Established cardiovascular disease and CVD risk factors in a primary care population of middle-aged Irish men and women

Contemporary Irish data on the prevalence of major cardiovascular disease (CVD) risk factors are sparse. The primary aims of this study were (1) to estimate the prevalence of major cardiovascular disease risk factors, including Type 2 Diabetes Mellitus, in the general population of men and women between the ages of 50 and 69 years; and (2) to estimate the proportion of individuals in this age group at high absolute risk of cardiovascular disease events on the basis of pre-existing cardiovascular disease or as defined by the Framingham equation. Participants were drawn from the practice lists of 17 general practices in Cork and Kerry using stratified random sampling. A total of 1018 people attended for screening (490 men, 48%) from 1473 who were invited, a response rate of 69.1%. Cardiovascular disease risk factors and glucose intolerance are common in the population of men and women aged between 50 and 69 years. Almost half the participants were overweight and a further quarter met current international criteria for obesity, one of the highest recorded prevalence rates for obesity in a European population sample. Forty per cent of the population reported minimal levels of physical activity and 19% were current cigarette smokers. Approximately half the sample had blood pressure readings consistent with international criteria for the diagnosis of hypertension, but only 38% of these individuals were known to be hypertensive. Eighty per cent of the population sample had a cholesterol concentration in excess of 5 mmol/l. Almost 4% of the population had Type 2 Diabetes Mellitus, of whom 30% were previously undiagnosed. A total of 137 participants (13.5%) had a history or ECG findings consistent with established cardiovascular disease. Of the remaining 881 individuals in the primary prevention population, a total of 20 high-risk individuals (19 male) had a risk of a coronary heart disease event 30% over ten years according to the Framingham risk equation, giving an overall population prevalence of 2.0% (95% CI 1.3 - 3.0). At a risk level 20% over ten years, an additional 91 individuals (8.9%) were identified. Thus a total of 24.4% of the population were at risk either through pre-existing CVD (13.5%) or an estimated 10-year risk exceeding 20% according to the Framingham risk equation (10.9%). Thus a substantial proportion of middle-aged men are at high risk of CVD. The findings emphasise the scale of the CVD epidemic in Ireland and the need for ongoing monitoring of risk factors at the population level and the need to develop preventive strategies at both the clinical and societal level.

A post-structuralist analysis of Irish youth crime prevention policy with specific emphasis on the Garda youth diversion projects

Garda Youth Diversion Projects (GYDPs) have since their beginnings in the early 1990s gained an increasingly important role and now constitute a central feature of Irish youth justice provision. Managed by the Irish Youth Justice Service and implemented by the Gardai and a variety of youth work organisations as well as independent community organisations, GYDPs are located at the crossroads of welfarist and corporatist approaches to youth justice, combining diversionary and preventative aspects in their work. To date, these projects have been subjected to very little systematic analysis and they have thus largely escaped critical scrutiny. To address this gap, this thesis locates the analysis of GYDP policy and practice within a post-structuralist theoretical framework and deploys discourse analysis primarily based on the work of Michel Foucault. It makes visible the official youth crime prevention and GYDP policy discourses and identifies how official discourses relating to youth crime prevention, young people and their offending behaviour, are drawn upon, negotiated, rejected or re-contextualised by project workers and JLOs. It also lays bare how project workers and JLOs draw upon a variety of other discourses, resulting in multi-layered, complex and sometimes contradictory constructions of young people, their offending behaviour and corresponding interventions. At a time when the projects are undergoing significant changes in terms of their repositioning to operate as the support infrastructure underpinning the statutory Garda Youth Diversion Programme, the thesis traces the discursive shifts and the implications for practice that are occurring as the projects move away from a youth work orientation towards a youth justice orientation. A key contribution of this thesis is the insight it provides into how young people and their families are being constituted in individualising and sometimes pathologising ways in GYDP discourses and practices. It reveals the part played by the GYDP intervention in favouring individual and narrow familial causes of offending behaviour while broader societal contexts are sidelined. By explicating the very assumptions upon which contemporary youth crime prevention policy, as well as GYDP policy and practice are based, this thesis offers a counterpoint to the prevailing evidence-based agenda of much research in the field of Irish youth justice theory and youth studies more generally. Rather, it encourages the reader to take a step back and examine some of the most fundamental and unquestioned assumptions about the construction of young people, their offending behaviour and ways of addressing this, in contemporary Irish youth crime prevention policy and practice.

Prediction and prevention of venous thrombosis in pregnancy

Venous thromboembolism (VTE) remains the leading cause of maternal mortality. Reports identified further research is required in obese and women post caesarean section (CS). Risk factors for VTE during pregnancy are periodically absent indicating the need for a simple and effective screening tool for pregnancy. Perturbation of the uteroplacental haemostasis has been implicated in placenta mediated pregnancy complications. This thesis had 4 main aims: 1) To investigate anticoagulant effects following a fixed thromboprophylaxis dose in healthy women post elective CS. 2) To evaluate the calibrated automated thrombogram (CAT) assay as a potential predictive tool for thrombosis in pregnancy. 3) To compare the anticoagulant effects of fixed versus weight adjusted thromboprophylaxis dose in morbidly obese pregnant women. 4) To investigate the LMWH effects on human haemostatic gene and antigen expression in placentae and plasma from the uteroplacental , maternal and fetal circulation. Tissue factor pathway inhibitor (TFPI), thrombin antithrombin (TAT), CAT and anti-Xa levels were analysed. Real-time PCR and ELISA were used to quantify mRNA and protein expression of TFPI and TF in placental tissue. In women post CS, anti-Xa levels do not reflect the full anticoagulant effects of LMWH. LMWH thromboprophylaxis in this healthy cohort of patients appears to have a sustained effect in reducing excess thrombin production post elective CS. The results of this study suggest that predicting VTE in pregnant women using CAT assay is not possible at present time. The prothrombotic state in pregnant morbidly obese women was substantially attenuated by weight adjusted but not at fixed LMWH doses. LMWH may be effective in reducing in- vivo thrombin production in the uteroplacental circulation of thrombophilic women. All these results collectively suggest that at appropriate dosage, LMWH is effective in attenuating excess thrombin generation, in low risk pregnant women post caesarean section or moderate to high risk pregnant women who are morbidly obese or tested positive for thrombophilia. The results of the studies provided data to inform evidence-based practice to improve the outcome for pregnant women at risk of thrombosis.

An examination of the construction of meanings for obesity in Ireland

Obesity has been defined as a consequence of energy imbalance, where energy intake exceeds energy expenditure and results in a build-up of adipose tissue. However, this scientific definition masks the complicated social meanings associated with the condition. This research investigated the construction of meaning around obesity at various levels of inquiry to inform how obesity is portrayed and understood in Ireland. A multi-paradigmatic approach was adopted, drawing on theory and methods from psychology and sociology and an analytical framework combining the Common Sense Model and framing theory was employed. In order to examine the exo-level meanings of obesity, content analysis was performed on two media data sets (n=479, n=346) and a thematic analysis was also performed on the multiple newspaper sample (n=346). At the micro-level, obesity discourses were investigated via the thematic analysis of comments sampled from an online message board. Finally, an online survey assessed individual-level beliefs and understandings of obesity. The media analysis revealed that individual blame for obesity was pervasive and the behavioural frame was dominant. A significant increase in attention to obesity over time was observed, manifestations of weight stigma were common, and there was an emotive discourse of blame directed towards the parents of obese children. The micro-level analysis provided insight into the weight-based stigma in society and a clear set of negative ‘default’ judgements accompanied the obese label. The survey analysis confirmed that the behavioural frame was the dominant means of understanding obesity. One of the strengths of this thesis is the link created between framing and the Common Sense Model in the development of an analytical framework for application in the examination of health/illness representations. This approach helped to ascertain the extent of the pervasive biomedical and individual blame discourse on obesity, which establishes the basis for the stigmatisation of obese persons.

Defining metabolically healthy obesity: role of dietary and lifestyle factors

Background: There is a current lack of consensus on defining metabolically healthy obesity (MHO). Limited data on dietary and lifestyle factors and MHO exist. The aim of this study is to compare the prevalence, dietary factors and lifestyle behaviours of metabolically healthy and unhealthy obese and non-obese subjects according to different metabolic health criteria. Method: Cross-sectional sample of 1,008 men and 1,039 women aged 45-74 years participated in the study. Participants were classified as obese (BMI ≥30kg/m2) and non-obese (BMI <30kg/m2). Metabolic health status was defined using five existing MH definitions based on a range of cardiometabolic abnormalities. Dietary composition and quality, food pyramid servings, physical activity, alcohol and smoking behaviours were examined. Results: The prevalence of MHO varied considerably between definitions (2.2% to 11.9%), was higher among females and generally increased with age. Agreement between MHO classifications was poor. Among the obese, prevalence of MH was 6.8% to 36.6%. Among the non-obese, prevalence of metabolically unhealthy subjects was 21.8% to 87%. Calorie intake, dietary macronutrient composition, physical activity, alcohol and smoking behaviours were similar between the metabolically healthy and unhealthy regardless of BMI. Greater compliance with food pyramid recommendations and higher dietary quality were positively associated with metabolic health in obese (OR 1.45-1.53 unadjusted model) and non-obese subjects (OR 1.37-1.39 unadjusted model), respectively. Physical activity was associated with MHO defined by insulin resistance (OR 1.87, 95% CI 1.19-2.92, p = 0.006).

The impact of a variety of factors on the obesity associated gut microbiota

The obesity pandemic has become perhaps the most prevalent health issue of our time, with more than 10% of the world’s population now being obese. Obesity can be defined as abnormal or excess fat accumulation that may impair health and results from an imbalance between energy intake and energy expenditure. A decrease in physical activity due to an increase in sedentary forms of work, changing modes of transport and increasing urbanization is likely a major contributory factor. Diet is another major factor with the increased availability and intake of calorie dense, high fat foods being of global concern. Notably, with respect to this thesis, over the last decade advances in the field of next generation sequencing (NGS) have facilitated investigations to determine the relationship between the gut microbiota and obesity. This thesis examines the impact of a variety of factors on the obesity associated gut microbiota. Overall the results presented in this thesis highlight that microbial diversity is influenced by diet, exercise, antibiotics and disease state, however it is only through further understanding of the structure and function that we can identify targets that can impact on health.

Childhood obesity in Ireland: recent trends and modifiable determinants

Background: Childhood obesity is a global epidemic posing a significant threat to the health and wellbeing of children. To reverse this epidemic, it is essential that we gain a deeper understanding of the complex array of driving factors at an individual, family and wider ecological level. Using a social-ecological framework, this thesis investigates the direction, magnitude and contribution of risk factors for childhood overweight and obesity at multiple levels of influence, with a particular focus on diet and physical activity. Methods: A systematic review was conducted to describe recent trends (from 2002-2012) in childhood overweight and obesity prevalence in Irish school children from the Republic of Ireland. Two datasets (Cork Children’s Lifestyle [CCLaS] Study and the Growing Up in Ireland [GUI] Study) were used to explore determinants of childhood overweight and obesity. Individual lifestyle factors examined were diet, physical activity and sedentary behaviour. The determinants of physical activity were also explored. Family factors examined were parental weight status and household socio-economic status. The impact of food access in the local area on diet quality and body mass index (BMI) was investigated as an environmental level risk factor. Results: Between 2002 and 2012, the prevalence of childhood overweight and obesity in Ireland remained stable. There was some evidence to suggest that childhood obesity rates may have decreased slightly though one in four Irish children remained either overweight or obese. In the CCLaS study, overweight and obese children consumed more unhealthy foods than normal weight children. A diet quality score was constructed based on a previously validated adult diet score. Each one unit increase in diet quality was significantly associated with a decreased risk of childhood overweight and obesity. Individual level factors (including gender, being a member of a sports team, weight status) were more strongly associated with physical activity levels than family or environmental factors. Overweight and obese children were more sedentary and less active than normal weight children. There was a dose response relationship between time spent at moderate to vigorous physical activity (MVPA) and the risk of childhood obesity independent of sedentary time. In contrast, total sedentary time was not associated with the risk of childhood obesity independent of MVPA though screen time was associated with childhood overweight and obesity. In the GUI Study, only one in five children had 2 normal weight parents (or one normal weight parent in the case of single parent families). Having overweight and obese parents was a significant risk factor for overweight and obesity regardless of socio-economic characteristics of the household. Family income was not associated with the odds of childhood obesity but social class and parental education were important risk factors for childhood obesity. Access to food stores in the local environment did not impact dietary quality or the BMI of Irish children. However, there was some evidence to suggest that the economic resources of the family influenced diet and BMI. Discussion: Though childhood overweight and obesity rates appear to have stabilised over the previous decade, prevalence rates are unacceptably high. As expected, overweight and obesity were associated with a high energy intake and poor dietary quality. The findings also highlight strong associations between physical inactivity and the risk of overweight and obesity, with effect sizes greater than what have been typically found in adults. Important family level determinants of childhood overweight and obesity were also identified. The findings highlight the need for a multifaceted approach, targeting a range of modifiable determinants to tackle the problem. In particular, policies and interventions at the shared family environment or community level may be an effective mean of tackling this current epidemic.