British Regional Heart Study Newsletter 2015
Welcome to the British Regional Heart Study (BRHS) Annual
Newsletter. We have had another busy period, with 32
published papers and 11 conference presentations based on
the study during 2014-2015.
UPDATE ON ACTIVITIES AND INITIATIVES
DATA COLLECTION Postal Questionnaire 2015: We are currently sending out a postal
questionnaire to all surviving participants, to provide an update on the health and health
determinants of study men. Record Review 2015: The annual review of participants’ GP records is
also in progress; we thank our colleagues in General Practices across England, Wales and Scotland
for taking the time to complete these forms which provide an important update on the health of
our cohort members. BRHS Physical Activity Survey – Phase 5: The physical activity survey is in
progress; participants are requested to wear an activity monitor for one week and to complete a
brief physical activity diary.
News from the team
Professor Wannamethee and colleagues have received funding from the National School of
Primary Care Research to identify potential practical tools for assessment and scope for
intervention of sarcopenia in primary care. Dr Sheena Ramsay and colleagues have received
funding from the Dunhill Medical Trust to develop a reliable, easy-to-use tool, to identify frail
older people in the community. Dr Ramsay has also received funds from the UCL Patient and
Public Involvement Bursary Fund to improve functional outcomes (mobility, disability) in older age,
involving older people in identifying research questions and objectives for our research.
OVERVIEW OF PAPERS PUBLISHED IN 2014-2015
Recent papers from the BRHS group have continued to address a wide range of important themes
relevant to cardiovascular health in older populations. The influence of diet quality in later life on
cardiovascular disease and all-cause mortality has been documented. Detailed information on
physical activity patterns among older men, their determinants, and the complex associations
between physical activity and risk of falls have been explored. In the ageing BRHS population,
sarcopenia (low muscle mass) and frailty have been of increasing relevance; their associations with
cardiovascular disease outcomes and cardiovascular risk markers have been examined in detail.
Prospective associations between haemostatic and inflammatory markers linked to cardiovascular
risk (particularly fibrin D-dimer and interleukin-6) with incident physical disability have also been
reported. We have continued to investigate the emergence of cardiovascular risk over the life
course, documenting the influence of body fatness in early adult life on risk markers for
cardiovascular disease and diabetes many years later, and the influence of socioeconomic status in
early life on diet quality many years later. We have also further explored the determinants of
heart failure, reporting an association between parathyroid hormone levels, though not vitamin D
status, and heart failure incidence. Finally, a growing number of papers reflect our involvement in
collaborations exploring novel and genetic risk factors for cardiovascular disease.
WORK IN PROGRESS Cardiovascular risk factors over the adult life course, carotid intima media thickness and carotid‐
femoral pulse wave velocity Cardiovascular disease (CVD) and cardiovascular ageing are processes which may begin well before later life. However, few prospective epidemiological studies have distinguished the influence of key cardiovascular risk factor exposures at different stages of the adult life course to relevant markers of cardiovascular disease and ageing in later life. We examined the associations between established cardiovascular risk factors at mean ages 45, 65 and 78 years on carotid intima media thickness (cIMT) and carotid‐femoral pulse wave velocity (CFPWV) at 78 years. cIMT was positively associated with body mass index (BMI) levels at 45, 65 and 78 years (stronger at 45 and 65), with systolic blood pressure (SBP) at 45, 65 and 78 years (stronger at 45 and 65), with plasma glucose and HDL‐cholesterol (inversely) at 78 years and with cigarette smoking at 45 years. Life course models suggested risk accumulation over all three age points for BMI and SBP but were inconclusive for the other risk factors. CFPWV was positively associated with SBP at 45, 65 and 78 years (strongest at 78 years), with DBP at 65 and 78 years (stronger at 78 years) and with non‐HDL cholesterol at 78 years only. Life course models suggested a sensitive period at 78 years for both SBP and DBP but were inconclusive for the other risk factors. Established CVD risk factors (particularly BP) are strong influences on these markers of cardiovascular disease and ageing. The influence of BP on cIMT appeared to be cumulative, while the influence of BP on CFPWV mainly reflected recent BP. Cardiovascular ageing is likely to be influenced both by longer‐term risk accumulation and by recent risk factor exposures. Serum sodium and incident cardiovascular disease Hyponatremia (usually defined as serum sodium <136 mEq/L) is one of the most common electrolyte abnormalities. Recent evidence has suggested that mild hyponatremia may be associated with adverse outcomes in the general population. We have examined the association between serum sodium concentration and incident major cardiovascular disease (CVD) outcomes in older men. A U‐shaped relationship was seen between serum sodium concentration and major CVD events. Hyponatremia (<136 mEq/L) and low sodium within the normal range (136‐138 mEq/L) showed significantly increased risks of major CVD events compared to men within the upper normal range (139‐143 mEq/L) even after adjustment for a wide range of confounders and cardiovascular risk factors, including inflammation and NT‐proBNP. Hypernatremia (>145 mEq/L) was associated with significantly increased risk of CVD events and mortality. Low circulating sodium concentration even within the normal range is associated with increased major CVD events in older men without CVD which is not explained by known adverse CV risk factors. Copeptin and incident diabetes Prior studies have suggested a role for the arginine vasopressin (AVP) system in the pathogenesis of diabetes. We have examined the association between plasma copeptin (the c‐terminal fragment of arginine vasopressin hormone) and risk of incident diabetes in older men. In a cross‐sectional analysis, copeptin was positively significantly associated with renal dysfunction, insulin resistance (HOMA‐IR) and metabolic risk factors (waist circumference, blood pressure, triglycerides, liver function) but not with plasma glucose. The risk of incident diabetes was significantly elevated only in men in the top fifth of the copeptin distribution (>6.79 pmol/L), which was partly mediated through lower insulin sensitivity. The findings suggest a potential role of the AVP system in diabetes. Sociodemographic and cardiometabolic correlates of the “Test your Memory” cognitive screening tool The Test Your Memory (TYM) is an established cognitive screening instrument with sound psychometric properties which was administered to 1,570 BRHS members during the 30‐year re‐
examination. To date it has only been used in smaller clinical samples. We sought to characterize study participants with differing cognitive abilities in terms of their sociodemographic and cardiometabolic correlates. 801 (51%) participants were classified as being in the normal cognitive ageing group, while 636 (41%) and 133 (8%) had TYM scores that indicated mild cognitive impairments and severe cognitive impairment consistent with Alzheimer’s disease respectively. Compared with participants in the normal cognitive ageing category, individuals in the Alzheimer’s disease range of cognitive functioning had lower socioeconomic position, slower average walking speed, mobility problems, poorer self‐reported overall health, a history of stroke, obesity and impaired lung function. A similar albeit slightly weaker pattern was observed for participants with milder cognitive impairments. The relationships between adipose tissue deposition and sarcopenia with cognitive functioning Although current research has established obesity as a key modifiable risk factor for dementia, evidence on the relationships of total and regional body composition measures, as well as sarcopenia, with cognitive functioning in the older population has been inconsistent. Using data from the 30‐year BRHS re‐examination, we examined the associations between body fatness and cognitive impairments defined using the Test Your Memory (TYM) cognitive screening instrument. Our results showed that participants in the Alzheimer’s disease range of cognitive functioning were significantly more likely to have elevated peripheral and visceral fat mass, a BMI>30 and a waist circumference>102 cm after adjustment for alcohol, smoking, social class, physical activity, history of cardiovascular diseases or diabetes, interleukin‐6 and insulin resistance. In contrast, central fat mass was not significantly associated with severe cognitive impairments after adjustments for interleukin‐6 or insulin resistance, suggesting that distinct pathophysiological mechanisms link regional adipose tissue deposition and cognitive functioning. Sarcopenia was associated with mild cognitive impairments only when we used strict definitions encompassing muscle functioning in addition to the loss of appendicular muscle mass. Socio‐demographic characteristics, lifestyle factors and burden of morbidity associated with sensory impairments Sensory impairments affecting hearing and vision are common health problems in older age. We examined the associations of self‐reported hearing and vision impairments with socio‐
demographic characteristics, physical functioning, quality of life and the overall burden of other health conditions in men aged 63‐85 years old. 27% of men reported having a hearing impairment (reporting the use of a hearing aid and/or not being able to follow a TV programme at a volume others find acceptable) and 3% reported vision impairment (defined by not being able to recognise a friend across a road). The results showed that not being able to hear, irrespective of use of a hearing aid, was associated with poor quality of life, poor social interaction and poor physical functioning when compared to men who could hear. Men who could not hear despite using a hearing aid were more likely to have had coronary heart disease (CHD). Vision impairment was associated with symptoms of CHD including breathlessness and chest pain. Sensory impairments and cardiovascular disease and mortality Hearing and vision impairment have been associated with greater risks of cardiovascular disease (CVD) but few studies have examined myocardial infarction (MI) and stroke separately. We investigated whether hearing impairment and/or vision impairment increased the risk of MI, stroke and CVD events and CVD mortality over a 10‐year period independent of age, social class, lifestyle factors and comorbidity. Compared to men who reported they could hear, men who could not hear and did not use a hearing aid had greater risks of incident CVD, stroke and CVD mortality. The lack of association between hearing impairment and incident MI suggests that the association between hearing impairment and incident CVD could be largely explained by the association with stroke. Vision impairment was associated with higher all‐cause mortality but not with CVD incidence. Sensory impairments and the risk of disability We explored the associations between reported impairments in hearing and vision in men aged 63‐85 years and the risk of developing difficulties walking, undertaking activities of daily living (ADL) (e.g. getting dressed, showering, etc.) and performing instrumental activities of daily living (IADL) (e.g. shopping, telephoning, etc.) over 2 years. Our initial results showed those men who reported hearing difficulties and who did not use a hearing aid had increased risks of walking difficulties and undertaking ADL compared to men who could hear. Men who reported they could hear and used a hearing aid and men who could not hear despite using a hearing aid were more likely to report difficulties undertaking IADL 2 years later compared to men with no hearing impairment. Dietary patterns and risk of CVD and mortality in older men Although diet quality is a major modifiable risk factor for CVD and mortality, few studies have examined the relationship between a posteriori defined dietary patterns (a data‐driven, exploratory approach to define dietary patterns based on the available data) and the risks of CVD and mortality in older adults. In the British Regional Heart Study we examined associations between dietary patterns (defined using principal component analysis) and the risk of CVD and all‐
cause mortality in men aged 60‐79 years followed up over an 11 year period. Principal component analysis of 34 food groups, derived from a food frequency questionnaire, identified three interpretable dietary patterns: “high fat /low fibre” (high consumption of red meat, meat products, white bread, fried potato), “prudent” (high consumption of poultry, fish, fruit, vegetables, pasta, rice, wholemeal bread) and “high sugar” (high consumption of biscuits, puddings, chocolate, sweets). We found that the “high fat /low fibre” dietary pattern was associated with an increased risk of all‐cause mortality and the “high sugar” dietary pattern was associated with an increased risk of CVD events and CHD events, independent of cardiovascular risk factors. The “prudent” diet did not however show a significant relationship with cardiovascular outcomes or mortality. Physical activity and sedentary behaviour in relation to adiposity and insulin resistance Ongoing research is investigating the association between patterns of moderate to vigorous and light activity and sedentary behaviour (SB) in relation to cardio‐metabolic risk factors. Despite conflicting findings in relation to SB, UK guidelines now suggest avoiding “long” sedentary breaks, but do not specify what duration of SB might be detrimental. Current guidelines also suggest accruing 150 minutes of moderate or vigorous activity per week in bouts lasting 10 minutes or more. However there are limited data on the health effects of shorter activity bouts. We used objective measures of physical activity (PA) to investigate the importance of each intensity of activity and also the patterns of activity in relation to measures of adiposity. We found that total time spent in each intensity of activity was related to the outcomes. Importantly we also found that patterns of accumulation of light activity and sedentary behaviours were independently associated with adiposity and metabolic health. There was no evidence that bouts of activity lasting 10 minutes or more were differently related to outcomes from bouts lasting less than 10 minutes. Hence for moderate to vigorous activity, the volume of activity was more important than the pattern for these measures of adiposity; health benefits could be gained even without sustaining activity in spells lasting 10 minutes or more. Findings could help refine current PA guidelines with respect to defined bouts of activity and SB. Physical activity and sedentary behaviour: patterns and correlates The ongoing accelerometer study is enabling us to quantify in detail the patterns of physical activity (PA) of different intensities, from sedentary behaviours (SB), through light to moderate and vigorous activities, and the duration of time spent in spells of activity. We found that on average men spent 5% of the day in moderate or vigorous activities and 23% in light activity. 73% of the waking day was spent in SB which was mostly accumulated in short spells, but spells lasting for over one hour accounted for 19% of the day. Men who were over 80 years old, obese, depressed and had multiple chronic conditions accumulated more sedentary time and spent more time in longer sedentary bouts. The patterns of activity varied over the course of the day, with most light and moderate to vigorous activities taking place in the morning (peaking around 10‐
11am), and declining until around 1pm, when there was a small early afternoon peak (2‐3pm), followed by a long decline until 9pm. The patterns of SB were mirror images of the activity pattern. We also investigated how activity patterns varied by season and meteorological conditions; men were more active (and less sedentary) in spring and summer months, when day length was longer, at higher mean temperatures and lower humidity levels. Temperatures, sunshine duration and humidity were independently associated with PA and SB even after adjustment for season. Our findings suggest that strategies to maintain PA levels in older people need to take account of differences over the course of the day and also seasonal and weather effects. Explaining excess winter mortality from CHD This project is investigating why more people die from CHD in winter months, by identifying hazards of cold spells for incidence of cardiovascular disease using data from 1998 to 2012 and examining how the cold spell effect is modified by socio‐demographic, clinical, behavioural and home‐related factors. Preliminary results showed that during a cold spell the odds of developing a cardiovascular event (e.g. stroke) are double in comparison with non‐cold days. No clear evidence emerged for relative susceptibility among socio‐demographic, behavioural or housing subgroups. Further analysis will investigate the association of both short and long‐term exposure to cold with haemostatic measures. EXTERNAL COLLABORATIONS We continue to collaborate with several external collaborative initiatives, including the Emerging Risk Factor Collaboration (ERFC) and the University College London‐London School of Hygiene and Tropical Medicine‐Edinburgh‐Bristol (UCLEB) Consortium; collaborative publications from these initiatives are shown in the publication list. PRESENTATIONS AT CONFERENCES Oral presentations Society for Social Medicine, Oxford, September 2014 ‐ Socioeconomic inequalities in poor oral health in older age: influence of neighbourhood‐level factors in a cross‐sectional study of older British men. Ramsay SE et al Nutrition Society Winter Meeting Nutrition and age‐related muscle loss, sarcopenia and cachexia., RSM, London, December 2014 (Invited Speaker) - Muscle loss and obesity: the health implications of sarcopenia and sarcopenic obesity”. Wannamethee SG et al Public Health England Conference on Applied Epidemiology, Warwick, March 2015 ‐ Sensory impairments and mortality in older British community‐dwelling men: a 10‐year follow‐up study. Liljas AEM et al International Association of Dental Research annual conference, Boston, March 2015 ‐ Burden of Oral Health Problems in Older Age: Results from a Population‐based Study of Older British Men. Ramsay SE et al The 9th UK & Ireland Conference on Occupational and Environmental Epidemiology, Oxford, April 2015. ‐ Hazards of cold spells for incidence of cardiovascular disease in older British men. Sartini C. et al British Geriatrics Society Spring Meeting, Nottingham, May 2015 ‐ Sensory impairments and mortality in older British community‐dwelling men: a 10‐year follow‐up study. Liljas AEM. et al International Society of Behavioral Nutrition & Physical Activity Edinburgh, June 2015. ‐ Duration of objectively measured physical activity and sedentary behaviour in relation to adiposity and markers of insulin resistance: a cross‐sectional study of community‐dwelling older men. Jefferis BJ et al 4th International Conference on Ambulatory Monitoring of Physical Activity and Movement, Limerick, Ireland, June 2015. ‐ Utility of sedentary behaviour questionnaires in older men; comparisons with accelerometer data. Jefferis BJ et al ‐ Influence of season and meteorological factors on objectively measured physical activity and sedentary behaviour patterns among older UK men. Sartini C. et al Poster presentations: UK Public Health Science, Glasgow, November 2014 ‐ Social and lifestyle characteristics and burden of ill‐health associated with hearing and vision impairments in older British men. Liljas AEM. et al American Heart Association EPI/Lifestyle, Baltimore, USA, March 2015. ‐ Principal Component Analysis of Dietary Patterns and the Risk of Cardiovascular Disease and Mortality in Older British Men. Atkins JL. et al 4th International Conference on Ambulatory Monitoring of Physical Activity and Movement, Limerick, Ireland, June 2015. ‐ Objectively measured physical activity and sedentary behaviour in older adults: diurnal patterns and their determinants. Sartini C. et al Exercise Medicine, Royal Society of Medicine, London, June 2015 ‐ Influence of season and meteorological factors on objectively measured physical activity and sedentary behaviour patterns among older UK men. PUBLICATIONS: 1. Atkins JL, Ramsay SE, Whincup PH, et al. Diet quality in older age: the influence of childhood and adult socio‐economic circumstances. Br J Nutr 2015; 113: 1441–52. 2. Atkins JL, Wannamethee SG. The effect of sarcopenic obesity on cardiovascular disease and all‐cause mortality in older people. Rev Cin Gerontol 2015 Apr: 1‐12. doi :10.1017/S0959259815000076 3. Atkins JL, Ramsay SE, Whincup PH, Morris RW, Lennon LT, Wannamethee SG. Diet quality in older age: the influence of childhood and adult socio‐economic circumstances. Br J Nutr. 2015 May;113(9):1441‐
52. doi: 10.1017/S0007114515000604. 4. Jefferis BJ, Merom D, Sartini C, Wannamethee SG, Ash S, Lennon LT, Iliffe S, Kendrick D, Whincup PH. Physical Activity and Falls in Older Men: The Critical Role of Mobility Limitations. Med Sci Sports Exerc. 2015 Feb 9. 5. Jefferis BJ, Sartini C, Ash S, Lennon LT, Wannamethee SG, Lee IM, Whincup PH. Trajectories of objectively measured physical activity in free‐living older men. Med Sci Sports Exerc. 2015 Feb;47(2):343‐9. doi: 10.1249/ 6. Nüesch E, Dale C, Palmer TM, White J, Keating BJ, et al. Adult height, coronary heart disease and stroke: a multi‐locus Mendelian randomization meta‐analysis. Int J Epidemiol. 2015 May 15. pii: dyv074. 7. Ramsay SE, Arianayagam DS, Whincup PH, Lennon LT, Cryer J, Papacosta AO, Iliffe S, Wannamethee SG. Cardiovascular risk profile and frailty in a population‐based study of older British men. Heart. 2015 Apr;101(8):616‐22. doi: 10.1136/heartjnl‐2014‐306472. 8. Swerdlow DI, Preiss D, Kuchenbaecker KB, Holmes MV, et al. HMG‐coenzyme A reductase inhibition, type 2 diabetes, and bodyweight: evidence from genetic analysis and randomised trials. Lancet. 2015 Jan 24;385(9965):351‐61. doi: 10.1016/S0140‐6736(14)61183‐1. 9. UCLEB Consortium. Talmud PJ, Cooper JA, Morris RW, et al. Sixty‐five common genetic variants and prediction of type 2 diabetes. Diabetes. 2015 May;64(5):1830‐40. doi: 10.2337/db14‐1504. 10. Wade KH, Forouhi NG, Cook DG, Johnson P, et al. Variation in the SLC23A1 gene does not influence cardiometabolic outcomes to the extent expected given its association with L‐ascorbic acid. Am J Clin Nutr. 2015 Jan;101(1):202‐9. doi: 10.3945/ajcn.114.092981. 11. Wade KH, Forouhi NG, Cook DG, Johnson P, McConnachie A, Morris RW et al. Variation in the SLC23A1 gene does not influence cardiometabolic outcomes to the extent expected given its association with L‐
ascorbic acid. Am J Clin Nutr. 2015 Jan;101(1):202‐9. doi: 10.3945/ajcn.114.092981. 12. Wannamethee SG, Atkins JL. Muscle loss and obesity: the health implications of sarcopenia and sarcopenic obesity. Proc Nutr Soc. 2015 Apr: 1‐8. doi:10.1017/S002966511500169X. 13. Arking DE, Pulit SL, Crotti L, van der Harst P, Munroe PB, Koopmann TT, et al. Genetic association study of QT interval highlights role for calcium signaling pathways in myocardial repolarization. Nat Genet. 2014 Aug;46(8):826‐36. doi: 10.1038/ng.3014. 14. Atkins JL, Whincup PH, Morris RW, Lennon LT, Papacosta O, Wannamethee SG. High diet quality is associated with a lower risk of cardiovascular disease and all‐cause mortality in older men. J Nutr. 2014 May;144(5):673‐80. doi: 10.3945/jn.113.186486. 15. Atkins JL, Whincup PH, Morris RW, Lennon LT, Papacosta O, Wannamethee SG. Sarcopenic obesity and risk of cardiovascular disease and mortality: a population‐based cohort study of older men. Journal of the American Geriatrics Society. J Am Geriatr Soc. 2014 Feb;62(2):253‐60. doi: 10.1111/jgs.12652. 16. Atkins JL, Whincup PH, Morris RW, Wannamethee SG. Low muscle mass in older men: the role of lifestyle, diet and cardiovascular risk factors. J Nutr Health Aging. 2014 Jan;18(1):26‐33. doi: 10.1007/s12603‐013‐0336‐9. 17. Atkins JL, Whincup PH, Morris RW, Wannamethee SG. Response to Safer et al. J Am Geriatr Soc. 2014 Jun;62(6):1208‐9. doi: 10.1111/jgs.12853. 18. Emerging Risk Factors Collaboration, Di Angelantonio E, Gao P, et al. Glycated hemoglobin measurement and prediction of cardiovascular disease. JAMA. 2014 Mar 26;311(12):1225‐33. doi: 10.1001/jama.2014.1873. 19. InterAct Consortium. Holmes MV, Dale CE, Zuccolo L, Silverwood RJ, et al. Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data. BMJ. 2014 Jul 10;349:g4164. doi: 10.1136/bmj.g4164. 20. Jefferis BJ, Whincup PH, Papacosta O, Wannamethee SG. Protective effect of time spent walking on risk of stroke in older men. Stroke 2014; 45(1):194‐9. 21. Jefferis BJ, Sartini C, Lee IM, Choi M, Amuzu A, Gutierrez C, Casas JP, Ash S, Lennnon LT, Wannamethee SG, Whincup PH. Adherence to physical activity guidelines in older adults, using objectively measured physical activity in a population‐based study. BMC Public Health. 2014 Apr 19;14(1):382. doi: 10.1186/1471‐2458‐14‐382. 22. Jefferis BJ, Whincup PH, Lennon LT, Papacosta O, Goya Wannamethee S. Physical activity in older men: longitudinal associations with inflammatory and hemostatic biomarkers, N‐terminal pro‐brain natriuretic Peptide, and onset of coronary heart disease and mortality. J Am Geriatr Soc. 2014 Apr;62(4):599‐606. doi: 10.1111/jgs.12748.. 23. Jefferis BJ, Sartini C, Shiroma E, Whincup PH, Wannamethee SG, Lee IM. Duration and breaks in sedentary behaviour: accelerometer data from 1566 community‐dwelling older men (British Regional Heart Study). Br J Sports Med. 2014 Sep 17. pii: bjsports‐2014‐093514. doi: 10.1136/bjsports‐2014‐
093514. 24. Jefferis BJ, Iliffe S, Kendrick D, Kerse N, Trost S, Lennon LT, Ash S, Sartini C, Morris RW, Wannamethee SG, Whincup PH. How are falls and fear of falling associated with objectively measured physical activity in a cohort of community‐dwelling older men? BMC Geriatr. 2014 Oct 27;14:114. doi: 10.1186/1471‐
2318‐14‐114. 25. Kapetanakis VV, Rudnicka AR, Wathern AK, Lennon L, Papacosta O, Cook DG, Wannamethee SG, Whincup PH, Owen CG. Adiposity in early, middle and later adult life and cardiometabolic risk markers in later life; findings from the British regional heart study. PLoS One. 2014 Dec 4;9(12):e114289. doi: 10.1371/journal.pone.0114289. eCollection 2014. 26. Ramsay SE, Whincup PH, Papacosta O, Morris R, Lennon L, Wannamethee SG. Inequalities in heart failure in older men: prospective associations between socioeconomic measures and heart failure incidence in a 10‐year follow‐up study. Eur Heart J. 2014 Feb;35(7):442‐7. doi: 10.1093/eurheartj/eht449. 27. Ramsay SE, Morris R, Papacosta O, Whincup PH, Lennon L, Wannamethee SG. Time trends in socioeconomic inequalities in cancer mortality: results from a 35 year prospective study in British men. BMC Cancer. 2014 Jun 30;14:474. doi: 10.1186/1471‐2407‐14‐474. 28. Taylor AE, Morris RW, Fluharty ME, Bjorngaard JH, et al. Stratification by smoking status reveals an association of CHRNA5‐A3‐B4 genotype with body mass index in never smokers. PLoS Genet. 2014 Dec 4;10(12):e1004799. doi: 10.1371/journal.pgen.1004799. eCollection 2014 Dec. 29. Wannamethee SG, Welsh P, Papacosta O, Lennon L, Whincup PH, Sattar N. Elevated parathyroid hormone, but not vitamin D deficiency, is associated with increased risk of heart failure in older men with and without cardiovascular disease. Circ Heart Fail. 2014 Sep;7(5):732‐9. oi:10.1161/CIRCHEARTFAILURE.114.001272. 30. Wannamethee SG, Whincup PH, Lennon L, Papacosta O, Lowe GD. Associations between fibrin D‐dimer, markers of inflammation, incident self‐reported mobility limitation, and all‐cause mortality in older men. J Am Geriatr Soc. 2014 Dec;62(12):2357‐62. doi: 10.1111/jgs.13133. 31. Wannamethee SG, Welsh P, Whincup PH, Lennon L, Papacosta O, Sattar N. NT‐proBNP but not copeptin improves prediction of heart failure over other routine clinical risk parameters in older men with and without cardiovascular disease: population based study. Eur J Heart Fail. 2014 Jan;16(1):25‐32. doi: 10.1093/eurjhf/hft124. 32. Wannamethee SG, Shaper AG, Whincup PH, Lennon L, Papacosta O, Sattar N. The obesity paradox in men with coronary heart disease and heart failure: the role of muscle mass and leptin. Int J Cardiol. 2014 Jan 15;171(1):49‐55. doi: 10.1016/j.ijcard.2013.11.043. ACKNOWLEDGEMENTS We are extremely grateful to all the men participating in the BRHS, who continue to respond to our requests for help more than 37 years after initially agreeing to take part in the study. We also wish to express our thanks to the BRHS General Practices for their continuing help and support. The continuing support provided by the British Heart Foundation (including both Programme and Project Grant support) is gratefully acknowledged. We would also like to thank the Medical Research Council for their current support and to the Department of Health and Diabetes UK for their support in previous years. With best wishes on behalf of the BRHS team,
Professor Peter Whincup Directors of the BRHS Research Group Professor Goya Wannamethee British Regional Heart Study Department of Primary Care & Population Health, Institute of Epidemiology and Health Care UCL Faculty of Population Health Sciences, UCL Medical School Royal Free Campus Rowland Hill Street, London NW3 2PF DDI: +44 (0) 20 7830 2335 | F: + 44 (0) 20 7472 6871 W: http://www.ucl.ac.uk/pcph/research‐groups‐themes/brhs‐pub