. Results were adjusted for child’s age, gender, pubertal stage and family clustering. Results: We observed no consistent associations between parental SEP and children’s CVD risk factors. Parental lifestyle had stronger effects, independent of parental SEP. Children of smoking fathers had higher BMI (4%, 95 % CI 1–7%) and leptin levels (27%, 95 % CI 1.00–61.60%). Children of mothers reporting vigorous PA had lower BMI, cholesterol and decreased odds for OW/OB with a possible dose effect. Compared with mothers reporting no vigorous activity, mothers with 75min and 76–150min/week of vigorous activity had 43 % (OR 0.57, 95 % CI 0.22–0.89) and 72 % (OR 0.28, 95 % CI 0.14–0.60) lower risk of having an OW/OB child, respectively, after adjustment fo

Supplemental Material - Adverse childhood experiences and mental ill-health - obesity comorbidity among British adolescents – A national cohort study

Supplemental Material for Adverse childhood experiences and mental ill-health - obesity comorbidity among British adolescents – A national cohort study by Alexis Karamanos and Amal R. Khanolkar in Journal of Multimorbidity and Comorbidity</p

Health and health-related behaviours in refugees and migrants who self-identify as sexual or gender minority – A National population-based study in Sweden

BACKGROUND: To examine health and health-related behaviors in migrant and refugee individuals who identify as sexual or gender minority, and in comparison to their heterosexual peers. METHODS: The study included 168,952 individuals (aged 16–84 years, males: 45·9%, sexual or gender minorities: 3·1%) who answered the Swedish National Public Health Survey in 2018 and 2020. Participants were grouped into Swedish-and Western-born (White) heterosexual, White sexual- or gender minority, migrant heterosexual, migrant sexual- or gender minority, refugee heterosexual, and refugee sexual- or gender minority. Outcomes included mental health (for example suicidal ideation, wellbeing), general health, risky behaviors (risk alcohol use, risk gambling, and substance use), and experiences of violence. Associations between 1) sexual- or gender -ethnic identities and 2) gender-ethnic identities and all outcomes were analyzed using logistic and linear regression adjusting for sex, age, and educational level. FINDINGS: Being a sexual- or gender minority, regardless of ethnic minority status, was associated with worse general health and mental ill-health compared to heterosexual peers including suicidal ideation in refugee sexual- or gender minority individuals (OR 2·42, 95 % CI 1·44–4·08). Ethnic minorities (heterosexual and sexual- or gender minority migrants and refugees) had lower odds of drug and risk alcohol use compared to White heterosexual peers but higher odds of risk gambling (1·88, 1·49–2·37 for refugee heterosexuals). Transgender refugees had high odds for risk gambling (8·62, 1·94–38·40) and exposure to physical violence (7·46, 2·97–18·70). INTERPRETATION: In this national population-based study, sexual and gender minority individuals have worse mental and general health regardless of ethnic minority status. We did not find evidence for worse health in sexual- or gender minority refugees in comparison to migrant, and White sexual- or gender minorities and their heterosexual peers. Transgender individuals (White and ethnic minority) experienced significantly higher levels of physical violence. Public health policy should emphasize preventive measures to reduce exposure to violence and discrimination in sexual- and gender minority individuals, increase access and use of mental healthcare services and sensitise healthcare professionals about higher rates of health and related issues faced by sexual- and gender minority individuals including those with multiple minority identities. FUNDING: We received no external funding for this study and hence the funder had no role in the study design, data collection, data analysis, data interpretation, writing of the manuscript and the decision to submit