This is a study of hunger and malnutrition in distinct spaces and during a long period of uniquely dramatic economic fluctuation. Focusing on Ghana’s often hungry Northern savannah, its wealthy and food secure Southern forest and its youthful, expanding cities, this study seeks to explain how hunger and malnutrition form in proximate yet readily contrasted environments. Resulting from failures of domestic reproduction as well as failures of local food economies, the history of malnutrition is, in essence, a history of food and family. As a conscious concern, hunger played a mediating role in the varied and rapidly changing livelihoods seen across Ghana. Anthropology and demography give insight into the weight of nutrition in precolonial, nineteenth-century contexts as well as the effects of colonial integration. Colony-wide labour and food markets encouraged new forms of food insecurity and new modes of survival, something seen particularly clearly in the trend of north-south migration. As a less-conscious concern than hunger, nutritional health was also partially directed by the medical environment and by consensuses regarding good and bad nutrition. Born as an arm of imperial rule which sought to override indigenous understandings of health, nutritional science was both politically reactive and scientifically reductive, reflecting Western concerns regarding Africa and Western understandings of nutrition long into independence. The process of capitalist development also promoted the devaluation of domestic reproduction, with wealth and poverty determined by cash-income rather than access to human capital. This transition preceded the gender conflict and higher-risk forms of childrearing which undermined nutrition security across the country. Recently reinvigorated by the neoliberal turn of the late twentieth century, this process helps explain the endurance of malnutrition in spite of economic growth. The pursuit of these ends also helps explains postcolonial hunger as market dependency fostered epidemic malnutrition during the market collapse of the 1970s and early 1980s.

Despite the rapid increase in both adiposity and diabetes in China, substantial uncertainty remains about the relationship between these two conditions in the population. Using data from the China Kadoorie Biobank study of 0.5 million adults recruited during 2004-8 from 10 diverse areas of China, this thesis examines the associations of different adiposity measures (overall adiposity: BMI and percentage body fat; central adiposity: waist circumference, waist-hip ratio, and waist-height ratio) with type 2 diabetes prevalence and incidence. To assess the quality of diagnosis, a separate event-verification study was conducted in ~1,000 reported diabetes cases. Overall at baseline, the mean age of the analysed participants was 52 years, 41% were men, 32% had a BMI≥25 kg/m² (4% ≥30 kg/m²) and 5.2% had self-reported or screen-detected diabetes. Both cross-sectional and prospective analyses of well-characterised diabetic cases (26,622 prevalent and 2,910 incident cases) showed that adiposity is strongly positively associated with diabetes (p<0.0001), throughout all or most of the distribution of each adiposity measure. Per 1 SD higher adiposity measure, measures of central adiposity were associated with ~90% increased risk, compared with ~80-85% increased risk for general adiposity measures. Among measures of central adiposity, waist-hip ratio was the most strongly associated with diabetes prevalence, whereas waist circumference was the most predictive of diabetes incidence. Although measures of central adiposity were the most strongly associated with diabetes risk, there was still a strong positive association with measures of general adiposity after adjusting for central adiposity (p<0.0001), and the combination of both types of measure improved risk prediction. Given waist circumference, hip circumference was inversely associated with both diabetes prevalence and incidence (p<0.0001). For many of the above associations, there was possible effect modification by age and sex. These findings will provide important and reliable evidence to quantify the level of diabetic risk associated with adiposity, hence to inform clinical interventional strategies and future public health programmes.

Despite widespread promotion of the benefits of regular activity, uptake by obese adults, particularly women, remains low. There is limited research on the physical barriers to exercise in younger obese adults, yet studies in elderly women suggested a relationship between obesity, fear of falling (FOF) and activity participation. It is feasible that FOF might be a problem in younger obese women and a subsequent barrier to activity participation. The aim of this thesis was to explore the phenomenon of FOF in obese women under 50 years of age and to develop a conceptual framework to explain its relationship to activity participation. An exploratory mixed methods approach was used. An initial study of 12 obese women used semi-structured interviews to elicit original knowledge of concerns they had about falling when active, which was analysed using a thematic approach. Eight participants reported FOF and there were suggestions that FOF led to activity avoidance. Younger participants and those more active were less likely to report problems. The results were used to develop a conceptual framework of FOF which informed the design of a larger study to measure the relationship between FOF and activity level in obese women. A review of FOF instruments to identify those appropriate for use in a further study of obese women was completed. Sixty-three participants completed self-reported questionnaires that measured different constructs of FOF, notably, falls-efficacy, feared consequences of falling and activity avoidance. Statistical analysis confirmed FOF to be an independent predictor of current low activity, irrespective of age, BMI or depression. These findings shed light on an important issue which could be used to inform the design of interventions to promote activity in overweight women. The development of such interventions that target FOF in obesity warrants further investigation.

Studies in health care professional (HCPs) have demonstrated a high prevalence of dehydration, which has been linked with morphological brain changes as well as cognitive impairment in other groups. Moreover, many age-related pathophysiological changes result in increased susceptibility to fluid and electrolyte imbalance, rendering older adults vulnerable to dehydration which may be associated with poor outcome. This thesis investigates the prevalence of dehydration and impact on cognitive function amongst HCPs. It also investigates the prevalence of dehydration in hospitalised older adults and the association between dehydration, acute kidney injury (AKI) and clinical outcome. Hydration status and cognition were objectively assessed in nurses and doctors working on emergency medical and surgical wards. This study demonstrated that a significant proportion of HCPs were dehydrated at the start and end of their shifts and many were oliguric. The prevalence of dehydration varied with level of experience and speciality and was associated with short-term memory impairment. Using serum osmolality, the key regulated variable in fluid homeostasis as a measure of hydration status in hospitalised older adults, prospective assessment of 200 patients demonstrated that over a third had hyperosmolar dehydration (HD) at admission, two-thirds of which were dehydrated 48 hours later. Dehydration at admission was independently associated with a six-fold increase in 30-day mortality. Subsequent retrospective assessment of 32,980 hospitalised older adults demonstrated that dehydration was diagnosed clinically in 8.9% of patients and was independently associated with a two fold increase in mortality. Nearly half of those dehydrated had a concomitant diagnosis of AKI and the median length of hospital stay (LOS) was nearly three times greater than those without the condition. Despite the widespread use of serum osmolality in human physiology studies, it is rarely used clinically to assess hydration. Analysis of published equations estimating osmolality, demonstrated that an equation by Khajuria and Krahn was 90% sensitivity and 97% specificity at diagnosing hyperosmolar dehydration. Using this equation, we demonstrated that 27.2% of 6632 older adults had HD at admission to hospital and the risk of developing AKI 12-24 hours after admission in these patients was five times those euhydrated at admission. Moreover, the 30-day mortality was nearly twice that of euhydrated patients, independent of key confounders. The median LOS in dehydrated patients was almost double. This work has highlighted the need to educate both patients and HCPs on the importance of hydration. Further work is required to prospectively assess the use of serum osmolality as a predictor of dehydration, AKI and outcomes. Given that hydration and nutrition are the hallmarks of compassionate care, there is clear room for improvement with findings from this thesis suggesting the need for further investigation and intervention in both community and hospital settings.

Introduction: Irritable bowel syndrome (IBS) has substantial impact on Quality of Life (QoL) and patients have high healthcare utilization. Guidelines recommend diagnosis and management within primary care, yet around 25% of patients are referred to gastroenterology. These studies aimed to assess the incidence of organic gastrointestinal disease in patients diagnosed with IBS, the cost of healthcare utilization and the QoL in patients with IBS before and after seeing a gastroenterologist and to estimate the cost-effectiveness of a gastroenterology appointment. Methods: Patients with IBS were identified within the UK Clinical Practice Research Dataset. Incidence rates of coeliac disease, colorectal cancer (CRC) and inflammatory bowel disease (IBD) were calculated. Individual-level healthcare utilization data were extracted for IBS patients who first visited a gastroenterologist in 2008 or 2009. Mean costs of total healthcare utilization were calculated before and after gastroenterology attendance. A questionnaire study of patients with IBS attending a gastroenterology outpatient clinic for the first time measured QoL and utility before and after the appointment. Quality Adjusted Life Years (QALYs) were modeled from these utility values. Cost-effectiveness of a referral to gastroenterology in IBS was assessed using mean cost per QALY. Results: Fifteen years after IBS diagnosis, the combined cumulative excess incidence of coeliac disease, IBD and CRC in IBS is 3.7%. Over one year following gastroenterology appointment, the expected QALY gain compared to no appointment was 0.03 and the expected extra total healthcare costs were £657. The incremental cost-effectiveness ratio was £27865.64/QALY. Referral for patients younger than 30, men, and increasing the time horizon, reduces the expected cost effectiveness. Conclusions: My findings provide reassurance that non-specialists are unlikely to be missing an organic condition in the majority of IBS patients. Referral to a gastroenterologist for IBS might be cost-effective for the NHS but more data, especially on potential QALY gains, are needed.

Introduction: Deaths due to chronic liver disease have increased significantly in recent decades. This is due to increases in alcohol consumption and obesity during this time period, and insensitive screening tests (liver function blood tests) utilised in primary care. This thesis describes a new liver disease community diagnostic pathway which focussed upon defined risk factors for chronic liver disease and uses Transient Elastography (TE) as the primary investigation modality. The aims of the thesis are to assess the feasibility of this pathway for detecting liver disease due to alcohol or non-alcoholic fatty liver disease within the United Kingdom healthcare system, to quantify the number of new cases detected with this approach and to evaluate patient experience of these investigations. Methods: Following a systematic review of the literature, an investigation pathway was derived and piloted in 4 general practice sites in Nottinghamshire in two phases between February 2012 and September 2014. Patients with hazardous alcohol use, type 2 diabetes or persistently raised alanine aminotransferase (ALT) level and negative liver serology were eligible for study. TE was performed in the community; a liver stiffness reading of ≥8 kilopascals defined clinically significant liver disease and subsequent review in a consultant led community clinic. Risk factors for new diagnoses of liver disease and cirrhosis were identified and the association with obesity investigated. A qualitative interview substudy was conducted to explore the experiences of 20 patients undergoing investigation. Results: In a total adult population of 20,868 patients, 2,022 patients were eligible for study of whom 909 (45%) underwent TE. Valid liver stiffness measurements were possible in 98% of patients. Overall, 230 cases of elevated liver stiffness and 27 new cases of cirrhosis were identified. Minimum cirrhosis prevalence in patients with type 2 diabetes was 2%. Obesity was significantly associated with diagnosis of cirrhosis in type 2 diabetics (odds ratio 9.4 (95% CI 2.2-40.9)) and hazardous alcohol users (OR 5.6 (95% CI 1.6-19.7)). The majority of new cases of liver disease had normal ALT levels. From the initial pilot phase in two general practices in Rushcliffe (Nottingham), in which liver function test data from 378 patients undergoing TE was analysed, 72.4% with elevated liver stiffness measurement, 60% with biopsy proven cirrhosis and 90% with cirrhosis diagnosis had normal ALT. Patients felt that TE was a useful adjunct to lifestyle change and described a positive experience of liver disease investigation. Conclusion: A new non-invasive diagnostic pathway for liver disease was feasible to implement in Nottinghamshire primary care and resulted in significantly increased diagnosis of chronic liver disease and cirrhosis. These findings warrant exploration of the pathway in a larger primary care population.

Rising obesity rates have generated serious policy concern and public interest. Along with biological and genetic factors contributing to weight gain, dietary and physical activity behaviours are considered the main determinants of individual body weight. In order to tackle the increasing obesity problem and change individual behaviour, effective policy interventions need to be developed which target specific groups within the population. Economic frameworks that have been designed to model individual choices can be applied to improve the understanding of how individual characteristics and socio-economic factors affect weight-related behaviours and body weight. This thesis uses data from the Scottish Health Survey and the HILDA (Household, Income, and Labour Dynamics in Australia) survey to empirically analyse (1) if average BMI and socio-economic characteristics differ across combinations of weight-related behaviours, (2) how diet and physical activity behaviours, as well as their determinants, can be adapted to explain BMI on average, (3) how determinants of BMI impact differently across a conditional BMI distribution, and (4) to what degree a change in BMI over time can be explained by changing influences. While previous economic research did not consider the combined effect of dietary and physical activity behaviours on body weight, this work will investigate the relationship between the weight-related behaviours and individual BMI on average and across the conditional BMI distribution to identify areas for policy interventions. Results indicate that an increase in individual physical activity is an effective measure to target individual weight. Although the energy balance framework suggests a promotion of both weight-related behaviours and traditional weight management measures promote a reduction in caloric intake, the analyses have shown that physical activity is the predominant behaviour regarding the influence on individual BMI (compared to individual diet measured by quality proxies rather than the overall caloric intake).

Background and Aims: To explore outcomes following gastrointestinal endoscopy using a clinical dataset and then routinely collected administrative data linked to death registry data. Predictors of outcome were studied and variations in crude mortality were analysed. Methods: Endoscopy cases from a single tertiary centre were identified retrospectively using a clinical endoscopy database. Sedation levels, type of procedure and demographic data were analysed. Adverse events following the procedures, including mortality were assessed before and after changes in sedation practice were introduced. For subsequent chapters national administrative data in the form of Hospital Episode Statistics (HES) were linked to the Office of National Statistics Death Registry. Data from 2006 – 2008 were analysed. Episodes of care containing codes for therapeutic endoscopic procedures were extracted (Endoscopic retrograde cholangio-pancreatography (ERCP) and percutaneous endoscopic gastrostomy (PEG)). Finally, episodes of care containing new stroke diagnoses were extracted to analyse the use of percutaneous gastrostomies in the stroke population in England. Factors associated with death following endoscopy were identified. Crude and case-mix adjusted mortality were analysed at institutional level. Results: 7,234 endoscopy cases were identified from the endoscopy clinical database. Following changes in sedation practice 7,071 cases were assessed. Significant reductions in sedation doses were achieved but mortality rates did not fall (0.7% in 2004 and 0.8% in 2006 (p=0.5)). 40,938 episodes of care containing ERCP procedures were identified within the HES data. Logistic regression analysis confirmed age, sex, cancer, emergency admission, and non-cancer co-morbidity as independent predictors of 30-day death after ERCP. Adjusted odds ratios for age were 6.2 for ≥85 yrs vs. <55 yrs; male sex 1.2 vs. female; emergency admission 2.0 vs. elective; cancer 8.6 vs. no cancer and non-cancer co-morbidity 1.5 vs. none. Trust volume of ERCP was not found to be a significant factor in post procedure mortality. Funnel plots of trust level mortality rates, both unadjusted and adjusted, showed all trusts lying within 3 standard deviations of the national mean. 10,952 PEG cases were identified. All-cause mortality was 4.2% at 7 days and 14.6% at 30 days. Logistic regression identified age over 85 years, male sex, emergency admission, motor neurone disease and dementia as predictors of death within 30 days of PEG procedure (p<0.03 for all). No correlation for 30-day death versus PEG volume was identified at NHS Trust level (Pearson r=0.04). 1560 emergency stroke admissions that had a new PEG procedure were identified. Admission to Trusts with a high PEG procedure volume was associated with lower 7-day mortality after PEG procedure of 4.3%, compared to 7.8% and 6.8% in low and medium volume Trusts respectively (p=0.045). Although suggestive of a lower threshold for PEG insertion, the 5 Trusts with the highest rate of PEG insertions in stroke patients had a higher mortality at 30 days (3% compared to 0.9% in the other Trusts). Conclusions: Patient factors are the main determinants of outcome following endoscopy. Analyses of clinical and administrative datasets both require significant man-hours to produce results. Assessing disease severity within HES data is unsatisfactory, limiting case-mix adjustment. However, the data have the advantage of allowing consistent methods of analysis across institutions at a national level providing a more real world analysis than smaller or single centre studies.

The hepatitis C virus (HCV) is highly prevalent among people who inject drugs (PWID) in Scotland and the large majority of new HCV infections occurring in Scotland are within this population group. Harm reduction interventions, mainly sterile injecting equipment provision (IEP) and opioid substitution treatment (OST), to prevent the transmission of blood-borne viruses among PWID, were implemented in Scotland in the late 1980s/early 1990s. More recently, government policy initiatives, particularly the Hepatitis C Action Plan for Scotland, have stipulated the scale-up of these interventions. The overarching aim of this thesis was to investigate the impact of harm reduction interventions on the transmission of HCV among PWID in Scotland. Five secondary objectives were addressed in order to fulfil the main aim: (i) to review the international literature on the effectiveness of IEP and OST in preventing HCV transmission; (ii) to determine the association between self-reported sharing of needles/syringes and incident/prevalent HCV infection; (iii) to determine the association between sharing non-needle/syringe injecting paraphernalia and incident HCV infection; (iv) to determine the incidence of HCV among PWID in Scotland; and (v) to determine the association between self-reported uptake of IEP/OST and incident HCV infection. To address the first thesis objective, a systematic review of the literature was undertaken to identify existing international research evidence (published up to March 2007) for the effectiveness of harm reduction interventions. While HCV was the main outcome of interest, HIV and injecting risk behaviour (IRB) were also considered. A review of reviews approach identified: insufficient evidence that sterile needle and syringe provision (NSP) was effective in preventing HCV transmission; tentative evidence that NSP was effective in preventing HIV transmission; sufficient evidence to support the effectiveness of NSP in reducing self-reported IRB; and little to no evidence on needle/syringe vending machines, outreach NSP or the provision of other injecting paraphernalia (spoons, filters, water) in relation to any of the outcomes. With regard to OST, the findings were: insufficient evidence to show that OST has an impact on HCV transmission; sufficient evidence to support the effectiveness of continuous OST in reducing HIV transmission; and sufficient evidence to support the effectiveness of OST in reducing IRB by reducing the frequency of injection, the sharing of injecting equipment and injecting risk scores. An update to the review of reviews was undertaken to include literature published through March 2011, and found that little changed as a result of additional published reviews: in the main, the evidence statement for the effectiveness of OST with regard to HCV was upgraded from insufficient to tentative. The finding of weaker evidence with regard to biological outcomes (e.g. HCV, HIV), as compared with behavioural outcomes, indicated that low levels of IRB may be insufficient to reduce high levels of transmission, particularly for HCV. The subsequent chapter aimed to address the second thesis objective, by summarising, and exploring factors that explained the variation in, the measure of association between self-reported sharing of needles/syringes and HCV prevalence/incidence among PWID. A systematic review and meta-analysis were undertaken to identify and combine the results of European studies of HCV prevalence (or incidence) among those who reported ever/never (or recent/non-recent) sharing of needles/syringes. Among the 16 cross-sectional studies and four longitudinal studies identified, the pooled prevalence of HCV was 59% among PWID who reported never sharing needles/syringes and the pooled incidence of HCV was 11% among PWID who reported not recently sharing needles/syringes. Random effects meta-analysis generated a pooled odds ratio (OR) of 3.3 (95% confidence interval [CI] 2.4-4.6), comparing HCV infection among those who ever (or recently) shared needles/syringes relative to those who reported never (or not recently) sharing. Differences in pooled ORs were found when studies were stratified by recruitment setting (prison vs. drug treatment sites), recruitment method (outreach vs. non-outreach), sample HCV prevalence and sample mean/median time since onset of injecting. High incidence/prevalence rates among those who did not report sharing needles/syringes during the risk period may be a result of a combination of unmeasured risk factors (such as sharing non-needle/syringe injecting paraphernalia) and reporting bias. Study design and population were found to be modifiers of the size and strength of association between HCV and needle/syringe-sharing. To address the third thesis objective, the risk of HCV associated with sharing injecting paraphernalia (spoons, filters and water) was investigated using data from the 2008-09 and 2010 sweeps in a series of national cross-sectional surveys of PWID in Scotland, collectively called the Needle Exchange Surveillance Initiative (NESI). Logistic regression was used to examine the association between recent HCV infection (anti-HCV negative and HCV-RNA positive individuals) and self-reported measures of injecting equipment sharing in the six months preceding interview. Twelve percent of the sample reported sharing needles/syringes and 40% reported sharing paraphernalia in the previous six months. The adjusted odds ratios (AORs) for sharing needles/syringes (with or without paraphernalia) and sharing only paraphernalia in the last six months were 6.7 (95% CI 2.6-17.1) and 3.0 (95% CI 1.2-7.5), respectively. Among those who reported not sharing needles/syringes, sharing spoons and sharing filters were significantly associated with recent HCV infection (AOR 3.1, 95% CI 1.3-7.8 and 3.1, 95% CI 1.3-7.5, respectively); sharing water was not. This cross-sectional approach to the analysis of the association between sharing paraphernalia and incident HCV infection demonstrated consistent results with previous longitudinal studies. The prevalence of paraphernalia-sharing in the study population was high, potentially representing a significant source of HCV transmission. Addressing the fourth and fifth thesis objectives, a method to determine the incidence of HCV among PWID using a cross-sectional design was applied, and the associations between self-reported uptake of harm reduction interventions (OST and IEP) and recent HCV infection were examined. This was undertaken on data from the first sweep (2008-09) of NESI. Twenty-four recent HCV infections (as defined above) were detected, yielding incidence rate estimates ranging from 10.8-21.9 per 100 person-years. After adjustment for confounders, those with high needle/syringe coverage had reduced odds of recent infection (AOR 0.32, 95% CI 0.10-1.00, p=0.050). In the Greater Glasgow and Clyde region only, there were reduced odds of recent infection among those currently receiving OST, relative to those on OST in the last six months but not currently (AOR 0.04, 95% CI 0.001-1.07, p=0.055). The effect of combined uptake of OST and high needle/syringe coverage was only significant in unadjusted analyses (OR 0.34, 95% CI 0.12-0.97, p=0.043; AOR 0.48, 95% CI 0.16-1.48, p=0.203). The final analysis chapter built on the previous chapter investigating the association between uptake of harm reduction interventions and recent HCV infection, by using data from three sweeps of the NESI survey, undertaken in 2008-09, 2010 and 2011-12. A framework to triangulate different types of evidence – ‘group-level/ecological’ and ‘individual-level’ – was applied. Data on service provision (injecting equipment provision and methadone dispensation) were also collated and analysed.

Background Nearly a quarter of UK adults are obese representing a significant public health problem. Motivational interviewing (MI) may be effective in helping people to lose weight. Planning could be a mechanism of action which is related to outcome. The aim is to define the types of planning talk used by clients during an MI session and examine their relation to weight loss maintenance (WLM) outcomes. Also to examine the skills the therapist used prior to a client talking about planning. Methods To define planning talk a literature review was conducted and an expert group listened to recorded MI sessions. Thematic content analysis was used to identify the types of planning talk. Thematic analysis was used to identify the therapist skills prior to planning within 50 MI sessions. Associations between types of planning talk and WLM outcomes were analysed using logistic and linear regression. Results The development of the coding system found several types of plans/goals. The reliability was 86% and 75% agreement with the gold standard, for examples of plans/goals and the transcript respectively. Frequent planners lost on average 2.8 kgs (95% CI) and 1.2kg/m² (95% CI) more than those who were low planners (not statistically significant). Medium goal setters statistically significantly increased on average their weight (8.8kg) and BMI (3.5 kg/m²) compared to low goal setters. Therapist’s skills prior to planning were asking the client planning questions and exploring with the client their planning ideas in order to increase specificity. Conclusion The coding system can be used to code WLM data with acceptable reliability. A possible association between planning and a decrease in weight and BMI was demonstrated. Understanding how MI works could lead to improvements in the practice of MI by therapist, efficacy, focus research efforts and facilitate a better understanding of what helps people to change behaviours.