Hertfordshire’s Babies 3

Front cover:Photographs of Mr Ron Farr, retired personnel director,

who was born in Hitchin in 1926 and still lives there. He has kindly taken part in our research since 1996.

Pictured from top left at ages:6 months

3 years 8 months6 years 6 months

12 years 8 months22 years45 years

with wife Hilda in 2004

© MRC Epidemiology Resource Centre 2007

MRC Epidemiology Resource Centre, University of Southampton,Southampton General Hospital, Southampton SO16 6YD

Contents

IntroductionBackground - what’s it all about?The nurse who made it all possibleHealthy ageing Heart Bones Joints Muscle Staying activeWhat is a healthy diet?Are stress & personality important?Studies in depthFrom Birth to Death…What next?

Hertfordshire’s Babies 3

The fi eldwork team 2002

Back row, left to right: Deirdre Cunningham (research nurse), Lynn Collier (research nurse), Lesley Nightingale (research nurse), Clare Stratton (research nurse), Lesley Self (research nurse), Helen Martin (research assistant).

Front row, left to right: Carol Ralph (research nurse), Susan Craighead (clinic doctor), Clare Watson (clinic doctor), Pauline Howell (nurse co-ordinator), Penney Billington (research nurse).

Introduction

This booklet describes a series of projects undertaken by the Medical Research Council (MRC) in Hertfordshire. The county is unique in having preserved its midwives’ and health visitors’ records since 1911. Information on early growth and health is therefore available for the majority of babies born there.

With the help of some of the babies born between 1931 and 1939 who are now in their 60s and 70s, we have tested the idea that early circumstances, particularly growth before birth and in the fi rst year of life, are indicators of our health as we age.

This booklet is primarily for them, to thank them for giving up literally hours of their time, and undergoing all sorts of questions, tests and measurements with endless cheer and generosity. It is also an opportunity to describe some of the things that we have discovered so far.

Thank you for all your help

The MRC Hertfordshire Cohort Study Team

Professor Cyrus CooperDr Avan Aihie SayerDr Elaine DennisonMrs Helen MartinMs Vanessa CoxDr Sian RobinsonMiss Karen JamesonMrs Holly SydallMrs Shirley SimmondsMrs Janet Cushnaghan

October 2006

Background - what’s it all about?

It must be rather surprising as a mature adult to receive a letter from strangers interested in your infancy and asking questions about your current health! We hope we explained our ideas and our methods well when we met, but to recap, some of the questions you might have had are answered below:

Who are these strangers and where have they come from?The Hertfordshire Cohort Study is being conducted by the Medical Research Council’s Epidemiology Resource Centre which is based at Southampton General Hospital. Epidemiology is the study of epidemics. It can be applied to any condition, not just the infectious diseases one might immediately think of as epidemic. We have been studying the links between early life and modern epidemics of adult disease since the mid 1980s. During the course of our research we have set up clinics in a number of locations in Hertfordshire to enable as many people as possible to reach us.

Locations of Hertfordshire clinics and our Southampton base

Why the interest in babies?If you compare a map of heart disease in England and Wales today with one of infant mortality seventy years ago, there is a startling similarity. Infant mortality was a general indicator of how healthy mothers were, how healthy the environment was, and the robustness of babies in a particular area. The parts of the country which once had the least healthy babies are the hotspots for heart disease now. This led us to ask ‘do poor conditions in early life lead to heart disease in adulthood?’, and subsequently ‘could the poor conditions contribute to other diseases of adult life too?’

Why use old birth records rather than studying new babies?Because the babies have grown up, and we can compare their early record with our measurements of their adult health. We work with pregnant mums and new babies too! Using technology which was unheard of in the 1930s we are collecting much more detailed information on the babies of today, but will have to wait a long time to see an effect on their adult health.

Are there any other sets of records?We wrote to every health authority and local archive in England and Wales in search of records we could use to investigate our ideas. Hertfordshire is unique in having health visitors’ records containing weight at birth and during infancy. There were a few sets of obstetric records giving only birthweights, and we have followed babies up in Preston and Sheffi eld.

Research Assistant, Shirley Simmonds with some of the Health Visitors’ Records in our purpose-built archive in Southampton.

What do the Health Visitors’ records cover?The records were found in three parts. The districts of East Hertfordshire were found fi rst, perfectly preserved by the County archive. North and West Hertfordshire were found in forgotten storerooms at Royston and Hemel Hempstead hospitals respectively, but try as we might we could not fi nd the records for the St Albans district, meaning that the towns of St Albans, Harpenden and Wheathampstead are missing, along with the surrounding rural areas. The parishes of Ayot St Lawrence and Broxbourne are also missing.The records began in 1911 and were continued until the late 1940s.

What details are recorded?Name and address at birth,Date and time of birth,Weight at birth,Method of feeding in infancy,Weight at one year of age,Number of teeth at one year,Whether vaccinated against smallpox by one year,Whether weaned by one year,Whether given a dummy,General comments about health up to 5 years,School attended at 5 years.

Isn’t that a rather small amount of information to justify such a lot of effort?That’s epidemiology! A small amount of information about a large number of people can tell us as much as a large amount of information about a small number of people.

With such a long run of records why just study people born 1931-39?We have already studied an older group and found links between the health visitors’ recorded measurements of birthweight and weight at one year and later heart disease, diabetes and osteoporosis (thinning bones).

Later Hertfordshire births are diluted by evacuees’ babies during the war.

How did you fi nd me from records which were 60 years out of date? I have moved a few times!The NHS keeps a central register to ensure that individuals’ unique medical records are passed between GPs when they move, and removed from the system when they die. The system pre-dates the NHS, having originally been set up in 1939 to issue ration books and call-up papers during the war. It is possible for medical researchers to use

the system in a carefully regulated and completely confi dential way to identify the GP of an individual if they know their full name and date of birth. The GP can then be asked to provide a current address.

Occasionally the Hertfordshire records did not give all the details we needed, in which case we did some careful detective work linking brothers and sisters in our fi les and using the National Index of Births (familiar to anyone who has traced their family tree). This is why we may have asked you your mother’s maiden name if there was any doubt that you were the person we thought you were!

Why hasn’t my brother or sister who still lives in Hertfordshire been asked to help with your research?Perhaps they were in the older or younger group or their record was not quite as complete as yours. We have only included people whose birthweight and weight at one year were recorded.

What about the people who don’t live in Hertfordshire any more? Can you get any information about them?Indeed we can! The NHS central register puts a mark called a ‘fl ag’ on the record of the people we are trying to trace. For practical reasons we can only follow-up people who are still living in Hertfordshire, but when the Central Register receives a notifi cation of death for anyone whose record is ‘fl agged’ they send a copy of the death certifi cate to the specifi ed researcher. There is some information about deaths among Hertfordshire babies later.

An extract from the health visitors’ records

The nurse who made it all possibleEthel Margaret Burnside OBE (1877-1953)

The Hertfordshire records were started by Miss Burnside in 1911. Audrey Davidson, a research nurse, has written a biography of her, excerpts of which appear here. The full version is in the Hertfordshire Archives and Local Studies, County Hall, Hertford.

Ethel Margaret Burnside (left) was born in Hertingfordbury in 1877, the fi fth child of Eliza and the Rev Frederick Burnside. This photograph was taken when she was a young woman. Her steady confi dent gaze is striking. But who would have guessed that she was to become a highly respected nurse and administrator, that her work would improve the health of Hertfordshire’s mothers and children, and that she would contribute to medical research 40 years after her death? Nor, by the way, does the photograph give a clue that she would grow into ‘a big bony woman, about fi ve feet ten inches tall, with a long thin face and dark hair, which she wore scraped back, a very imposing presence, a penetrating voice and a dominant personality’.

She trained at St George’s Hospital in London, and on 29th September

1904 joined the Midwives Roll as number 7204. Only two years later, on the recommendation of the County Medical Offi cer, Dr Freemantle, she was appointed to the new post of Lady Inspector of Midwives for Hertfordshire. Her job was to raise the standards of midwifery and baby care and improve the health and survival of Hertfordshire’s babies. Her work was both practical and administrative; organising training, writing reports, and campaigning for better equipment for her staff. She worked hard, and for 7 years went everywhere by bicycle, travelling up to 3,000 miles in a year.

Through her reports we know much about her work. She did not try to do everything at once, but made small methodical changes, paying attention to basics. Finding that untrained nurses could not read the index of a thermometer, she asked the Medical Supply Association to produce the “Grevillite Large Index Thermometer”, which had a red line at 100.4°F (38°C), indicating “Send for the Doctor”, important in the days when puerperal fever was still a big hazard to mothers. Equally, few of the health visitors were equipped with weighing scales, necessary equipment for judging the health of infants. She persuaded

the County Council to provide 60 spring balances at fi ve shillings each, which, ‘while remaining the property of the Council, would be put to good use by the nurses’. She complained about the lack of trained midwives, especially in smaller villages such as Bishops Stortford (!), and obtained £25 scholarships to train Hertfordshire’s ‘cottage nurses’, unqualifi ed but experienced practising midwives. In 1908 she founded the County Training Home for village midwives in Watford. Miss Burnside thus built up an “army” of good nurses throughout the county.

Remarkably, she also set up a system which recorded their activities for posterity. Midwives notifi ed new births, and the babies’ birthweights, to County Hall. For each birth the health visitor was sent a card on which to record her visits to the infant during its fi rst year, the type of feeding it received, its general development, and any illnesses. At the end of one year the infant was re-weighed, and the card was returned to Miss Burnside’s offi ce. The details were transcribed in immaculate handwriting, by a small group of women, into ledgers, a separate book for each village. So

began the Hertfordshire records, now world famous, and much treasured in Southampton University. A few doctors practising in the county at that time saw Miss Burnside’s system as a threat and refused to notify births, or wrote ‘not to be visited’. But the system was unstoppable, mainly because mothers liked having their babies weighed and appreciated the advice the health visitors gave them.

Miss Burnside was highly respected in her work. The Clerk to the County Council would make himself immediately available to her if he knew she was in the building and wished to see him. In 1913 the Council purchased for her a 9.5hp Standard motor car, which she called ‘Little Hero’. She was perhaps the fi rst lady driver to use a company car! She left Hertfordshire in 1919 to join the newly formed Ministry of Health in London. She retired in 1935, and lived with her brother, John, in Chapel Lane, Letty Green until her death in 1953. How gratifi ed she would be to know that the Hertfordshire baby records, which she initiated, would prove to be such a goldmine for research by the Medical Research Council, over 40 years later.

that other tests can be run in the future if necessary. We are still working on the comparison of the blood measurements with the information from the health visitors’ records. So far, looking at cholesterol, we have found that for the group as a whole diet and birthweight both infl uence adult levels. There is some more information about this later.

Blood pressure was measured standing, sitting, and lying down. This gives a better indication of what is usual than a single reading.

Healthy ageing - Heart

Our interest in the effect of early growth on health in later life was kindled by the observation of unexpectedly high rates of heart disease in people who did not grow well as babies. We have seen this relationship in deaths at a national level and in the older group of people initially studied in Hertfordshire. With your help Professor David Barker has measured some of the things which give a clue to the health of the heart and blood vessels. They will check the results against the fi ndings in the older group.

The 3000 people who came to our clinics all had an electrocardiogram (ECG). This is a test during which electrodes are stuck on the chest to measure the fl ow of electricity in the heart as it beats. A tracing like the one above is produced. This one is normal; the pattern is different in people with coronary heart disease.

Blood was taken and tested for all sorts of things. The samples were sent to the laboratory to be analysed straight away, and if anybody’s results were abnormal or worrying they would have been contacted via their GP. The blood remaining from each sample is returned to us after they have been analysed, so

Research nurse, Lesley Nightingale processing blood samples

Healthy ageing - Bones

Osteoporosis, or thinning of the bones, is a very common condition affecting over one in fi ve women after the menopause and one in twenty fi ve men. It is very important because it may lead to a tendency to broken bones, particularly of the hip, wrist and spine. Dr Elaine Dennison and Professor Cyrus Cooper studied the relationship between early growth and osteoporosis.

Our previous work in Hertfordshire has shown that weight gain in the fi rst year of life had a signifi cant effect on osteoporosis risk at the age of 60-70 years. We have now performed similar studies to check our fi ndings. Around 500 men and 500 women came up to have a bone density test, or DXA scan, at Hertford County Hospital, and once again we found that men and women who were heavier at birth, and at one year of age, had larger (and hence stronger) bones. Our study has also confi rmed that a good diet, regular exercise and not smoking are important in promoting good bone health. We were also able to look at other medical conditions that might infl uence the risk of osteoporosis; we found that newly diagnosed diabetics tended to have thicker bones, as did individuals with lower cholesterol levels.

A DXA scan report: four vertebrae from the lumbar spine are scanned to calculate bone density

Many of the men and women who came to Hertford County Hospital for a DXA scan have come back to help us for a second clinic visit. At this visit, we measured bone structure using another instrument – peripheral Quantitative Computed Tomography, or pQCT, in addition to a second DXA scan. We were very lucky to be able to perform this research as there are very few pQCT machines in this country at present. We are still working hard to complete the analyses from this phase of our research, but we have already

Dr Susan Craighead and Dr Clare Watson demonstating how the pQCT machine is set up.

discovered that bone strength, a quality measured well with the pQCT machine, is also improved by favourable growth in infancy. Those of you who helped us with this research will remember that we measured your arm (radius bone) and leg (tibia bone) with this machine.

The study gave us unique information about how early growth alters the size and architecture of our bones, and infl uences fracture risk many years later.

Healthy ageing - Joints

Arthritis literally means infl ammation of the joints. Osteoarthritis (OA) is the most common type, affecting the knees, hips, hands, feet, or spine. It is most common among people over 65. By this age around 50% of people have OA in one or more of their joints, and around 10% have some disability caused by it.

Drs Nigel Arden and Kelsey Jordan and Professor Cyrus Cooper wondered whether growth in early life could affect the risk of developing OA in the knees later on.

A number of you completed a questionnaire in clinic that asked whether you had pain in one or both knees ‘on most days in the last month’. People who answered ‘yes’ to this question were considered to have knee OA.

Weight at one year (lbs)

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X rays were also taken of some people’s knees. On these, we could look at the severity of any arthritis on the x-ray fi lms. This was very helpful as often damage may be too slight to cause symptoms.

We found no link between birthweight and knee OA. However, people who had the lowest weight at the age of one year were more likely to develop OA in adulthood than heavier babies (see graph). From this, we concluded that growth during infancy rather than before birth affects the risk of developing OA later on.

Preparing for a knee X ray

Healthy ageing – Muscle

There is a trend for muscle strength and the ability to perform physical tasks to decline in later life. This decline is important because of its association with an increased risk of disability and dependency. Dr Avan Aihie Sayer and Mrs Helen Martin have undertaken a series of studies to identify important infl uences on muscle function operating throughout the lifecourse. The aim is to develop effective interventions to both minimise decline and maximise independence for healthy ageing in older people.

A new fi nding has been the demonstration of a link between birth weight, infant growth and adult muscle strength as shown in the graphs on the right.

Higher birth weight has now been associated with improved grip strength in three separate studies and this relationship is there even after allowing for the fact that larger babies tend to become bigger and therefore stronger adults.

We don’t know the underlying mechanism yet but we have done a study to look at the association between birth weight and body composition in older people. This has shown that higher birth weight

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is associated not only with increased muscle strength but also with increased fat-free mass, a measure of the amount of muscle in the body.

Mr Anthony Durrant having his grip strength measured with a dynamometer, which gives a useful assessment of general muscle strength

Healthy ageing - Staying active

Our interesting fi ndings showing links between better growth in early life and stronger muscle strength in adulthood, led us to consider whether the way older people perform physical tasks and activities was also infl uenced by growth in early life.

We measured the speed that people could complete a battery of physical performance tests which are similar to tasks people need to carry out on a daily basis, such as rising from a chair, walking a set distance, and balancing. We also measured grip and quadriceps (leg) muscle strength.

We found that good muscle strength was needed in order to be successful at these tasks but growth in early life did not appear to be an important infl uence. In fact we found that the most important factors helping to retain good levels of physical performance in older people were maintaining a healthy weight and remaining physically active, especially for women.

Mr Kenneth Maynard performing the “chair rise” test

We are now setting up an intervention study to see if we can improve levels of muscle strength and physical performance in older men and women from Hertfordshire, in response to a programme of physical activity in a local sports centre.

Current advice is to eat up to four portions of oily fi sh per week – these results from the Hertfordshire study suggest that this would be of benefi t for grip strength too!

Our next analyses looked at the relationship between the amount of fat in the diet and blood cholesterol level. When we looked at the whole group of men and women studied in East Hertfordshire we found that blood cholesterol and dietary fat weren’t linked. But when we divided the men up according to their weight at birth - we found that the fat-cholesterol relationship was different in the low and high birth weight groups. What this suggests is that individual responses to diet may depend on early growth and experience – and importantly – that as a result of these differences the diet that is healthiest for one person is not the same as the diet that is healthiest for another.

What is a healthy diet?

It has been known for many years that there are links between conditions such as cardiovascular disease and some cancers, and particular foods and patterns of diet. What we don’t know is what the best or optimal pattern of diet is – and whether this is the same for everyone. Does it depend on your genes? Could diet & growth in early life be important? Are there combined effects of early growth and later diet on disease risk? Dr Sian Robinson has tried to answer these questions.

In the Hertfordshire study we have collected information about diet using a questionnaire and a food diary (some of you will remember!) Using this information we have been able to start to look at the effects of differences in adult diet on health and disease. The fi rst aspect of health we studied was grip strength. Because vitamin D has been shown to be important for muscle function, we looked at how grip strength varies with the amount of oily fi sh eaten – the most important source of vitamin D in the diet. We found that eating more oily fi sh was associated with higher grip strength in both men and women (see graph).

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Are stress and personality important?

Although we often blame a stressful lifestyle for the illnesses we get later in life, it comes as a surprise to many that there is a lack of good scientifi c evidence that stress has an important infl uence on disease. A major part of the problem is that although we are all exposed to events at home and at work which we fi nd stressful, the way we respond to stress varies according to personality. Some people seem to thrive under circumstances which others fi nd very diffi cult. Dr Alex Ward has measured physical responses to stress among Hertfordshire people, and Dr Wolff Schlotz has recently started to investigate the differences in personality which we think contribute to them.

One recent fi nding in the Hertfordshire studies is that our susceptibility to stress may be related to growth in early life. We found for example, that people who were smaller at birth had higher levels of the hormones associated with the stress response. We have studied how people respond to simple ‘stressful’ tasks like doing mental arithmetic, and measured the body’s responses to these tests (for example changes in pulse and

blood pressure). The results will help us understand how stress and disease are linked.

If growth in early life alters the functioning of our bodies, we wondered if it could also affect personality by shaping the way a situation is processed in the brain. Of course, lifetime events and experiences contribute to each individual’s unique pattern of personality traits too, so we would not expect the link between early growth and personality to be very strong. This is currently being investigated by a postal questionnaire, and results will be presented in a later edition of this booklet.

Studies in depth

The strength of our research in Hertfordshire has usually been its ability to draw conclusions from small amounts of information about large numbers of people. Sometimes however, it is necessary to study fewer people in more depth to fi nd out how the links between early circumstances and later health actually come about. Professor David Phillips and Dr Mayank Patel invited 32 of the men among you to stay overnight at the Wellcome Trust Clinical Research Facility in Southampton, where they subjected you to some really rigorous tests!

They measured body composition using a special DXA scan and found that the bodies of people who had been small babies had a greater percentage of fat (and thus a lower percentage of muscle) than the bodies of people who were large babies. The small babies also had a greater tendency to carry their fat around their waist. This helps to explain the link between early growth and heart disease because we have known for a long time that being fat, especially round the middle, increases our risk of heart disease.

In depth measurements of body composition of a few people also helped us to interpret the measurements of height, weight, waist,

hips and skinfolds made on the large number of you who came to clinic.

In order to see whether early growth affects the way our bodies use the food we eat, the men who came to Southampton had their energy expenditure measured before and after a meal. This was done using a hood to collect and analyse the gases they breathed out. Although they ate the same meal, and rested in the same way after it, the men who had been small babies burned fewer calories than those who had been large.

Osteoporosis affects men less frequently than women, but when it does they are less likely to survive a major fracture. The hormones which determine bone density are known to vary in response to activity and can be measured in blood and urine. Men who came to Southampton had blood taken or collected urine in a variety of situations including after sleep and whilst exercising. Some also had tests in which the hormone levels were artifi cially manipulated. The tests helped us to understand the complicated interaction between these hormones, and suggested that the liver might affect their levels. The fi ndings also throw light on new treatments for osteoporosis.

From Birth to Death…..

The health visitor’s records covered many, many more babies than we could invite to our clinics in Hertfordshire. There were lots of reasons why people were not seen: their records may have been too sketchy for us to attempt to trace them, they may have left the country, lived in Britain but too far away to travel to clinic, or they may have died. Nearly 38,000 men and women born in Hertfordshire from 1911-39 have been ‘fl agged’ on the NHS central register. This means that when they die we will receive a copy of their death certifi cate, usually within about three months. The people we have seen in clinic are part of this group. By the millennium about 8000 of the original 38,000 had died. Holly Syddall and Shirley Simmonds have compared certifi ed causes of death with early records to provide another link in the chain, this time covering people who had moved away from Hertfordshire as well as those who had stayed.

We found that as expected, men and women who were small babies shared a higher risk of death from heart disease and stroke. For other diseases there were differences between the sexes:

Women: In addition to their increased risk of heart disease and stroke, women of lower birthweight had higher rates of death from pneumonia, injury (particularly falls) and diabetes. Deaths from bone and joint diseases, though uncommon, were also increased in women of low birthweight.

Men: Among men, smaller babies also had higher rates of death from accidental falls in adult life. Conversely, they had a lower risk of death from cancer.

The lower risk of cancer in men did not negate the effects of small birth size on death; when all possible causes of death were added together, smaller babies of either sex were more likely to have died by the age of 75 than those who were born large.

Smedley Hydro in Southport – home of the NHS Central Register since 1939 when the former hotel was requisitioned as offi ces for the national registration scheme

What next?

We hope you have enjoyed reading about our fi ndings to date. Our studies are ongoing, and we answer some queries about our current work and future plans below:

Not all the questions I answered are covered here. Why not?What with home visit and clinic records for 3000 of you, and subsidiary tests and procedures for large subgroups, we have collected a mountain of data from Hertfordshire. Two statisticians Holly Syddall and Karen Jameson are kept very busy analysing it all.

Who looks after all the information in Southampton?Computer Manager Vanessa Cox and her team of programmers and data processors computerise all the information from clinic and link it to the health visitors’ records. There are checks in the system so that if your test results are abnormal your GP is informed swiftly.

Is it all stored securely?MRC staff are required to sign a declaration of confi dentiality on

appointment that is even more strict than the one signed by NHS staff. We are registered under the Data Protection Act and follow all the requirements for computer security very carefully. All our fi les are backed up daily and copies stored both on- and off-site. The original ledgers are stored in a purpose-built archive with restricted access.

What about the samples?Freezer Manager Keith Gardner has two large storerooms stocked with enormous freezers running at –80°C. The contents are ‘mapped’ so we know where to fi nd an individual sample, and there is an alarm to tell us if any of them are getting too warm. We even carry a bleep on a rota system so the alarm can summon us from our beds or our Christmas lunches if all is not well with the samples!

May I have a copy of my birth records?Yes, you may. We are not able to photocopy the original records because they are large, unwieldy and increasingly fragile. We can, however, supply you with a computerised copy if you contact us at the address opposite telling us your name, date and place of birth, and ladies, your maiden name too please.

Hard at work: Karen Jameson above and Keith Gardner below

Are any more clinics or postal questionnaires planned?We have no immediate plans for large scale clinics, but will undoubtedly be returning in the future. Our colleagues and collaborators from the MRC unit in Cambridge are going to invite a small number of people in North Hertfordshire to participate in some exercise tests soon.

There will certainly be more posta l questionnaires, the fi rst being co-ordinated by Janet Cushnaghan.

Can I withdraw from the study?We would be very sorry if anyone wanted to remove themselves permanently from our study. Remember, each time we contact you your co-operation is entirely voluntary, and if you do not feel able or willing to participate in a particular phase of the project you only have to say so. We hope you will not mind us contacting you again when the next phase is running, but if you really feel you have had enough, let us know.

Would you like to know if I move house?Yes please! We are very keen to keep in touch with you in the future.

Where can I get more information?Write to: The Hertfordshire Team, MRC ERC, Southampton General Hospital,Southampton, SO16 6YD

email: sjs@mrc.soton.ac.uk, telephone: 023 8077 7624

We will do our best to help.

Where are they now?May Queen Parade, Hillshott Infants’ School Letchworth, 1936. We know that we have met at least two of these young attendants in our clinics!Photographs kindly supplied by Mr Gilbert Robinson

Behind the scenes at the MRC ….

Nurses Penney Billington and Pauline Howell between clinics…..

...and Dr Mayank Patel being put through some of the physical performance tests.

Lastly, over to you……

These are just a few of the things you have written to us after we met:

‘Thank you for my MOT, I think this will be the only way I will make history’

‘It was good to feel that although only a minute cog in the overall research of this project, that the results are giving good guidelines to helping the future health of other people’

‘First they get you to take your shirt off, then they draw all over you, they shave your chest, and fi nally get you to take your wedding ring off!!’

‘I did enjoy my morning with you all – it was fun’

‘I was impressed by the high standard of care and organisation of such a complex research project. I am glad that I was able to contribute, and will look forward with interest to the subsequent fi ndings’

‘It was nice to meet the other ladies who came for tests too’

‘The computer printout of my early life was fascinating. I enjoyed the morning I spent with you.’

‘Thanks for the printout – very interesting. I shall add it to my scrapbook of the family through the years.’

‘I am very happy I took part’

‘It was certainly a full and interesting morning’

MRC Epidemiology Resource Centre, University of Southampton,Southampton General Hospital, Southampton SO16 6YD