The Middle-Out Perspective: an approach to formalise 'normal practice' in public health advocacy.

AIMS: The middle-out perspective (MOP) provides a lens to examine how actors positioned between government (top) and individuals (bottom) act to promote broader societal changes from the middle-out (rather than the top-down or bottom-up). The MOP has been used in recent years in the fields of energy, climate change, and development studies. We argue that public health practitioners involved with advocacy activities and creating alliances to amplify health promotion actions will be familiar with the general MOP concept if not the formal name. The article aims to demonstrate this argument. METHODS: This article introduces the MOP conceptual framework and customises it for a public health audience by positioning it among existing concepts and theories for actions within public health. Using two UK case studies (increasing signalised crossing times for pedestrians and the campaign for smoke-free legislation), we illustrate who middle actors are and what they can do to result in better public health outcomes. RESULTS: These case studies show that involving a wider range of middle actors, including those not traditionally involved in improving the public's health, can broaden the range and reach of organisations and individuals involving in advocating for public health measures. They also demonstrate that middle actors are not neutral. They can be recruited to improve public health outcomes, but they may also be exploited by commercial interests to block healthy policies or even promote a health-diminishing agenda. CONCLUSION: Using the MOP as a formal approach can help public health organisations and practitioners consider potential 'allies' from outside traditional health-related bodies or professions. Formal mapping can expand the range of who are considered potential middle actors for a particular public health issue. By applying the MOP, public health organisations and staff can enlist the additional leverage that is brought to bear by involving additional middle actors in improving the public's health.

Current issues in the impacts of transport on health.

Introduction or background: Transport affects health in many ways. Benefits include access to education, employment, goods, services and leisure, and opportunities for incorporating physical activity into daily living. There are major inequalities: benefits generally accrue to wealthier people and harms to the more deprived, nationally and globally. Sources of data: Health on the Move 2; Journal of Transport and Health. Areas of agreement: Benefits of travel for access and physical activity. Harms include health impacts of air and noise pollution; injuries and fatalities from falls or collisions; sedentary behaviour with motorized transport; community severance (barrier effect of busy roads and transport infrastructure); global climate change; impacts on inequalities; transport's role in facilitating spread of communicable diseases. Areas of controversy include: Biofuels; cycle safety; driving by older people. Growing points and areas for research include: Effects of default 20 mph speed limits; impacts of autonomous vehicles on health and inequalities.

Explanatory factors for health inequalities across different ethnic and gender groups: data from a national survey in England.

BACKGROUND: The objective of this study was to examine the relative contribution of factors explaining ethnic health inequalities (EHI) in poor self-reported health (pSRH) and limiting long-standing illness (LLI) between Health Survey for England (HSE) participants. METHOD: Using HSE 2003-2006 data, the odds of reporting pSRH or of LLI in 8573 Bangladeshi, Black African, Black Caribbean, Chinese, Indian, Irish and Pakistani participants was compared with 28,470 White British participants. The effects of demographics, socioeconomic position (SEP), psychosocial variables, community characteristics and health behaviours were assessed using separate regression models. RESULTS: Compared with White British men, age-adjusted odds (OR, 95% CI) of pSRH were higher among Bangladeshi (2.05, 1.34 to 3.14), Pakistani (1.77, 1.34 to 2.33) and Black Caribbean (1.60, 1.18 to 2.18) men, but these became non-significant following adjustment for SEP and health behaviours. Unlike Black Caribbean men, Black African men exhibited a lower risk of age-adjusted pSRH (0.66, 0.43 to 1.00 (p=0.048)) and LLI (0.45, 0.28 to 0.72), which were significant in every model. Likewise, Chinese men had a lower risk of age-adjusted pSRH (0.51, 0.26 to 1.00 (p=0.048)) and LLI (0.22, 0.10 to 0.48). Except in Black Caribbean women, adjustment for SEP rendered raised age-adjusted associations for pSRH among Pakistani (2.51, 1.99 to 3.17), Bangladeshi (1.85, 1.08 to 3.16), Black Caribbean (1.78, 1.44 to 2.21) and Indian women (1.37, 1.13 to 1.66) insignificant. Adjustment for health behaviours had the largest effect for South Asian women. By contrast, Irish women reported better age-adjusted SRH (0.70, 1.51 to 0.96). CONCLUSIONS: SEP and health behaviours were major contributors explaining EHI. Policies to improve health equity need to monitor these pathways and be informed by them.

Biomarkers of diabetes risk in the National Diet and Nutrition Survey rolling programme (2008-2011).

This study describes the distribution of glycosylated haemoglobin (Hb(A1c)) and glucose concentrations in the combined year 1 (2008-2009), year 2 (2009-2010) and year 3 (2010-2011) of the National Diet and Nutrition Survey (NDNS) rolling programme. The NDNS rolling programme is a nationally representative survey of food consumption, nutrient intakes and nutritional status of people aged 1.5 years and over living in England, Wales, Scotland and Northern Ireland. The study population comprised survey members who completed three or four days of dietary recording and who provided a blood sample. After excluding survey members with self-reported diabetes (n=25), there were 1016 results for HbA1c and 942 for glucose (not the same individuals in each case). Around 5.4% of men and 1.7% of women aged 19-64 years, and 5.1% of men and 5.9% of women aged ≥65 years had impaired fasting glucose (glucose concentrations 6.1-6.9 mmol/L). Over 20% of men aged ≥65 years had fasting glucose concentrations above the clinical cut-off for diabetes (≥7 mmol/L) compared to 2.1% of women of similar age (p=0.007). Similarly, 16.4% of men had Hb(A1c) concentrations ≥6.5%, compared to 1.5% of women (p=0.003). Children and teenagers had fasting glucose and Hb(A1c) values largely within the normal range. To conclude, this is the first study to provide data on the distribution of HbA1c and glucose concentrations in a nationally representative sample of the British population. The high prevalence of men aged ≥65 years with Hb(A1c) and glucose concentrations above the clinical cut-off of diabetes warrants further attention.

Use of data from the Health Survey for England in obesity policy making and monitoring.

Health data and statistics are the foundation of health policy. Over the last 20 years, numerous government documents have been commissioned and published to inform obesity strategies in the UK. The Health Survey for England, an annual cross-sectional survey of a nationally representative random general population sample in England, collects information on health, lifestyle and socioeconomic factors, physical measurements and biological samples. Heights and weights measured by the Health Survey for England are believed to have played a major part in promoting, shaping and evaluating obesity strategies. A formal review of how these data have been used has not been conducted previously. This paper reviews government documents demonstrating the contribution of Health Survey for England examination data to every stage of the policy making process: quantifying the obesity problem in England (e.g. Chief Medical Officer's reports); identifying inequalities in the burden of obesity (Acheson report); modelling potential future scenarios (Foresight); setting and monitoring specific, measurable, attainable targets (calorie reduction challenge in manufacturers' Responsibility Deal); developing and informing strategies and clinical guidance; and evaluating the success of obesity strategies (Healthy Weights, Healthy Lives progress report). Measurement data are needed and used by governments to produce evidence-based strategies to combat obesity.

Changes in waist circumference among adolescents in England from 1977-1987 to 2005-2007.

OBJECTIVE: To assess change in abdominal obesity in adolescents in England. STUDY DESIGN: Health Survey for England (HSE), annual cross-sectional surveys of nationally representative samples in England. METHODS: This study included 1770 children aged 11-16 years in HSE 2005-2007 with valid waist circumference (WC) measurements. WC and body mass index (BMI) were expressed as standard deviation scores (z scores) against the growth references used for British children. RESULTS: Mean WC z scores were substantially higher than mean BMI z scores for both sexes: WC 1.0 [95% confidence interval (CI) 0.93-1.1], BMI 0.54 (95% CI 0.44-0.63) for boys; WC 1.3 (95% CI 1.2-1.4), BMI 0.48 (95% CI 0.40-0.56) for girls (both P < 0.001). Mean WC z score was higher for girls than boys (P < 0.001). Between 1997 and 2005-2007, WC increased for both boys (P < 0.01) and girls (P < 0.001), but BMI did not (P > 0.05). Only children in the lowest WC decile had an increase in WC z score less than +1 standard deviation compared with the 1977-1987 baseline. BMI z score increased across the top nine deciles of the BMI distribution by 0.4 (2nd-4th deciles) to 0.9 (top decile). CONCLUSIONS: WC in adolescents has increased substantially, and probably more than BMI. The whole population has become fatter.

Persistent regional variation in treatment of hypertension.

OBJECTIVES: To assess regional variation within England in the proportion of people with survey-defined hypertension who were on treatment, and hypothesize if this was due to chance or confounding. STUDY DESIGN: Data from three annual, cross-sectional health examination surveys, the Health Survey for England. METHODS: Nationally representative random samples of the free-living general population were visited by an interviewer and a nurse. Blood pressure was measured with an automated monitor using a standardized protocol (2005: n = 5321, 2006: n = 10,213, 2007: n = 4848). Hypertension was defined as systolic blood pressure ≥140 mmHg, diastolic blood pressure ≥90 mmHg, and/or taking prescribed medication to lower blood pressure. RESULTS: In London, a higher proportion of participants with survey-defined hypertension were on anti-hypertensive medication in each separate year's sample compared with the rest of England [2005-2007 average: 61% men, 66% women in London; 43% men, 55% women in England (P for London vs rest of England <0.001 for each sex)]. Regression analysis showed that this regional effect [odds ratio (OR) 1.47 95% confidence interval (CI) 1.94-2.47, P = 0.031] was no longer significant after adjustment for demographic and socio-economic factors (OR 1.37, 95% CI 0.94-1.98, P = 0.101), but was strengthened (OR 1.69, 95% CI 1.09-2.60, P = 0.018) by including longstanding illness, diabetes, cardiovascular disease and health behaviours in the model. CONCLUSIONS: The proportion of hypertensive patients on anti-hypertensive medication was consistently above the national average in London, and this was associated with personal characteristics. Comorbidities increased the effect, even after adjustment for personal characteristics. This result may be due to greater population mobility in London, with more people having new patient health checks. Understanding this variation could enhance treatment nationally and internationally.

Genetic and environmental influences on sleep problems: a study of preadolescent and adolescent twins.

BACKGROUND/AIM: The aim of this study was to examine the extent to which additive genetic, shared environmental and non-shared environmental factors contribute to adolescent and preadolescent sleep problems. METHODS: The sample consisted of a cohort of 270 monozygotic and 246 dizygotic twins from a university-based twin registry. RESULTS: Results demonstrated that genetic and environmental influences each appear to be important to adolescent sleep problems. CONCLUSIONS: While the magnitude of genetic influence on sleep problems was consistent with findings from the adult literature, it was smaller than in studies with younger children, suggesting genetic effects may be less influential in adolescence and adulthood.

Sleep problems and temperament in adolescents.

The aim of this study was to determine the association between temperament and sleep in adolescents. Participants included 516 adolescents and their mothers drawn from the community. Findings indicated that as with younger children, sleep and dimensions of temperament (sociability, impulsivity and negative affect) are related in adolescents.

Institutionalizing health impact assessment in London as a public health tool for increasing synergy between policies in other areas.

OBJECTIVES: To describe the background to the inclusion of health impact assessment (HIA) in the development process for the London mayoral strategies, the HIA processes developed, how these evolved, and the role of HIA in identifying synergies between and conflicting priorities of different strategies. STUDY DESIGN: Case series. METHODS: Early HIAs had just a few weeks for the whole HIA process. A rapid appraisal approach was developed. Stages included: scoping, reviewing published evidence, a stakeholder workshop, drafting a report, review of the report by the London Health Commission, and submission of the final report to the Mayor. The process evolved as more assessments were conducted. More recently, an integrated impact assessment (IIA) method has been developed that fuses the key aspects of this HIA method with sustainability assessment, strategic environmental assessment and equalities assessment. RESULTS: Whilst some of the early strategy drafts encompassed some elements of health, health was not a priority. Conducting HIAs was important both to ensure that the strategies reflected health concerns and to raise awareness about health and its determinants within the Greater London Authority (GLA). HIA recommendations were useful for identifying synergies and conflicts between strategies. HIA can be successfully integrated into other impact assessment processes. CONCLUSIONS: The HIAs ensured that health became more integral to the strategies and increased understanding of determinants of health and how the GLA impacts on health and health inequalities. Inclusion of HIA within IIA ensures that health and health inequalities impacts are considered robustly within statutory impact assessments.

Time trends in childhood and adolescent obesity in England from 1995 to 2007 and projections of prevalence to 2015.

BACKGROUND: The aim was to examine the 1995-2007 childhood and adolescent obesity trends and project prevalence to 2015 by age group and social class. METHODS: Participants were children aged 2-10 and adolescents aged 11-18 years from general population households in England studied using repeated cross-sectional surveys. Obesity was computed using international standards. Prevalence projections to 2015 were based on extrapolation of linear and non-linear trends. RESULTS: Obesity prevalence increased from 1995 to 2007 from 3.1% to 6.9% among boys, and 5.2% to 7.4% among girls. There are signs of a levelling off trend past 2004/5. Assuming a linear trend, the 2015 projected obesity prevalence is 10.1% (95% CI 7.5 to 12.6) in boys and 8.9% (5.8 to 12.1) in girls, and 8.0% (4.5, 11.5) in male and 9.7% (6.0, 13.3) in female adolescents. Projected prevalence in manual social classes is markedly higher than in non-manual classes [boys: 10.7% (6.6 to 14.9) vs 7.9% (3.7 to 12.1); girls: 11.2% (7.0 to 15.3) vs 5.4% (1.3 to 9.4); male adolescents: 10.0% (5.2 to 14.8) vs 6.7% (3.4 to 10.0); female adolescents: 10.4% (5.0 to 15.8) vs 8.3% (4.3 to 12.4)]. CONCLUSION: If the trends in young obesity continue, the percentage and numbers of obese young people in England will increase considerably by 2015 and the existing obesity gap between manual and non-manual classes will widen further. This highlights the need for public health action to reverse recent trends and narrow social inequalities in health.

Smoke-free homes in England: prevalence, trends and validation by cotinine in children.

OBJECTIVE: To examine the prevalence of smoke-free homes in England between 1996 and 2007 and their impact on children's exposure to second-hand smoke via a series of annual cross-sectional surveys: the Health Survey for England. These comprised nationally representative samples of non-smoking children aged 4-15 (n = 13 365) and their parents interviewed in the home. Main outcome measures were cotinine measured in saliva, smoke-free homes defined by "no" response to "Does anyone smoke inside this house/flat on most days?", self-reported smoking status of parents and self-reported and cotinine validated smoking status in children. RESULTS: The proportion of homes where one parent was a smoker that were smoke free increased from 21% in 1996 to 37% in 2007, and where both parents were smokers from 6% to 21%. The overwhelming majority of homes with non-smoking parents were smoke free (95% in 1996; 99% in 2007). For children with non-smoking parents and living in a smoke-free home the geometric mean cotinine across all years was 0.22 ng/ml. For children with one smoking parent geometric mean cotinine levels were 0.37 ng/ml when the home was smoke free and 1.67 ng/ml when there was smoking in the home; and for those with two smoking parents, 0.71 ng/ml and 2.46 ng/ml. There were strong trends across years for declines in cotinine concentrations in children in smoke-free homes for the children of smokers and non-smokers. CONCLUSIONS: There has been a marked secular trend towards smoke-free homes, even when parents themselves are smokers. Living in a smoke-free home offers children a considerable, but not complete, degree of protection against exposure to parental smoking.

Undiagnosed diabetes-data from the English longitudinal study of ageing.

AIMS: Diabetes UK estimates a quarter of UK cases of diabetes are undiagnosed; 750,000 people have undiagnosed diabetes in addition to 2.25 million with known diabetes, but research studies examining this are contradictory. The aim was to determine the prevalence of, and risk factors for, undiagnosed diabetes in the population of England aged > 50 years and to calculate the percentage of cases of undiagnosed diabetes. METHODS: This was a cross-sectional study in a nationally representative sample of 6739 people aged 52-79 years from the English Longitudinal Study of Ageing (ELSA) 2004/2005. Diabetes cases were ascertained by self-reported doctor diagnosis of diabetes. A fasting plasma glucose measurement after a minimum of 8-h fast was available for 2387 (38% of the participants without diabetes). Undiagnosed diabetes cases were based on a fasting plasma glucose >or= 7.0 mmol/l. RESULTS: The overall weighted prevalence of diabetes was 9.1%; 502 people (7.5%) had self-reported diabetes (9.0% of men and 6.0% of women); 36 (1.7%) had undiagnosed diabetes (2.6% of men and 0.8% of women). Of cases of diabetes, 18.5% were undiagnosed (22% in men, 12% in women). Significant risk factors for undiagnosed diabetes were male sex, higher body mass index, waist circumference, systolic blood pressure and triglycerides. CONCLUSIONS: In 2004 the prevalence of undiagnosed diabetes, and the proportion of cases of diabetes that were undiagnosed, appear smaller than in previous studies. This is likely to be due to increased awareness of diabetes and improved clinical care resulting in many of those with previously undetected disease having been diagnosed.

Cardiorespiratory risk factors as predictors of 40-year mortality in women and men.

OBJECTIVE: Most historical studies of cardiorespiratory risk factors as predictors of mortality have been based on men. This study examines whether they predict mortality over long periods in women and men. DESIGN: Prospective cohort study. SETTING: Participants were employees of the General Post Office. METHODS: Risk factor data were collected via clinical examination and questionnaire, 1966-7. Associations between cardiorespiratory risk factors and 40-year mortality were determined for 644 women and 1272 men aged 35-70 at examination. MAIN OUTCOME MEASURES: All-cause, cardiovascular (CVD), cancer and respiratory mortality. RESULTS: Associations between systolic blood pressure and all-cause and stroke mortality were equally strong for women and men, hazard ratio (95% confidence interval) 1.25 (1.1 to 1.4) and 1.18 (1.1 to 1.3); and 2.17 (1.7 to 2.8) and 1.69 (1.4 to 2.1), respectively. Cholesterol was higher in women and was associated with all-cause 1.22 (1.1 to 1.4) and CVD 1.39 (1.2 to 1.7) mortality, while associations between 2-hour glucose and all-cause 1.15 (1.1 to 1.2), coronary heart disease (CHD) 1.25 (1.1 to 1.4) and respiratory mortality 1.21 (1.0 to 1.5) were observed in men. Obesity was associated with stroke in women (2.42 (1.12 to 5.24)) and CHD in men (1.59 (1.02 to 2.49)), while ECG ischaemia was associated with CVD in both sexes. The strongest, most consistent predictor of mortality was smoking in women and poor lung function in men. However, evidence of sex differences in associations between the cardiorespiratory risk factors measured and mortality was sparse. CONCLUSIONS: Data from a 40-year follow-up period show remarkably persistent associations between risk factors and cardiorespiratory and all-cause mortality in women and men.

Trends in obesity among adults in England from 1993 to 2004 by age and social class and projections of prevalence to 2012.

BACKGROUND: This study aims to project the prevalence of adult obesity to 2012 by age groups and social class, by extrapolating the prevalence trends from 1993 to 2004. Repeated cross-sectional surveys were carried out of representative samples of the general population living in households in England conducted annually (1993 to 2004). METHODS: Participants were classified as obese if their body mass index was over 30 kg/m(2). Projections of obesity prevalence by 2012 were based on three scenarios: extrapolation of linear trend in prevalence from 1993 to 2004; acceleration (or slowing down) in rate of change based on the best fitting curve (power or exponential); and extrapolation of linear trend based on the six most recent years (1999 to 2004). RESULTS: The prevalence of obesity increased significantly from 1993 to 2004 from 13.6% to 24.0% among men and from 16.9% to 24.4% among women. If obesity prevalence continues to increase at the same rate, it is projected that the prevalence of obesity in 2012 will be 32.1% (95% CI 30.4 to 34.8) in men and 31.0% (95% CI 29.0 to 33.1) in women. The projected 2012 prevalence for adults in manual social classes is higher (43%) than for adults in non-manual social classes (35%). CONCLUSION: If recent trends in adult obesity continue, about a third of all adults (almost 13 million individuals) would be obese by 2012. Of these, around 43% are from manual social classes, thereby adding to the public health burden of obesity-related illnesses. This highlights the need for public health action to halt or reverse current trends and narrow social class inequalities in health.

A review of health impact assessment frameworks.

BACKGROUND: Consideration of health impacts of non-health sector policies has been encouraged in many countries, with health impact assessment (HIA) increasingly used worldwide for this purpose. HIA aims to assess the potential impacts of a proposal and make recommendations to improve the potential health outcomes and minimize inequalities. Although many of the same techniques can be used, such as community consultation, engagement or profiling, HIA differs from other community health approaches in its starting point, purpose and relationship to interventions. Many frameworks have been produced to aid practitioners in conducting HIA. OBJECTIVE: To review the many HIA frameworks in a systematic and comparative way. STUDY DESIGN: Systematic review. METHOD: The literature was searched to identify published frameworks giving sufficient guidance for those with the necessary skills to be able to undertake an HIA. RESULTS: Approaches to HIA reflect their origins, particularly those derived from Environmental Impact Assessment (EIA). Early HIA resources tended to use a biomedical model of health and examine projects. Later developments were designed for use with policy proposals, and tended to use a socio-economic or environmental model of health. There are more similarities than differences in approaches to HIA, with convergence over time, such as the distinction between 'narrow' and 'broad' focus HIA disappearing. Consideration of health disparities is integral to most HIA frameworks but not universal. A few resources focus solely on inequalities. The extent of community participation advocated varies considerably. CONCLUSION: It is important to select an HIA framework designed for a comparable context, level of proposal and available resources.

The epidemiology of fractures in England.

INTRODUCTION: Fractures are a considerable public health burden in the United Kingdom but information on their epidemiology is limited. OBJECTIVE: This study aims to estimate the true annual incidence and lifetime prevalence of fractures in England, within both the general population and specific groups, using a self-report methodology. METHODS: A self-report survey of a nationally representative general population sample of 45,293 individuals in England, plus a special boost sample of 10,111 drawn from the ethnic minority population. RESULTS: The calculated fracture incidence is 3.6 fractures per 100 people per year. Lifetime fracture prevalence exceeds 50% in middle-aged men, and 40% in women over the age of 75 years. Fractures occur with reduced frequency in the non-white population: this effect is seen across most black and minority ethnic groups. CONCLUSIONS: This study suggests that fractures in England may be more common than previously estimated, with an overall annual fracture incidence of 3.6%. Age-standardised lifetime fracture prevalence is estimated to be 38.2%. Fractures are more commonplace in the white population.

The impact of private-sector provision on equitable utilisation of coronary revascularisation in London.

OBJECTIVE: To investigate the impact of including private-sector data on assessments of equity of coronary revascularisation provision using NHS data only. DESIGN: Analyses of hospital episodes statistics and private-sector data by age, sex and primary care trust (PCT) of residence. For each PCT, the share of London's total population and revascularisations (all admissions, NHS-funded, and privately-funded admissions) were calculated. Gini coefficients were derived to provide an index of inequality across subpopulations, with parametric bootstrapping to estimate confidence intervals. SETTING: London. PARTICIPANTS: London residents undergoing coronary revascularisation April 2001-December 2003. INTERVENTION: Coronary artery bypass graft or angioplasty. MAIN OUTCOME MEASURES: Directly standardised revascularisation rates, Gini coefficients. RESULTS: NHS-funded age-standardised revascularisation rates varied from 95.2 to 193.9 per 100,000 and privately funded procedures from 7.6 to 57.6. Although the age distribution did not vary by funding, the proportion of revascularisations among women that were privately funded (11.0%) was lower than among men (17.0%). Privately funded rates were highest in PCTs with the lowest death rates (p = 0.053). NHS-funded admission rates were not related to deprivation nor age-standardised deaths rates from coronary heart disease. Privately funded admission rates were lower in more deprived PCTs. NHS provision was significantly more egalitarian (Gini coefficient 0.12) than the private sector (0.35). Including all procedures was significantly less equal (0.13) than NHS-funded care alone. CONCLUSION: Private provision exacerbates geographical inequalities. Those responsible for commissioning care for defined populations must have access to consistent data on provision of treatment wherever it takes place.

Prevalence of cardiovascular risk factors among ethnic groups: results from the Health Surveys for England.

OBJECTIVE: To identify independent risk factors associated with cardiovascular disease (CVD) and diabetes for each minority ethnic group and the general population in England and explore the independent association of ethnicity and CVD and diabetes. PARTICIPANTS: Nationally representative samples of 2362 Black Caribbean, 2467 Indian, 2204 Pakistanis, 1985 Bangladeshis, 1385 Chinese, 2398 Irish, and 30,744 adults from the general population living in private households. RESULTS: CVD was relatively more common among: Indian and Chinese men with high waist-hip ratio; Indian, Bangladeshi and Irish with diabetes; Black Caribbean, Indian and Pakistani with hypertension; Bangladeshi and Pakistani ex-smokers and Indian ex-smokers and current-smokers; Pakistani that were moderate-drinkers and Indian heavy drinkers; Black Carribean Indian, Pakistani and Irish physically inactive; Pakistani in manual social class; and Bangladeshi in low income. Black Caribbean, Bangladeshi and Chinese participants and Indian and Pakistani women had significantly lower odds ratios of having CVD, compared with the general population. The odds of having diabetes were significantly higher for Black Caribbean, Indian, Pakistani and Bangladeshi, Chinese (men only) than participants from the general population. CONCLUSIONS: CVD prevention through control of risk factors, especially diabetes and hypertension, should not only address the general population, but also target people from these groups.