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Institute of Epidemiology and Health Care Blog



Archive for November, 2018

Why we need health examination surveys to understand health and health risks

By guest blogger, on 16 November 2018

Would you let a stranger into your home? Would you then answer questions about yourself, your family and your health for an hour or so? Luckily, 10,000 people in England do so every year. Most also allow the interviewer to measure their height and weight. Many agree to a nurse visiting them later. The nurse measures their waist and blood pressure and takes blood, urine or saliva samples.

The Health Survey for England (HSE) is one of the biggest and longest-running health examination surveys in the world. It is organised by NatCen Social Research and UCL. What makes the HSE unique in the UK is that we take these measurements and we ask the general population – anyone living in a private home. We don’t rely only on questions (a ‘health interview survey’). We don’t rely only on information collected by the NHS. We work on three surveys at a time. We are currently: writing the report for the 2017 survey, running the 2018 survey, and preparing for the 2019 survey. We always obtain approval from an NHS Research Ethics Committee for the questions and measurements we plan to include before we start the survey.

Why is this important? Most people report that they are taller than they actually are, and weigh less than they actually do. Relying on self-reported information underestimates how big the obesity problem is in England. People who have undiagnosed diseases cannot tell us about them. By measuring blood pressure, we can find out how many people have high blood pressure (‘hypertension’) but don’t know it. We do the same for diabetes by measuring blood sugar levels. We also collect saliva to measure cotinine. This is made by the body when exposed to nicotine. Smokers have high levels. Non-smokers have measurable cotinine if they spend time in places where other people smoke. Although levels are much lower, it shows they are exposed to the thousands of harmful chemicals in tobacco smoke.

The HSE has been running since 1991. Some information on how health and health risk factors have changed over time has been put onto the HSE website. Obesity in children increased from the early 1990s to the early 2000s. It fell a little but is still too high. We also showed that waist circumference has increased in teenagers even more than general obesity. In adults, too, obesity increased in the 1990s to the mid-2000s. It hasn’t changed much in recent years. However, waist circumference continues to rise. This is more worrying as it is a marker of ‘abdominal obesity’, with fat collecting in the abdomen. This gives people a high risk of developing diseases such as diabetes, heart disease, or some types of cancer.

There is also good news in the health trends. The proportion of adults who smoke cigarettes has fallen from 27% in 1993 to 18% in 2016. Even where parents smoke, the proportion who try to keep their home smoke free has increased.[i] In 2006, two-thirds of non-smoking children had cotinine in their saliva, because of exposure to other people’s smoke. By 2014/15, this had fallen to just over one-third of non-smoking children. The management of high blood pressure is much better than it used to be.[ii] However, it still needs to improve further.

The Health Survey for England 2016 report provided information on many topics. 16% of children, 26% of men and 27% of women were obese. Chronic liver disease was most common in adults aged 55 to 64 years. Almost one in five adults (19%) had probable mental illness. Almost one in four adults (24%) had taken three or more prescribed medicines in the previous seven days. 66% of men and 58% of women met the aerobic physical activity guidelines.

Cases of diabetes are on the rise. Is that because more people are becoming diabetic or because doctors are better at finding those people? HSE data show that both are happening. At one time, for every diagnosed case of diabetes, there were two more people with undiagnosed diabetes. By 2013, 7% of people had diabetes. Four-fifths were diagnosed.[iii] In other words, there were eight people with diagnosed diabetes for every two who didn’t know they had diabetes. A great improvement.

UCL staff are analysing data on adult health; combinations of health risk factors; and circulatory diseases, such as heart attacks and strokes. NatCen staff are analysing data on social care; adult and child obesity; and health of children. Watch out on the UCL, NatCen and NHS Digital websites (listed below) and in the news to see what we find. And if you ever receive a letter inviting you to take part in the HSE, please do!

Professor Jennifer Mindell is a public health doctor who has also worked in general practice and health promotion. She is interested in policies outside the health services that affect health and inequalities. She leads the UCL team dealing with the Health Survey for England and other health examination surveys in the UK; comparative work across Europe (EHES); and a comparison project (ESARU) across the Americas and the UK. Prior to this, she was the Deputy Director of the London Health Observatory. She led health impact assessments (HIAs) of the London Mayor’s Transport and other strategies. She was the chief investigator for a large research project at UCL, Street Mobility. This developed tools to measure the barrier effect of busy roads and the effects on local people. She chairs the UK Faculty of Public Health’s Health Improvement Committee and sits on the FPH Health Policy Committee. She is the health lead for the UCL Transport Institute. She is also Editor-in-chief of the new, award-winning Journal of Transport and Health. She was also very involved nationally in tobacco control for many years. See Jenny Mindell’s IRIS profile web page

For more information about the Health Survey for England, visit the following websites:


[i] Jarvis M, Sims M, Gilmore A, Mindell JS. Impact of smoke-free legislation on children’s exposure to passive smoking: cotinine data from the Health Survey for England. Tobacco Control. 2012;21:18-23. https://tobaccocontrol.bmj.com/content/21/1/18

[ii] Falaschetti E, Mindell JS, Knott C, Poulter N. Hypertension management in England: a serial cross-sectional study from 1994 to 2011. Lancet. 2014;383:1912-9. https://linkinghub.elsevier.com/retrieve/pii/S0140673614606887

[iii] Moody A, Cowley G, NgFat L, Mindell JS. Social inequalities in prevalence of diagnosed and undiagnosed diabetes and impaired glucose regulation in participants in the Health Surveys for England series. BMJ Open. 2016;6:e010155. https://bmjopen.bmj.com/content/6/2/e010155