Understanding interactions between lifestyle and deprivation to support policy and intervention development.

Background:

An unhealthy lifestyle is one of the main risks for chronic disease and death. An unhealthy lifestyle can be defined by a number of single lifestyle factors such as smoking, high alcohol intake, or low levels of physical activity. However, the risks posed by having combinations of more than one unhealthy lifestyle factor (e.g. low physical activity and high alcohol intake) is rarely studied and is poorly understood in terms of risk of death or developing a chronic disease. This is particularly the case for combinations of lifestyle factors that include so called 'newer' lifestyle factors (e.g. sleep duration or TV viewing time).

People who live in more deprived communities have the highest rates of death and chronic disease. This is not only due to unhealthy lifestyles being more common in these populations, but is also due to an increased vulnerability to the effects of unhealthy lifestyles. This means that unhealthy lifestyles have a worse effect on more deprived populations (resulting in more deaths) than is the case for more affluent populations with similarly unhealthy lifestyles.

Our understanding of how different combinations of lifestyle factors, including more recently recognised factors such as sleep duration, affect health is limited because so far research has focussed on single and well-known lifestyle factors like smoking. Furthermore, current health policies and support to reduce lifestyle risks consider the risk to all individuals as equal. However, the greater vulnerability to unhealthy lifestyles in more deprived populations means that strategies and support could be tailored to help those at greatest risk. Understanding these risks, and the impact on people in deprived communities, forms the basis of this Fellowship.

Aims:
1) To gather and examine the published evidence regarding the effects that unhealthy lifestyle factor combinations, including newer lifestyle factors such as sleep duration and TV watching time, have on health and whether the effects vary by socioeconomic status.

2) To perform a detailed statistical analysis of two large existing research datasets to determine the risks associated with combinations of established and new unhealthy lifestyle factors in both affluent and deprived populations. (Two datasets will be used to compare and contrast the findings in different populations and therefore increase our confidence in any consistent findings)

3) To share the results obtained from addressing aims 1) and 2), with people living in deprived areas and with professionals involved in promoting healthy living; to explore their views of the results and on how best to incorporate the new evidence on lifestyle and combinations of risk factors into policies and interventions to improve health for individuals and communities.

This PhD will take place in the University of Glasgow and in collaboration with a team from the Norwegian University of Science and Technology. The work will involve: i) a systematic review of the existing research evidence; ii) new and advanced statistical analysis of two large and comprehensive population datasets (one from UK and the other from Norway); and iii) detailed exploration of the views of members of the public, health professionals and policymakers who could make use of the new evidence generated by this PhD.

Deliverables and Benefits from the Planned Programme of Research:

Improved understanding of which combinations of lifestyle factors pose the greatest risks, particularly to deprived populations, would allow policy makers, health professionals and individuals to prioritise or target particularly harmful combinations. The work undertaken in this PhD will provide evidence to inform future policies, research and design of interventions to promote healthy lifestyles in more deprived populations. This work therefore has the potential to help reduce health inequalities that are strongly linked to unhealthy lifestyle factors.

Aim:

To improve our understanding of the risks of mortality and morbidity associated with combinations of lifestyle factors across the socioeconomic spectrum in order to inform future health policy and interventions.

Objectives:

1) To examine the evidence for lifestyle factor combinations associated with adverse health outcomes and for interactions between these combinations and deprivation.

2) To assess associations between lifestyle factor combinations (including newer lifestyle factors) and health outcomes and describe whether the associations are modified by deprivation.

3) To determine which lifestyle factor combinations are associated with greatest risk for adverse health across socioeconomic groups.

4) To explore the views of key stakeholders of how the new evidence for the risks of both a wider range of lifestyle factors and high-risk combinations could be incorporated into efforts to reduce lifestyle harm, particularly in deprived areas.

Methods:

This is a mixed methods PhD involving: 1) a systematic review; 2) analyses of two large population cohorts to assess the relationships between lifestyle factor combinations and health outcomes, including the effect of deprivation on those relationships; and 3) qualitative work with stakeholders.

Scientific/Medical Opportunities:

Much is known about the adverse effects of unhealthy lifestyle factors such as smoking but little is known about the impact of unhealthy lifestyle combinations (including newer lifestyle factors) on health outcomes, especially for those living in deprived communities. Understanding these issues and stakeholder views on how such evidence should be translated into efforts to reduce lifestyle harm is essential to inform future health policy and workable interventions. This work will identify new targets for future complex interventions or natural experiments aimed at individual and population level.

Unhealthy lifestyles are crucial modifiable risk factors for non-communicable disease (NCD), a leading cause of mortality. Our recent research suggests that socioeconomically deprived populations are more vulnerable to the effects of a wide range of unhealthy lifestyle factors. However, there is little understanding of which combinations of lifestyle factors (e.g. smoking in combination with high alcohol intake and low levels of physical activity) have the greatest impact on these vulnerable populations. This PhD will provide a novel and detailed description of the combinations of lifestyle risk factors with the strongest mortality and morbidity risks across socioeconomic groups. It will also involve a formal evaluation of the implications of these risks for key stakeholders living in and working with deprived populations. As a result, there will be a broad range of impacts from this proposed work including public, clinical, policy level and academic impacts.

Public impact:

In the long term, the main beneficiaries of this research will be members of the public. Given the global rise of lifestyle related NCDs, improved understanding of lifestyle related-risk would benefit everyone. New knowledge of the specific combinations of lifestyle factors that are likely to be the most harmful could, if embedded in future interventions, help individuals prioritise which lifestyle factors to address first and improve awareness around wider lifestyle risks. Identifying specific high-risk lifestyle factor combinations for populations affected by deprivation will have particular benefit for deprived populations, which are more vulnerable to the effects of unhealthy lifestyle factors. The views of patients and the public have been integral to this study's design and, in order to maximise the impact for the public, this Fellowship has a key component of public engagement throughout its lifespan. This project has a third sector partner, ALLIANCE, which represents members who provide support to and individuals living with NCDs. This collaboration will maximise interaction with and dissemination of study findings to the public.

Clinical impact:

The study findings will enable practitioners who regularly discuss lifestyle factors with patients (e.g. community nurses and General Practitioners) to have more meaningful discussions with patients about lifestyle related risk, particularly in deprived populations. More detailed understanding of the risks posed by a wider range of lifestyle factors and high-risk combinations could improve clinical consultations on prioritising wider lifestyle risks and lead to more effective preventive services decreasing costs to health services in the long term.

Policy impact:

Identifying new combinations of lifestyle factors involved in incurring harm could inform new policies and strategies that aim to reduce lifestyle-related harm. This PhD proposal involves a detailed evaluation of key stakeholders, including policymakers and public health professionals. This will formalise the implications of the study findings for strategy and policy and catalyse policy level engagement. This will contribute directly to developing new policy and public health strategy in this area.

Academic impact:

Dissemination of the methods used in this Fellowship will benefit researchers who can apply these methods to similar problems, especially epidemiological problems where there are numerous variables to consider. The computer code developed as part of the methods will be made available, which will help researchers working in similar fields and using the same datasets. New information from this PhD will facilitate social scientists in generating new ideas in improving our understanding of healthy lifestyles for individuals affected by deprivation. Results from this fellowship will also guide researchers involved in the design of new lifestyle supports, particularly those tailored for deprived populations.