Volume 1 Cardiovascular disease and risk factors in adults Health Survey for England 2006 2 A survey carried out on behalf of The Information Centre Edited by Rachel Craig and Jennifer Mindell Joint Health Surveys Unit National Centre for Social Research Department of Epidemiology and Public Health at the Royal Free and University College Medical School

C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d Health Survey for England 2006 Volume 1 Cardiovascular disease and risk factors in adults

C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d Volume 1 Cardiovascular disease and risk factors in adults Edited by Rachel Craig and Jennifer Mindell Principal authors Ayesha Ali, Elizabeth Becker,Moushumi Chaudhury, Elizabeth Fuller, Jenny Harris, Frances Heeks, Vasant Hirani, Dhriti Jotangia, Soazig Nicholson, Sarah Pigott, Marilyn Roth, Shaun Scholes, Nicola Shelton, Hilde Stephansen, Kerina Tulland Heather Wardle. Joint Health Surveys Unit National Centre for Social Research Department of Epidemiology and Public Health at the Royal Free and University College Medical School THE INFORMATION CENTRE A survey carried out on behalf of The Information Centre Health Survey for England 2006 2

C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d Published by The Information Centre Summary booklet available from: Online www.ic.nhs.uk Mail, telephone & e-mail The Information Centre 1 TrevelyanSquare, Boar Lane, Leeds LS1 6AE Telephoneorders/General enquiries: 0845 300 6016 E-mail: enquiries@ic.nhs.uk The full text of this publication has been made available to you on the Internet at www.ic.nhs.uk/pubs/HSE06CVDandriskfactors Copyright �� 2008, The Information Centre. All rights reserved. This work remains the sole and exclusive property of The Information Centre and may only be reproduced where there is explicit reference to the ownership of The Information Centre. This work may only be reproduced in a modified format with the express written permission of The Information Centre. First published 2008 Designed by Davenport Associates Printed in the United Kingdom

C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d Foreword 8 Editors��� acknowledgements 9 Notes 10 1 Introduction 11 1.1 The Health Survey for England series 11 1.2 The 2006 survey 11 1.3 Ethical approval 12 1.4 2006 survey design 12 1.5 Survey response 14 1.6 Data analysis 14 1.7 Content of this report 17 References and notes 18 2 Cardiovascular disease Marilyn Roth, Jennifer Mindell 19 2.1 Introduction 20 2.2 Methods and definitions 21 2.3 Results 22 2.4 Discussion 26 References and notes 29 Tables 31 3 Hypertension Moushumi Chaudhury 43 3.1 Introduction 44 3.2 Methods and definitions 44 3.3 Results 46 3.4 Discussion 48 References and notes 50 Tables 51 Contents Volume 1: Cardiovascular disease and risk factors in adults

4 Diabetes Nicola Shelton 63 4.1 Introduction 65 4.2 Methods and definitions 65 4.3 Results 66 4.4 Discussion 69 References and notes 70 Tables 72 5 BMI, overweight and obesity Vasant Hirani 85 5.1 Introduction 87 5.2 Methods and definitions 87 5.3 Results 89 5.4 Discussion 94 References and notes 94 Tables 96 6 Physical activity Moushumi Chaudhury,Marilyn Roth 111 6.1 Introduction 113 6.2 Methods and definitions 114 6.3 Results 116 6.4 Discussion 119 References and notes 121 Tables 124 7 Diet Dhriti Jotangia, Sarah Pigott 135 7.1 Introduction 136 7.2 Methods and definitions 137 7.3 Results 139 7.4 Discussion 141 References and notes 142 Tables 144 8 Cigarette smoking Heather Wardle 161 8.1 Introduction 163 8.2 Methods 163 8.3 Results 164 8.4 Discussion 168 References and notes 169 Tables 170 C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d

9 Alcohol consumption Elizabeth Fuller 179 9.1 Introduction 180 9.2 Methods and definitions 180 9.3 Results 182 9.4 Discussion 186 References and notes 187 Tables 189 10 Blood analytes Kerina Tull 209 10.1 Introduction 211 10.2 Methods and definitions 212 10.3 Results 212 10.4 Discussion 216 References and notes 219 Tables 221 C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d

C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d 8 HSE 2006 | VOL 1: CARDIOVASCULAR DISEASE AND RISK FACTORS IN ADULTS This report presents the findings of the sixteenth annual survey of health in England. I am pleased to present this important research which has been undertaken on behalf of The Information Centre for health and social care. The Health Survey for England is conducted annually and collects information about a representative sample of the general population. It is vital to our understanding of the health situation and behaviours of the public in England and helps to ensure that policies are informed by these data. The survey combines information gathered through interviewing the sampled respondents, including a wealth of socio-demographic variables, with objective measures of health, such as blood pressure measurements, and analyses of blood samples. Thus we can study the inter-relationship of the characteristics and circumstances of adults and their children, with their health situation. The primary focus of the 2006 HSE report is cardiovascular disease and associated risk factors such as high blood pressure, diabetes and obesity.In 2000 the National Service Framework (NSF) for Coronary Heart Disease set out 12 standards for improved prevention, diagnosis and treatment of CHD over a 10-year period. Although death rates for CVD are falling, it remains the leading cause of death in England. The report investigates associated lifestyle factors such as physical activity,diet, smoking and drinking, and also focuses on inequalities. The 2006 HSE had a secondary focus of childhood obesity and other health risk factors for children, including diet, physical activity and smoking. Childhood obesity is associated with many illnesses, and in adulthood is linked to increased mortality and reduced life expectancy. I am honoured to welcome this valuable report and to thank all my colleagues in the Information Centre and our counterparts in the Joint Health Surveys Unit for their work. Surveys of this complexity are a team effort. The dedication of the skilled interviewing force is especially noteworthy. May I also thank the anonymous respondents across England who gave up their time to take part in the survey and who were willing to submit to various health tests. Without their help we would lose a public tool of enormous potential to benefit and protect the health of every one of us. Tim Straughan Chief Executive The Information Centre for health and social care Foreword

C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d HSE 2006 | VOL 1: CARDIOVASCULAR DISEASE AND RISK FACTORS IN ADULTS 9 Editors��� acknowledgements We wish to thank, first of all, all those who gave up their time to be interviewed and who welcomed interviewers and nurses into their homes. We would also like to acknowledge the debt the survey���ssuccess owes to the commitment and professionalism of the interviewers and nurses who worked on the survey throughout the year. We would like to thank all those colleagues who contributed to the survey and this report. In particular we would like to thank: ������ The authors of all the chapters: Ayesha Ali, Elizabeth Becker,Moushumi Chaudhury, Elizabeth Fuller,Jenny Harris, Frances Heeks, Vasant Hirani, Dhriti Jotangia, Soazig Nicholson, Sarah Pigott, Marilyn Roth, Shaun Scholes, Nicola Shelton, Hilde Stephansen, Kerina Tull and Heather Wardle. ������ Kelly Ward and Claire Deverill, whose hard work and support have been crucial in putting this report together. ������ Other research colleagues, especially Shaun Scholes, Kevin Pickering, Sarah Tipping and Danielle Whitehurst. ������ Operations staff, especially Lesley Mullender, Sue Roche and the Area Managers at NatCen and Barbara Carter-Szatynska at UCL. ������ The principal programmers, Jo Periam, Sven Sjodin and Colin Micelli. ������ All the field interviewers and nurses who worked on the project. We would also like to express our thanks to Professor Ian Gibb and his staff at the Department of Clinical Biochemistry at the Royal Victoria Infirmary in Newcastle upon Tyne, and to Dr Colin Feyerabend and his staff at ABS Laboratories, London, for their helpfulness and efficiency. Last, but certainly not least, we wish to express our appreciation of the work of the staff at the Information Centre for health and social care at all stages of the project, and in particular the contribution made by Andy Sutherland, Alison Crawford, Bethan Thomas, Alyson Whitmarsh, Katie Barnes and Nicola Dawes. Rachel Craig and Jennifer Mindell

10 HSE 2006 | VOL 1: CARDIOVASCULAR DISEASE AND RISK FACTORS IN ADULTS C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d 1. The data used in the report have been weighted. The weighting is described in Chapter 7, in Volume 3 of this report. Both unweighted and weighted sample sizes are shown at the foot of each table. The weighted numbers reflect the relative size of each group in the population, not numbers of interviews made, which are shown by the unweighted bases. 2. Children���sdata each year have been weighted to adjust for the probability of selection, since a maximum of two children are selected in each household. This ensures that children from larger households are not under-represented. Since 2003, as for adults, non-response weighting has also been applied. 3. In this report, in trend tables that show years with and without non-response weighting, data for the first year where non-reponse weighting was applied are shown in two rows or columns, one showing unweighted results and the other weighted results. 4. Three different non-response weights have been used: one for non-response at the interview stage, one for non-response to the nurse visit, and one for non-response to the blood sample. 5. The following conventions have been used in tables: - no observations (zero value) 0 non-zero values of less than 0.5% and thus rounded to zero [ ] used to warn of small sample bases, if the unweighted base is less than 50. If a group���sunweighted base is less than 30, data are normally not shown for that group. 6. Because of rounding, row or column percentages may not add exactly to 100%. 7. A percentage may be quoted in the text for a single category that aggregates two or more of the percentages shown in a table. The percentage for the single category may, because of rounding, differ by one percentage point from the sum of the percentages in the table. 8. Values for means, medians, percentiles and standard errors are shown to an appropriate number of decimal places. Standard Error may sometimes be abbreviated to SE for space reasons. 9. ���Missing values��� occur for several reasons, including refusal or inability to answer a particular question refusal to co-operate in an entire section of the survey (such as the nurse visit or a self-completion questionnaire) and cases where the question is not applicable to the informant. In general, missing values have been omitted from all tables and analyses. 10. The group to whom each table refers is stated at the upper left corner of the table. 11. The term ���significant��� refers to statistical significance (at the 95% level) and is not intended to imply substantive importance. Notes

HSE 2006: VOL 1 | CHAPTER 1: INTRODUCTION 11 C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d 1.1 The Health Survey for England series The Health Survey for England (HSE) comprises a series of annual surveys, of which the 2006 survey is the sixteenth. All surveys have covered the adult population aged 16 and over living in private households in England. Since 1995, the surveys have also covered children aged two to 15 living in households selected for the survey,and since 2001 infants aged under two have been included as well as older children. The Health Survey for England (HSE) is part of a programme of surveys currently commissioned by the Information Centre for health and social care, and before April 2005 commissioned by the Department of Health. The surveys provide regular information that cannot be obtained from other sources on a range of aspects concerning the public���shealth and many of the factors that affect health. The series of Health Surveys for England was designed to: 1. Provide annual data from nationally representative samples to monitor trends in the nation���s health 2. Estimate the proportion of people in England who have specified health conditions 3. Estimate the prevalence of certain risk factors associated with these conditions 4. Examine differences between subgroups of the population (by age, sex or income) in their likelihood of having specified conditions or risk factors 5. Assess the frequency with which particular combinations of risk factors are found, and in which groups these combinations most commonly occur 6. Monitor progress towards selected health targets 7. (Since 1995) measure the height of children at different ages, replacing the National Study of Health and Growth and 8. (Since 1995) monitor the prevalence of overweight and obesity in children. Each survey in the series includes core questions and measurements such as blood pressure, anthropometric measurements and analysis of saliva and urine samples, as well as modules of questions on specific issues that vary from year to year. In recent years, the core sample has also been augmented by an additional boosted sample from a specific population subgroup, such as minority ethnic groups, older people or,as in 2006, children. The Health Survey for England has been designed and carried out since 1994 by the Joint Health Surveys Unit of the National Centre for Social Research (NatCen) and the Department of Epidemiology and Public Health at the Royal Free and University College Medical School (UCL). 1.2 The 2006 survey The primary focus of the Health Survey for England in 2006 was cardiovascular disease (CVD). CVD is disease which involves the blood circulatory system: the heart, blood vessels and the consequences of impaired blood supply to the heart or brain. The two most Introduction 1

common types of CVD are ischaemic heart disease (IHD), also called coronary heart disease (CHD) or coronary artery disease (CAD), and stroke. In 2000 the National Service Framework (NSF) for Coronary Heart Disease set out 12 standards for improved prevention, diagnosis and treatment of CHD over a 10-year period.1 Although death rates for CVD are falling, it remains the leading cause of death in England.2 In 2005/06 CVD caused 184,000 deaths in England and Wales, and 28% of premature deaths.2 In addition, there were 312,164 hospital admissions for IHD and 178,321 admissions for stroke.2 The Health Survey for England 2006 had a secondary focus of childhood obesity and other health risk factors for children, including diet, physical activity and smoking. Childhood obesity is associated with many illnesses, and in adulthood is linked to increased mortality and reduced life expectancy. Data from the HSE has demonstrated that levels of obesity among children are increasing, and the Government has responded to the increase in obesity/overweight by publishing a Public Service Agreement (PSA) to ���Reduce the proportion of overweight and obese children to 2000 levels by 2020 in the context of tackling obesity across the population���.3 A total of 14,142 adults and 7,257 children were interviewed, with 3,491 children from the core sample and 3,766 from the boost. Data collection involved an interview, followed by a visit from a specially trained nurse for all in those in the core sample who agreed. The nurse visit included measurements and collection of blood, urine and saliva samples, as well as additional questioning. 1.3 Ethical approval Ethical approval for the 2006 survey was obtained from the London Multi-centre Research Ethics Committee (MREC). 1.4 2006 survey design 1.4.1 Introduction The survey was designed to yield a representative sample of the general population of any age, and a boost sample of children aged 2-15, living in private households in England. More detailed information about survey design is presented in Chapters 2-7, Volume 3 of this report. People living in institutions, who are likely to be older and, on average, in poorer health than those in private households, were not covered. This should be borne in mind when considering the Health Survey���s account of the population���shealth. 1.4.2 The core general population sample A random sample of 14,400 addresses was selected from the Postcode Address File (PAF), using a multi-stage sample design with appropriate stratification. This was to ensure that households were sampled proportionately across the nine Government Office regions of England. 720 postcode sectors were selected, and 20 addresses selected within each sector. Where an address was found to have multiple dwelling units, one was selected at random. Where there were multiple households at a dwelling unit, up to three households were included, and if there were more than three, a random selection was made. Each individual within a selected household was eligible for inclusion. Where there were more than two children in a household, two were randomly selected for inclusion, to limit the burden on any household. A total of 14,142 adults and 3,491 children were interviewed in the core sample. 12 HSE 2006: VOL 1 | CHAPTER 1: INTRODUCTION C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d

1.4.3 The child boost sample Toincrease the number of children in the sample, a boost sample was used. The boost sample of was obtained by randomly selecting 16,848 addresses in an additional 468 postcode sectors to supplement the sample obtained in the core sectors. As for the core sample, where there were three or more children in a household, two of the children were selected at random to limit the respondent burden for parents. An additional 3,766 children were interviewed in the boost sample, giving a total child sample of 7,257. 1.4.4 Fieldwork Interview A letter stating the purpose of the survey was sent to each sampled address before the interviewer visited. The interviewer sought the permission of each eligible selected adult in the household to be interviewed, and parents��� and children���sconsent to interview selected children aged up to 15. Computer-assisted interviews were conducted. The content of the interview is detailed in Volume 3, Chapter 1 full documentation is provided in the Appendices to Volume 3. The 2006 survey for adults focused on cardiovascular disease and its risk factors. Adults were asked modules of questions on general health, cardiovascular disease (including the Rose Angina Questionnaire), physical activity,alcohol consumption, smoking, and fruit and vegetable consumption. Toavoid an overlong interview for older informants, those aged 65 and over were allocated at random to one of two questionnaire versions. This included either the CVD and short physical activity modules, or the long physical activity module but not the CVD module. Adults aged 16-64 completed both the CVD and long physical activity modules. Children aged 13-15 were interviewed themselves, and parents of children aged 0-12 were asked about their children, with the interview including questions on physical activity,eating habits (fat and sugar consumption) and fruit and vegetable consumption. Parents were normally present when older children were interviewed. Height and weight measurements were taken at the end of the interview. Nurse visit Informants in the core sample were offered a nurse visit. Questions were asked about prescribed medication, vitamin supplements and nicotine replacement treatments. For infants, additional information was collected on immunisations and measurements at birth. Nurses measured infant length (for those aged six weeks to under two years). The nurse also took the blood pressure of those aged five and over,and took waist and hip measurements for those aged 11 and over. Demi-span measurements (the length between the sternal notch and the end of the outstretched arm) were taken for informants aged 65 and over. With written agreement, a small (non-fasting) sample of blood was taken by venepuncture from those aged 16 and over. The blood sample was analysed for total and HDL cholesterol, ferritin, haemoglobin, glycated haemoglobin, fibrinogen, and C-reactive protein. Nurses also sought written agreement for the storage of a small sample of blood for possible future analysis. Spot urine samples were taken from informants aged 16 and over and samples of saliva (for the analysis of cotinine, a derivative of nicotine) were taken from children aged 4-15. Written consent was obtained for these samples. Nurses administered a self-completion booklet about eating habits to those aged 16 and over. HSE 2006: VOL 1 | CHAPTER 1: INTRODUCTION 13 C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d

1.5 Survey response Interviews were held in 8,614 households with 14,142 adults aged 16 or over,and 3,491 children from the general population. The boost sample resulted in an additional 3,766 children aged 2-15 being interviewed, giving a total child sample of 7,257. Among the general population sample, 10,489 adults and 2,574 children had a nurse visit. More detailed information on survey response can be found in Volume 3, Chapter 6. Response to the survey can be calculated in two ways: at a household level and at an individual level. Interviews were carried out at 68% of sampled eligible households in the general population (after removing vacant addresses etc.), and at 73% of known eligible boost sample households. Within the general population sample, interviews were obtained with 88% of adults and 94% of (sampled) children in interviewed (���co-operating���) households. Assuming that households where the number of adults and children was not known contained, on average, the same number of adults and children as households where it was known, the individual response rate for the general population sample, based on all eligible households, was estimated to be 61% among adults and 66% among (sampled) children. Table 1A below shows individual response rates to the different stages of the survey for adults in the general population sample. The first column gives the individual response rates for adults in all eligible households, and the second column gives individual response rates for adults in co-operating households. Table 1B below shows a summary of responses obtained to each component of the survey among the total sample of children (from the core and boost sample) in co-operating households. 1.6 Data analysis 1.6.1 Introduction As a cross-sectional survey,the Health Survey for England gives information on the proportions of the population with certain characteristics. It also examines associations between various health states, personal characteristics and behaviours but cannot comment on whether these are causal. In particular,associations between current health states and current behaviour need careful interpretation, as current health may reflect past, rather than present, behaviour. 14 HSE 2006: VOL 1 | CHAPTER 1: INTRODUCTION C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d Table 1A Individual response: adults in the general population sample Adults Adults in all in co- eligible operating house- house- holds holds % % Interviewed 61 88 Height measured 55 80 Weight measured 53 77 Saw nurse 45 66 Waist and hip measured 43 64 Blood pressure measured 44 64 Blood sample obtained 33 48 Urine sample obtained 38 56 Table 1B Individual response: children in core and boost samples Children aged 0-15 in co-operating households % Interviewed 94 Height measured 80 Weight measured 78 Saw nurse 69 Infant length measured 52 Waist and hip measured 64 Blood pressure measured 63 Saliva sample obtained 59

1.6.2 Weighting the samples The general population sample For the general population sample, weights were calculated at the household level and at the individual informant level. The household weight corrected for the probability of selection where additional dwelling units or households were identified at a selected address. Calibration weighting was also used for adults to reduce non-response bias resulting from differential non-response at the household level, based on the age and sex profile of the residents and the region in which the household was situated. 88% of adults in participating households were interviewed, and weights were therefore also calculated at an individual level to correct for non-response within participating households. The sample of children The sample of children comprised all those aged 0-15 from either the core or boost sample. The weights for the child sample include selection weights for the dwelling unit/household, selection weights for the children in the household, and calibration weighting to adjust the sex and age profile of the achieved sample. Non-response weighting for the nurse visit and blood samples Two further weights were calculated for the core sample, as well as weights to allow for non-response at the interview stage. One was to adjust for non-response to the nurse visit, and the second to adjust for non-response for obtaining a blood sample. Further details on the weighting procedures are given in Volume 3, Chapter 7. 1.6.3 Weighted and unweighted data and bases in the report All 2006 data in this report are weighted. Both weighted and unweighted bases are given in each table. The unweighted bases show the number of participants involved. The weighted bases show the relative sizes of the various sample elements after weighting, reflecting their proportions in the English population, so that data from different columns can be combined in their correct proportions. Non-response weighting was introduced to the HSE in 2003, and has been used in all subsequent years. In this report, in trend tables that show years with and without non- response weighting, data for the first year where non-response weighting was applied are shown in two rows or columns, one showing unweighted results and the other weighted results. For tables showing trends in children���sdata, results for years up to 2002 have selection weighting only,and results for 2003-2006 have selection and non-response weighting. 1.6.4 Age as an analysis variable Age is a continuous variable but results are presented in the report by age groups. Age in Health Survey for England reports always refers to age at last birthday. 1.6.5 Age standardisation Adult data have been age-standardised throughout the 2006 report to allow comparisons between groups after adjusting for the effects of any differences in their age distributions. When different sub-groups are compared in respect of a variable on which age has an important influence, any differences in age distributions between these sub-groups are likely to affect the observed differences in the proportions of interest. All results are presented separately for men and women. Age standardisation used the direct standardisation methodology, and was based on the mid-year 2005 population estimates for England, with men standardised to the male population and women to the female population. HSE 2006: VOL 1 | CHAPTER 1: INTRODUCTION 15 C o p y r i g h t �� 2 0 0 8 , T h e I n f o r m a t i o n C e n t r e . A l l r i g h t s r e s e r v e d