Harsh socio-economic conditions affect the genetic health of children

Environmental health practitioners, particularly those who studied and qualified in the last twenty years, will be very familiar with Margaret Whitehead and Göran Dahlgren’s model of the social determinants of health, shown below in the well-known model from their 1991 publication.

Social determinants of health - Dahlgren and Whitehead 1991

Environmental health as a profession works at the interfaces between, generally, people’s living and working conditions and their health and wellbeing. But these are only one set of environmental factors that affect health in terms of morbidity and mortality, and there are other governmental and social actors that can work together to intervene and change the outcomes for real people in the real world. That’s why the new public health arrangements in England are game-changing for the profession and for the health of the public generally, and that’s why finding an evidence-base to target suitable and effective interventions that will really make a difference for people is so important.

A recent paper by Daniel Notterman and colleagues from Penn State University, and published in the Proceedings of the National Academy of Sciences of the United States of America, studied the genetic effects of harsh socio-economic environments on a group of children over a nine-year period. What they found was very striking – there was a statistically-significant shortening of the telomeres on the chromosomes of children who experienced a harsher socio-economic environment than those children who grew up in a more advantaged environment. And these effects were visible by the age of nine.

The story was picked up by several news outlets and New Scientist carried an article on it this week, which caught my attention and drew me to read the original paper.  I wanted to find out what was actually meant by “harsh environment” in the context of the research.

The authors chose a study group of African American children, and boys specifically, for this study. Choosing a single-sex group from a single racial cohort, as in this case, reduces some of the potentially-confounding factors for the study. The authors refer to research which indicates that boys may be more sensitive to negative family factors that girls.

In the context of this study, “harsh environment” means poorer, harsher parenting styles as against more nurturing styles, more changes in family structure particularly parental transitions, a younger mother at birth and poorer maternal educational achievement. A study group of 40 boys was chosen distributed between the harsh environment and more advantaged environments, where there was more stability in the family, a more nurturing parenting style, an older mother at birth and a mother with more educational achievement.

Telomeres are the repeating strings of TTAGGG bases at the ends of the chromosomes which are thought to protect functional genes  from damage during mitosis. Telomere length is a measure of the number of these repeats. Telomere length decreases over lifespan and are thought to be associated with aging and mortality. Therefore, the identification of factors which affect the telomere length in children and at such an early age is important in public health terms.

This study found as follows:

Model 1 (M1) of Table 2 shows that living in a disadvantaged environment was associated with a 19%shorter TL (P = 0.02). The next set of models (M2–M5) show the associations between boys’ TL and each of the environmental measures separately. Model 2 (M2) shows that a
doubling of the family income/needs ratio was associated with a 5% increase in the boys’ TL (P = 0.03). To provide more context for this estimate, in the larger Fragile Families sample the mean income/needs ratio is 0.7 for children at the 25th percentile and 2.7 for children at the 75th percentile, which is equivalent to an 8% difference in TL under this model. As a robustness test for economic conditions, we also examined the association between a boy’s TL and his mother’s education (see M5 in Table 2). Compared with children of mothers with less
than a high school education, having a mother with a high school degree is associated with a 32% increase in a child’s TL (P = 0.006), and having a mother with at least some postsecondary education is associated with a 35% increase in TL (P = 0.005). In sum, family economic status was a significant predictor of a boy’s TL measured in middle childhood. Model 3 shows that a low score on the parenting quality index was associated with a 3% decrease in a boy’s TL. Finally, model 4 shows that being exposed to multiple changes in family structure was associated with a 40% decline in a boy’s TL (P = 0.010).

As Dahlgren and Whitehead also write (Levelling up (part 1): a discussion paper on concepts and principles for tackling social inequities in health, WHO 2007),

… a stepwise, or linear, decrease in health – and not just an extreme group in poor health and the rest in reasonably good health – is seen with decreasing social position and is referred to as the social gradient (Marmot,2004). For example, the health of the populations of Florence, Leghorn and Turin has been followed over a number of years, and the findings clearly show that mortality increases linearly with increasing degree of social disadvantage. This is so both when social disadvantage is measured by the characteristics of individuals, such as education, employment or social class, and when it is measured by deprivation of the area in which people live …

This is a small study, and has some methodological problems, but it strongly suggests that public health workers need to look as closely at interventions in the family circumstances of children as at their physical environments if those children are to achieve their potential for long lives. Making them long, healthy lives is another challenge.

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Brazen Scottish Conservatives refuse to admit their lying over food safety in Scottish schools

I’ve now heard from Tom Wall, the Digital Editor for Environmental Health News, that he’s had a response form the Scottish Conservative party about their mischief-making over food safety in Scottish schools. They do not deny the accusation of lying or mischief-making. Draw your own conclusions, folks.

In fact, you can email them at michael.tait@scottish.parliament.uk if you think their position is cowardly and contemptuous of the electorate – or if you think their position is virtuous and bold and you wish to congratulate them for sticking by their guns. Or you can follow their Twitter feed at @ScotTories, or even send them a message congratulating them on their brass neck.

The email exchange between Tom Wall and Michael Tait is below:

From: Michael.Tait@scottish.parliament.uk <Michael.Tait@scottish.parliament.uk>
Sent: Monday, March 17, 2014 11:40 PM
To: Tom Wall
Subject: RE: School standards press release ‘misleading’

Dear Tom,

We have no further response beyond the letter to Mr Mackie.

Regards

Michael

From: Tom Wall
Sent: 17 March 2014 12:54
To: Tait M (Michael)
Subject: Re: School standards press release ‘misleading’

Hi Michael

Would be useful to know if you are going to respond?

The FSA data provides no basis for claiming improvement notices were served and or making inferences about cleanliness of school kitchens. But your press release does both. Are you going to amend the press release?

Thanks

Tom

​Tom Wall
Environmental Health News
Digital Editor

Twitter @EHN_Online
Web www.ehn-online.com

Chartered Institute of Environmental Health
Chadwick Court 15 Hatfields London SE1 8DJ

Foodsafety mischief by Scottish Conservatives published in EHN_Online

My small but persistent request for evidence from the Scottish Conservatives about the data underlying their mischievous claims about food safety in Scottish schools has been picked up by the prestigious on-line environmental health journal, EHN Online. Tom Wall, the reporter who wrote the story based upon the posts in this blog, relates that even he couldn’t get the party to show their working. Perhaps shaming on a UK stage will now prompt a response. As always, watch this space.

Let’s be clear – the Scottish Conservatives lied about food safety in schools

I’m a patient old Hector, but five weeks is plenty long enough for me to wait for the Scottish Conservatives to offer up the evidence behind their unfounded assertions about food safety in Scottish school kitchens. They may well be right in thinking that I’m an insignificant blogger – and my stats wouldn’t disagree – but that’s not the point. I care about evidence-based environmental health, and I care about the press and the public being given accurate information based on reliable sources about food safety and other matters of public health interest. In fact, it’s more important that the press are given accurate information, because the majority of media outlets simply don’t have either the scientifically-trained staff, the time or the inclination to check the assertions that are presented to them as facts.

And this is where the Scottish Conservatives fall down. I’m going to reiterate the whole sorry saga just for the record, although it is set out in previous posts on this blog, here, here and here.

Eight weeks ago, a number of newspapers published – probably verbatim (because they say almost exactly the same things) – a press release from the Scottish Conservative party, who were trying to make mischief about the state of food hygiene in Scottish schools. I say “make mischief” because that is the only conclusion that can be drawn from their refusal to produce evidence of the assertions that they made.

This is what I wrote in my first post on the subject:

The summary of the story is, that over the period from 2009 to 2013, 83 schools, nurseries and after-school clubs received “Improvement Required” food hygiene ratings. This means that the establishments failed to meet the “broadly compliant” rating scores for the rating elements of food hygiene, premises condition or confidence in management. Obviously, this is a matter of concern, but it does not indicate that any of these sites were serving unsafe food – a site could fail to meet the requisite standard simply by failing to maintain adequate records of temperature checks, or having some structural problems, which are not themselves directly hazardous to the safety of food being prepared. More serious deficiencies would include failure of cross-contamination controls, but this cannot be interpreted from the food hygiene rating given to a site after inspection.

There are a number of interesting aspects to this story, so let’s deal with the factual errors first.

All the reports refer to “FSA [Food Standards Agency] inspections”

This is wrong. The FSA do not carry out food safety/food hygiene inspections of caterers in Scotland, nor in any other part of the UK. This work is done by local authority environmental health officers (EHOs) and specialist-qualified food safety officers.

Food hygiene ratings in Scotland (and the rest of the UK) are published on the FSA’s website at http://ratings.food.gov.uk, which is an easily searchable and up-to-date resource giving information about the most recent inspection outcome for a catering establishment. In Scotland, unlike other parts of the UK, there is a binary rating system of “Pass” or “Improvement Required”. There is no requirement for a food business to display the certificate and they are, in fact, rarely seen on the streets. <snip>

Facilities in Glasgow, Highlands and the Scottish Borders were among the worst offenders for cleanliness in their catering facilities.

This statement about cleanliness cannot be interpolated from the food hygiene ratings website, which is the only source given for the data in the study.

Parents will be horrified to know their child may have been served a meal from a facility that inspectors saw fit to serve with an improvement notice.

This quote is from Mary Scanlon MSP, who is the party’s education spokeswoman. Unless the study carried out specifically identified whether a Hygiene Improvement Notice had been served under the Food Hygiene (Scotland) Regulations 2006, it will be wrong (a) to assume that an Improvement Required rating would automatically be accompanied by a formal notice under the regulations or (b) to conflate the Improvement Required rating with being an improvement notice, which it is not.

The intervention that follows an unsatisfactory food safety inspection can range from informal advice, to an informal letter, to a formal hygiene improvement notice, all the way through to emergency closure of the premises or prosecution by the Crown. None of that can be interpreted simply from the food hygiene rating data on the FSA’s website.

I wrote to the Scottish Conservatives asking for more information and received no reply. A further enquiry elicited a response on behalf of Mary Scanlon MSP, the party’s Education Spokesman, which is reproduced in full here. That reply failed to provide any evidence for the misleading statements widely reproduced in the media, and which caused unnecessary alarm for parents and consternation for diligent school meals operations across Scotland, so I asked again:

Dear Mrs Scanlon,
Thank you for your response and I know it’s useful to be alerted to problems with particular channels of communication.
As to the interpretation of the FSA ratings data, your own quote stated that:
(a) improvement notices were served, and
(b) many of the adverse ratings were for cleanliness.
Neither statement can be derived from the rating data, which is why I have requested a copy of the study on which your media report and quoted statements were made. I wish to verify whether your researcher has done a good job in sourcing and interpreting the data which was used in your story. This is not a matter of nuance, but facts, and the public deserve to be provided with accurate facts, even though there may be disagreement on their interpretation or the proper response to them.
Thank you in anticipation,
Yours sincerely,
Patrick Mackie

I’ve heard nothing from them.

So: in the absence of evidence to demonstrate that the party’s researchers were using any source of information other that the FSA’s food hygiene ratings website, I confidently declare that the following statements made by the Scottish Conservatives were made-up and therefore mendacious, a word which my dictionary defines as given to deception or  falsehood, or in plain English, a pack of lies:

Erroneous assertion 1: School kitchens are inspected by the Food Standards Agency. See above. Okay, I can be a bit generous here and let this pass as sloppy research, but even so …

Lie 2: That any conclusion could be drawn from the ratings data about why school kitchens failed to achieve the Pass standard and that some schools failed on the grounds of cleanliness. See above

Lie 3: That any conclusion could be drawn from the ratings data about whether or not Improvement Notices had been served on any of the school kitchens inspected. See above

Now, I am perfectly happy to change my interpretation of the statements of the Scottish Conservatives and retract the allegation of mendacity/lying if they provide me the evidence for the statements made, i.e. that they have reliable sources of data other than the food hygiene ratings published on the FSA’s website. As a wise man once said, “When my information changes, I alter my conclusions. What do you do, sir?”

Politicians, huh?

Preaching what you practice

I spent Friday in Wolverhampton at the Chartered Institute of Environmental Health’s Education and Research Special Interest Group’s conference. This is the second year we’ve seen a conference aimed specifically at promoting research, writing and publication for the environmental health profession. And this year the CIEH’s Education team came along and joined in. For the record, the event was sponsored by the CIEH West Midlands Region and Highfield Publications.

The title for the conference was “Preaching what you Practice”, which speaks to the generally dismal performance of environmental health practitioners (EHPs) in building the evidence base for the profession by failing to design studies in environmental health practice, or even to write up and publish their experiences in tackling the conditions that affect the health outcomes of everyone in our communities.

The challenge for putting environmental health practice on a firm foundation of evidence is now increasingly urgent, particularly in England, where environmental health and public health are coming together in their natural home in local government. Public health is a field founded in clinical thinking and practice where research and publication are the essential prerequisites of practice. Environmental health, although rich in data, has a very poor track record of writing and publishing what it does and how it achieves its successes. This must change. Continue reading

My pledge to Kelvin – fulfilled

In June I referred to the meeting of the CIEH’s Assembly of Representatives, at which members were asked to pledge something to further the cause of environmental health research and help to build the knowledge base.

I have now posted a paper on an obscure corner of environmental health administrative practice on this blog. That fulfills the pledge, but begins another journey of enquiry.

This is the first time I’ve ever published a paper, even on a blog, so it will be full of epistemological and other rational holes, and readers are invited to comment on it to improve the quality and usefulness of the information.

You can read the paper on this page.

When Jigsaw met Graham

Another great podcast from Jigsaw PSPH. This time, talking to Graham Jukes, the Chief Executive of the Chartered Institute of Environmental Health, who remains ever positive, energetic and optimistic about the future of the environmental health profession in UK.

The CEO of the Chartered Institute of Environmental Health gave up his lunch to talk 2 us find out what he had 2 say http://jigsawpsph.podomatic.com

My Pledge to Kelvin

In the CIEH’s Royal Charter, environmental health is described as an art and a science. I suspect that this duality has long undermined the collective will of the profession to do our damnedest to put environmental health practice on a sound scientific basis. After all, if we have no evidence base for a particular way of doing things, we can always claim art, can’t we?
It is true that the stressors that affect public health and drive health inequalities are not all biological like typhoid, or physical like noise, or chemical like lead. Some are social as when people are in overcrowded housing or have no security of tenure. Some are financial such as being unable to afford to heat a home in winter or buy fresh food for a family.
Equally, some of our professional interventions are scientific, such as ensuring that water is clean and that E. coli O157 is absent from the steak pie you’ve just bought for your Sunday lunch.
Other interventions are social, providing money to enable people to insulate their homes and thus afford to heat them.
And yet others are more artful, such as providing training to workers in health and safety or food safety, or carers in first aid for young children.
But the crucial question remains: how do we know what works? Continue reading