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1.  Wealth and mortality at older ages: a prospective cohort study 
Despite the importance of socioeconomic position for survival, total wealth, which is a measure of accumulation of assets over the life course, has been underinvestigated as a predictor of mortality. We investigated the association between total wealth and mortality at older ages.
We estimated Cox proportional hazards models using a sample of 10 305 community-dwelling individuals aged ≥50 years from the English Longitudinal Study of Ageing.
2401 deaths were observed over a mean follow-up of 9.4 years. Among participants aged 50–64 years, the fully adjusted HRs for mortality were 1.21 (95% CI 0.92 to 1.59) and 1.77 (1.35 to 2.33) for those in the intermediate and lowest wealth tertiles, respectively, compared with those in the highest wealth tertile. The respective HRs were 2.54 (1.27 to 5.09) and 3.73 (1.86 to 7.45) for cardiovascular mortality and 1.36 (0.76 to 2.42) and 2.53 (1.45 to 4.41) for other non-cancer mortality. Wealth was not associated with cancer mortality in the fully adjusted model. Similar but less strong associations were observed among participants aged ≥65 years. The use of repeated measurements of wealth and covariates brought about only minor changes, except for the association between wealth and cardiovascular mortality, which became less strong in the younger participants. Wealth explained the associations between paternal occupation at age 14 years, education, occupational class, and income and mortality.
There are persisting wealth inequalities in mortality at older ages, which only partially are explained by established risk factors. Wealth appears to be more strongly associated with mortality than other socioeconomic position measures.
PMCID: PMC4819652  PMID: 26511887
2.  Is the association between depressive symptoms and glucose metabolism bidirectional? Evidence from the English Longitudinal Study of Ageing (ELSA) 
Psychosomatic medicine  2014;76(7):555-561.
To examine whether the prospective association between depressive symptoms and glucose metabolism is bidirectional.
We used a national sample of 4,238 community-dwelling individuals aged ≥50 years from the English Longitudinal Study of Ageing. Participants were categorized into normoglycemic, impaired glucose metabolism (IGM), and undiagnosed and diagnosed diabetes using HbA1c and self-reported doctor diagnosis. Subthreshold and elevated depressive symptoms were defined by a score between 2 and 3 and ≥4, respectively, on the 8-item Center for Epidemiological Studies-Depression scale.
In the age-adjusted model, categories of depressive symptoms were associated with incident undiagnosed (OR 1.54, 95% CI 0.86 to 2.73 and OR 1.91, 95% CI 1.03 to 3.57 for subthreshold and elevated depressive symptoms, respectively) and diagnosed diabetes (OR 1.53, 95% CI 0.80 to 2.93 and OR 3.03, 95% CI 1.66 to 5.54, respectively) over six years of follow-up. The latter association remained significant after adjustment for covariates. Depressive symptoms were not associated with future IGM. Diagnosed diabetes was associated with future elevated depressive symptoms in participants aged 52 to 64 years (OR 2.17, 95% CI 1.33 to 3.56), but not those aged 65 years and older (OR 0.96, 95% CI 0.59 to 1.57) over four years of follow-up. Adjustment for covariates partially explained this association. IGM and undiagnosed diabetes were not associated with subsequent elevated depressive symptoms.
These data suggest that there is a bidirectional association between depressive symptoms and diagnosed diabetes in people aged 52 to 64 years, but not people aged 65 years and older.
PMCID: PMC4458700  PMID: 25077428
depressive symptoms; type 2 diabetes; glucose metabolism; prospective study; older adults
3.  English Longitudinal Study of Aging: Can Internet/E-mail Use Reduce Cognitive Decline? 
Cognitive decline is a major risk factor for disability, dementia, and death. The use of Internet/E-mail, also known as digital literacy, might decrease dementia incidence among the older population. The aim was to investigate whether digital literacy might be associated with decreased cognitive decline in older adulthood.
Data from the English Longitudinal Study of Aging cohort with 6,442 participants aged 50–89 years, followed for 8 years, with baseline cognitive testing and four additional time points. The main outcome variable was the relative percentage change in delayed recall from a 10-word-list learning task across five separate measurement points. In addition to digital literacy, socioeconomic variables, including wealth and education, comorbidities, and baseline cognitive function were included in predictive models. The analysis used Generalized Estimating Equations.
Higher education, no functional impairment, fewer depressive symptoms, no diabetes, and Internet/E-mail use predicted better performance in delayed recall.
Digital literacy may help reduce cognitive decline among persons aged between 50 and 89 years.
PMCID: PMC4202262  PMID: 25116923
Cognitive decline; Prevention; Digital literacy; Cohort study; Ageing.
4.  Is Social Capital a Determinant of Oral Health among Older Adults? Findings from the English Longitudinal Study of Ageing 
PLoS ONE  2015;10(5):e0125557.
There are a number of studies linking social capital to oral health among older adults, although the evidence base mainly relies on cross-sectional study designs. The possibility of reverse causality is seldom discussed, even though oral health problems could potentially lead to lower social participation. Furthermore, few studies clearly distinguish between the effects of different dimensions of social capital on oral health. The objective of the study was to examine the longitudinal associations between individual social capital and oral health among older adults. We analyzed longitudinal data from the 3rd and 5th waves of the English Longitudinal Study of Ageing (ELSA). Structural social capital was operationalized using measures of social participation, and volunteering. Number of close ties and perceived emotional support comprised the functional dimension of social capital. Oral health measures were having no natural teeth (edentate vs. dentate), self-rated oral health and oral health-related quality of life. Time-lag and autoregressive models were used to explore the longitudinal associations between social capital and oral health. We imputed all missing data, using multivariate imputation by chained equations. We found evidence of bi-directional longitudinal associations between self-rated oral health, volunteering and functional social capital. Functional social capital was a strong predictor of change in oral health-related quality of life – the adjusted odds ratio of reporting poor oral health-related quality of life was 1.75 (1.33–2.30) for older adults with low vs. high social support. However in the reverse direction, poor oral health-related quality of life was not associated with changes in social capital. This suggests that oral health may not be a determinant of social capital. In conclusion, social capital may be a determinant of subjective oral health among older adults rather than edentulousness, despite many cross-sectional studies on the latter.
PMCID: PMC4436243  PMID: 25992569
5.  Impaired Glucose Metabolism among Those with and without Diagnosed Diabetes and Mortality: A Cohort Study Using Health Survey for England Data 
PLoS ONE  2015;10(3):e0119882.
The extent that controlled diabetes impacts upon mortality, compared with uncontrolled diabetes, and how pre-diabetes alters mortality risk remain issues requiring clarification.
We carried out a cohort study of 22,106 Health Survey for England participants with a HbA1C measurement linked with UK mortality records. We estimated hazard ratios (HRs) of all-cause, cancer and cardiovascular disease (CVD) mortality and 95% confidence intervals (CI) using Cox regression.
Average follow-up time was seven years and there were 1,509 deaths within the sample. Compared with the non-diabetic and normoglycaemic group (HbA1C <5.7% [<39mmol/mol] and did not indicate diabetes), undiagnosed diabetes (HbA1C ≥6.5% [≥48mmol/mol] and did not indicate diabetes) inferred an increased risk of mortality for all-causes (HR 1.40, 1.09–1.80) and CVD (1.99, 1.35–2.94), as did uncontrolled diabetes (diagnosed diabetes and HbA1C ≥6.5% [≥48mmol/mol]) and diabetes with moderately raised HbA1C (diagnosed diabetes and HbA1C 5.7-<6.5% [39-<48mmol/mol]). Those with controlled diabetes (diagnosed diabetes and HbA<5.7% [<39mmol/mol]) had an increased HR in relation to mortality from CVD only. Pre-diabetes (those who did not indicate diagnosed diabetes and HbA1C 5.7-<6.5% [39-<48mmol/mol]) was not associated with increased mortality, and raised HbA1C did not appear to have a statistically significant impact upon cancer mortality. Adjustment for BMI and socioeconomic status had a limited impact upon our results. We also found women had a higher all-cause and CVD mortality risk compared with men.
We found higher rates of all-cause and CVD mortality among those with raised HbA1C, but not for those with pre-diabetes, compared with those without diabetes. This excess differed by sex and diabetes status. The large number of deaths from cancer and CVD globally suggests that controlling blood glucose levels and policies to prevent hyperglycaemia should be considered public health priorities.
PMCID: PMC4365017  PMID: 25785731
6.  Enjoyment of life and declining physical function at older ages: a longitudinal cohort study 
Positive affective well-being (i.e., feelings of happiness and enjoyment) has been associated with longer survival and reduced incidence of serious illness. Our objective was to discover whether enjoyment of life also predicted a reduced risk of functional impairment over an 8-year period in a large population sample.
We carried out a prospective analysis involving 3199 men and women aged 60 years or older from the English Longitudinal Study of Ageing. Enjoyment of life was assessed by questionnaire. Outcomes were impairment in 2 or more activities of daily living and changes in gait speed on a walking test. Covariates included sociodemographic factors, baseline health, depressive symptoms, impairment of mobility and health behaviours.
Two or more impaired activities of daily living developed among 4.4%, 11.7% and 16.8% of participants in the high, medium and low enjoyment-of-life tertiles, respectively. After adjustment for covariates, the odds of impaired activities of daily living developing were 1.83 (95% confidence interval 1.13–2.96) in the low compared with high tertile. Gait speed after 8 years was also related to baseline enjoyment of life after adjustment for gait speed and other covariates at baseline (p < 0.001). We obtained similar results when we limited analyses to participants younger than 70 years at baseline.
This is an observational study, so causal conclusions cannot be drawn. But our results provide evidence that reduced enjoyment of life may be related to the future disability and mobility of older people.
PMCID: PMC3940591  PMID: 24446463
7.  Perceived age discrimination in older adults 
Age and Ageing  2013;43(3):379-386.
Objectives: to examine perceived age discrimination in a large representative sample of older adults in England.
Methods: this cross-sectional study of over 7,500 individuals used data from the fifth wave of the English Longitudinal Study of Ageing (ELSA), a longitudinal cohort study of men and women aged 52 years and older in England. Wave 5 asked respondents about the frequency of five everyday discriminatory situations. Participants who attributed any experiences of discrimination to their age were treated as cases of perceived age discrimination. Multivariable logistic regression analysis was used to estimate the odds ratios of experiencing perceived age discrimination in relation to selected sociodemographic factors.
Results: approximately a third (33.3%) of all respondents experienced age discrimination, rising to 36.8% in those aged 65 and over. Perceived age discrimination was associated with older age, higher education, lower levels of household wealth and being retired or not in employment. The correlates of age discrimination across the five discriminatory situations were similar.
Conclusion: understanding age discrimination is vital if we are to develop appropriate policies and to target future interventions effectively. These findings highlight the scale of the challenge of age discrimination for older adults in England and illustrate that those groups are particularly vulnerable to this form of discrimination.
PMCID: PMC4081784  PMID: 24077751
discrimination; ageing; ageism; ELSA; England; older adults
8.  The English Longitudinal Study of Ageing (ELSA): Depressive symptoms and physical performance 
BMC Proceedings  2013;7(Suppl 4):S8.
PMCID: PMC3892679  PMID: 24899926
9.  The Bidirectional Association between Depressive Symptoms and Gait Speed: Evidence from the English Longitudinal Study of Ageing (ELSA) 
PLoS ONE  2013;8(7):e68632.
Depressive symptoms and physical performance are inversely associated, but it is unclear whether their association is bidirectional. We examined whether the association between depressive symptoms and physical performance measured using gait speed is bidirectional.
We used a national sample of 4,581 community-dwelling people aged 60 years and older from the English Longitudinal Study of Ageing (from 2002–03 to 2008-09). We fitted Generalized Estimating Equation (GEE) regression models to analyse repeated measurements of gait speed (m/sec) and elevated depressive symptoms (defined as a score of ≥4 on the eight-item Center for Epidemiological Studies-Depression scale).
Slower gait speed was associated with elevated depressive symptoms both concurrently and two years later. After adjustment for previous depressive symptoms and sociodemographic, clinical, lifestyle, psychosocial, and cognitive factors the concurrent association was partially explained (Odds Ratio [OR] 0.42, 95% confidence interval [CI], 0.30 to 0.59, per 1m/sec increase in gait speed) and the two-year lagged association fully (OR 0.75, 95% CI, 0.56 to 1.00). Elevated depressive symptoms were associated with slower gait speed. Full adjustment for covariates (including previous gait speed) partially explained both the concurrent (β regression coefficient [β] -0.038, 95% CI, -0.050 to -0.026, for participants with elevated depressive symptoms compared with those with no or one symptom) and the two-year lagged associations (β -0.017, 95% CI, -0.030 to -0.005). Subthreshold depressive symptoms (defined as a score of two or three on the eight-item Center for Epidemiological Studies-Depression scale) were also associated with slower gait speed. Full adjustment for covariates partially explained both the concurrent (β -0.029, 95% CI, -0.039 to -0.019, for participants with subthreshold symptoms compared with those with no or one symptom) and the two-year lagged associations (β -0.011, 95% CI, -0.021 to -0.001).
The inverse association between gait speed and depressive symptoms appears to be bidirectional.
PMCID: PMC3706406  PMID: 23874698
10.  Body Mass Index, Muscle Strength and Physical Performance in Older Adults from Eight Cohort Studies: The HALCyon Programme 
PLoS ONE  2013;8(2):e56483.
To investigate the associations of body mass index (BMI) and grip strength with objective measures of physical performance (chair rise time, walking speed and balance) including an assessment of sex differences and non-linearity.
Cross-sectional data from eight UK cohort studies (total N = 16 444) participating in the Healthy Ageing across the Life Course (HALCyon) research programme, ranging in age from 50 to 90+ years at the time of physical capability assessment, were used. Regression models were fitted within each study and meta-analysis methods used to pool regression coefficients across studies and to assess the extent of heterogeneity between studies.
Higher BMI was associated with poorer performance on chair rise (N = 10 773), walking speed (N = 9 761) and standing balance (N = 13 921) tests. Higher BMI was associated with stronger grip strength in men only. Stronger grip strength was associated with better performance on all tests with a tendency for the associations to be stronger in women than men; for example, walking speed was higher by 0.43 cm/s (0.14, 0.71) more per kg in women than men. Both BMI and grip strength remained independently related with performance after mutual adjustment, but there was no evidence of effect modification. Both BMI and grip strength exhibited non-linear relations with performance; those in the lowest fifth of grip strength and highest fifth of BMI having particularly poor performance. Findings were similar when waist circumference was examined in place of BMI.
Older men and women with weak muscle strength and high BMI have considerably poorer performance than others and associations were observed even in the youngest cohort (age 53). Although causality cannot be inferred from observational cross-sectional studies, our findings suggest the likely benefit of early assessment and interventions to reduce fat mass and improve muscle strength in the prevention of future functional limitations.
PMCID: PMC3577921  PMID: 23437142
11.  Age and Gender Differences in Physical Capability Levels from Mid-Life Onwards: The Harmonisation and Meta-Analysis of Data from Eight UK Cohort Studies 
PLoS ONE  2011;6(11):e27899.
Using data from eight UK cohorts participating in the Healthy Ageing across the Life Course (HALCyon) research programme, with ages at physical capability assessment ranging from 50 to 90+ years, we harmonised data on objective measures of physical capability (i.e. grip strength, chair rising ability, walking speed, timed get up and go, and standing balance performance) and investigated the cross-sectional age and gender differences in these measures. Levels of physical capability were generally lower in study participants of older ages, and men performed better than women (for example, results from meta-analyses (N = 14,213 (5 studies)), found that men had 12.62 kg (11.34, 13.90) higher grip strength than women after adjustment for age and body size), although for walking speed, this gender difference was attenuated after adjustment for body size. There was also evidence that the gender difference in grip strength diminished with increasing age,whereas the gender difference in walking speed widened (p<0.01 for interactions between age and gender in both cases). This study highlights not only the presence of age and gender differences in objective measures of physical capability but provides a demonstration that harmonisation of data from several large cohort studies is possible. These harmonised data are now being used within HALCyon to understand the lifetime social and biological determinants of physical capability and its changes with age.
PMCID: PMC3218057  PMID: 22114723
12.  Depressive Symptoms and Risk of Type 2 Diabetes in a National Sample of Middle-Aged and Older Adults 
Diabetes Care  2010;33(4):792-797.
To examine the association between baseline elevated depressive symptoms and incident type 2 diabetes in a national sample of people aged ≥50 years.
The sample consisted of 6,111 individuals free from self-reported doctor-diagnosed diabetes at baseline in 2002–2003. The eight-item Center for Epidemiological Studies–Depression (CES-D) scale was the measurement of depressive symptoms. Cox proportional hazards regression models were used to assess whether baseline elevated (≥4) depressive symptoms were associated with a higher risk of type 2 diabetes over 45.8 months of follow-up.
The hazard ratio (HR) for diabetes was 1.62 (95% CI 1.15–2.29) in a model adjusted for age, sex, marital status, education, total net household wealth, cardiovascular and psychiatric and other noncardiovascular comorbidities, BMI, and health behaviors for participants with elevated CES-D symptoms compared with those without. Complementary analysis performed for a subsample (n = 5,090) showed that additional adjustment of this model for use of antidepressants did not explain the association (HR 1.58, 95% CI 1.09–2.29).
Elevated depressive symptoms were associated with a higher risk of developing type 2 diabetes after accounting for sociodemographic, lifestyle, and clinical factors in a national sample of people aged ≥50 years.
PMCID: PMC2845029  PMID: 20086253
13.  Childhood Socioeconomic Position and Objectively Measured Physical Capability Levels in Adulthood: A Systematic Review and Meta-Analysis 
PLoS ONE  2011;6(1):e15564.
Grip strength, walking speed, chair rising and standing balance time are objective measures of physical capability that characterise current health and predict survival in older populations. Socioeconomic position (SEP) in childhood may influence the peak level of physical capability achieved in early adulthood, thereby affecting levels in later adulthood. We have undertaken a systematic review with meta-analyses to test the hypothesis that adverse childhood SEP is associated with lower levels of objectively measured physical capability in adulthood.
Methods and Findings
Relevant studies published by May 2010 were identified through literature searches using EMBASE and MEDLINE. Unpublished results were obtained from study investigators. Results were provided by all study investigators in a standard format and pooled using random-effects meta-analyses. 19 studies were included in the review. Total sample sizes in meta-analyses ranged from N = 17,215 for chair rise time to N = 1,061,855 for grip strength. Although heterogeneity was detected, there was consistent evidence in age adjusted models that lower childhood SEP was associated with modest reductions in physical capability levels in adulthood: comparing the lowest with the highest childhood SEP there was a reduction in grip strength of 0.13 standard deviations (95% CI: 0.06, 0.21), a reduction in mean walking speed of 0.07 m/s (0.05, 0.10), an increase in mean chair rise time of 6% (4%, 8%) and an odds ratio of an inability to balance for 5s of 1.26 (1.02, 1.55). Adjustment for the potential mediating factors, adult SEP and body size attenuated associations greatly. However, despite this attenuation, for walking speed and chair rise time, there was still evidence of moderate associations.
Policies targeting socioeconomic inequalities in childhood may have additional benefits in promoting the maintenance of independence in later life.
PMCID: PMC3027621  PMID: 21297868
14.  Socioeconomic status and health: the role of subjective social status 
Social science & medicine (1982)  2008;67(2):330-340.
Studies have suggested that subjective social status (SSS) is an important predictor of health. This study examined the link between SSS and health in old age and investigated whether SSS mediated the associations between objective indicators of socioeconomic status and health. It used cross-sectional data from the second wave (2004–05) of the English Longitudinal Study of Ageing, which were collected through personal interviews and nurse visits. The study population consisted of 3368 men and 4065 women aged 52 years or older. The outcome measures included: self-rated health, long-standing illness, depression, hypertension, diabetes, central obesity, high-density lipoprotein cholesterol, triglycerides, fibrinogen, and C-reactive protein. The main independent variable was SSS measured using a scale representing a 10-rung ladder. Wealth, education, and occupational class were employed as covariates along with age and marital status and also, in additional analyses, as the main independent variables. Gender-specific logistic and linear regression analyses were performed. In age-adjusted analyses SSS was related positively to almost all health outcomes. Many of these relationships remained significant after adjustment for covariates. In men, SSS was significantly (p≤0.05) related to self-rated health, depression, and long-standing illness after adjustment for all covariates, while its association with fibrinogen became non-significant. In women, after adjusting for all covariates, SSS was significantly associated with self-rated health, depression, long-standing illness, diabetes, and high-density lipoprotein cholesterol, but its associations with central obesity and C-reactive protein became non-significant. Further analysis suggested that SSS mediated fully or partially the associations between education, occupational class and self-reported and clinical health measures. On the contrary, SSS did not mediate wealth’s associations with the outcome measures, except those with self-reported health measures. Our results suggest that SSS is an important correlate of health in old age, possibly because of its ability to epitomize life-time achievement and socioeconomic status.
PMCID: PMC2547480  PMID: 18440111
subjective social status; health inequalities; education; wealth; UK; occupational class; old age
15.  The health related quality of life of the employees in the Greek hospitals: assessing how healthy are the health workers 
The main aim of the study was to assess the health status and health related quality of life of the personnel of the Hellenic Network of Health Promotion Hospitals. The instrument used was SF-36. An additional aim was to contribute to the validation of the SF-36.
The study instrument was administered to 347 randomly selected employees from seven hospitals within major Athens area. Completed questionnaire were obtained by 292 employees. The statistical significance of the observed differences was tested with parametric (t-test and ANOVA) and non-parametric tests (Mann-Whitney and Kruskall-Wallis). Also, since the Greek national norms have not been published yet, the mean scores on all eight SF-36 dimensions of this study were compared with the U.S and several European national norms just to assess the extent to what there are significant differences between a Greek healthy population and the general populations of several other countries.
Medical doctors and technical personnel (mostly engineers) reported better health status than nurses and administrative and auxiliary personnel; women reported poorer health status than men on all eight SF-36 dimensions; younger employees reported poorer health status than their older counterpartners. Moreover the mean scores on all SF-36 dimensions reported by the participants on this study were considerably lower than the U.S and many European national norms. Also the study results constitute an indication of the SF-36 construct validity.
The findings of this study show that there are major and intense health inequalities among the employees in Greek hospitals.
PMCID: PMC269998  PMID: 14613561
health related quality of life; Greece; hospitals; health inequalities; occupational health

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