Public health and population sciences 2014

Public Health and Population Sciences 2014

PHOTO: Phil Mynott

PHOTO: Flickr/ United Nations Photo

Our overarching mission is to improve the public’s health, using our research, teaching and analysis to promote well-being, prevent disease and reduce health inequalities.

PHOTO: James Cridland

PHOTO: Phil Mynott

PHOTO: Phil Mynott

PHOTO: Phil Mynott

PHOTO: Phil Mynott

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Health services research – highlights . . . . . . . . . . . . . . . . . . 21

Professor Dame Sally Davies, UK Chief Medical Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

MRC Epidemiology Unit . . . . . . . . . . . . . . . . . . . . . . . . 22 From understanding to prevention – epidemiology in action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

SECTION ONE: PURPOSE . . . . . . . . . . . . . .7

Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Epidemiology research – highlights . . . . . . . . . . . . . . . . . . . 23

Institute snapshot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Fenland Study passes key milestones . . . . . . . . . . . . . . . . . . 24

PublicHealth@Cambridge . . . . . . . . . . . . . . . . . . . . . . . 8

Building research expertise and infrastructure across borders – a new data sharing platform . . . . . . . . . . . . . . . . 24

Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Diet and physical activity – the population picture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Connecting public health and population sciences – a message from the Director, Professor Carol Brayne . . . 10

Visualising relationships between income, education and diet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

SECTION TWO: RESEARCH . . . . . . . . . . . 11

Diet and physical activity – highlights . . . . . . . . . . . . . . . . . 26

MRC Biostatistics Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Influencing public health in the UK and around the world – introduction by Professor Sir Leszek Borysiewicz . . . . . . . . . . . . . . . . . . . . . . . 12

Statistics for health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Biostatistics – highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Breadth and depth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

New at the Biostatistics Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Population studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

MRC Human Nutrition Research . . . . . . . . . . . . . . . 29

Department of Public Health and Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Improving health through nutrition . . . . . . . . . . . . . . . . . . . 29

Generating evidence to improve health . . . . . . . . . . . . . . 15 Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Health and nutrition – highlights . . . . . . . . . . . . . . . . . . . . . 30 The interface between epidemiology and clinical medicine – highlights . . . . . . . . . . . . . . . . . . . . . . . . . . 15

New developments in obesity research . . . . . . . . . . . . . . . 30

Evidence to support new screening and risk management initiatives – highlights . . . . . . . . . . . . . . . . . . . 15

NIHR School of Public Health Research . . . . . . 31

A new look at vitamin D deficiency . . . . . . . . . . . . . . . . . . . . 16

Research highlights from the Cambridge hub of the NIHR School of Public Health Research . . . . . . . . . . 31

Public Health, Ageing and the Brain – highlights . . . . . . . 16

University of North Carolina . . . . . . . . . . . . . . . . . . . 32

Embedding population research into routine health services – highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Reducing dementia risk factors in later life . . . . . . . . . . . . 32

International health research – highlights . . . . . . . . . . . . . . 17 Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Mobile data collection on marketing and regulatory compliance of tobacco, alcohol and food retailers . . . . 32

Primary Care research – highlights . . . . . . . . . . . . . . . . . . . . . 19

Information to inform obesity policy . . . . . . . . . . . . . . . . . . 33

Behaviour and health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Advancing longitudinal and missing data methodology for “big data” research in health . . . . . . . . . 33

Behaviour and health research – highlights . . . . . . . . . . . 20

Making research accessible – principles . . . . . . . . . . . . . . 34 4

SECTION THREE: ANALYSIS AND HEALTH INTELLIGENCE . . . . . . . . . . . . . . . 35 Public Health England . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Regional Knowledge and Intelligence . . . . . . . . . . . . . . . . . 36 Analysis and health intelligence . . . . . . . . . . . . . . . . . . . . . . 37 Health Intelligence – highlights . . . . . . . . . . . . . . . . . . . . . . . 37 Informing service delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Disease reports for professional audiences . . . . . . . . . . . . 38

The PHG Foundation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Informing service delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Making a difference in health policy and healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

SECTION FOUR: TEACHING AND TRAINING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Building leadership through our teaching and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Our teaching and training offer . . . . . . . . . . . . . . . . . . . . . . . 42 A culture of learning across disciplines . . . . . . . . . . . . . . . . 43 Spotlight on teaching and training . . . . . . . . . . . . . . . . . . . 44 Teaching and training the public health leaders of the future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

NIHR Collaboration for Leadership in Applied Health Research & Care (CLAHRC) East of England . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Pioneering partnership at NIHR CLAHRC East of England: research by staff in health and social care services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

SECTION FIVE: GOVERNANCE . . . . . . .

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Introduction Professor Dame Sally Davies, UK Chief Medical Officer The UK faces many health challenges: the way we live our lives is leading to an ever-increasing burden of conditions such as diabetes, obesity and liver disease. These are strongly linked to our behaviours: levels of physical activity and what we eat, smoke and drink. Antimicrobial resistance threatens to render many treatments useless, and problems such as mental illness are major concerns.

Professor Dame Sally Davies, UK Chief Medical Officer

Globally, as people are living longer, we are seeing the increasing importance of disorders affecting quality of life such as sensory loss and cognitive decline.

Non-communicable diseases are now the most frequent causes of death in most countries. These changes will have a significant impact on health systems, both in terms of cost and the focus away from communicable diseases to longterm care and management.

As the UK government’s principal medical adviser and the professional head of all directors of public health in local government, I have strived to ensure that data and scientific evidence is placed at the heart of policy making and advice to government. Research should underpin all our decision-making: we need evidence-informed policy and evidence-based implementation.

The Cambridge Institute of Public Health is one of our national strengths and plays a key role in generating the evidence and data we need, as a member of the NIHR School for Public Health Research, and by connecting its world class public health and population sciences research with clinical and public health services. It is the home of major national and international population studies and at the cutting edge of developments in the biomedical and population health sciences, behavioural sciences, health services research and biostatistics.

Meanwhile the Institute’s teaching and training programmes equip our future leaders of public health with the skills and knowledge they need to ensure that data and evidence drive decision-making.

I welcome the Institute’s latest report and commend its contribution to the public health agenda.

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SECTION ONE: PURPOSE

Our overarching mission is to improve the public’s health, using our research, teaching and analysis to promote well-being, prevent disease and reduce health inequalities.

Institute snapshot Our overarching mission is to improve public health, using our research, teaching and analysis to promote well-being, prevent disease and reduce health inequalities.

“Public health is the science and art of promoting and protecting the health and well-being of whole populations, preventing ill-health and prolonging life through the organised efforts of society.1” The Institute is a vibrant, multi-disciplinary partnership of academics and public health professionals, based at the University of Cambridge School of Clinical Medicine on the Cambridge Biomedical Campus.

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We carry out research in public health and population sciences

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We educate scientists, clinicians and public health professionals

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We analyse and interpret population health evidence and data

Director: Professor Carol Brayne

PublicHealth@Cambridge The PublicHealth@Cambridge Strategic Research Network was established in 2012 to bring investigators together from a range of disciplines who are engaged in research relevant to public health.

The Network facilitates collaboration beyond that enabled by the Cambridge Institute of Public Health, connecting a community of 850 public health specialists right across Cambridge. Dr Paula Frampton, Network coordinator, says: “We bring together anthropologists, engineers, computer scientists, geographers, sociologists, chemists and more, aiming to enable a transdisciplinary approach to understanding and seeking to solve local, national and international public health problems”.

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PublicHealth@Cambridge Network, 2013

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Section one: Purpose

Members Department of Public Health and Primary Care, University of Cambridge (John Danesh)

Medical Research Council Units MRC Biostatistics Unit (Sylvia Richardson) MRC Human Nutrition Research Unit (Ann Prentice)

Behaviour and Health Research Unit (Theresa Marteau) Cambridge Centre for Health Services Research (Martin Roland) Cardiovascular Epidemiology Unit (John Danesh) Centre for Cancer Genetic Epidemiology (Doug Easton, Paul Pharoah) Clinical Gerontology Unit (Kay-Tee Khaw) NIHR Biomedical Research Unit in Donor Health and Genomics (John Danesh) Nursing Research Group (Christi Deaton) Primary Care Unit (Jonathan Mant) Public Health, Ageing and the Brain (Carol Brayne)

Health policy think tank PHG Foundation (Hilary Burton)

Public Health England Units East of England Field Epidemiology Unit (Mark Reacher) The National Cancer Registration Service Eastern Office (Jem Rashbass) PHE Knowledge and Intelligence Team East (Julian Flowers)

Cross departmental programmes at the Institute Cambridge Biomedical Resource Centre – Evaluation and Implementation Theme (Carol Brayne, Hilary Burton, Martin Roland) Cambridge Biomedical Resource Centre – Population Science Theme (John Danesh, Nick Wareham) NIHR CLAHRC East of England (Carol Brayne, Peter Jones) NIHR School for Public Health Research (Cambridge hub: Carol Brayne)

MRC Epidemiology Unit, University of Cambridge (Nick Wareham)

Primary Care Unit

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Professor Carol Brayne, Director

Section one: Purpose

Connecting public health and population sciences – a message from the Director, Professor Carol Brayne The Institute was set up in 1993 to facilitate collaboration between population health scientists and the health service. Now, our strategic connections reach right across the academic, health service and policy arenas for public health.

We operate at the heart of the Cambridge Biomedical Campus, at the forefront of innovation and research in healthcare. Our health service partners include public health teams in local authorities, Cambridge University Hospitals, Papworth and the Cambridgeshire and Peterborough Foundation Trusts.

The PublicHealth@Cambridge Network that the Institute hosts for the University has a wider remit to connect research on all aspects of public health and population health across the six schools of the University and the wider Cambridge research base. The Network has already established an 850-person strong community of engineers, sociologists, clinicians, geographers and many others working on population health and well-being.

Our partnership at the Institute includes world class scientists working in many of the disciplines that are needed to address the multi-faceted wicked problems that face our global populations, from obesity and cardiovascular disease to dementia and mental illness.

This report describes the range and scope of our work in 2014, highlighting research news and key facts about our activities.

At the Institute, the internationally recognised research focus has been on non communicable diseases and diseases of ageing; we look in depth at how they reduce well-being in populations in the UK and internationally; and we are concerned with prevention, treatments, interventions and services to reduce the impact of these disorders and improve health.

Our ambitions are to develop an even stronger hub to connect experts across disciplines who can together generate the evidence and knowledge we need to tackle public health ‘grand challenges’ here and across the globe.

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SECTION TWO: RESEARCH

Embedded in a world-class university, with expertise across a range of research disciplines, Cambridge Institute of Public Health is uniquely placed to tackle the global challenges that reduce life expectancy and limit health and well-being in populations around the world.

Influencing public health in the UK and around the world – introduction by Professor Sir Leszek Borysiewicz Embedded in a world-class university, with expertise across a range of research disciplines, Cambridge Institute of Public Health is uniquely placed to tackle the global challenges that reduce life expectancy and limit health and well-being in populations around the world.

Professor Sir Leszek Borysiewicz, Vice- Chancellor of the University of Cambridge

The University of Cambridge has ambitious long term commitment to applying our combined expertise to public health issues, including the growing burden of non-communicable disease; the impact of our behaviour on our health (most importantly: diet, physical activity, alcohol and smoking) and the challenges of promoting active and healthier ageing. The Cambridge Institute of Public Health is playing a key role in this endeavour by helping to generate the capacity, reach and knowledge we need to tackle the global health issues of the 21st century.

Breadth and depth The Cambridge Institute of Public Health brings together population and public health research across the biological, medical and social sciences. We are hosted by the University of Cambridge School of Clinical Medicine and located at the heart of the Cambridge Biomedical Campus. Our strategic links with key research, clinical and service institutions provide a dynamic and innovative environment for research, within which our scientists deliver world class research programmes and produce knowledge and methodologies that help shape effective public health policy and practice in the UK and internationally.

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Section two: Research

Population studies Our population studies are the backbone of our epidemiological work and offer detailed assessments of participants over time. We help lead major studies in East Anglia, UK, and worldwide, including: ■■

The 2.5 million-participant Emerging Risk Factors Collaboration

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The INTERVAL bioresource of 50,000 healthy people across England

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50,000-participant case-control studies of acute vascular events in South Asia (including the studies, “BRAVE” and “PROMIS”)

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SEARCH, a population-based study of 30,000 cancer cases in Eastern England

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EMBRACE, a prospective national epidemiological study of families with BRCA1 and BRCA2 mutations

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The MRC Cognitive Function and Ageing study (CFAS), a longitudinal multi- centre study of ageing with research hubs throughout the country and Cambridge as the lead centre

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EPIC-Norfolk, a prospective population-based cohort study of 25,000 men and women followed up in Norfolk since 1993. EPIC-Norfolk is one of the two UK contributing cohorts to the EPIC-Europe study

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The Fenland study, a quantitative trait metabolic study of 12,500 participants aged 30-62 years at recruitment, who have undergone detailed metabolic phenotyping

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EPIC-Interact, the world’s largest study of incident type 2 Diabetes Mellitus with 12,403 incident cases, nested as a case-cohort study within the pan-European EPIC study which has amassed 4 million person years of follow-up

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EPIC-CVD, the world’s largest study of incident cardiovascular disease with over 20,000 incident coronary disease and stroke cases nested within the EPIC study

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The ADDITION study, a trial of screening for type 2 diabetes and intensive cardiovascular risk reduction in three European countries

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Department of Public Health and Primary Care The 400-person Department of Public Health and Primary Care (DPHPC) at the University of Cambridge is one of Europe’s leading academic departments of population health sciences. Its overall research mission is to generate evidence that will inform the prevention of premature death and disability, the promotion of health, and the formulation of evidence-based health policy.

Professor John Danesh

A major element of the Department’s research strategy is to build longterm relationships with key external partners in order to benefit from complementary perspectives and expertise and to accelerate the impact and dissemination of our research findings. Our strategic partners include major research institutes (eg the Wellcome Trust Sanger Institute), components of the health service (eg NHS Blood and Transplant), the notfor-profit sector (eg RAND-Europe), and industry (eg pharmaceutical and small biotechnology companies).

Section two: Research

Generating evidence to improve health The interface between epidemiology and clinical medicine – highlights

Evidence to support new screening and risk management initiatives – highlights

The Cambridge-Pfizer Centre for Cardiovascular Genomics (Director: Professor John Danesh), established to advance therapeutic target identification and validation, has identified interleukin-6 signalling as a novel causal risk factor (Lancet 2012, PLoS Genetics 2013). In 2013/14, the Centre was awarded MRC CASE studentships for joint PhD training, and was highlighted in the UK government’s Strategy for Life Sciences Report.

New national screening programme for aortic aneurysm The national screening programme for aortic aneurysm, rolled out by the Department of Health in England in 2013/14, was directly influenced by findings from the MASS trial and related studies (PI: Professor Simon Thompson).

These studies showed that ultrasound screening in men for abdominal aortic aneurysm reduces mortality and is costeffective (BMJ 2009, NEJM 2010, JAMA 2013).

Discovery of genetic risk factors

Cardiovascular risk management

In the past few years, scientists in the Department have led the discovery of >350 genetic loci in a range of common diseases (eg cancers, cardiometabolic diseases) and traits reported in >30 publications in Nature and Nature Genetics, opening new avenues of biology.

Findings from the Emerging Risk Factors Collaboration (PI: Professor John Danesh) have been cited in no less than 10 major contemporary risk management guidelines, such as those of the American Heart Association. The collaboration has shown that lipid assessment can be simplified by cholesterol measurement without the need to fast and without regard to triglyceride, and that assessing inflammation biomarkers and glycaemia measures provides only modest incremental value (eg. JAMA 2014, NEJM 2012, JAMA 2012).

Clinical epidemiology In 2013, the MRC and British Heart Foundation made a £3.5 million award under the Experimental Medicine Challenge Grant scheme to establish a UK-wide network to study the aetiology of pulmonary artery hypertension (PI: Professor Nick Morrell), including a national epidemiology component led by Professor John Danesh.

Cancer prediction tools Findings from SEARCH, a population-based study of 30,000 cancer cases in Eastern England, and EMBRACE, a prospective national epidemiological study of families with BRCA1 and BRCA2 mutations have led to the development of online prediction tools. The BOADICEA risk model for familial breast and ovarian cancer risk has been incorporated into NICE and other guidelines (Dr Antonis Antoniou, Professor Doug Easton). The PREDICT model for predicting breast cancer prognosis in the context of adjuvant therapy is also widely used (Professor Paul Pharoah).

Bioresources to support experimental medicine In 2014, the INTERVAL study (PI: Professor John Danesh) completed recruitment of 50,000 healthy blood donors across England and commenced genome-wide genotyping. As these individuals have agreed to invitation to research studies on the basis of their genetic make-up, INTERVAL can support experimental medicine as the UK’s largest recall-by-genotype bioresource (and the largest component of the NIHR BioResource).

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Department of Public Health and Primary Care

Generating evidence to improve health

A new look at vitamin D deficiency

Public Health, Ageing and the Brain – highlights

As many as one in ten people in Britain over forty years old may be vitamin D deficient, according to findings from a study of levels of vitamin D in blood samples taken from around 15,000 participants from the European Prospective Investigation into Cancer (EPIC) Norfolk Study, in order to identify optimal levels of the vitamin for health.

Dementia prevalence

“We know that vitamin D deficiency can be detrimental to health, but until now there has been no clear answer as to what is actually the ideal amount of the vitamin,” explains Professor Nick Wareham, Director of the Medical Research Council Epidemiology Unit at the University of Cambridge.”

“Our data suggest that a modest increase in vitamin D in the general population may minimise the number of people with very low levels of the vitamin and may have some benefits even for those whose levels are acceptable,” adds Professor Kay-Tee Khaw from the Clinical Gerontology Group at the Department of Public Health and Primary Care, University of Cambridge.

The Cognitive Function and Ageing Study (Professor Carol Brayne, Dr Fiona Matthews) reported new dementia prevalence figures for the UK (Lancet 2013), showing that dementia in the population, when ageing is taken into account, is significantly lower than it was 20 years ago. This paper won the Neurology, Mental Health and Dementia category of the Royal College of GPs paper of the year 2014 and the studies have had direct impact on policy and modelling.

Seven risk factors for dementia Modelling work undertaken by researchers within the NIHR Collaborative Leadership in Applied Research and Care East of England (CLAHRC EoE) updated the potential proportion of dementia in the population that might be prevented through tackling seven risk factors. This exercise led to an estimate of 30% of cases being associated with one or more of these risks (Lancet Neurology 2014).

Identifying research gaps A public consultation on perceived research gaps in dementia, conducted by the CLAHRC EoE with the James Lind Alliance (JLA) and the Alzheimer’s Society, elicited 1563 responses. These were sifted and turned into questions, followed by a comprehensive check of the literature to establish true gaps. The top ten list that emerged is now contributing to funders’ calls in the UK; and the Alzheimer’s Society in Canada is planning to replicate our methods.

The UK Dementia Platform The Cambridge studies are founder cohorts within the newly funded UK Dementia Platform, which aims to bring cohorts together to maximize the country’s potential for dementia research. Three of the UKDP programmes draw on the Institute’s strengths: i) Biostatistics; ii) Ethical, Legal and Social implications of new research; iii) brain donation programmes. This work is closely linked to the wider University, particularly neuroscience.

Reviewing evidence to underpin NICE guidance Systematic reviewing and synthesis of existing evidence is a strength in many groups across the Institute. The Public Health, Ageing and the Brain group was commissioned by NICE to review the published evidence on midlife interventions to prevent dementia, frailty and disability in later life for the upcoming guidance, currently at the consultation stage. Dr Louise Lafortune is the lead for this work and also sits on the relevant NICE committee.

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Section two: Research

Embedding population research into routine health services – highlights In 2014, the National Institute of Health Research awarded Cambridge a £4 million Biomedical Research Unit in Donor Health and Genomics (Director: Professor John Danesh). Partners include NHS Blood and Transplant, the Wellcome Trust Sanger Institute and the University of Oxford.

donors more frequently than present practice in England.

A secondary comparison evaluates whether a pro-active approach to the management of donor appointments can yield better outcomes than the service’s conventional approach.

E-health initiatives

A key strategy is to embed large trials and observational studies into the routine blood service.

A demonstration study (PI: Dr Emanuele Di Angelantonio) has commenced to link 200,000 blood donors with a wide range of electronic health records, with the objective of extending this linkage to 5 million donors. The goal is to create an “e-haemovigilance” platform that can address immediate questions (eg is apheresis donation associated with adverse consequences for bone health?) and unanticipated hypotheses about the effects of repeated donation on health and chronic disease.

Policy-oriented randomised trials In an unprecedentedly deep collaboration of research and operational teams working between the University of Cambridge and NHS Blood and Transplant, a randomised trial (PI: Professor John Danesh) completed recruitment of 50,000 men and women in 2014. It aims to determine whether blood can be safely and acceptably collected from

International health research – highlights There is a growing portfolio of international health research led from Cambridge.

Capacity-building in Africa

Cancer in West Asia

In 2013, the Wellcome Trust named Cambridge as the site of one of its five Centres for Global Health Research (Professors Danesh, Roland and Wareham are co-PIs of the Centre), focusing on support for public health researchers in Africa.

The Golestan Cohort Study is monitoring 50,000 people in northern Iran to identify risk factors for oesophageal cancer (co-PI: Professor Paul Pharoah).

Nutrition in resource-poor countries MRC Human Nutrition Research has programmes of work based in The Gambia, South Africa, Uganda and Bangladesh to study the nutritional requirements of vulnerable groups in resource-poor countries (Dr Ann Prentice and Dr Sophie Moore).

Pan-European research to inform screening policy A €6 million EU Framework 7 award supports the EPIC-CVD initiative (PI: Professor John Danesh), which aims to provide policy makers throughout Europe with a menu of evidencebased options for targeted and cost-effective cardiovascular risk assessment approaches tailored to the needs of Europe’s diverse populations.

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Cardiovascular disease in South Asia Case-control studies of acute cardiovascular events in Bangladesh (PIs: Dr Rajiv Chowdhury, Dr Di Angelantonio, Professor John Danesh) and Pakistan (PIs: Dr Danish Saleheen, Professor John Danesh) have recruited more than 50,000 participants during the past several years. A key goal is to elucidate the relevance of local risk factors (eg arsenic exposure in Bangladesh and consanguinity in Pakistan) to acute myocardial infarction.

Department of Public Health and Primary Care

Primary care The goal of the Primary Care Unit, in the Department of Public Health and Primary Care, is to reduce the burden of ill health by:

Professor Jonathan Mant

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identifying and targeting behaviours that lead to chronic disease

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improving early detection of illness

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improving the delivery of health services in community settings

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educating medical students, clinicians, researchers and educators.

Research at the Primary Care Unit is multidisciplinary, drawing in particular on clinical epidemiology and social and behavioural science. It ranges from qualitative interviews to meta-analyses of randomised trials. Particular strengths include the development of interventions based on expertise in behavioural techniques and the determinants of patient and practitioner behaviour, access to well-characterised cohorts, evaluation of interventions using precise objective measures of behaviour, conduct of randomised trials in primary care, extended follow-up to enable assessment of important clinical endpoints, and health care quality improvement.

We have five research groups with the following senior leadership: Cardiovascular and Diabetes (Professors Mant, Griffin & Deaton), Health Services Research (Professor Roland) Cancer (Dr Walter); Behaviour and Health (Professors Sutton & Marteau) and End of Life Care (Dr Barclay). The Primary Care Unit hosts the Department of Health funded Behaviour and Health Research Unit – see page 20 (Director: Marteau), the Clinical Nursing Research Group (Director: Deaton) and with RAND-Europe, forms a part of the Cambridge Centre for Health Services Research – see page 21 (Director: Roland).

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Section two: Research

Primary Care research – highlights Lifestyle changes and type 2 diabetes The importance of lifestyle changes after diagnosis of type 2 diabetes to reduce risk of cardiovascular complications were highlighted in four publications from the ADDITION study (Diabetes Care, Eur J Clin Nutr, Diabetic Medicine, Diabetologia 2014) and a randomised trial incorporating precise objective measurement of behaviours among nearly 500 recently diagnosed patients underlined the challenges of achieving recommended changes (Diabetologia 2014).

Self-treatment for high risk blood pressure patients

News

Self-monitoring of hypertension with self-titration of medication in people with stroke, coronary heart disease, diabetes and chronic renal failure can lead to better control of blood pressure (JAMA 2014).

Clinical Nursing Research Group

Better management of heart failure Management of heart failure in primary care can be improved through a programme of audit, feedback and support from heart failure specialist nurses, but facilitation of evidence-based practice must negotiate tensions within practice, local and national contexts (BMC Family Practice 2014).

Chemotherapy in the community The first UK randomised trial of chemotherapy in the community found home or GP practice based chemotherapy were preferred to hospital based chemotherapy by patients with no difference in health outcomes or costs (British Journal of Cancer 2013).

Patient preferences for cancer investigation A study of patient preferences for cancer investigation (Lancet Oncology, 2014) provided evidence for the current revision of the NICE clinical guideline on referral for suspected cancer, and findings from a qualitative study of symptom appraisal and help-seeking among people newly diagnosed with melanoma (BMJ Open, 2014) influenced the Department of Health’s ‘Be Clear on Cancer’ skin cancer campaign.

Supporting smokers to quit The iQuit in Practice trial (Addiction 2014) showed that an intervention combining web-based advice and tailored text messages produced a clinically significant increase in prolonged abstinence at 6 months among smokers in primary care.

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This new research programme currently focuses on patients with heart disease, diabetes and stroke.

The goal is to help patients live healthier lives through exercise and physical activity, supported self-management, and improved care. There is a focus on building research knowledge and skills among nurses, midwives and allied health professionals at Cambridge University and Cambridge University Hospitals NHS Foundation Trust, and supporting them in developing clinical academic careers.

Christi Deaton was appointed November 2013 as the Florence Nightingale Foundation Professor of Clinical Nursing Research.

Department of Public Health and Primary Care

Behaviour and health The Behaviour and Health Research Unit (BHRU), hosted by the Primary Care Unit at the Department of Public Health and Primary Care, is funded as part of the Department of Health Policy Research Programme as the Policy Research Unit on behaviour and health. Our aim is to contribute evidence to UK policy makers as well as national and international efforts to achieve sustained behaviour change that improves health outcomes and reduces health inequalities. In addition we study public acceptability of government intervention to change health-related behaviour.

The four sets of behaviour of interest to us are smoking, excessive consumption of alcohol and food, and physical inactivity.

Professor Theresa Marteau

Our particular focus is upon the impact of changing micro-environments (also known as “choice architecture” or “nudging”) to alter behaviour, often without awareness of the actor. Examples of such interventions include the sizes in which food and drinks are presented (which influences how much is consumed), the branding in which tobacco is sold (which influences its appeal and in turn likelihood of purchasing and consumption), the design of desks (which influences how much energy is expended during a working day, with those using sit-stand desks expending more energy than those using traditional desks). The methods we use for estimating effect sizes for these types of interventions include systematic reviews and primary research, particularly experiments

Behaviour and health research – highlights Choice architecture The first large scale scoping review of “choice architecture” interventions, which included an operational definition and provisional typology, was published (BMC Public Health 2013). This directly informed NICE research recommendations (Public Health Guidance #49) and led to an NIHR call for research.

Placement of alcohol and other beverages in supermarkets The first estimate of the impact of placing alcohol and other drinks on end-of-aisle displays showed that altering these displays may have as much impact as some pricing interventions currently being considered by policy-makers (Soc, Sci and Med 2014).

Public acceptability of government intervention to change behaviour The first systematic review of studies of public attitudes to government interventions to reduce tobacco and alcohol use, increase physical activity and improve diet was completed. Acceptability varied as a function of i. the targeted behaviour, with more support for smoking-related interventions; ii. the type of intervention, with most support for least intrusive interventions, those targeting children and young people; iii. respondents, with those not engaging in the targeted behaviour, women and older respondents being more supportive of intrusive interventions (BMC Public Health 2013).

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Section two: Research

Health services The Cambridge Centre for Health Services Research (CCHSR) is a collaboration between the Primary Care Unit at the Department of Public Health and Primary Care at the University of Cambridge and the Health and Healthcare group at RAND Europe. Our work focuses on: ■■

Developing methods of measuring quality of care

■■

Evaluating ways of improving the quality of health care

■■

International healthcare comparisons

Professor Martin Roland

Health services research – highlights Quality of care Our work on measuring quality of care this year has focused on using measures of patient experience. We have shown that the current NHS approach to measuring patient experience at practice level is fine for high scoring practices which are very unlikely to include a low scoring GP. However, low scoring practices often contain both high and low scoring GPs (BMJ in press). Analysis of the national GP Patient Survey showed that people from sexual minorities are not only more likely to report poor health (especially mental health), but also report worse experiences of healthcare (Journal of General and Internal Medicine 2014). Our work on patient surveys in patients with cancer shows how routine survey data can be used to explain delay patterns in presentation of specific cancers.

Evaluating pay for performance We continue with evaluation of both pay for performance schemes and interventions designed to integrate care. The initial reduction in mortality which we showed associated with a pay for performance scheme in the North West of England (NEJM 2012) appeared to have been lost when followed up 30 months later. However some of the apparent loss of effect appeared to be due to positive spill overs of the incentives scheme onto other aspects of care (NEJM 2014).

Analysis of the GP Quality and Outcomes Framework showed an effect of the scheme in reducing emergency admissions to hospital (BMJ in press). Both these studies are among the first to show that pay for performance schemes may have a positive impact on health outcomes. Our expertise on pay for performance has been used through advisory work for Monitor and visits to advise governments in Singapore and Brazil.

International comparisons Published international comparisons this year include a study of chronic care across Europe, and comparative studies of teenage exposure to alcohol advertising, patient choice of healthcare, pharmaceutical pricing, regulation of quality and safety in health and social care, and a comparison of the four healthcare systems in the UK.

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MRC Epidemiology Unit From understanding to prevention – epidemiology in action The MRC Epidemiology Unit aims to understand the genetic, developmental and environmental determinants of obesity, diabetes and related metabolic disorders and to translate this understanding into preventive action.

Professor Nick Wareham

The Unit has a number of inter-linked programmatic areas that are supported by a core set of large scale epidemiological studies, detailed quantitative trait metabolic studies, case control studies and trials that serve both aetiological and preventive purposes.

Underpinning all MRC Epidemiology Unit scientific programmes are specialist research support teams which are primarily involved in data collection, measurement and providing core scientific infrastructure. The shared use of a common set of studies which are supported by a shared infrastructure is a key feature of how the Unit operates

Section two: Research

Research Epidemiology research – highlights Lifestyle factors outweigh genetics in risk for type 2 diabetes

Measuring different fatty acids and their contribution to health and disease

Obese individuals have the highest risk of developing type 2 diabetes regardless of their genetic risk score, according to a study by Unit Director Professor Nick Wareham and colleagues (PLoS Medicine 2014). The study examined the combined effects of a genetic risk score for type 2 diabetes based on 49 known genetic variants for the disease, and lifestyle factors, on the development of diabetes in participants in the EPIC-InterAct study.

The MRC Epidemiology Unit collaborated with Jules Griffin and colleagues in the MRC Human Nutrition Research Unit to develop a sophisticated method for high throughput measurement of phospholipid fatty acids in blood, and applied these methods in the large scale EPIC-InterAct project in order to examine the associations between individual saturated fatty acids of different carbon chain lengths and the risk of Type 2 Diabetes.

Commenting on the implications for public health, Professor Nick Wareham said:

Dr Nita Forouhi of the MRC Epidemiology Unit and colleagues showed that the relationship between saturated fat and type 2 diabetes is more complex than previously thought, as saturated fatty acids were found to be associated with both an increased and decreased risk of developing the disease, depending on the type of fatty acids present in the blood (Lancet Diabetes and Endocrinology August 2014). By combining large-scale population data with advanced laboratory analysis, this research has delivered a compelling case to look more closely at the contribution of individual components of fat to health and disease.

“We need effective strategies in place if we are going to stem the rapid rise in the number of cases of type 2 diabetes and the burden this places on our health systems.

Our research suggests that focusing on tackling the lifestyle factors that lead to obesity at a population level will have a much greater impact than tailoring prevention strategies according to an individual’s genetic risk.”

New insight into the activity of imprinted genes Epigenetics, the study of heritable changes that are not caused by changes in the DNA sequence, is an increasingly important area of medical research. It includes the study of ‘imprinted’ genes, a small sub-set of genes whose activity differs depending on which parent the gene is inherited from. An international study led by Dr Ken Ong and involving scientists from 166 institutions worldwide, demonstrated for the first time that imprinted genes can control rate of development after birth in humans. The results of the study of more than 180,000 women (Nature 2014) showed that the age at which girls reach sexual maturity is influenced by imprinted genes.

“We need effective strategies in place if we are going to stem the rapid rise in the number of cases of type 2 diabetes and the burden this places on our health systems.

Our research suggests that focusing on tackling the lifestyle factors that lead to obesity at a population level will have a much greater impact than tailoring prevention strategies according to an individual’s genetic risk.”

Lead author Dr John Perry highlighted the growing appreciation of the potential role of imprinted genes in health and disease: “We knew that some imprinted genes control antenatal growth and development – but there is increasing interest in the possibility that imprinted genes may also control childhood maturation and later life outcomes, including disease risks.”

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MRC Epidemiology Unit

Research

Fenland Study passes key milestones The Fenland Study investigates the interaction between environment and genetic factors in determining intermediate quantitative metabolic traits related to obesity and risk of type 2 diabetes. It is unique in the level of detail collected about the genetics, health and lifestyle of participants, and the objective measurement techniques used, for example, individually-calibrated combined heart rate and movement sensing to measure free-living physical activity and direct measures of resting energy expenditure and cardio-respiratory fitness.

We were delighted that the 12,000th volunteer joined the Fenland study in 2014 and this year has also seen the launch of a follow up Fenland study to investigate the relationship between change in objectively quantified behaviours and body composition and the risk of obesity, type 2 diabetes and related metabolic disorders.

The methods we have pioneered in the Fenland study are now being implemented in studies around the world such as those in Alaska, Cameroon and Kuwait.

Building research expertise and infrastructure across borders – a new data sharing platform A major new project for 2014 is the EU FP7 funded InterConnect project which is coordinated by the Unit. InterConnect aims to change the way in which data is used in population research into the causes of diabetes and obesity. It seeks to create the foundation to enable research to move from explaining the differences in risk of diabetes and obesity within populations to being able to explain differences in risk between populations. InterConnect provides a new approach to data sharing which is secure, scalable and sustainable. There are three main elements to the platform that is being created: ■■

A study registry that enables scientists to identify the full range of resources available

■■

Tools and processes for the harmonisation of data

■■

A secure, federated network that provides a mechanism for meta-analysis of individual participant data while the data stays within the governance arrangements of the organisation that collected it.

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Section two: Research

Diet and physical activity – the population picture The MRC Epidemiology Unit hosts the Centre for Diet and Activity Research (CEDAR), one of five UKCRC funded Centres of Excellence in Public Health Research. CEDAR, which also includes researchers from MRC BSU and the University of East Anglia, has enabled the Unit to develop its work on the wider determinants of dietary and physical activity related behaviours.

CEDAR is building research capacity, broadening understanding of the factors that influence what we eat and how much we move around, and is developing and evaluating population level interventions. This is enabling it to work with practice and policy to influence strategies to support sustainable healthy behaviours at the population level.

Visualising relationships between income, education and diet As part of its work in knowledge exchange, CEDAR produces a range of Evidence Briefs. “These are succinct summaries of our findings, developed in collaboration with policymakers and practitioners, and aimed at making our findings useful for public health decision makers.” said Oliver Francis, knowledge broker at CEDAR. Soft drinks (not low calorie) Low calorie soft drinks Other bread

Wine Beer, lager, cider, perry

High bre breakfast cereals Yogurt & fromage frais

White bread Burgers, kebabs

Tea, co ee, water

Brown, granary & wheatgerm bread Other breakfast Nuts & cereals seeds Bacon & ham

1% fat milk

Meat pies & pastries

Meat pies & pastries Coated chicken Beef & veal dishes

Skimmmed milk Cheese

Ice cream

Wine Beer, lager, cider, perry Skimmmed milk Yogurt & fromage frais Semi-skimmed milk

Sausages

Chicken & turkey dishes Sugar confectionery Low fat spread Puddings

Spirits & liqueurs

Smoothies & 100% fruit juice

Chocolate confectionery

Fruit Dietary supplements

Biscuits Crisps & savoury snacks Low fat spread

Ar cial sweeteners

Pasta rice & Tea, co ee, water other cereals Brown, granary & wheatgerm bread Other bread Wholemeal bread

Wine

Cheese 1% fat milk

Nuts & seeds

Game birds

Oily sh

Lamb & lamb dishes

Other white sh

Buns, cakes, pastries, fruit pies Low fat spread

Yogurt & fromage frais Skimmmed milk Salad & other raw vegetables Fruit

Smoothies & 100% fruit juice

Fruit juice Vegetables, not raw

This image is taken from a very popular 2014 data visualisation, which explored income, education and diet relationships.

See it at: www.cedar.iph.cam.ac.uk/resources/evidence/

Physical inactivity is estimated to account for around 1 in 10 deaths worldwide, comparable to the impact of smoking; and 70,000 premature deaths in the UK alone could be avoided each year if diets matched nutritional guidelines. The behaviours behind these statistics do not exist in isolation: they are driven as much by the social, cultural, economic and physical environment in which we live as they are by our personal attitudes and beliefs.

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MRC Epidemiology Unit

Diet and physical activity - the population picture

Diet and physical activity – highlights Impact of the Boris Bike and cycling infrastructure The London cycle hire scheme has had a positive overall effect on the health of its users by increasing physical activity (BMJ 2013). These benefits outweigh the potential negative impacts from injuries and exposure to air pollution, although the health benefits are not as pronounced in younger adults.

Dr James Woodcock noted “Reducing road traffic danger is another key factor.

If cycling in central London was as safe as in cities in the Netherlands, the health benefits from initiatives like the cycle hire scheme would be far more substantial.

The Netherlands manages to achieve high levels of cycling with low risks, not by focusing on helmets and hi-vis, but by providing high quality infrastructure that physically protects cyclists from busy, fast moving traffic.”

Other recent CEDAR research in the area of active travel has found that the provision of new, high-quality, traffic-free cycling and walking routes in local communities has encouraged more people to get about by foot and by bike.

CEDAR health economists also found that walking, cycling or taking public transport to work is better for people’s mental health than driving.

Price gap between more and less healthy foods grow

News

Research which tracked the price of 94 key food and beverage items from 2002 to 2012 showed that more healthy foods were consistently more expensive than less healthy foods, and have risen more sharply in price over time (PLOS One 2014).

Professor Martin White

“Food poverty has become an issue of public concern in the UK, and it is important that a healthy diet remains affordable,” said lead author Nicholas Jones. “The increase in the price difference between more and less healthy foods is a factor that may contribute towards growing food insecurity, increasing health inequalities, and a deterioration in the health of the population.”

Takeaway exposure associated with increased consumption and obesity People who live and work near a high number of takeaway food outlets tend to eat more of these foods and are more likely to be obese than those less exposed (BMJ 2014). Those most exposed to takeaway outlets were almost twice as likely to be obese than those who encountered the fewest outlets.

Dr Thomas Burgoine said: “Our study provides new evidence that there is a relationship between the number of takeaway food outlets we encounter, our consumption of these foods, and how much we weigh. Our findings suggest that taking steps to limit takeaway outlets in our towns and cities, particularly around workplaces, may be among the ways we can positively influence our diet and health.”

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Among a number of new developments linked to the successful refunding of CEDAR for a second five year period, Professor Martin White has been appointed from October 2014 to lead research on the determinants of behaviour and the development and evaluation of interventions that impact dietary behaviours.

Section two: Research

MRC Biostatistics Unit Statistics for health The MRC Biostatistics Unit (BSU) is one of the largest groups of biostatisticians in Europe, and a major centre for research, training and knowledge transfer, with the mission “to advance biomedical science by maintaining an international leading centre for the development, application and dissemination of statistical methods”.

“Statistics is applicable in all aspects of medicine, epidemiology and public health,” says Sylvia Richardson, Director of the MRC BSU in Cambridge since 2012. “Statistics should be the base for designing clinical trials as well as evaluating the effectiveness of public policies.”

Professor Sylvia Richardson

Our current and recent research on new trial designs, accounting for biases arising from missing data, evidence synthesis methods to inform health, longitudinal and multi-state processes and models for linking genetic information to disease, has direct impact on clinical practice and public health.

MRC Biostatistics Unit

Research Biostatistics – highlights Detecting Streptococcus pneumoniae HIV incidence in England and Wales among subtypes to effectively fight acute respiratory men who have sex with men not falling infections

Figures from a new study by the MRC BSU and Health Protection Agency found that despite a significant increase in HIV testing and treatment, the number of new HIV infections in men who have sex with men (MSM) has remained unchanged over the last 10 years in England and Wales. The research also reports that undiagnosed HIV infections remained high and annual new diagnoses rose steadily from 2001-2010. These results show that HIV transmission amongst MSM remains a significant public health issue. (Lancet Infectious Diseases 2013).

Lorenz Wernisch’s group, from the Statistical Genomics theme at the MRC Biostatistics Unit (BSU), is analysing data on Streptococcus pneumoniae, also called pneumococcus, the main cause of pneumonia and meningitis in children and the elderly and a major cause of mortality worldwide.

The Bacterial Microarray Group at St. George’s, University of London (BμG@S) designed a novel genomic microarray (this is a collection of microscopic DNA spots attached to a solid surface) capable of detecting multiple subtypes in clinical samples. BSU scientists developed a sophisticated Bayesian statistical model for detection and classification of these subtypes from the microarray data with both high specificity and sensitivity. Their research utilises a multidisciplinary approach that incorporates microbiology, immunology, and molecular biology to investigate carriage of the pneumococcus and other respiratory pathogens in order to evaluate and enhance vaccination strategies worldwide.

Understanding smoking cessation trials This collaboration with the Behavioural Science Group at the Primary Care Unit used statistical analyses of data from the iQuit smoking cessation trial, and found that participants who did not report their smoking status were much more similar to those who did report than is commonly assumed (Addiction 2014).

New at the Biostatistics Unit

Dementia prevalence figures show decline Dementia prevalence figures in the UK show a marked decline over the past 20 years in results from two major cohort studies supported by the Medical Research Council and led by the Cambridge Institute of Public Health. The figures revealed that the number of people with dementia in the UK is substantially lower than expected because overall prevalence in the 65 and over age group has dropped. The two studies provide the first estimate of the change in the number of people living with dementia in the UK, and the new figures give a more accurate picture for those developing policies and planning healthcare services for dementia patients. The multi-partner team includes Dr Fiona Matthews from the BSU and Professor Carol Brayne, Director of the Institute.

The University of Bristol, with partners at University College London, the MRC Biostatistics Unit, and the University of the West of England, were awarded government funding of £3,865,761 for health protection research. The money will be used to fund one of 12 National Institute for Health Research (NIHR) Health Protection Research Units (HPRUs) - partnerships between universities and Public Health England (PHE) in a range of priority areas. Dr Daniela De Angelis (BSU) and Dr Mary Ramsay (PHE) will lead the Evidence synthesis stream.

News: Sach Mukherjee is the new Programme Leader in Statistics and Machine Learning for Precision

Medicine and Brian Tom now leads the Stratified Medicine Initiative at the MRC Biostatistics Unit.

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Section two: Research

MRC Human Nutrition Research Improving health through nutrition MRC Human Nutrition Research (HNR) conducts internationallyrenowned research aimed at improving health through nutrition. The Unit is led by Dr Ann Prentice.

Our mission is to conduct nutrition research and surveillance to improve the health of the population with a focus on cardiometabolic risk and obesity, musculoskeletal health, intestinal function and nutritional vulnerabilities.

Dr Ann Prentice

To do this we take an integrative ‘molecules-to-man’, multidisciplinary approach to address priority research questions in nutritional physiology that are of public health and clinical relevance and that advance knowledge through discovery science. We work to translate our research through the exchange of knowledge and technology with governments, nutrition and health professionals, industry, academia and the public.

MRC Human Nutrition Research

Research Health and nutrition – highlights Calcium supplementation in the Gambia Calcium supplementation of Gambian children and pregnant women causes unintended, potentially adverse, long-term effects on growth and skeletal mineralisation, without the anticipated benefits. This finding cautions against applying dietary recommendations based on Western populations to countries such as The Gambia without supporting evidence (Am J Clin Nutr. 2013).

Nano iron A successful human trial of iron absorption from nano-formed, organic acidmodified Fe(III) oxo-hydroxide materials, found the most promising preparation (iron hydroxide adipate tartrate: IHAT) showed a bioavailability similar to that of Fe(II) sulphate but without the negative effects of the latter such as luminal redox activity and intestinal cell toxicity(Nanomedicine 2014). Dr Jonathan Powell, Dr Dora Pereira and colleagues hope to attract further funding to continue trials in humans with the aim of developing an effective and safe treatment for iron deficiency anaemia.

Fatty acids analysis Led by Dr Albert Koulman, and collaborators at the MRC Epidemiology Unit, we analysed the fatty acid component of blood plasma from the Interact cohort (aprox 28,000). This has shown that an increased risk of type 2 diabetes is associated with higher proportions of dietary myristatep, palmitate and stearate, a result that contributes to the data about health risks of saturated fat in the diet (Lancet Diabetes Endocrinol. 2014). More about this collaboration on Page 23.

Vitamin D metabolism HNR is developing new mechanistic approaches to studying vitamin D requirements in health and disease. We have recently developed novel stable isotope tracer and mass spectrometric methods to measure the plasma disappearance of 25-hydroxyvitamin D.

New developments in obesity research MRC Human Nutrition Research has been awarded £1 million to fund a new collaborative programme to investigate human fat metabolism, led

by Dr Jules Griffin, in collaboration with Professor Antonio Vidal-Puig (MRC Metabolic Disease Unit) and Professor Nick Wareham and Dr Nita Forouhi, MRC Epidemiology. The funding is part of a Medical Research Council (MRC) and Wellcome Trust £24m investment into obesity research, led by the Wellcome Trust-MRC Institute of Metabolic Science (IMS) and the MRC Epidemiology Unit.

30

News Dr Sophie Moore is Group Leader of the new Maternal and Child Nutrition Research Group and Dr Mario Siervo was appointed to lead the new Nutrition, Ageing and Health Group.

Section two: Research

NIHR School of Public Health Research The Cambridge Institute of Public Health is a member of the NIHR School for Public Health Research, and is leading several national programmes of research and delivering a set of local programmes. The School is a national partnership between eight leading academic centres with excellence in applied public health research in England, aiming to build the evidence base for effective public health practice.

Research highlights from the Cambridge hub of the NIHR School of Public Health Research Reducing obesity in young children Dr Rajalakshmi Lakshman’s project will inform the design and content of interventions to reduce obesity in young children. Three systematic reviews were conducted, protocols have been published and final peer-review publications are well underway, focusing on the following interventions: intake of sugary drinks, intake of high calorie foods, fruit and vegetable consumption, and sedentary behaviours.

The reviews will guide intervention and policy development to prevent childhood obesity.

Ageing well The Ageing Well Programme is a 4-year national programme, co-ordinated by Dr Louise Lafortune and steered by Professor Carol Brayne. This programme is developing an integrated public health approach to optimise health in older age groups, building on a translational framework and four building blocks: a) risk prediction and stratification, b) synthesis and development of evidence about current practice and equity, c) identification and evaluation of preventive interventions tailored for gains in health and well-being, and d) population modelling.

Relocation and well-being The RElocation to New environments (RENEW) study is led by Dr David Ogilvie.

This study is evaluating the impact of relocation to new residential environments on active living, individual and social well-being and related outcomes.

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Pioneering collaboration with the University of North Carolina A collaboration to transform public health has been forged between the University of Cambridge and the University of North Carolina at Chapel Hill (UNC) Gillings School of Global Public Health. The collaboration builds on the two universities’ complementary strengths in areas such as biostatistics, epidemiology, obesity, non-communicable diseases, ageing, health behaviour and global health. Four pilot projects are ongoing since 2012, funded by contributions from both University partners, together with a recent donation from Dennis and Mireille Gillings.

Reducing dementia risk factors in later life

Mobile data collection on marketing and regulatory compliance of tobacco, alcohol and food retailers

Professor Carol Brayne (Cambridge) and Professor Peggye Dilworth-Anderson (UNC)

Professor Theresa Marteau (Cambridge) and Professor Kurt Ribisl (UNC)

Building on the principles of Community Based Participatory Research (CBPR), evidence reviews and large datasets, this project has two general aims: ■■

To further our understanding of the complex relationship between cognitive health and culturally sensitive risk and protective factors, such as ethnicity, urban versus rural settings, quality and intensity of social networks, participation.

■■

To develop a framework for developing interventions to maintain and improve cognitive health, tailored to diverse cultural groups.

This project aims to evaluate how consumers respond to alternative point of sale (POS) information (eg, price and alcohol content). POS marketing for tobacco and alcohol products was very high in Wake County. By contrast, in London POS marketing for tobacco was very low while alcohol marketing was more common.

The team discovered these marked differences reflect dramatic differences in tobacco regulations between the two countries. Similarly, the relatively high rates of POS marketing for alcohol in both countries again reflect the absence of such regulation in both countries.

The team are now completing a wide scoping literature review, exploring available datasets and planning to roll out the CBPR approach in Fenland to establish community perceptions of need and identify effective health and wellbeing strategies that are meaningful to older people.

The prevalence of POS marketing of tobacco and alcohol reflect the regulations governing them suggesting that regulation might be an effective way of reducing POS marketing and in turn youth drinking and smoking.

“We are very excited by our findings: although our study is modest, it is, to our knowledge, the first direct comparison of USA and UK on point of sale marketing of tobacco and alcohol products, revealing some stark contrasts. This is not a project that would have happened without our UNC/ Cambridge initiative,” said Professor Theresa Marteau, Behaviour and Health Research Unit.

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Section two: Research

Information to inform obesity policy Professor John Danesh (Cambridge) and Professor June Stevens (UNC)

This project aims to inform US and UK obesity policies by investigating clinical and public health guidelines that address obesity.

The work involves a new method of breaking behavioural intervention down into a taxonomy of “Behaviour Change Therapies”. This allows comparisons of different interventions by breaking interventions down into commonly named component parts, allowing the investigators to study a multi-component intervention.

This field has the potential to change intervention development from “theory driven” to “BCT driven” and to produce more effective obesity prevention and treatment interventions.

Advancing longitudinal and missing data methodology for “big data” research in health Professor Michael Kosorok (UNC) and Professor Vern Farewell (Cambridge)

This project will aim to offer clear guidance on the choice of models for zero-inflated count data arising in health research by comparing published methods by UNC and Cambridge researchers for the meta-analysis of individual patient data to provide advice on the analyses of such data.

The hope is that this will have an impact on methodology for Big Data for Health Research internationally, and therefore improve population-based research internationally and enable more meaningful harvesting of information from the many existing and emerging large health data sets.

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Section two: Research

Making research accessible – principles Dr Kai Ruggeri, University of Cambridge, Department of Engineering, Engineering Design Centre

Brief, engaging and audience-specific texts. These are primarily to present a topic or issue to non-experts. These will have greater readership than peer-reviewed articles or corporate reports. This may require reduced use of expert language but should not compromise accuracy or misrepresent findings in any way. These summaries of salient points for media usage should be derived directly from the central outputs and message of the underlying science.

Short statements to summarise the context, approach, results and recommendations of work being done. These documents establish parameters for application, with findings and recommendations most critical. They apply the ‘3rd paragraph rule’: a concise, clear explanation of findings that leave little room for interpretation prior to closing recommendations.

As information on projects is reduced to fit shorter or more directed outputs, integrity of the central points must be maintained throughout.

While fundamental, systematic reviews should remain at the foundation of all dissemination, the growth of such work has made it necessary to have more rapid integration of findings with existing bodies of evidence.

Such ‘wiki’ platforms provide faster comparisons between studies and may continue to develop peer-reviewed approaches.

Accessible mainstream texts

INSTITUTIONAL REPORTS. Reports with specific information deriving from major research of interest to a particular stakeholder or body of stakeholders. These may contain abbreviated versions of complex analysis or summary visualisations that maintain the scientific message.

Executive summaries

Living reviews

Peer-reviewed articles are meant for experts or practitioners and should inherently involve gains in knowledge through best scientific practice. These are advanced, expert descriptions of methods, analysis and findings. These include the most detailed and complex topics, though it is important that some level of accessibility be considered to limit exclusion.

Institutional reports

Original scientific research Theory, history, background, review

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This is the basis for all scientific work in the field.

It is the broadest and most widely-encompassing of sources. It covers the consolidation of information on a topic, inclusive of general reviews of past work, prevailing theories with implications for understanding or further study, underlying research and major issues involved.

SECTION THREE: ANALYSIS AND HEALTH INTELLIGENCE

The Institute’s partnership with Public Health England provides multi-level links with the local, regional and national public health infrastructure.

Public Health England Public Health England (PHE) is the executive agency, sponsored by the Department of Health, to protect and improve the nation’s health and wellbeing, and reduce health inequalities.

Regional Knowledge and Intelligence Public Health England’s regional Knowledge and Intelligence Service, led

by Dr Julian Flowers, is based at the Cambridge Institute of Public Health.

It provides Information and insight from data to improve health.

Dr Julian Flowers

Dr Sian Evans said: “Our goal is to work with our partners in the public health system to answer key questions such as: ■

what are the health needs of local people?

■

are there key groups which have additional or specific needs?

■

what more could we do to improve local people’s health and wellbeing?”

Our work includes the development of the key PHE products for sharing and displaying data for analysts and broader audiences - Fingertips and the Longer Lives programme. We run Health Intelligence Networks to connect public health practitioners and develop primary care data to inform primary care strategy. We also manage data on musculoskeletal disease with Arthritis Research UK; and non-communicable respiratory disease with the NHS and the British Thoracic Society. Our data and analysis service provides support to local authority public health colleagues and PHE centres.

KIT East also hosts the Improving Health and Lives Learning Disabilities Observatory (IHaL) which aims to improve the health and social care of people with learning disabilities by improving information about the extent and causes of health inequalities for this group and encouraging health and social care providers and commissioners to improve services (www.ihal.org.uk).

Section Three: Analysis And Health Intelligence

Analysis and health intelligence Health Intelligence – highlights Case Study: improving health through information Evidence has shown the importance of the early years in a child’s development for current and future health. The Norfolk Public Health team have analysed local data to understand local need for early years care. The team has also linked with the local Maternal and Child Health Network specialist based within the Institute-based Knowledge and Intelligence Team East (KIT East) to use the PREview modelling tool.

PREview is a set of planning resources developed by the Public Health England Maternal and Child (CHiMat) Health Intelligence Network to help commissioners and professional target preventive resources, in particular around the Healthy Child Programme. The Norfolk team used the PREview modelling tool to help identify local areas with high levels of early years need within Great Yarmouth and Waveney.

Health intelligence for the public health system locally and nationally Longer Lives, the national resource highlighting premature mortality across every local authority in England, has been a major area of work during 2013/14 and won first place at the 2014 international Interaction Awards, in the ‘disrupting’ category, for completely re-imagining an existing product or service by creating new behaviours, usages or markets.

Other national health intelligence work programmes led from KIT East include the national general practice profiles and primary care. KIT East also hosts Fingertips, the online platform used to deliver a suite of PHE resources including the Public Health Outcomes framework.

The Fingertips online platform continues to grow with a range of new profiles during 2014 including: NHS Health Checks, mental health, dementia and neurology, cardiovascular disease and sexual and reproductive health.

Public Health Outcomes Framework online tool: www.phoutcomes.info

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Public Health England

Section three: Analysis and health intelligence

Informing service delivery Surveillance of infectious diseases to inform service delivery and protect public health is carried out at the Institute by the Eastern Field Epidemiology Unit (EFEU). EFEU is one of eight Field Epidemiology Units within the Field Epidemiology Services of Public Health England.

Our surveillance work covers adverse trends and outbreak detection and we undertake and support outbreak investigations within the Eastern Counties, South Midlands and Hertfordshire. Six analytic and seven descriptive epidemiological outbreak investigations were completed in the year ending September 2014.

Dr Mark Reacher

At local level, we collaborate with Health Protection teams, health service providers and commissioners and local authorities. We act as a bridge between local and national surveillance by working with other Field Epidemiology Units across England and the National Public Health England Departments for Infection, Chemicals and Radiation; and Emergency Response.

Disease reports for professional audiences We produce timely trend reports on: ■

Respiratory infections (tuberculosis, Legionnaires disease, influenza);

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Health Care Associated Infections and antibiotic resistance (eg Clostridium difficile diarrhoea, MRSA bloodstream infections, Carbapenem resistant enterococci);

■

Sexually transmitted infections (eg gonorrhoea, syphilis, HIV);

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Vaccine preventable disease and delivery of vaccination programmes (eg mumps, measles, rubella, whooping cough, rotavirus, influenza);

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Hepatitis viruses B and C infections;

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Enteric infections and food poisoning (eg salmonella, campylobacter, cryptosporidium, norovirus and Vero cytotoxin producing Escherichia coli).

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The PHG Foundation The PHG Foundation is a pioneering health policy think-tank with a special focus on genomics, directed by Dr Hilary Burton. We work from our Cambridge base to help policy-makers and health providers realise the benefits of society’s investment in life sciences research.

Through research, analysis and advocacy, we aim to stimulate change in healthcare practice to meet the challenges of the government’s health agenda of innovation by adding value, without raising cost.

Dr Hilary Burton

The PHG Foundation

Section three: Analysis and health intelligence

Informing service delivery Making a difference in health policy and healthcare “We work to help policy makers understand the costs and benefits of novel technologies and to help health systems implement them to benefit public health” says Dr Burton, Director of the PHG Foundation.

Assessing health needs Our ground breaking Health Needs Assessment Toolkit for Congenital Disorders, aimed at low and middle income countries, became freely available online in Spring 2014. This toolkit provides global data and detailed guidance on what can be done to improve prevention, diagnosis, treatment and care of birth defects. The toolkit has already played a significant role in changing government policy on newborn screening in Uruguay, and informing Brazil’s rare diseases policy. In April 2014, we formally transferred its ownership to a team of experts from the Universidade Federal do Rio Grande do Sul, the Hospital de Clínicas de Porto Alegre and INaGeMP, in Brazil.

Newborn screening The UK National Screening Committee announced that the current newborn screening programme in England will be expanded to include four new conditions, as originally proposed in our report, Expanded Newborn Screening: a review of the evidence.

Evaluating genomics tools for diagnosis An economic evaluation we conducted on the use of a single assay - the Illumina TruSight One panel test, which sequences 4,813 clinically relevant genes for providing genetic testing – in clinical genetics services has shown a potential cost saving of £242 per patient, with no negative impact on diagnostic yield.

This project was undertaken as part of our work with the Cambridge Biomedical Research Centre, which also includes analyses of the knowledge gaps and barriers to effective implementation and supports the implementation of new guidelines for the clinical investigation of learning disability.

Developing genomics expertise To help develop genomics expertise within medical specialties, PHG Foundation Director Hilary Burton chairs a joint group on behalf of the Joint Committee on Genomics in Medicine (JCGM), the Royal College of Physicians and the HEE Genomics Education Centre. Early successes include the successful recruitment of ‘clinical champions’ to advocate for the integration of genomics within their own specialties.

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We work to help policy makers understand the costs and benefits of novel technologies and to help health systems implement them to benefit public health

SECTION FOUR: TEACHING AND TRAINING

The Institute of Public Health is a vibrant and robust partnership of world class scientists and Public Health professionals, and the cornerstone of Cambridge’s Public Health research-service collaboration work.

Building leadership through our teaching and training The Institute of Public Health is a vibrant and robust partnership of world class scientists and Public Health professionals, and the cornerstone of Cambridge’s Public Health research-service collaboration work. We draw together the public policy/research/medical spheres through our Public Health England and Medical Research Council members, and our extended collaborations across the Cambridge Biomedical Campus and with industry, the NHS and other public agencies that impact on the public’s health.

The teaching and training capabilities at the Institute are enabled by the partnership between the University, MRC units and our Public Health England colleagues. This link between the academic and service/policy world means we can deliver specialist Public Health training for undergraduate medical students, a strong tradition of research training through postgraduate opportunities, and a range of continuing education opportunities for public health professionals throughout their careers.

Our teaching and training offer The Cambridge Institute of Public Health educates and inspires the next generation of public health leaders, scientists and practitioners.

Teaching undergraduate medical students

PhD students

We deliver specialist public health and primary care teaching to undergraduate medical students studying at the School of Clinical Medicine, University of Cambridge.

Public health is integrated with teaching delivered in hospital-based specialties and is coordinated through the leadership of the Clinical Dean and the Clinical School Education Division.

Our PhD students are deeply embedded in their host research teams within our member Units. Many students are supervised jointly by supervisors from more than one unit, to foster cross-disciplinary work.

105 PhD students were studying with us in 2013.

Access to our rich and varied seminar series is augmented by teaching on entrepreneurism, informatics, computing, and transferable skills by the Graduate School of Life Sciences. All our PhD students now engage in 1-year Masters courses followed by a 3-year project-based doctoral programme.

Postgraduate education The Institute has a strong tradition of postgraduate education and offers three separate Masters Programmes for 2015 - in Epidemiology, Public Health and Clinical Sciences (Primary Care Research).

Training and continuing education for public health professionals

Three Masters Programmes: ■

Epidemiology

■

Public Health

■

Clinical Sciences (Primary Care Research)

The Cambridge Institute of Public Health continues to support public health professionals throughout their careers. This includes offering training to Public Health Registrars and providing a range of short courses throughout the year addressing topics within biostatistics, public health intelligence and epidemiology

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Section four: Teaching and training

A culture of learning across disciplines We promote a culture of cross-disciplinary research across our membership and beyond by bringing researchers together at seminars and events that cut across themes and methodologies. These include the prestigious Bradford Hill Seminars, cross-Institute Away Days, masterclass series, and themed seminar series related to genomics, primary care, cardiovascular disease, behavioural science, biostatistics, diet and activity, health economics and social sciences in public health.

In 2014 we held our inaugural Public Health Annual Lecture with Dr Salim Yusuf, cardiologist and epidemiologist from McMaster University in Canada.

Dr Salim Yusuf, McMaster University

Supporting our alumni Public health is about improving and protecting the health of groups of people, rather than about treating individual patients. Public health career paths reach into politics, health planning and academia at the highest levels. The public health landscape in the UK is evolving rapidly, offering all sorts of new opportunities to make a difference to public health and our alumni are building careers all over the world.

In 2014 we launched a new online alumni hub to help our alumni keep in touch as their careers develop and to enable them to support each other with the public health challenges they are encountering across the globe.

Visit the alumni page at: http://alumni.iph.cam.ac.uk/

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Spotlight on teaching and training How PHE partners contribute to our teaching and training programmes The Foundation Course in Health Intelligence delivered by the Knowledge and Intelligence Team has trained over 500 public health staff in the East of England. The Knowledge and Intelligence Team also provides a range of specialist training and acts as a public health speciality training location. For the first time, the team is also hosting a specialist registrar from the GP training scheme.

The Eastern Field Epidemiology Unit offers continuing education for health services and public health professionals and looks after the Health Protection Module of the Master’s degree programme in Public Health at the University of Cambridge. We also supervise students on the MPhils in Epidemiology and Public Health.

Postgraduate Teaching at the MRC Biostatistics Unit Members of the MRC Biostatistics Unit teach on five Master’s courses at the University of Cambridge. Several staff supervise, examine, lecture and organise modules in biostatistics, clinical trials and psychiatric epidemiology for the MPhils in Epidemiology and Public Health. Other contributions are to the MPhil in Computational Biology, the Master of Mathematics (Applied Statistics and Statistics in Medical Practice) and the MPhil in Translational Medicine and Therapeutics.

General Practice for clinical medical students The Primary Care Unit works with partner general practices to make a significant contribution to the medical student programme in Cambridge, integrating teaching with other medical specialties. We run postgraduate education programmes for clinical educators, for GPs in training and for Masters and PhD students. The General Practice Education Group (GPEG) is taking a leading role in the development of the new teaching programme for Undergraduate Medical Students at the University of Cambridge commencing in 2015.

GP teaching will increase from 60 to 90 days during the course and the number of clinical students is rising from 160 to 260 per year. Curriculum developments include teaching basic clinical method and managing acute illness in primary care.

Students will experience a longitudinal placement in General Practice and learn as apprentices in practices across the east of England.

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Section four: Teaching and training

Teaching and training the public health leaders of the future We believe that our role is to inspire and train future public health leaders, academics and decision-makers, enabling graduates to progress to senior leadership and academic positions. To achieve our strategic goal of being an international leader in higher education for public and population health, we aim to provide a cutting edge portfolio of continuing education to support public health professionals and decision-makers as they use health intelligence to make strategic decisions and allocate resources – critically important in the fluid environment of health policy.

We are proceeding with an external review of our teaching, to examine: ■

The structure of the taught course

■

The content of the teaching programme

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The most appropriate approaches to learning eg online and onsite learning, case study method, field learning in the community, e-portfolios

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The most appropriate teaching style for the taught courses, for example from a formal lecture based approach to teachers as facilitators of learning, spending more time spent on coaching students, and less time on lecturing

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An extension of the teaching programme to offer advanced training in Public Health Leadership in conjunction with our international partners at the UNC Gillings School for Public Health

The teaching review will inform the overall strategy for public health at Cambridge in the 21st century.

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NIHR Collaboration for Leadership in Applied Health Research & Care (CLAHRC) East of England NIHR CLARHC East of England is hosted by Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) and involves the Universities of Cambridge, Hertfordshire and East Anglia, as well as working in partnership with a wide range of health and social care providers across the region.

The aim is to ensure the findings of academic studies can be used to make a real difference to front-line patient care as soon as possible. Our research is structured around five key themes which have been selected to ensure they reflect the needs of the local population, including those with complex health problems who are vulnerable when multiple agencies are involved in their care; the frail elderly, those with dementia, learning disabilities, acquired brain injuries or mental ill health. We also have ‘cross cutting themes’ which include the best ways to involve patients and the public in health research, health economics and patient safety.

Pioneering partnership at NIHR CLAHRC East of England: research by staff in health and social care services The use of research evidence in health and social care should be an everyday occurrence. For this to happen, clinical and non-clinical staff need to be encouraged to scrutinise and question the way things are done, and to welcome innovation, ensuring more rapid diffusion and adoption of evidence-based best practice. Capacity development to enable staff to have the skills to understand and carry out research is a major component of the CLAHRC East of England, an academic/service partnership to improve health.

Forty-five CLAHRC Fellowships have been awarded since 2011. The focus is on local applied research and evaluation projects and the aim is to enable the Fellows to make sense of the research world and promote the use of research based evidence in healthcare organisations.

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SECTION FIVE: GOVERNANCE The Institute of Public Health is an institution within the Faculty of Clinical Medicine at the University of Cambridge.

Committee of Management We are under the general control of a Committee of Management, which was inaugurated in 2014. The Committee will promote teaching in the field of public health, and promote research in that field.

Carol Brayne

Peter Jones (Chair)

Cyrus Cooper

Patrick Maxwell

Sue Dunkerton

Gina Radford

Caroline Edmonds

Stefan Scholtes

Tony Jewell

Pim Van Gool

The Institute is steered by the Executive Committee.

Carol Brayne (Chair)

Lucy Lloyd

Hilary Burton

Jonathan Mant

John Danesh

Theresa Marteau

Doug Easton

Ann Prentice

Julian Flowers

Mark Reacher

Paula Frampton

Sylvia Richardson

Christine Hill

Martin Roland

Keith Hoddy

Nick Wareham

Kay-Tee Khaw

Director of the Institute The Director is the administrative Head of the Institute, responsible for the direction of study and research in public health in the Institute. Professor Carol Brayne was reappointed in 2012 for a second five year term.

Publication date: October 2014 Edited by Lucy Lloyd Designed by Dip Creative 47

Our overarching mission is to improve the public’s health, using our research, teaching and analysis to promote well-being, prevent disease and reduce health inequalities.

For more information about any aspect of our work, please get in touch:

Cambridge Institute of Public Health University of Cambridge School of Clinical Medicine Forvie Site Cambridge Biomedical Campus Cambridge CB2 0SR 01223 330300 www.iph.cam.ac.uk @InstPubHealth