Informal care and mental health in Germany: What are the differences between non-migrants and ethnic German immigrants? A longitudinal comparative analysis.

OBJECTIVE: In aging Germany, a large part of care is provided by informal caregivers. We aimed to analyze the main drivers of the mental health of caregivers and their intersection with migration status. METHODS: Using panel data covering 18 years (n = 25,659 individuals, aged 16 to 103 years; mean age of 49.5 years) and applying linear regression models we investigated the association between informal caregiving and mental health. We compared non-migrant Germans (NMG) and ethnic German immigrants (EGI), who are the oldest immigrant group in Germany. Informal caregiving was defined as living with a person in need of care or by providing care for ≥2 h per day; the main health outcomes were mental health and mental health changes, measured by a metric scale of six items. RESULTS: Even accounting for selection into caregiving, short-term care seemed to be disadvantageous only for NMG, while long-term care was generally associated with poorer mental health, with a particular disadvantage for EGI. Socio-economic characteristics and personality traits affected mental health changes, but only weakly the caregiving-health association. CONCLUSION: Informal caregiving presents a health burden which is not explained by socio-economic characteristics and personality, but by migration status. Policies to promote health in an aging society need to consider differences in short- and long-term care provision and between migrants and the non-migrants.

The Impact of Sex-Specific Survival on the Incidence of Dementia in Parkinson's Disease.

OBJECTIVE: The aim of our study is to analyze sex-specific patterns of Parkinson's disease dementia (PDD) incidence. We are investigating the extent to which sex differences in survival after initial Parkinson's disease (PD) diagnosis influence differences in PDD risk among PD patients. METHODS: We used a random sample of German longitudinal health claims data of persons ages 50+ (2004-2019; n = 250,000) and identified new PD cases ages 65+ who were followed-up for a PDD diagnosis or death between 2006 and 2017. We performed Cox and competing-risk regression models, with death as competing event, to calculate PDD hazard ratios (HR) adjusted for age at PD onset, PD severity as measured by the modified Hoehn and Yahr (HY) scale, comorbidities, and medications. RESULTS: Of 2195 new PD cases, 602 people died before PDD and 750 people developed PDD by the end of 2017. The adjusted risk of PDD differs by sex, with men having a higher PDD risk than women. When accounting for death, men and women do not differ in their PDD risk (HR = 1.02, P = 0.770). Sex-specific analyses showed significant age and severity effects in women (age: HR = 1.05, P < 0.001; HY 3-5 vs. 0-2.5: HR = 1.46, P = 0.011), but not in men. CONCLUSION: Older age at first PD diagnosis and higher disease severity increase PDD risk, but this association is attenuated for PD men when controlling for death. This implies that the most frail PD men die rapidly before receiving a dementia diagnosis, whereas women with PD survive at higher rates, regardless of their age at onset and disease severity. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Dementia risk predictions from German claims data using methods of machine learning.

INTRODUCTION: We examined whether German claims data are suitable for dementia risk prediction, how machine learning (ML) compares to classical regression, and what the important predictors for dementia risk are. METHODS: We analyzed data from the largest German health insurance company, including 117,895 dementia-free people age 65+. Follow-up was 10 years. Predictors were: 23 age-related diseases, 212 medical prescriptions, 87 surgery codes, as well as age and sex. Statistical methods included logistic regression (LR), gradient boosting (GBM), and random forests (RFs). RESULTS: Discriminatory power was moderate for LR (C-statistic = 0.714; 95% confidence interval [CI] = 0.708-0.720) and GBM (C-statistic = 0.707; 95% CI  = 0.700-0.713) and lower for RF (C-statistic = 0.636; 95% CI  = 0.628-0.643). GBM had the best model calibration. We identified antipsychotic medications and cerebrovascular disease but also a less-established specific antibacterial medical prescription as important predictors. DISCUSSION: Our models from German claims data have acceptable accuracy and may provide cost-effective decision support for early dementia screening.

Potential of prevention strategies for the modifiable risk factor type 2 diabetes with relation to the future number of dementia patients in Germany- a multi-state projection through 2040.

BACKGROUND: We assess the impact of prevention strategies regarding type 2 diabetes as a modifiable risk factor for dementia and its consequences for the future number of dementia patients in Germany. METHODS: We used a random sample of health claims data (N = 250,000) of insured persons aged 50+ drawn in 2014, and data on population size and death rates in 2015 from the Human Mortality Database. Using exponential hazard models, we calculated age- and sex-specific transition probabilities and death rates between the states (no diabetes/no dementia, diabetes/no dementia, no diabetes/dementia, diabetes/dementia). In multi-state projections, we estimated the future number of dementia cases aged 75+ through 2040 depending on the development of the incidence of diabetes among persons without diabetes and without dementia, and the dementia incidence among persons with and without diabetes. RESULTS: In 2015 there were 1.53 million people with dementia aged 75+ in Germany. A relative annual reduction in death rates of 2.5% and in dementia incidence in persons without diabetes of 1% will increase this number to 3.38 million by 2040. A relative reduction of diabetes incidence by 1% annually would decrease dementia cases by around 30,000, while a reduction of dementia incidence among people with diabetes by 1% would result in 220,000 fewer dementia cases. Both prevention strategies combined would prevent 240,000 dementia cases in 2040. CONCLUSIONS: The increase in life expectancy is decisive for the future number of people with dementia. Strategies of better diabetes treatment have the potential to lower the increase in the number of dementia patients in the coming decades.

Diabetes duration and the risk of dementia: a cohort study based on German health claims data.

OBJECTIVE: Diabetes is a risk factor for dementia but little is known about the impact of diabetes duration on the risk of dementia. We investigated the effect of type 2 diabetes duration on the risk of dementia. DESIGN: Prospective cohort study using health claims data representative for the older German population. The data contain information about diagnoses and medical prescriptions from the in- and outpatient sector. METHODS: We performed piecewise exponential models with a linear and a quadratic term for time since first type 2 diabetes diagnosis to predict the dementia risk in a sample of 13,761 subjects (2,558 dementia cases) older than 65 years. We controlled for severity of diabetes using the Adopted Diabetes Complications Severity Index. RESULTS: We found a U-shaped dementia risk over time. After type 2 diabetes diagnosis the dementia risk decreased (26% after 1 year) and reached a minimum at 4.75 years, followed by an increase through the end of follow-up. The pattern was consistent over different treatment groups, with the strongest U-shape for insulin treatment and for those with diabetes complications at the time of diabetes diagnosis. CONCLUSIONS: We identified a non-linear association of type 2 diabetes duration and the risk of dementia. Physicians should closely monitor cognitive function in diabetic patients beyond the first few years after diagnosis, because the later increase in dementia occurred in all treatment groups.

Long-term exposure to fine particulate matter, lung function and cognitive performance: A prospective Dutch cohort study on the underlying routes.

BACKGROUND: Exposure to fine particulate matter and black carbon is related to cognitive impairment and poor lung function, but less is known about the routes taken by different types of air pollutants to affect cognition. OBJECTIVES: We tested two possible routes of fine particulate matter (PM2.5) and black carbon (BC) in impairing cognition, and evaluated their importance: a direct route over the olfactory nerve or the blood stream, and an indirect route over the lung. METHODS: We used longitudinal observational data for 49,705 people aged 18+ from 2006 to 2015 from the Dutch Lifelines cohort study. By linking current home addresses to air pollution exposure data from ELAPSE in 2010, long-term average exposure to PM2.5 and BC was assessed. Lung function was measured by spirometry and Global Initiative (GLI) z-scores of forced expiratory volume in 1s (FEV1) and forced vital capacity (FVC) were calculated. Cognitive performance was measured by cognitive processing time (CPT) assessed by the Cogstate Brief Battery. Linear structural equation modeling was performed to test direct/indirect associations. RESULTS: Higher exposure to PM2.5 but not BC was related to higher CPT and slower cognitive processing speed [Total Effect PM2.5: FEV1 model = 8.31 × 10-3 (95% CI: 5.71 × 10-3, 10.91 × 10-3), FVC model = 8.30 × 10-3 (95% CI: 5.69 × 10-3, 10.90 × 10-3)]. The direct association of PM2.5 constituted more than 97% of the total effect. Mediation by lung function was low for PM2.5 with a mediated proportion of 1.32% (FEV1) and 2.05% (FVC), but higher for BC (7.01% and 13.82% respectively). DISCUSSION: Our results emphasise the importance of the lung acting as a mediator in the relationship between both exposure to PM2.5 and BC, and cognitive performance. However, higher exposure to PM2.5 was mainly directly associated with worse cognitive performance, which emphasises the health-relevance of fine particles due to their ability to reach vital organs directly.

Left-censored dementia incidences in estimating cohort effects.

We estimate the dementia incidence hazard in Germany for the birth cohorts 1900 until 1954 from a simple sample of Germany's largest health insurance company. Followed from 2004 to 2012, 36,000 uncensored dementia incidences are observed and further 200,000 right-censored insurants included. From a multiplicative hazard model we find a positive and linear trend in the dementia hazard over the cohorts. The main focus of the study is on 11,000 left-censored persons who have already suffered from the disease in 2004. After including the left-censored observations, the slope of the trend declines markedly due to Simpson's paradox, left-censored persons are imbalanced between the cohorts. When including left-censoring, the dementia hazard increases differently for different ages, we consider omitted covariates to be the reason. For the standard errors from large sample theory, left-censoring requires an adjustment to the conditional information matrix equality.

[Risk of Reduced Earning Capacity Pension due to Cardiovascular Diseases after Medical Rehabilitation: An Event History Analysis based on German Statutory Pension Insurance Data]. / Das Risiko für Erwerbsminderungsrente bei Herz-Kreislauf-Erkrankungen nach medizinischen Rehabilitationen: Eine ereignisdatenanalytische Studie auf Basis von Daten der Deutschen Rentenversicherung.

AIM: Not much is known on risks for reduced earning capacity pensions (RECP) for patients with specific diseases. Our study focusses on individuals who have completed a course of rehabilitation due to cardiovascular disease. METHODS: This study is based on a scientific use file from the German statutory pension insurance that covers completed rehabilitations between 2006-2013. Using survival analysis, we modeled the transition into RECP in general and for specific diagnostic groups. We used Kaplan-Meier-estimates and age-standardized and sex-specific transition rates. Multivariate Cox Proportional Hazard models are used to identify the most important socio-demographic risk factors for RECP. RESULTS: Patients who completed rehabilitation after cerebral infarction, cardiomyopathy or cerebrovascular diseases were most likely to transition into RECP due to these diseases. The most important socio-demographic risk factors for RECP were low educational attainments, part-time or no employment and living in Eastern Germany. CONCLUSION: Especially patients with cerebral infarction, cardiomyopathy or cerebrovascular diseases require successful medical rehabilitation. In case of multimorbid patients, these diagnoses require special attention. Also, the reintegration into the labor market of people from lower social strata after medical rehabilitation to avoid RECP appears to be especially difficult.

[Trends in the Prevalence of Dementia and Parkinson's Disease: An Analysis Based on Health Claims Data from all German Statutory Health Insurance Funds for Persons aged 65+in Germany 2009-2012]. / Trends in der Prävalenz von Demenz und Parkinson ­ Eine Analyse auf Basis aller gesetzlich versicherten Personen im Alter 65+in Deutschland zwischen 2009 und 2012.

OBJECTIVES: There will be an increase in the number of people with dementia (DEM) and Parkinson's disease (PD) with the ageing of the population. The aim of the study was to calculate prevalences and trends of prevalences for DEM and PD in Germany to enable reliable public health planning. METHODS: For the years 2009-2012, sex-specific period prevalences of DEM and PD for 5-year age-groups based on health claims data from all German statutory health insurance funds were calculated. Time trends were estimated using a negative binomial regression. RESULTS: In 2012 and for persons aged 65 or older, the crude prevalence was 7.9% for DEM and 2.2% for PD. Between 2009 and 2012, a mean decrease of the DEM prevalence by 1.2% per year was found for women and men above age 65. For PD we found constant rates between 2009-2012 among men and an annual mean decrease of PD prevalence of 0.5% among women. CONCLUSION: A reduction of the DEM prevalence by 1.2% per year could partially counterbalance the increase of people with dementia resulting from ageing population. For PD we found decreasing prevalences only among women.

Effects of changes in living environment on physical health: a prospective German cohort study of non-movers.

BACKGROUND: Longitudinal studies on associations between changes in living environment and health are few and focus on movers. Next to causal effects, differences in health can, however, result due to residential mobility. The present study explored changes in living environment related to (changes in) physical health among non-movers. Causality was reinforced by a novel study design. METHODS: We obtained longitudinal data on both living environment and physical health covering 4601 non-movers aged 18+ with 16 076 health observations from the German Socio-Economic Panel between 1999 and 2014. Changing and stable perceived living environment from three domains (infrastructure, environmental pollution, housing conditions) were included at household level. We performed linear regressions with robust standard errors and generalized estimating equations to predict the physical component summary (PCS) at baseline and changes in PCS over time. RESULTS: Stable moderate and worst as well as worsened environmental pollution and infrastructure were associated with worse PCS at baseline, as were stable poor and worsened housing conditions. Stable worst infrastructure was associated with negative changes in PCS for both sexes. Men's changes in PCS were more affected by worsened environmental pollution than women's. CONCLUSION: A suboptimal living environment has short- and long-term negative effects on physical health. Because even short-term changes in the living environment have an immediate influence on an individual's health status and health trajectories, public attention to living environment is essential to fight existing health inequalities.

Association of joint replacement surgery with incident dementia diagnosis in German claims data.

ABSTRACTBackground:Cognitive decline is an important complication of joint replacement surgeries in senior people. METHODS: We determined incidence rates of dementia diagnosis following endoprosthetic joint replacement surgery (upper and lower extremities). The observation period covered up to 28 quarters using German claims data comprising 154,604 cases 65 years and older. Effects were controlled for cerebrovascular and vascular risk factors, age, sex, the presence of a diagnosis of delirium, and regular prescription of sedative or analgesic drugs (SAD). RESULTS: The rate of incident dementia diagnoses in people without joint replacement surgery was 21.34 per 1,000 person years, compared with 80.76 incident cases when joint replacement surgery was conducted during the quarter of the incident dementia diagnosis; rates declined to 21.77 incident cases 7 and more quarters after joint replacement surgery had taken place. This pattern was maintained when controlling for delirium diagnosis and regular prescription of SAD. Among 10,563 patients with at least one joint replacement surgery, patients with a diagnosis of delirium in the quarter of the surgery were at increased risk of a dementia diagnosis compared to patients without such a diagnosis (HR=2.00, p < 0.001). CONCLUSION: In people surviving the high-risk phase for dementia immediately after surgery, long-term risk of dementia may reach the level of those without surgery. These findings encourage consequent perioperative management to reduce the risk of dementia as well as prospective studies of potentially beneficial effects of joint replacement surgery on mid- to long-term recovery of mobility and cognition in geriatric patients.

Effect of pioglitazone medication on the incidence of dementia.

OBJECTIVE: Peroxisome proliferator activated receptor γ-activating drugs show various salutary effects in preclinical models of neurodegenerative disease. The decade-long clinical usage of these drugs as antidiabetics now allows for evaluation of patient-oriented data sources. METHODS: Using observational data from 2004-2010, we analyzed the association of pioglitazone and incidence of dementia in a prospective cohort study of 145,928 subjects aged ≥60 years who, at baseline, were free of dementia and insulin-dependent diabetes mellitus. We distinguished between nondiabetics, diabetics without pioglitazone, diabetics with prescriptions of <8 calendar quarters of pioglitazone, and diabetics with ≥8 quarters. Cox proportional hazard models explored the relative risk (RR) of dementia incidence dependent on pioglitazone use adjusted for sex, age, use of rosiglitazone or metformin, and cardiovascular comorbidities. RESULTS: Long-term use of pioglitazone was associated with a lower dementia incidence. Relative to nondiabetics, the cumulative long-term use of pioglitazone reduced the dementia risk by 47% (RR = 0.53, p = 0.029). If diabetes patients used pioglitazone <8 quarters, the dementia risk was comparable to those of nondiabetics (RR = 1.16, p = 0.317), and diabetes patients without a pioglitazone treatment had a 23% increase in dementia risk (RR = 1.23, p < 0.001). We did not find evidence for age effects, nor for selection into pioglitazone treatment due to obesity. INTERPRETATION: These findings indicate that pioglitazone treatment is associated with a reduced dementia risk in initially non-insulin-dependent diabetes mellitus patients. Prospective clinical trials are needed to evaluate a possible neuroprotective effect in these patients in an ageing population.

Expansion or compression of long-term care in Germany between 2001 and 2009? A small-area decomposition study based on administrative health data.

BACKGROUND: Studies state profound cross-country differences in healthy life years and its time trends, suggesting either the health scenario of expansion or compression of morbidity. A much-discussed question in public health research is whether the health scenarios are heterogeneous or homogeneous on the subnational level as well. Furthermore, the question arises whether the morbidity trends or the mortality trends are the decisive drivers of the care need-free life years (CFLY), the life years with care need (CLY), and, ultimately, the health scenarios. METHODS: This study uses administrative census data of all beneficiaries in Germany from the Statutory Long-Term Care Insurance 2001-2009. We compute the CFLY and CLY at age 65+ for 412 counties. The CFLY and CLY gains are decomposed into the effects of survival and of the prevalence of care need, and we investigate their linkages with the health scenarios by applying multinomial regression models. RESULTS: We show an overall increase in CFLY, which is higher for men than for women and higher for severe than for any care need. However, spatial variation in CFLY and in CLY has increased. In terms of the health scenarios, a majority of counties show an expansion of any care need but a compression of severe care need. There is high spatial heterogeneity, with expansion-counties surrounding compression-counties and vice versa, which is mainly caused by divergent trends in the prevalence of care need. We show that mortality is responsible for the absolute changes in CFLY and CLY, while morbidity is the decisive driver that determines the health scenario of a county. CONCLUSION: Combining regionalized administrative data and advanced statistical methods permits a deeper insight into the complex relationship between health and mortality. Our findings demonstrate a compression of life years with severe care need, which however, depends on the region of residence. To attenuate regional inequalities, more efforts are needed that improve health by medical and infrastructural interventions and by the exchange of insights in the efficiency of small- and large-area policy measures between the vanguard and the rearguard counties. In future research, the underlying latent mechanisms should be investigated in more detail.

Years of life lost due to lower extremity injury in association with dementia, and care need: a 6-year follow-up population-based study using a multi-state approach among German elderly.

BACKGROUND: Dementia and care need are challenging aging populations worldwide. Lower extremity injury (LEI) in the elderly makes matters worse. Using a multi-state approach, we express the effect of LEI on dementia, care need, and mortality in terms of remaining life expectancy at age 75 (rLE) and years of life lost (YLL). METHODS: A population-based random sample of beneficiaries aged 75-95 years was drawn from the largest public health insurer in Germany in 2004 and followed until 2010 (N 62,103; Mean Age ± SD 81.5 ± 4.8 years; Female 71.2%). We defined a five-state model (Healthy, Dementia, Care, Dementia & Care, Dead), and calculated transition-specific hazard ratios of LEI using Cox regression. The transition probabilities as well as the YLL due to LEI were estimated. RESULTS: LEI significantly increased the risk for each transition, with a maximum risk for the transition from Healthy to Care (HR: 1.70, 95% CI: 1.63-1.77) and a minimum risk for the transition from Care to Dead (HR: 1.16, 95% CI: 1.10-1.22). If the elderly had LEI-history, their age-specific mortality was generally higher and their probabilities of transient states peaked at younger ages. At age 75, initially dementia-free and care-independent elderly experiencing LEI lost about 2 years of life, of which more than 90% were life years free of dementia or care need. Dementia patients lost about one and a half year, more than 60% were free of long-term care need. CONCLUSIONS: LEI not only casts a large health burden on care need, but is also associated with cognitive decline and shortened rLE. LEI plus dementia extend the relative life time in need of care, despite generally shortening rLE. Using the composite measure YLL may help to better convey these results to the elderly, families, and health professionals. This may strengthen preventive measures as well as improve timely and rehabilitative treatment of LEI, not only in cognitive and physically intact elderly.

Short-term trends in dementia prevalence in Germany between the years 2007 and 2009.

Recent studies have been cautiously optimistic about declining trends in dementia prevalence and incidence. Newly available claims data from a German public health insurance company covering 30% of the total population permitted us to explore short-term trends based on millions of observations up to the highest ages. Diagnoses stemmed from the inpatient and outpatient services and covered both the community-dwelling population and those living in nursing homes. Data spanning more than 3 years were examined, and the examination revealed a significant yearly reduction between 1% and 2% in the prevalence of dementia among women aged 75 to 84 years. The extent of the reduction was comparable with reports from earlier studies. A similar tendency existed among men, however, statistically not significant. Trends in medical, lifestyle, and societal risk factors of dementia may have contributed to this decline.

Colonoscopy and Subsequent Risk of Parkinson's Disease.

Background: Parkinson's disease (PD) is caused by the misfolding and aggregation of α-synuclein in neurons into toxic oligomers and fibrils that have prion-like properties allowing them to infect healthy neurons and to be transmitted to animal models of PD by injection or oral exposure. Given α-synuclein fibrils' potential transmission on the gut-brain axis, α-synuclein may be transmitted through colonoscopy procedures. Objective: This study examines a possible association between colonoscopy and PD. Methods: Longitudinal health insurance data of 250,000 individuals aged 50+ from 2004-2019 was analyzed. Cox proportional hazard and competing risk models with death as a competing event were estimated to calculate the risk of PD. Colonoscopy was categorized as never receiving colonoscopy, colorectal cancer (CRC) screening without or with biopsy, destruction or excision (BDE), and diagnostic colonoscopy without or with BDE. Results: We identified 6,422 new cases of PD among 221,582 individuals. The Cox model revealed a significantly increased risk of PD for patients who ever had a diagnostic colonoscopy without or with BDE (HR = 1.31; 95% CI: [1.23-1.40]; HR = 1.32 [1.22-1.42]) after adjustment for age and sex. After controlling for covariates and death, persons who ever underwent CRC screening had a 40% reduced risk of PD (CRHR = 0.60 [0.54-0.67]), while persons who underwent diagnostic colonoscopy had a 20% reduced risk of PD (CRHR = 0.81 [0.75-0.88]). Conclusions: Colonoscopy does not increase the risk of PD, after adjusting for death and covariates. Individuals who underwent only CRC screening had the lowest risk of PD, which may be a result of a more health-conscious lifestyle.

A re-analysis of the long-term effects on life expectancy of the Great Finnish Famine of 1866-68.

The results of studies exploring the long-term consequences of famine during foetal or infant development are inconsistent. We tested the hypothesis that selection forces occurring during a famine change the distribution of frailty in the affected cohorts, possibly hiding negative long-term effects. Using mortality data for Finland, gathered from the Human Mortality Database, we explored the effect of being born during the Great Finnish Famine of 1866-68 by comparing mortality at age 60 and over for the 1850-89 births, taking into account unobserved cohort heterogeneity. Contemporaneous Swedish cohorts, unexposed to the famine, were used as an additional control group. When cohort heterogeneity is accounted for, a lower life expectancy at age 60 for male cohorts in Finland born during the famine is observed. The results for females are less conclusive. No substantial changes are seen in the Swedish cohorts. In order to provide consistent estimates of the long-run effects of famines, selection forces need to be considered.

Association between the starting age of non-parental Early Childhood Education and Care (ECEC), and psycho-social problems in adolescence in West and East Germany - a natural experiment using data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS).

INTRODUCTION: The study aimed to investigate the association between the start age of non-parental Early Childhood Education and Care (ECEC) and psycho-social problems in adolescence. The similarities and differences between West and East Germany were also investigated in a natural experiment. METHODS: Our sample consisted of 1022 children (621 from West Germany, 401 from East Germany) aged 3-4 years at wave 2003-2006 that were followed up to wave 2014-2017 as adolescents (mean ± SD age = 14.4 ± 0.03 years) in the KiGGS study. The psycho-social problems were measured by the parent-reported Strengths and Difficulties Questionnaire (SDQ) at wave 2014-2017. Linear regression was used to explore the relationship between ECEC-start-age and psycho-social problems in adolescence in Germany, and stratified by West and East Germany. RESULTS: Those who started ECEC between 2 and 3 years old (reference) had the lowest scores of psycho-social problems in the whole Germany and in West Germany in adolescence. In comparison, those who started ECEC older than 3 years old had higher scores of internalizing psycho-social problems in both West Germany (with statistically significant results) and East Germany (with a relatively larger effect size but insignificant results). Those who started ECEC younger than 1 year old had statistically significant higher scores for externalizing psycho-social problems in West Germany, even though less children started ECEC younger than 1 in West Germany compared to East Germany. This significant association was not found in East Germany. Those who started ECEC between 1 and 2 years old tended to have higher scores of externalizing psycho-social problems in both West and East Germany. CONCLUSION: The results suggest that if children start ECEC older than 3 years or younger than 2 years, more attention needs to be given to internalizing or externalizing psycho-social problems respectively. The regional differences for children younger than 1 year old may suggest a selection effect in West Germany where only fewer parents bring babies to ECEC, while the regional similarities for children over 3 years old indicate the importance of providing access to ECEC for children over 3 years old.

The association of unhealthy and healthy food store accessibility with obesity prevalence among adults in the Netherlands: A spatial analysis.

Introduction: Obesity prevalence has almost tripled in Europe since 1980, and the obesogenic (food) environment is hypothesised to be one of the main drivers. Still, empirical evidence is rare for Europe. Objective: This ecological study explores spatial patterns of obesity prevalence of adults (aged 19+) in the Netherlands in 2016. It studies, in particular, its global associations with (un)healthy food store accessibility while assessing local differences and evaluating the importance of the immediate versus the wider food surroundings. Methods: In our ecological study, we used small-area estimated obesity prevalence (adults, aged 19+) from 2836 neighbourhoods (six-digit postal codes, wijken) and combined this with measures from Statistics Netherlands on accessibility to (unhealthy) fast food and (healthy) fresh food. Spatial lag of X (SLX) models were estimated for the entire Netherlands to explore global associations. Separate models for urban, suburban, and rural neighbourhoods and a geographically weighted regression (GWR) were estimated to explore and visualise local variations in the associations. Total associations from the SLX models were then decomposed to yield contributions of the immediate and wider food surroundings. Results: Regional clusters of high obesity were observed in selected areas in the north-east, the south-west, and south-east. Limited accessibility to unhealthy food was globally associated with lower obesity prevalence, whereas better accessibility to fresh food stores and supermarkets was not. The association regarding worse accessibility to unhealthy food was strongest for urban neighbourhoods, especially for the Randstad region. In urban settings, also better accessibility to fresh food stores proved relevant. The wider food surrounding proved more important than the immediate food surrounding, throughout. Discussion: Public policies addressing obesity might be more effective when reducing the presence of unhealthy food rather than expanding healthy food supply. Moreover, they should focus on urban regions and high obesity clusters, thereby considering wider food surroundings.