Distribution and determinants of glycosylated hemoglobin in adolescents - Results from a nationwide population-based survey in Germany.

The role of glycosylated hemoglobin (HbA1c) in youth is largely unclear. The aims of this study are to investigate the distribution and potential determinants of HbA1c among a population-based sample of adolescents. The German Health Interview and Examination Survey for Children and Adolescents (KiGGS) Wave 2 includes a nationwide representative sample of 0-17-year-old participants. For this evaluation, data from a randomly selected subgroup aged 14-17 years and without diagnosed diabetes was included (n = 857). Percentile-based HbA1c values (measured at laboratory in whole blood samples by high performance liquid chromatography) were calculated to examine HbA1c distribution. Multivariable linear regression analyses were performed to investigate factors (age, sex, parental socioeconomic status, body mass index (BMI), birth weight, smoking, alcohol consumption, healthy food diversity, sport activity, oral contraceptive use) associated with HbA1c. The mean HbA1c level was 5.2% (minimum: 3.9%, P10: 4.8%, P50: 5.1%, P90: 5.5%, maximum: 6.7%). Overall, 2.8% of adolescents had an HbA1c value in the prediabetic range (5.7-6.4%) and 0.1% had an undiagnosed diabetes (≥6.5%). Multivariable regression analysis showed an inverse association of age with HbA1c (17 vs. 14 years: ß: -1.18; 95% CI -2.05, -0.31). Higher HbA1c values were observed for higher BMI-standard deviation scores (SDS) (ß: 0.24; 95% CI -0.04, 0.52) and smoking (ß: 0.73; 95% CI -0.12, 1.57), but these tendencies were non-significant. In sex-stratified analysis, smoking and birth weight were significantly associated with HbA1c in boys. Among adolescents without diagnosed diabetes in Germany, HbA1c values ranged from 3.9% to 6.7%. To ensure health in adulthood, the influence of determinants on HbA1c levels in younger age should be further investigated.

Long-term health consequences among individuals with SARS-CoV-2 infection compared to individuals without infection: results of the population-based cohort study CoMoLo Follow-up.

BACKGROUND: Most of the previous studies on health sequelae of COVID-19 are uncontrolled cohorts and include a relatively short follow-up. This population-based multi-center cohort study examined health consequences among individuals about 1 to 1.5 years after SARS-CoV-2 infection compared with non-infected. METHODS: The study population consisted of adults (≥ 18 years) from four municipalities particularly affected by the COVID-19 pandemic in the year 2020 who completed a detailed follow-up questionnaire on health-related topics. Exposure was the SARS-CoV-2 infection status (based on IgG antibodies, PCR test, or physician-diagnosis of COVID-19) at baseline (May to December 2020). Outcomes assessed at follow-up (October 2021 to January 2022; mean: 452 days) included recurrent or persistent health complaints, incident diseases, health-related quality of life (PROMIS-29), subjective health, and subjective memory impairment. Logistic and linear regression models were adjusted for baseline sociodemographic and lifestyle characteristics (age, sex, municipality, education, smoking, body mass index), pre-existing health conditions (chronic disease/health problem, health-related activity limitation, depressive/anxiety disorder), and follow-up time. RESULTS: Among 4817 participants, 350 had a SARS-CoV-2 infection at baseline and 4467 had no infection at baseline or during follow-up. Those with an infection statistically significantly more often reported 7 out of 18 recurrent or persistent health complaints at follow-up: smell/taste disorders (12.8% vs. 3.4%, OR 4.11), shortness of breath (23.0% vs. 9.5%, 3.46), pain when breathing (4.7% vs. 1.9%, 2.36), fatigue (36.9% vs. 26.1%, 1.76), weakness in legs (12.8% vs. 7.8%, 1.93), myalgia/joint pain (21.9% vs. 15.1%, 1.53) and cough (30.8% vs. 24.8%, 1.34) and 3 out of 6 groups of incident diseases: liver/kidney (2.7% vs. 0.9%, 3.70), lung (3.2% vs. 1.1%, 3.50) and cardiovascular/metabolic (6.5% vs. 4.0%, 1.68) diseases. Those with an infection were significantly more likely to report poor subjective health (19.3% vs. 13.0%, 1.91), memory impairment (25.7% vs. 14.3%, 2.27), and worse mean scores on fatigue and physical function domains of PROMIS-29 than non-infected. CONCLUSION: Even after more than one year, individuals with SARS-CoV-2 infection showed an increased risk of various health complaints, functional limitations, and worse subjective well-being, pointing toward profound health consequences of SARS-CoV-2 infection relevant for public health.

[Algorithm for the Classification of Type 1 and Type 2 Diabetes Mellitus for the Analysis of Routine Data]. / Algorithmus zur Unterscheidung von Diabetes mellitus Typ 1 und Typ 2 bei der Analyse von Routinedaten.

BACKGROUND: Diabetes mellitus is a disease of high public health relevance. To estimate the temporal development of prevalence, routine data of statutory health insurances (SHI) are being increasingly used. However, these data are primarily collected for billing purposes and the case definition of specific diseases remains challenging. In this study, we present an algorithm for differentiation of diabetes types analyzing SHI routine data. METHODS: The basis for the analysis was an age and sex-stratified random sample of persons of the Barmer SHI with a continuous insurance duration from 2010 to 2018 in the magnitude of 1% of the German population. Diabetes was defined in the reporting year 2018, as documentation of (1) a "confirmed" ICD diagnosis E10.- to E14.- in at least two quarters, (2) a "confirmed" ICD diagnosis E10.- to E14.- in one quarter with an additional prescription of an antidiabetic drug (ATC codes A10), or (3) an ICD diagnosis E10.- to E14.- in the inpatient sector, outpatient surgery, or work disability. Individuals were assigned to a diabetes type based on the specific ICD diagnosis E10.- to E14.- and prescribed medications, differentiated by insulin and other antidiabetics. Still unclear or conflicting constellations were assigned on the basis of the persons' age or the frequency and observation of the diagnosis documentation over more than one year. The participation in a disease management program was considered in a sensitivity analysis. RESULTS: The prevalence of documented diabetes in the Barmer sample was 8.8% in 2018. Applying the algorithm, 98.5% of individuals with diabetes could be classified as having type 1 diabetes (5.5%), type 2 diabetes (92.6%), or another specific form of diabetes (0.43%). Thus, the prevalence was 0.48% for type 1 diabetes and 8.1% for type 2 diabetes in 2018. CONCLUSION: The vast majority of people with diabetes can be classified by their diabetes type on the basis of just a few characteristics, such as diagnoses, drug prescription, and age. Further studies should assess the external validity by comparing the results with primary data. The algorithm enables the analysis of important epidemiological indicators and the frequency of comorbidities based on routine data differentiated by type 1 and type 2 diabetes, which should be considered in the surveillance of diabetes in the future.

Diabetes-related distress and associated factors among adults with diabetes in Germany: Results of the nationwide study "Disease knowledge and information needs - Diabetes mellitus 2017".

BACKGROUND: Diabetes-related distress (DRD) can affect diabetes management adversely. In lack of population-based data, the frequency and determinants of DRD among adults with diabetes in Germany remain controversial. METHODS: This study included 1367 adults with diabetes who participated in a nationwide health telephone survey conducted among German adults aged 18 years and older in 2017. The short form of the Problem Areas in Diabetes (PAID-5) scale was used to assess DRD. The associations of high DRD (PAID-5 sum score ≥ 8) with socio-demographics, diabetes-related risk factors, diabetes clinical characteristics as well as quality of self-care and chronic illness care assessed by patients were tested in multivariable logistic regression models. RESULTS: The overall DRD prevalence was 15.1% (95% confidence intervals, 95% CIs, 12.5-18.0%) with no significant difference between men (14.7%, 95% CIs 11.2-19.1%) and women (15.4%, 11.9-19.8%). In multivariable analyses, DRD was significantly associated with younger age (odds ratio 0.96, 95% CIs 0.94-0.98, per year), immigration background (2.26, 1.16-4.42), current smoking (2.06, 1.14-3.70), insulin use (2.57, 1.45-4.56), and the presence of diabetes-specific complications (1.80, 1.10-2.94) or depressive symptoms (5.34, 3.24-8.81). Among those with depressive symptoms (18,4% of the study population), 38.3% also had DRD, which accounted for 7.0% (95% CIs 5.3-9.3%) of the study population. CONCLUSION: DRD is a common health problem among adults with diabetes in Germany, and highly correlates with depressive symptoms, current smoking, immigration background, and insulin use. Addressing DRD needs to become an integrative part of ambulatory diabetes care.

German Diabetes Risk Score for the Determination of the Individual Type 2 Diabetes Risk.

BACKGROUND: The German Diabetes Risk Score (GDRS) currently enables prediction of the individual risk of developing type 2 diabetes (T2D) within five years. The aim of this study is to extend the prediction period of the GDRS, including its non-clinical version and its HbA1c extension, to 10 years, and to perform external validation. METHODS: In data from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study (n = 25 393), Cox proportional hazards regression was used to reweight the points that were used to calculate the five-year risk. Two population-based prospective cohorts (EPIC-Heidelberg n = 23 624, GNHIES98 cohort n = 3717) were used for external validation. Discrimination was represented by C-indices, and calibration by calibration plots and the expected-to-observed (E/O) ratio. RESULTS: Prediction performance in EPIC-Potsdam was very good (C-index for the non-clinical model: 0.834) and was confirmed in EPIC-Heidelberg (0.843) and in the GNHIES98 cohort (0.851). Among persons in the GNHIES98 cohort with a greater than 10% predicted probability of disease, 14.9% developed T2D within 10 years (positive predictive value). The models were very well calibrated in EPIC-Potsdam (E/O ratio for the non-clinical model: 1.08), slightly overestimated the risk in EPIC-Heidelberg (1.34), and predicted T2D very well in the GNHIES98 cohort after recalibration (1.06). CONCLUSION: The extended GDRS prediction period of 10 years, with a non-clinical version and an HbA1c extension that will soon be available in both German and English, enables the even longer-range, evidence-based identification of high-risk individuals with many different applications, including medical screening.

Estimating the impact of tax policy interventions on the projected number and prevalence of adults with type 2 diabetes in Germany between 2020 and 2040.

INTRODUCTION: As a population-wide intervention, it has been proposed to raise taxes on unhealthy products to prevent diseases such as type 2 diabetes. In this study, we aimed to estimate the effect of tax policy interventions in 2020 on the projected prevalence and number of people with type 2 diabetes in the German adult population in 2040. RESEARCH DESIGN AND METHODS: We applied an illness-death model and the German Diabetes Risk Score (GDRS) to project the prevalence and number of adults with type 2 diabetes in Germany under a base case scenario and under a tax policy intervention scenario. For the base case scenario, we assumed constant age-specific incidence rates between 2020 and 2040. For the intervention scenario, we assumed a 50% price increase for sugar-sweetened beverages, tobacco and red meat products in the year 2020. Based on price elasticities, we estimated the impact on these risk factors alone and in combination, and calculated subsequent reductions in the age-specific and sex-specific GDRS. These reductions were used to determine reductions in the incidence rate and prevalence using a partial differential equation. RESULTS: Compared with the base case scenario, combined tax interventions in 2020 resulted in a 0.95 percentage point decrease in the prevalence of type 2 diabetes (16.2% vs 17.1%), which corresponds to 640 000 fewer prevalent cases of type 2 diabetes and a relative reduction by 6%. CONCLUSIONS: Taxation of sugar-sweetened beverages, tobacco products and red meat by 50% modestly lowered the projected number and prevalence of adults with type 2 diabetes in Germany in 2040. Raising taxes on unhealthy products as a stand-alone measure may not be enough to attenuate the future rise of type 2 diabetes.

Care for the chronically ill in Germany - The challenges during the COVID-19 pandemic.

The COVID-19 pandemic is posing major challenges to the health care sector. This scoping review compiles evidence concerning changes to health care service availability and utilisation as well as possible impacts on health for selected groups of chronically ill people in Germany. The focus is on cancer, cardiovascular diseases, diabetes mellitus and mental disorders. Most empirical data available concerned inpatient care and showed a clear decline in the utilisation of inpatient treatments in March and April 2020 in the areas of oncology and cardiology as well as in mental health. For cardiovascular emergencies such as heart attack and stroke, a decline was observed especially regarding less serious cases. Although there were indications of treatment delays, there was no evidence thus far that emergency care had been generally compromised due to adjustments to inpatient care capacities. In the outpatient setting, extensive adjustments to health care services availability were observed for all disease groups considered. Overall, very limited empirical data were available. In particular, hardly any data were available on how changes in care impacted population health. There is an urgent need for continuous surveillance and evaluation based on health care and epidemiological data.

Health App Use and Its Correlates Among Individuals With and Without Type 2 Diabetes: Nationwide Population-Based Survey.

BACKGROUND: Evidence suggests that mobile health app use is beneficial for the prevention and management of type 2 diabetes (T2D) and its associated complications; however, population-based research on specific determinants of health app use in people with and without T2D is scarce. OBJECTIVE: This cross-sectional study aimed to provide population-based evidence on rates and determinants of health app use among adults with and without T2D, thereby covering a prevention perspective and a diabetes management perspective, respectively. METHODS: The study population included 2327 adults without a known diabetes diagnosis and 1149 adults with known T2D from a nationwide telephone survey in Germany conducted in 2017. Rates of smartphone ownership and health app use were estimated based on weighted sample proportions. Among smartphone owners, determinants of health app use were identified for both groups separately in multivariable logistic regression models. Sociodemographic factors, diabetes-related factors or indicators, psychological and health-related factors, and physician-provided information were selected as potential determinants. RESULTS: Among participants without known diabetes, 74.72% (1690/2327) were smartphone owners. Of those, 49.27% (717/1690) used health apps, most often to improve regular physical activity. Among participants with T2D, 42.26% (481/1149) were smartphone owners. Of those, 41.1% (171/481) used health apps, most commonly to target a healthy diet. Among people without known diabetes, determinants significantly (all P values <.05) associated with an increased likelihood of health app use compared with their reference group were as follows: younger and middle age of 18 to 44 or 45 to 64 years (odds ratios [ORs] 3.89; P<.001 and 1.76; P=.004, respectively), overweight or obesity (ORs 1.58; P<.001 and 2.07; P<.001, respectively), hypertension diagnosis (OR 1.31; P=.045), former or current smoking (ORs 1.51; P=.002 and 1.58; P<.001, respectively), perceiving health as very good (OR 2.21; P<.001), other chronic diseases (OR 1.48; P=.002), and having received health advice from a physician (OR 1.48; P<.001). A slight or high perceived diabetes risk (ORs 0.78; P=.04 and 0.23; P<.001, respectively) was significantly associated with a decreased likelihood of health app use. Among people with T2D, younger and middle age (18-64 years; OR 1.84; P=.007), female gender (OR 1.61; P=.02), and using a glucose sensor in addition or instead of a glucose meter (OR 2.74; P=.04) were significantly positively associated with health app use. CONCLUSIONS: In terms of T2D prevention, age, diabetes-related risk factors, psychological and health-related factors, and medical health advice may inform app development for specific target groups. In addition, health professionals may encourage health app use when giving advice on health behaviors. Concerning T2D management, only a few determinants seem relevant for explaining health app use among people with T2D, indicating a need for more future research on which people with T2D use health apps and why.

Participation in structured diabetes mellitus self-management education program and association with lifestyle behavior: results from a population-based study.

OBJECTIVE: Whether participation in structured diabetes self-management education programs (DSME) for participants with diabetes mellitus is associated with a healthy lifestyle in routine care apart from randomized-controlled studies remains unclear and is this studies' research question. RESEARCH DESIGN AND METHODS: We identified 1300 persons with diabetes mellitus drawn from the cross-sectional population-based analysis German Health Update 2014/2015 (GEDA 2014/2015), which integrated the modules of the European Health Interview Survey (EHIS) wave 2. Of those, 816 were ever-DSME participants and 484 never-participants. We conducted multivariable weighted logistic regression analyses for lifestyle differences comparing ever-DSME and never-DSME participants. Lifestyle was defined by physical activity (PA), current smoking, fruit/vegetable consumption and body mass index (BMI). Age, sex, socioeconomic status, living together, limitation due to health problems for at least for 6 months, self-efficacy and attention to one's health were included as confounders in the regression models. RESULTS: Ever-DSME participants engaged significantly more often in cycling at least 1 day per week (OR 1.62, 95% CI: 1.15-2.30) and performed significantly more often aerobic endurance training of 150 min per week (including walking: OR 1.42, 95% CI: 1.03-1.94, without walking: OR 1.48, 95% CI: 1.08-2.03) compared with never-DSME participants. Ever-DSME participants were significantly more often ex-smoker compared with never-DSME participants (OR 1.39, 95% CI: 1.03-1.88). DSME attendance was not significantly associated with current smoking, BMI and fruit or vegetable consumption. CONCLUSION: DSME participation is associated with a moderately healthier lifestyle particularly for PA even in routine healthcare. Study results emphasize the importance of a broadly dissemination of DSME access for nationwide diabetes healthcare. Future studies should adjust for DSME participation when investigating lifestyle in persons with diabetes.

[Prevalence and incidence of documented diabetes based on health claims data-reference analysis for diabetes surveillance in Germany]. / Prävalenz und Inzidenz des dokumentierten Diabetes mellitus ­ Referenzauswertung für die Diabetes-Surveillance auf Basis von Daten aller gesetzlich Krankenversicherten.

BACKGROUND: The prevalence and incidence of documented diabetes are two essential indicators intended to be reported on a periodic basis within the framework of diabetes surveillance in Germany. METHODOLOGY: Data provided based on the Data Transparency Act were analyzed. The data contain information on outpatient and inpatient care for all approximately 70 million persons with statutory health insurance. The case definition for the prevalence of documented diabetes comprises a confirmed outpatient diagnosis in at least two quarters of a year or an inpatient diagnosis in at least one quarter of a year in accordance with ICD-10 codes E10.- to E14.-. The incidence was calculated based on the same definition and with one year of diagnosis-free lead time. RESULTS: In 2011, a prevalence of 9.7% (women: 9.4%, men: 10.1%) was observed for persons with statutory health insurance. There are considerable differences in prevalence between the federal states and the maximum gap is 7.1 percentage points (age standardized: 4.0 percentage points). Type 2 and type 1 diabetes show a documented prevalence of 7.5% and 0.28%, respectively. Unspecified diabetes is documented relatively frequently with 1.9%. In 0.21% of persons, the diagnosis diabetes is documented via one inpatient secondary diagnosis. In addition, 0.17% of people without documented diabetes have at least one prescription of an antidiabetic drug. In 2012, 565,040 insured persons were newly diagnosed with diabetes; this corresponds to 1.0% of the insured persons (women: 1.0%, men: 1.1%). DISCUSSION: The developed reference analysis is suitable for reporting the prevalence and incidence of documented diabetes within the framework of diabetes surveillance. The differentiation of diabetes types is difficult due to coding practice.

Time trends in healthy lifestyle among adults in Germany: Results from three national health interview and examination surveys between 1990 and 2011.

BACKGROUND: The combined impact of multiple healthy behaviors on health exceeds that of single behaviors. This study aimed to estimate trends in the prevalence of a healthy lifestyle among adults in Germany. METHODS: A data set of 18,058 adults aged 25-69 years from three population-based national health examination surveys 1990-92, 1997-99 and 2008-11 with complete information for five healthy behavior factors was used. A 'daily intake of both fruits and vegetables, 'sufficient physical exercise', 'no current smoking' and 'no current risk drinking' were assessed with self-reports and 'normal body weight' was calculated based on measured body weight and height. A dichotomous 'healthy lifestyle' indicator was defined as meeting at least four out of five healthy behaviors. Age-standardized prevalence was calculated stratified by sex, age groups (25-34, 35-44, 45-54 and 55-69 years) and education level (low, medium and high). Trends were expressed in relative change (RC) between 1990-92 and 2008-11. RESULTS: In Germany, the overall prevalence of healthy lifestyle increased from 9.3% in 1990-92 to 13.5% in 1997-99 and to 14.7% in 2008-11 (RC: +58.1%). The prevalence increased among men and women and in all age groups, with the exception of men aged 45-54 years. The RC of increasing healthy lifestyle prevalence between 1990-92 and 2008-11 was stronger albeit on a higher level among women compared to men. Therefore, the gender difference in healthy lifestyle has increased, but age-related differences have overall decreased in this period. Among high educated men the prevalence of a healthy lifestyle increased between 1990-92 and 2008-11 from 10.6% to 16.3% (p = 0.01) and among high educated women from 16.4% to 30.3% and also among medium educated women (10.9 to 16.6, p<0.01), but no significant increase in healthy lifestyle prevalence was observed among men with low and medium education and among women with low education level. CONCLUSIONS: The prevalence of a lifestyle with at least four out of five healthy behaviors markedly increased from 1990-92 to 2008-11. Nevertheless, additional health promotion interventions are needed to improve the number of combined healthy behavior factors and the awareness in the population that each additional healthy behavior factor leads to a further improvement in health, especially in men in the age-range 45 to 54 years, and among persons with low education level.

Individual and area-level determinants associated with C-reactive protein as a marker of cardiometabolic risk among adults: Results from the German National Health Interview and Examination Survey 2008-2011.

BACKGROUND: High-sensitivity C-reactive protein (hsCRP) is a sensitive biomarker of systemic inflammation and is related to the development and progression of cardiometabolic diseases. Beyond individual-level determinants, characteristics of the residential physical and social environment are increasingly recognized as contextual determinants of systemic inflammation and cardiometabolic risks. Based on a large nationwide sample of adults in Germany, we analyzed the cross-sectional association of hsCRP with residential environment characteristics. We specifically asked whether these associations are observed independent of determinants at the individual level. METHODS: Data on serum hsCRP levels and individual sociodemographic, behavioral, and anthropometric characteristics were available from the German Health Interview and Examination Survey for Adults (2008-2011). Area-level variables included, firstly, the predefined German Index of Socioeconomic Deprivation (GISD) derived from the INKAR (indicators and maps on spatial and urban development in Germany and Europe) database and, secondly, population-weighted annual average concentration of particulate matter (PM10) in ambient air provided by the German Environment Agency. Associations with log-transformed hsCRP levels were analyzed using random-intercept multi-level linear regression models including 6,768 participants aged 18-79 years nested in 162 municipalities. RESULTS: No statistically significant association of PM10 exposure with hsCRP was observed. However, adults residing in municipalities with high compared to those with low social deprivation showed significantly elevated hsCRP levels (change in geometric mean 13.5%, 95%CI 3.2%-24.7%) after adjusting for age and sex. The observed relationship was independent of individual-level educational status. Further adjustment for smoking, sports activity, and abdominal obesity appeared to markedly reduce the association between area-level social deprivation and hsCRP, whereas all individual-level variables contributed significantly to the model. CONCLUSIONS: Area-level social deprivation is associated with higher systemic inflammation and the potentially mediating role of modifiable risk factors needs further elucidation. Identifying and assessing the source-specific harmful components of ambient air pollution in population-based studies remains challenging.

Derivation and external validation of a clinical version of the German Diabetes Risk Score (GDRS) including measures of HbA1c.

OBJECTIVE: The German Diabetes Risk Score (GDRS) is a diabetes prediction model which only includes non-invasively measured risk factors. The aim of this study was to extend the original GDRS by hemoglobin A1c (HbA1c) and validate this clinical GDRS in the nationwide German National Health Interview and Examination Survey 1998 (GNHIES98) cohort. RESEARCH DESIGN AND METHODS: Extension of the GDRS was based on the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study with baseline assessment conducted between 1994 and 1998 (N=27 548, main age range 35-65 years). Cox regression was applied with the original GDRS and HbA1c as independent variables. The extended model was evaluated by discrimination (C-index (95% CI)), calibration (calibration plots and expected to observed (E:O) ratios (95% CI)), and reclassification (net reclassification improvement, NRI (95% CI)). For validation, data from the GNHIES98 cohort with baseline assessment conducted between 1997 and 1999 were used (N=3717, age range 18-79 years). Missing data were handled with multiple imputation. RESULTS: After 5 years of follow-up 593 incident cases of type 2 diabetes occurred in EPIC-Potsdam and 86 in the GNHIES98 cohort. In EPIC-Potsdam, the C-index for the clinical GDRS was 0.87 (0.81 to 0.92) and the overall NRI was 0.26 (0.21 to 0.30), with a stronger improvement among cases compared with non-cases (NRIcases: 0.24 (0.19 to 0.28); NRInon-cases: 0.02 (0.01 to 0.02)). Almost perfect calibration was observed with a slight tendency toward overestimation, which was also reflected by an E:O ratio of 1.07 (0.99 to 1.16). In the GNHIES98 cohort, discrimination was excellent with a C-index of 0.91 (0.88 to 0.94). After recalibration, the calibration plot showed underestimation of diabetes risk in the highest risk group, while the E:O ratio indicated overall perfect calibration (1.02 (0.83 to 1.26)). CONCLUSIONS: The clinical GDRS provides the opportunity to apply the original GDRS as a first step in risk assessment, which can then be extended in clinical practice with HbA1c whenever it was measured.

[Regional differences in the prevalence of cardiovascular risk factors in men and women in Germany]. / Regionale Unterschiede in der Prävalenz von kardiovaskulären Risikofaktoren bei Männern und Frauen in Deutschland.

BACKGROUND: More than half of all cardiovascular diseases are caused by eight, mostly preventable risk factors. OBJECTIVES: In view of the considerable differences in the prevalence and mortality of cardiovascular diseases between the 16 German federal states, the regional distribution of cardiovascular risk factors was analyzed stratified for men and women, using population-based data. METHODS: Pooled data (n = 62,606) from the national, telephone health surveys "German Health Update" from 2009, 2010 and 2012 were used to estimate the prevalence of physical inactivity, risky alcohol consumption, smoking, low fruit and vegetable consumption, obesity and diagnosed hypertension, diabetes and dyslipidemia and the accumulated number of risk factors stratified for men and women in the federal states. Furthermore, we analyzed the influence of age and social status on prevalence differences. RESULTS: At the national level, 36.0% of men and 26.6% of women had three or more risk factors. Large differences between men and women were found for risky alcohol consumption (32.8% versus 21.7%), low fruit and vegetable consumption (20.6% versus 10.4%) and current smoking (32.6% versus 24.9%). The prevalence of all eight risk factors differed considerably between federal states. The highest prevalence of physical inactivity, obesity, hypertension and diabetes in both sexes as well as risky alcohol consumption in men were observed in the Eastern federal states (except for Berlin). Sachsen-Anhalt was the only federal state with the highest prevalence for two risk factors. Current smoking was most prevalent in the three federal city states Berlin, Hamburg and Bremen. Saarland had the highest prevalence of low fruit and vegetable consumption in both sexes. Regional differences remained after adjustment for age and social status. CONCLUSIONS: There is evidence for regional differences in cardiovascular risk factor levels in Germany that resemble variations in the prevalence and mortality of cardiovascular diseases between federal states with a more unfavorable situation in the East (except for Berlin). Overall, this study shows a considerable need for the prevention of mostly modifiable risk factors for cardiovascular diseases in men and women in Germany.

Time Trends in Cardiometabolic Risk Factors in Adults.

BACKGROUND: Data from three representative health examination surveys in Germany were analyzed to examine secular trends in the prevalence and magnitude of cardiometabolic risk factors. METHODS: The target variables were the following cardiometabolic risk factors: lack of exercise, smoking, obesity, systolic blood pressure, total cholesterol, serum glucose, self-reported high blood pressure, hyperlipidemia, and diabetes, and the use of antihypertensive, cholesterol-lowering, and antidiabetic drugs. 9347 data sets from men and 10 068 from women were analyzed. The calculated means and prevalences were standardized to the age structure of the German population as of 31 December 2010 and compared across the three time periods of the surveys: 1990-1992, 1997-1999, and 2008-11. RESULTS: Over the entire period of observation (1990-2011), the mean systolic blood pressure fell from 137 to 128 mmHg in men and from 132 to 120 mmHg in women; the mean serum glucose concentration fell from 5.6 to 5.3 mmol/L in men and from 5.4 to 5.0 mmol/l in women; and the mean total cholesterol level fell from 6.2 to 5.3 mmol/L in both sexes. In men, smoking and lack of exercise became less common. On the other hand, the prevalence of use of antidiabetic, cholesterol-lowering, and antihypertensive drugs rose over the same time period, as did that of self-reported diabetes. The first of the three surveys (1990-1992) revealed differences between persons residing in the former East and West Germany in most of the health variables studied; these differences became less marked over time, up to the last survey in 2008-2011. CONCLUSION: The cardiometabolic risk profile of the German adult population as a whole improved over a period of 20 years. Further in-depth analyses are now planned.

Changes in diabetes care indicators: findings from German National Health Interview and Examination Surveys 1997-1999 and 2008-2011.

OBJECTIVES: To investigate changes in type 2 diabetes care indicators over time in Germany. METHODS: Adults aged 45-79 years with type 2 diabetes were identified from two national health examination surveys conducted in 1997-1999 (GNHIES98, n=333) and in 2008-2011 (DEGS1, n=526). We examined diabetes care indicators including treatment and preventive targets (glycemic control, blood pressure (BP), total cholesterol (TC), smoking, weight reduction, sports activity), self-management and care process measures (glucose self-monitoring, holding a diabetes passport, annual foot and eye examination; statin use), and the presence of diabetes-specific complications (diabetic nephropathy, retinopathy, neuropathy, diabetic foot, amputations) and comorbid cardiovascular disease (CVD) or chronic kidney disease (CKD). We calculated proportions of persons meeting these care indicators by survey and examined unadjusted and adjusted changes between surveys. RESULTS: Significant improvement (GNHIES98 vs DEGS1) over time was observed for glycated hemoglobin (HbA1c) <7.0% (53 mmol/mol) (32.4% vs 65.4%), BP <130/80 mm Hg (32.0% vs 47.2%), TC <190 mg/dL (13.5% vs 41.9%), statin use (11.7% vs 35.9%), eye (51.1% vs 78.4%) and foot (48.0% vs 61.4%) examination within the past 12 months, diabetes-specific complications (29.7% vs 21.8%), and CVD (44.5% vs 37.1%). Blood glucose self-monitoring significantly increased (37.4% vs 62.8%), while holding a diabetes passport did not change. Current smoking did not change and obesity rose, although sports activity significantly increased over time. Proportions of adults achieving combination goals of HbA1c, BP, TC, and smoking cessation were low in both surveys in spite of significant improvement. CONCLUSIONS: In Germany, the quality of diabetes care improved over time. There is much room for improvement, in particular regarding preventive goals and diabetes self-management.

Area level deprivation is an independent determinant of prevalent type 2 diabetes and obesity at the national level in Germany. Results from the National Telephone Health Interview Surveys 'German Health Update' GEDA 2009 and 2010.

OBJECTIVE: There is increasing evidence that prevention programmes for type 2 diabetes mellitus (T2DM) and obesity need to consider individual and regional risk factors. Our objective is to assess the independent association of area level deprivation with T2DM and obesity controlling for individual risk factors in a large study covering the whole of Germany. METHODS: We combined data from two consecutive waves of the national health interview survey 'GEDA' conducted by the Robert Koch Institute in 2009 and 2010. Data collection was based on computer-assisted telephone interviews. After exclusion of participants <30 years of age and those with missing responses, we included n=33,690 participants in our analyses. The outcome variables were the 12-month prevalence of known T2DM and the prevalence of obesity (BMI ≥ 30 kg/m(2)). We also controlled for age, sex, BMI, smoking, sport, living with a partner and education. Area level deprivation of the districts was defined by the German Index of Multiple Deprivation. Logistic multilevel regression models were performed using the software SAS 9.2. RESULTS: Of all men and women living in the most deprived areas, 8.6% had T2DM and 16.9% were obese (least deprived areas: 5.8% for T2DM and 13.7% for obesity). For women, higher area level deprivation and lower educational level were both independently associated with higher T2DM and obesity prevalence [highest area level deprivation: OR 1.28 (95% CI: 1.05-1.55) for T2DM and OR 1.28 (95% CI: 1.10-1.49) for obesity]. For men, a similar association was only found for obesity [OR 1.20 (95% CI: 1.02-1.41)], but not for T2DM. CONCLUSION: Area level deprivation is an independent, important determinant of T2DM and obesity prevalence in Germany. Identifying and targeting specific area-based risk factors should be considered an essential public health issue relevant to increasing the effectiveness of diabetes and obesity prevention.

Dietary patterns of adolescents in Germany--associations with nutrient intake and other health related lifestyle characteristics.

BACKGROUND: The aim of this study was to identify dietary patterns among a representative sample of German adolescents and their associations with energy and nutrient intake, socioeconomic and lifestyle characteristics, and overweight status. METHODS: In the analysis, data from the German Health Interview and Examination Survey for Children and Adolescents were used. The survey included a comprehensive dietary history interview conducted among 1272 adolescents aged 12 to 17 years. Dietary patterns were determined with principal component analysis (PCA) based on 48 food groups, for boys and girls separately. RESULTS: Three dietary patterns among boys and two among girls were identified. Among boys, high adherence to the 'western' pattern was associated with higher age, lower socioeconomic status (SES), and lower physical activity level (PA). High adherence to the 'healthy' pattern among boys, but not among girls, was associated with higher SES, and higher PA. Among boys, high adherence to the 'traditional' pattern was associated with higher age. Among girls, high adherence to the 'traditional and western' pattern was associated with lower age, lower SES and more hours watching TV per day. The nutrient density of several vitamins and minerals, particularly of B-vitamins and calcium, increased with increasing scores of the 'healthy' pattern among both sexes. Conversely, with increasing scores of the 'western' pattern among boys, most nutrient densities decreased, particularly of fibre, beta-carotene, vitamin D, biotin and calcium. Among girls with higher scores of the 'traditional and western' pattern, nutrient densities of vitamin A, C, E, K and folate decreased. Among boys, high adherence to the 'traditional' pattern was correlated with higher densities of vitamin B12 and vitamin D and lower densities of fibre, magnesium and iron. No significant associations between dietary patterns and overweight were found. CONCLUSIONS: Higher scores for dietary patterns characterized by higher consumption of take away food, meat, confectionary and soft drinks ('western' and 'traditional and western') were found particularly among 16- to 17-years old boys and among adolescents with lower SES. These patterns were also associated with higher energy density, higher percent of energy from unsaturated fatty acids and lower percent of energy from carbohydrates as well as lower nutrient densities of several vitamins and minerals. Therefore, nutritional interventions should try to focus more on adolescents with lower SES and boys in general.

Dietary patterns are associated with cardiometabolic risk factors in a representative study population of German adults.

Studies that investigated complex actual eating behaviours of the general population and their relation to cardiometabolic risk markers are sparse. We aimed to identify dietary patterns within a nationally representative sample of 4025 German adults by factor analysis based on validated dietary history interviews. Furthermore, we evaluated associations of the derived dietary patterns with abnormalities clustered within the metabolic syndrome and related metabolic markers by logistic regression models and ANCOVA. A high adherence to the 'processed foods' pattern reflected a high intake of refined grains, processed meat, red meat, high-sugar beverages, eggs, potatoes, beer, sweets and cakes, snacks and butter, whereas a high adherence to the 'health-conscious' pattern represented a high intake of vegetables, vegetable oils, legumes, fruits, fish and whole grains. For subjects in the highest compared with those in the lowest quintile of the processed foods pattern, the occurrence of abdominal obesity was 88 (95 % CI 31, 169) % higher, hypertension was 34 (95 % CI - 4, 86) % higher, hypertriacylglycerolaemia was 59 (95 % CI 11, 128 ) % higher and the metabolic syndrome was 64 (95 % CI 10, 143) % higher when adjusted for age, sex, energy intake, socio-economic status, sport activity and smoking. Furthermore, subjects in the highest quintile had statistically significantly higher uric acid concentrations and lower folate concentrations (P for trend < 0·05). In contrast, subjects in the highest quintile of the health-conscious pattern had a 30 (95 % CI 10, 46) % lower occurrence of hypertension, higher folate concentrations and lower homocysteine and fibrinogen concentrations (P for trend < 0·05). These data strengthen the findings from non-representative studies and emphasise the importance of healthy overall food patterns for preventing metabolic disturbances.

Association of a diabetes risk score with risk of myocardial infarction, stroke, specific types of cancer, and mortality: a prospective study in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam cohort.

To evaluate the impact of a recently developed, non-invasive risk score predictive for type 2 diabetes on the incidence and mortality of cardiovascular diseases and specific types of cancer. A total of 23,455 participants from the population-based European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study aged 35-65 years and free of diabetes and major chronic diseases at baseline (1994-1998) were followed through 2006 for incident myocardial infarction, stroke, types of cancer, and death. Risk score points were assigned to each participant based on age, waist circumference, height, physical activity, history of hypertension, smoking, alcohol consumption, and intake of red meat, whole-grain bread, and coffee. Hazard ratios (HRs) were estimated by Cox regression models. In age- and sex-adjusted analyses, participants with a high risk score (5-year probability to develop diabetes > or = 10%) had significantly higher risks of myocardial infarction (HR 2.7, 95% CI 1.5-5.0) and stroke (1.9, 1.0-3.6), but not of colon, breast or prostate cancer incidence, than those with a low score (5-year probability < 1%). In addition, participants with a high risk score had considerably higher risks of cardiovascular (HR 4.6, 95% CI 2.3-9.4), cancer (1.7, 1.1-2.7), and total mortality (2.4, 1.8-3.4), the latter being equivalent to a difference in life expectancy of 13 years. These data indicate that a risk score predictive for type 2 diabetes is also related to elevated risks of myocardial infarction, stroke, and premature death in apparently healthy individuals and emphasize the need for early intervention in high-risk individuals.