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.

Prevalence of children with blood pressure measurements exceeding adult cutoffs for optimal blood pressure in Germany.

BACKGROUND: Despite a growing interest in the epidemiology of paediatric hypertension, data on how often blood pressure in children and adolescents already exceeds adult thresholds for optimal blood pressure are scarce. The aim of this study was to estimate the prevalence of higher-than-optimal and hypertensive blood pressure values according to adult cutoffs in an unselected representative sample of children and adolescents living in Germany. METHODS: Standardized oscillometric blood pressure measurements were performed in 14 730 children aged 3-17 years (7203 girls and 7527 boys) participating in a nationally representative examination survey of children and adolescents living in Germany (The German Health Interview and Examination Survey for Children and Adolescents, KiGGS, response rate 67%). The mean of two measurements was used for this analysis. RESULTS: The prevalences of higher-than-optimal blood pressure values by adult criteria (>or=120/80 mmHg) increased with age and was 52.2% in boys aged 14-17 years and 26.2% in girls aged 14-17 years (including 6.0% of boys and 1.4% of girls with hypertensive values >or=140/90 mmHg). More than half of these adolescents with nonoptimal blood pressure values had additional cardiovascular risk factors (overweight defined as body mass index >or=90th percentile for sex and age, dyslipidaemia defined as total cholesterol >5.0 mmol/l or high-density lipoprotein cholesterol less than 1.0 mmol/l or smoking). CONCLUSION: These results suggest the need for routine blood pressure measurements in children and adolescents as required by clinical guidelines, for more attention to coexisting other cardiovascular risk factors and for a sustained focus on healthy lifestyles that can be learned best at a young age.

Population attributable fraction for lung cancer due to residential radon in Switzerland and Germany.

Studies on miners as well as epidemiological studies in the general population show an increased lung cancer risk after exposure to radon and its progeny. The European pooled analysis of indoor radon studies estimates an excess relative risk of 8% (16% after correction for measurement uncertainties) per 100 Bq m(-3) indoor radon concentration. Here, we determine the population attributable fraction (PAF) for lung cancer due to residential radon based on this risk estimate for Switzerland and Germany. Based on regionally stratified radon data, the PAF was calculated following the World Health Organization concept of global burden of disease, compared to a realistic baseline radon concentration equal to the outdoor concentration. Lifetable approaches were used taking smoking and sex into account. Measurement error corrections were applied to both risk estimates and the radon distribution. In Switzerland, the average indoor radon concentration is 78 Bq m(-3), resulting in a PAF of 8.3%. Therefore, 169 male lung cancer deaths and 62 deaths in women can be attributed to residential radon per year. For Germany, the average indoor radon concentration is 49 Bq m(-3), corresponding to a PAF of 5.0% (1,422 male and 474 female deaths annually). In both countries, a large regional variation in the PAF was observed due to regional differences in radon concentrations and population structure. Both calculations show a strong dependency on the risk model used. Risk models based on miner studies result in higher PAF estimates than risk models based on indoor radon studies due to different assumptions regarding exposures received more than 35 years ago. The use of a non-zero baseline radon concentration also contributes to the lower PAF estimates reported here. Although the estimates of the population attributable fraction of residential radon presented here are lower than previously reported estimates, the risk is still one of the most widespread environmental hazards. Radon monitoring and radon reduction programs are therefore important issues for environmental public health management.

Impact of measurement error in exposures in german radon studies.

Case-control studies on lung cancer and residential radon exposure were conducted in West and East Germany. Odds ratio (OR) estimates from primary analysis are now subject to correction for measurement error in exposure. We apply the regression calibration method adopting a bivariate multiplicative error model of the classical type; that is, we investigate the impact of errors in the exposure of primary interest, radon, and of errors in the most potent confounder, smoking. The OR estimates per 100 Bq/m3 are throughout higher after correcting for errors in radon exposure (e.g., 1.02 and 1.11 for the West and the East German study, respectively, corrected for an error of size 0.4); ignoring the clear but small correlation between radon exposure and smoking of about -0.06 would lead to less conservative corrections (1.10 and 1.13 for West and East, respectively). Accounting for a realistically sized error in the smoking variable additionally increases the OR estimates slightly. Remarkable is the fact that the naive OR estimate of the West study of 0.97 exceeds unity after correcting for errors in radon exposure larger than 0.3. We conclude that correcting for errors in radon exposure has a meaningful impact on OR estimates, that the correlation between radon exposure and the smoking variable affects the correction even if the smoking variable was error-free, and that such an analysis is extremely valuable to grasp an important issue in epidemiology, that is, the dimension of residual confounding due to adjusting for an imprecisely measured smoking variable.

Radon epidemiology: continuous and categorical trend estimators when the exposure distribution is skewed and outliers may be present.

As other epidemiological exposure variables, indoor radon levels have a right-skewed, approximately lognormal distribution. The continuous linear trend estimator is then known to be sensitive to outlying observations. We consider trend estimators based on replacing the exposure x by a transformed variable z: (1) trimmed estimators, that is, extreme values are deleted in z; (2) winsorized estimators, that is, extreme values are replaced by a lower value; (3) categorical estimators, that is, x is categorized and the continuous variable z takes on scores such as the mean or median within categories. The latter approach is often used in meta-analyses of published odds ratios. Statistically optimal categories can be defined. The corresponding scores are the expected values within the categories, based on the assumption of a lognormal distribution. In a simulation study, it turned out that procedures with different cutpoints for cases and controls, winsorized estimators, and categorical estimators based on category medians can be badly biased upward. Categorical estimators using category means are not always robust against outlying observations. However, categorical estimators employing optimal categories with expected values are nearly unbiased, even in the presence of outliers. Cutpoints should be determined according to the overall distribution of cases and controls combined. Trimmed estimators based on this distribution are unbiased, but highly variable. For right-skewed exposure variables, we therefore suggest sensitivity analyses based on the categorical estimator with optimal cutpoints and expected value scores. In the West German case-control study on indoor radon and lung cancer, these sensitivity analyses lead to increased risk estimates.

Residential radon and lung cancer--detailed results of a collaborative analysis of individual data on 7148 persons with lung cancer and 14,208 persons without lung cancer from 13 epidemiologic studies in Europe.

OBJECTIVES: Studies seeking direct estimates of the lung cancer risk associated with residential radon exposure lasting several decades have been conducted in many European countries. Individually these studies have not been large enough to assess moderate risks reliably. Therefore data from all 13 European studies of residential radon and lung cancer satisfying certain prespecified criteria have been brought together and analyzed. METHODS: Data were available for 7148 persons with lung cancer and 14,208 controls, all with individual smoking histories and residential radon histories determined by long-term radon gas measurements. RESULTS: The excess relative risk of lung cancer per 100 Bq/m3 increase in the observed radon concentration was 0.08 [95% confidence interval (95% CI) 0.03-0.16; P=0.0007] after control for confounding. The dose-response relationship was linear with no evidence of a threshold, and it remained significant when only persons with observed radon concentrations of <200 Bq/m3 were included. There was no evidence that the excess relative risk varied with age, sex, or smoking history. Removing the bias induced by random uncertainties related to radon exposure assessment increased the excess relative risk of lung cancer to 0.16 (95% CI 0.05-0.31) per 100 Bq/m3. With this correction, estimated risks at 0, 100, and 400 Bq/m3, relative to lifelong nonsmokers with no radon exposure, were 1.0, 1.2, and 1.6 for lifelong nonsmokers and 25.8, 29.9, and 42.3 for continuing smokers of 15-24 cigarettes/day. CONCLUSIONS: These data provide firm evidence that residential radon acts as a cause of lung cancer in the general population. They provide a solid basis for the formulation of policies with which to manage risk from radon and reduce deaths from the most common fatal cancer in Europe.

Lung cancer risk among former uranium miners of the WISMUT Company in Germany.

UNLABELLED: After 1946, the WISMUT Company developed the third-largest uranium-mining province in the world in the German Democratic Republic. METHODS: A case-control study among former WISMUT miners was conducted to investigate the lung cancer risk in relation to attained age, time since exposure, exposure duration, and exposure rate. It consisted of 505 patients with lung cancer and 1,073 controls matched to cases according to the year of birth. The cumulative exposure to radon and radon decay products was calculated as the sum of yearly exposures and expressed in Working Level Months (WLM). Cases had a mean cumulative exposure of 552 WLM compared to 420 WLM in controls. RESULTS: There was a statistically significant increase in lung cancer risk for cumulative exposures above 800 WLM. Under the assumption of a linear risk model, there was a significant increase in the relative risk of 0.10 per 100 WLM after adjusting for smoking and asbestos exposure. For current smokers the increase in relative risk was lower (0.05 per 100 WLM), whereas it was higher (0.20 per 100 WLM) among nonsmokers and longtime ex-smokers. After correcting in a sensitivity analysis for the fact that the controls of this study had a higher average exposure than the population of WISMUT workers they were recruited from, the adjusted ERR increased to 0.24 per 100 WLM. Lung cancer risk declined with time since exposure, except for exposures received 45 or more years ago. No inverse dose rate effect was observed.

Increased lung cancer risk due to residential radon in a pooled and extended analysis of studies in Germany.

Residential radon has been shown to be a risk factor for lung cancer in several studies-but with limited power in each single study. The data of two case-control studies performed during 1990-1997 in Germany and used for previous publications have been extended and pooled. Both studies have identical study designs. In total, data of 2,963 incident lung cancer cases and 4,232 population controls are analyzed here. One-year radon measurements were performed in houses occupied during the 5-35 y prior to the interview. Conditional logistic and linear relative risk regression was used for the analysis. Measurements covered on average 70% of the exposure time window, with an average radon exposure of 61 Bq m(-3). The smoking and asbestos-adjusted ORs were 0.97 [95% confidence interval (CI) 0.85 to 1.11] for 50-80 Bq m(-3), 1.06 (95% CI 0.87 to 1.30) for 80-140 Bq m(-3) and 1.40 (95% CI 1.03 to 1.89) for radon concentrations above 140 Bq m(-3), compared to the reference category <50 Bq m(-3). The linear increase in the odds ratio per 100 Bq m(-3) was 0.10 (95% CI -0.02 to 0.30) for all subjects and 0.14 (95% CI -0.03 to 0.55) for less mobile subjects who lived in only one home in the last 5-35 y. The risk coefficients generally were higher when measurement error in the radon concentrations was reduced by restricting the population. With respect to histopathology, the risk for small cell carcinoma was higher than for other subtypes. This analysis strengthens the evidence that residential radon is a relevant risk factor for lung cancer.

Risk factors for lung cancer among nonsmoking women.

To evaluate risk factors for lung cancer in nonsmoking women, we used data of a case-control study conducted between 1991 and 1996 in Germany. A total of 234 female histologically confirmed lung cancer patients and 535 population controls who had never smoked more than 400 cigarettes in their lifetime were personally interviewed with respect to occupation, exposure to environmental tobacco smoke (ETS), family history of cancer, prior physician-diagnosed lung diseases or cancer and diet. One-year radon measurements in the last dwelling were performed. Odds ratios (OR) adjusted for age and region and 95% confidence intervals (CI) were calculated via logistic regression. When cumulative duration of exposure to ETS in hours was considered, the OR for high compared to not or low ETS exposed women was 2.62 (CI:1.35-5.06) for occupational exposure and OR=1.67 (CI:0.86-3.25) for spousal exposure, exhibiting a significant trend for ETS at work. Working more than 10 years in jobs or industries with known or suspected lung carcinogens was associated with OR=2.0 (CI:0.99-4.0). An elevated risk due to prior lung diseases was present for pneumonia (OR=1.6; CI:1.07-2.40) and tuberculosis (OR=1.6; CI:0.77-3.37). No significant increase in risk with increasing residential radon levels or with the presence of a family history of lung cancer was apparent. Protective effects were observed for high vs. low consumption of fresh vegetables (OR=0.5; CI:0.25-0.82) and cheese (OR=0.3, CI:0.21-0.55). ETS at work, occupational hazards and previous pneumonia may be risk factors for lung cancer in nonsmoking women, while a diet rich in fresh vegetables and cheese seems to be protective.