The EPIC-Norfolk prospective population study: biological and behavioural determinants of health and disease in an ageing population

The aim of the European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) is to help us understand what we can do to improve health and prevent disease and disability in later life. There is a particular focus on patterns of diet and physical activity.

EPIC-Norfolk is a study of 30,000 men and women living in Norfolk who first agreed to take part in the study in 1993 when aged 40-79 years of whom 25,00 attended a detailed health examination and who have been followed up to the present for health. At the original health examination in 1993-1997 they gave detailed information on their health and lifestyle, including very detailed diet and physical activity records, medical and family history, had assessments of heart disease risk factors including blood cholesterol and blood pressure, and provided blood and urine samples for analysis. Participants have continued to take part in repeated health assessments with further measures to assess bone health, eye health and visual function, and physical and mental performance, the most recent being between 2006-2011, and answered further questionnaires about their health including psychosocial factors such as stress and anxiety, sleep patterns and quality of life. We have thus been able to track the health experiences over 20 years of this middle aged older population who are comparable to the British general population. We are able to obtain an understanding of the risk factors for important diseases such as heart diseases and strokes, individual cancers, osteoporotic fractures, arthritis and diabetes and what we can do to reduce risk of these diseases. As the population ages, there is increasing emphasis on outcomes relevant to older people, not just disease occurrence and death, but functional capacity including physical function, mental function, visual health as well as self perceived quality of life. The detailed data available enable us to understand not just how the mind and body age biologically, but behavioural factors such as diet and physical activity may affect this process and how wider environmental determinants such as socioeconomic status, residential deprivation and access to green space can influence our health.

This is an ongoing population study and have an active participants' panel that advises us on research questions of interest and future studies.

Results from the study have already contributed to health policy and recommendations including a Department of Health Public Health initiative"Small changes Big difference". We have now been able to conduct genetic profiling of the participants to enable us to identify how our genetic make up can influence risk of disease and will explore how environmental factors such as health behaviours may modify genetic susceptibility.

The current application is to maintain follow up of participants and assessments to understand how different individuals may age differently and further clarify what factors influence the ageing process and risk of disease and disability to enable interventions to improve health and quality of life.

The aim of the European Prospective Investigation into Cancer in Norfolk (EPIC-Norfolk) is to help us understand what we can do to improve health and prevent disease and disability in later life. There is a particular focus on patterns of diet and physical activity.

EPIC-Norfolk is a study of 30,000 men and women living in Norfolk who first agreed to take part in the study in 1993 when aged 40-79 years of whom 25,623 attended a detailed health examination in 1993-1997 and who have been followed up to the present for health. This is a very well characterised population with extensive baseline data available on behavioural factors, health including medical and family history, and anthropometry, assessment of heart disease risk factors including blood cholesterol and blood pressure, and provided blood and urine samples for analysis and for establishment of a biological sample bank. Participants have continued to take part in repeated health assessments 1997-2000 and 2006-2011 with further Participants have continued to take part in repeated health assessments with further measures to assess bone health, eye health and visual function, and physical and mental performance, the most recent being between 2006-2011, and answered further questionnaires about their health including psychosocial factors such as stress and anxiety, sleep patterns and quality of life. All participants have been followed up to the present for health outcome including total mortality by cause and disease incidence through routine record linkage with health records. We are proposing to continue maintenance and follow up the cohort, including testing of new hypotheses relating to health and disease, and to resurvey the cohort to characterise longitudinal trajectories of objective physical and cognitive functional performance.

Understanding what we can do to improve health and prevent disease and disability in ageing populations will have benefits for society and the general public nationally and internationally. Results have already and will continue to contribute to health and clinical policy. Clarification of the mechanisms underlying diseases will enable us to understand pathophysiological processes to support better prevention and treatment, understanding the risk profile for diseases will enable more targeted screening and prevention programmes and understanding and quantifying specific behaviours that influence functional health and healthy ageing will enable us to improve the health experience and quality of life in populations as they age.

EPIC Investigators have contributed to national and international (e.g. WHO) clinical and public health guideline panels, Department of Health initiatives, and invited to provide evidence to Select Committees on health issues in the Houses of Parliament

Examples include:
Research from EPIC-Norfolk quantifying the association between four health behaviours (not smoking, modest alcohol intake, physical activity and consumption of 5 servings of fruit and vegetable intake) were associated with a 14 year difference in life expectancy. This directly influenced the Department of Health "Small change big difference" national public health campaign launched from Downing Street, underpinned regional initiatives to promote health behaviour change and has been taken up in national guidance. http://webarchive.nationalarchives.gov.uk/20080905235643/http://dh.gov.uk/en/Publichealth/Healthimprovement/Smallchangebigdifference/DH_4134042; http://learning.nhslocal.nhs.uk/features/making-every-contact-count/mecc-post-march-2013/mecc-case-studies-and-workshops. www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/10PrioritiesFinal2.pdf

EPIC findings have been reported to meetings contributing European policies on ageing (invited presentations to the European Commission DG Health on Frailty in Old Age 2013) http://ec.europa.eu/dgs/health_consumer/dyna/enews/enews.cfm?al_id=1365

Results from EPIC have also contributed to clinical guidelines on screening for osteoporosis using heel ultrasound measures, a low cost and safe feasible assessment ( Lewiecki EM et al, Official Positions for FRAX Bone Mineral Density and FRAX simplification from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX. J Clin Densitom. 2011 Jul-Sep;14(3):226-36)

and to clinical guideline on the use of glycated haemoglobin in the diagnosis of diabetes. (RydenL et al, ESC Guidelines on diabetes, prediabetes and cardiovascular diseases in collaboration with the EASD- Summary. Eur Heart J 2013;34: 3035; Anderson T et al. 2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidaemia for the prevention of cardiovascular disease in the adult. Can J Cardiol 2013;29:151-167.

In addition general findings from EPIC-Norfolk have informed publications from charities (e.g. Cancer Research UK, British Heart Foundation, Stroke Association, AgeUK) on disease prevention and maintenance of health.