A systematic review and evaluation of statistical methods for group variable selection

This review condenses the knowledge on variable selection methods implemented in R and appropriate for datasets with grouped features. The focus is on regularized regressions identified through a systematic review of the literature, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 14 methods are discussed, most of which use penalty terms to perform group variable selection. Depending on how the methods account for the group structure, they can be classified into knowledge and data-driven approaches. The first encompass group-level and bi-level selection methods, while two-step approaches and collinearity-tolerant methods constitute the second category. The identified methods are briefly explained and their performance compared in a simulation study. This comparison demonstrated that group-level selection methods, such as the group minimax concave penalty, are superior to other methods in selecting relevant variable groups but are inferior in identifying important individual variables in scenarios where not all variables in the groups are predictive. This can be better achieved by bi-level selection methods such as group bridge. Two-step and collinearity-tolerant approaches such as elastic net and ordered homogeneity pursuit least absolute shrinkage and selection operator are inferior to knowledge-driven methods but provide results without requiring prior knowledge. Possible applications in proteomics are considered, leading to suggestions on which method to use depending on existing prior knowledge and research question.

Effects of empagliflozin on left ventricular diastolic function in addition to usual care in individuals with type 2 diabetes mellitus-results from the randomized, double-blind, placebo-controlled EmDia trial

BACKGROUND

The sodium-glucose co-transporter 2 inhibitor empagliflozin improves cardiovascular outcome in patients with type 2 diabetes mellitus (T2DM) and heart failure. Experimental studies suggest a direct cardiac effect of empagliflozin associated with an improvement in left ventricular diastolic function.

METHODS

In the randomized, double-blind, two-armed, placebo-controlled, parallel group trial EmDia, patients with T2DM and elevated left ventricular E/E´ ratio were enrolled and randomized 1:1 to receive empagliflozin 10 mg/day versus placebo. The primary endpoint was the change of left ventricular E/E´ ratio after 12 weeks of intervention.

RESULTS

A total of 144 patients with T2DM and an elevated left ventricular E/e´ ratio (age 68.9 ± 7.7 years; 14.1% women; E/e´ ratio 9.61[8.24/11.14], left ventricular ejection fraction 58.9% ± 5.6%). After 12 weeks of intervention, empagliflozin resulted in a significant higher decrease in the primary endpoint E/e´ ratio by - 1.18 ([95% confidence interval (CI) - 1.72/- 0.65]; P < 0.0001) compared with placebo. The beneficial effect of empagliflozin was consistent across all subgroups and also occurred in subjects with heart failure and preserved ejection fraction (n = 30). Additional effects of empagliflozin on body weight, HbA1c, uric acid, red blood cell count, hemoglobin, mean corpuscular hemoglobin, and hematocrit were detected (all P < 0.001). Approximately one-third of the reduction in E/e´ by empagliflozin could be explained by the variables examined.

CONCLUSIONS

Empagliflozin improves diastolic function in patients with T2DM and elevated end-diastolic pressure. Since the positive effects were consistent in patients with and without heart failure with preserved ejection fraction, the data add a mechanistic insight for the beneficial cardiovascular effect of empagliflozin.

TRIAL REGISTRATION

Clinicaltrials.gov, unique identifier: NCT02932436.

Tinnitus and Its Relation to Depression, Anxiety, and Stress-A Population-Based Cohort Study

Tinnitus is a common symptom reported in otolaryngologic practice. Although the pathophysiology of tinnitus has not been fully understood, clinical studies suggest that psychological symptoms of depression, anxiety, and somatization are increased in tinnitus patients. However, patients seeking medical treatment for tinnitus may be especially vulnerable. Population-based studies reporting on the association between tinnitus and psychological distress are still lacking. The aim of this study was to investigate the correlation of tinnitus with depression, anxiety, or somatization in a large population-based cohort. The Gutenberg Health Study is a population-based cohort study. Participants were asked about the occurrence of tinnitus (yes/no) and how much they were bothered by it. In addition, they completed the PHQ-9, GAD-7, and SSS-8 questionnaires to assess depressive symptoms, anxiety, and somatic symptom disorders. A total of 8539 participants were included in the study cohort. Tinnitus prevalence was 28.0% (2387). The prevalence of depression/anxiety/somatic symptom disorders was significantly higher among participants with tinnitus than among participants without tinnitus (7.9%/5.4%/40.4% participants with tinnitus vs. 4.6%/3.3%/26.9% participants without tinnitus, p-value < 0.0001). Logistic regression results showed that participants with tinnitus were more likely to suffer from depression (OR = 2.033, 95% CI [1.584; 2.601], p-value < 0.0001), anxiety (OR = 1.841, 95% CI [1.228; 2.728], p-value = 0.0027), or somatic symptom disorders (OR = 2.057, 95% CI [1.799; 2.352], p-value < 0.0001). Symptoms of depression, anxiety, and somatic symptom disorders were increased in participants with tinnitus. This must be taken into account when treating these patients.

The BUrn Mortality Prediction (BUMP) Score - An improved mortality prediction score based on data of the German burn registry

BACKGROUND

Burn injuries constitute the fourth most common injuries globally. Patient outcomes must be currently assessed to provide appropriate patient care with high quality standards. However, existing mortality prediction scoring methods have been shown to lack accuracy in current burn patient populations. Therefore, this study aimed to validate existing scores using current patient data and assess whether new prediction parameters can provide better accuracy.

METHODS

A retrospective analysis of the patient data from the German Burn Registry between 2016 and 2019 was performed to evaluate all Abbreviated Burn Severity Index (ABSI) score parameters. All patients over 16 years of age who received intensive care were included. Descriptive statistics and logistic regression analysis were used to identify novel prediction parameters based on the parameters documented at admission and establish a new prediction score, the BUrn Mortality Prediction (BUMP) score. The quality of the new score was subsequently compared to that of the original ABSI, modified ABSI, Galeiras, Revised Baux score and TIMM. The new prediction score was then validated using patient data collected in the German Burn Registry in 2020.

RESULTS

In total, 7276 patients were included. Age; the presence of at least two comorbidities; burn injuries caused by work-related accidents, traffic accidents and suicide attempts; total burn surface area; inhalation trauma and full-thickness burns were identified as independent significant predictors of mortality (p < 0.001). Additionally, we evaluated new age groups to improve prediction accuracy. The number of comorbidities (p < 0.001) and the aetiology (burns occurring at work [p = 0.028], burns caused by traffic accidents [p < 0.001] or burns due to attempted suicide [p < 0.001]) had a significant influence on mortality. The BUMP score, which was developed based on these parameters, showed the best fitness and showed more accurate mortality prediction than all the above-mentioned scores (area under the receiver operating characteristic curve: 0.947 [0.939-0.954] compared to 0.926 [0.915-0.936], 0.928 [0.918-0.939], 0.937 [0.928-0.947], 0.939 [0.930-0.948], 0.940 [0.932-0.949] respectively).

CONCLUSIONS

A novel score (BUMP score) was developed for the purpose of external quality assessment of burn centres participating in the German burn registry, where observed and expected outcomes are compared on a hospital level, and for scientifically applications. The clinical impact of this score and its generalisability to other patient populations needs to be evaluated.

Aircraft noise exposure induces pro-inflammatory vascular conditioning and amplifies vascular dysfunction and impairment of cardiac function after myocardial infarction

AIMS

Traffic noise may play an important role in the development and deterioration of ischemic heart disease. Thus, we sought to determine the mechanisms of cardiovascular dysfunction and inflammation induced by aircraft noise in a mouse model of myocardial infarction (MI) and in humans with incident MI.

METHODS AND RESULTS

C57BL/6J mice were exposed to noise alone (average sound pressure level 72 dB; peak level 85 dB) up to 4d, resulting in pro-inflammatory aortic gene expression in the myeloid cell adhesion/diapedesis pathways. Noise alone promoted adhesion and infiltration of inflammatory myeloid cells in vascular/cardiac tissue, paralleled by an increased percentage of leukocytes with a pro-inflammatory, reactive oxygen species (ROS)-producing phenotype and augmented expression of Nox-2/phospho-NFκB in peripheral blood. Ligation of the LAD resulted in worsening of cardiac function, pronounced cardiac infiltration of CD11b+ myeloid cells and Ly6Chigh monocytes and induction of interleukin (IL) 6, IL-1β, CCL-2 and Nox-2, being aggravated by noise exposure prior to MI. MI induced stronger endothelial dysfunction and more pronounced increases in vascular ROS in animals preconditioned with noise. Participants of the population-based Gutenberg Health Cohort Study (median follow-up:11.4y) with incident MI revealed elevated CRP at baseline and worse LVEF after MI in case of a history of noise exposure and subsequent annoyance development.

CONCLUSION

Aircraft noise exposure before MI substantially amplifies subsequent cardiovascular inflammation and aggravates ischemic heart failure, facilitated by a pro-inflammatory vascular conditioning. Our translational results suggest, that measures to reduce environmental noise exposure will be helpful in improving clinical outcome of subjects with MI.

Tryptophan catabolites and depression in the general population: results from the Gutenberg Health Study

Previous studies reported significantly altered tryptophan catabolite concentrations in major depression. Thus, tryptophan catabolites were considered as potential biomarkers of depression and their modulators as potential targets for psychopharmacotherapy. However, the results were based mainly on studies with small sample sizes limiting their generalizability. Against this background, we investigated the relationship of peripheral tryptophan catabolites with depression in a population-based sample with n = 3,389 participants (with fasting status ≥ 8 h and C-reactive protein < 10 mg/L). N = 248 had clinically significant depression according to a PHQ-9 score of ≥ 10, n = 1,101 subjects had mild depressive symptoms with PHQ-9 scores between 5 and 9, and n = 2,040 had no depression. After multivariable adjustment, clinically significant depression was associated with lower kynurenine and kynurenic acid. Spearman correlation coefficients of the tryptophan catabolites with the severity of depression were very small (rho ≤ 0.080, p ≤ 0.015). None of the tryptophan catabolites could diagnostically separate depressed from not depressed persons. Concerning linear associations, kynurenine and kynurenic acid were associated only with the severity and the cognitive dimension of depression but not its somatic dimension. Tryptophan catabolites were not associated with persistence or recurrence of depression at the 5 year follow-up. The results replicated the association between kynurenine and kynurenic acid with depression. However, the associations were small raising doubts about their clinical utility. Findings underline the complexity of the relationships between depression and tryptophan catabolites. The search for subgroups of depression with a potentially higher impact of depression might be warranted.

Chronic cigarette smoking is associated with increased arterial stiffness in men and women: evidence from a large population-based cohort

BACKGROUND

Cigarette smoking is a threat to global human health and a leading cause of the cardiovascular disease (CVD) morbidity and mortality. Importantly, sex-specific differences in smoking-induced arterial stiffness, an early key event in the development of atherosclerotic CVD, remain still elusive. Thus, this study sought out to investigate sex-specific associations between smoking and measures of arterial stiffness.

METHODS AND RESULTS

Overall, 15,010 participants (7584 men and 7426 women aged 35-74 years) of the Gutenberg Health Study were examined at baseline during 2007-2012. Smoking status, pack-years of smoking, and years since quitting smoking were assessed by a standardized computer-assisted interview. Arterial stiffness and wave reflection were determined by stiffness index (SI) and augmentation index (AI). In the total sample, 45.8% had never smoked, 34.7% were former smokers, and 19.4% were current smokers. Median cumulative smoking exposure was 22.0 pack-years in current male smokers and 16.0 in current female smokers. In general, multivariable linear regression models adjusted for a comprehensive set of confounders revealed that smoking status, pack-years of smoking, and years since quitting smoking were dose-dependently associated with markers of arterial stiffness. In sex-specific analyses, these associations were overall more pronounced in men and SI was stronger related to the male sex, whereas differences between men and women in the case of AI appeared to be less substantial.

DISCUSSION

The present results indicate that chronic smoking is strongly and dose-dependently associated with increased arterial stiffness in a large population-based cohort regardless of sex but with a stronger association in men.

Determinants of mammography screening participation-a cross-sectional analysis of the German population-based Gutenberg Health Study (GHS)

PURPOSE

We investigated the association between social inequality and participation in a mammography screening program (MSP). Since the German government offers mammography screening free of charge, any effect of social inequality on participation should be due to educational status and not due to the financial burden.

METHODS

The 'Gutenberg Health Study' is a cohort study in the Rhine-Main-region, Germany. A health check-up was performed, and questions about medical history, health behavior, including secondary prevention such as use of mammography, and social status are included. Two indicators of social inequality (equivalence income and educational status), an interaction term of these two, and different covariables were used to explore an association in different logistic regression models.

RESULTS

A total of 4,681 women meeting the inclusion criteria were included. Only 6.2% never participated in the MSP. A higher income was associated with higher chances of ever participating in a mammography screening (odds ratios (OR): 1.67 per €1000; 95%CI:1.26-2.25, model 3, adjusted for age, education and an interaction term of income and education). Compared to women with a low educational status, the odds ratios for ever participating in the MSP was lower for the intermediate educational status group (OR = 0.64, 95%CI:0.45-0.91) and for the high educational status group (0.53, 95%CI:0.37-0.76). Results persisted also after controlling for relevant confounders.

CONCLUSIONS

Despite the absence of financial barriers for participation in the MSP, socioeconomic inequalities still influence participation. It would be interesting to examine whether the educational effect is due to an informed decision.

Unmasking systolic impairment in HFpEF by cardiovascular magnetic resonance derived hemodynamic force assessment: insights from the HFpEF stress trial

Background

The diagnosis of heart failure with preserved ejection fraction (HFpEF) remains challenging. Exercise-stress testing is recommended in case of uncertainty; however, this approach is time-consuming and costly. Since preserved EF does not represent normal systolic function, we evaluated cardiovascular magnetic resonance (CMR) comprehensive cardiac hemodynamic forces (HDF) analyses for an in-depth characterisation of cardiac function at rest.

Methods

The HFpEF Stress Trial (DZHK-17) prospectively recruited 75 patients with exertional dyspnea, preserved EF (≥50%) and signs of diastolic dysfunction (E/e' ≥8) on echocardiography. Patients underwent right heart catheterisation, echocardiography and CMR. 68 patients entered the final study cohort (HFpEF n=34 and non-cardiac dyspnea n=34 according to pulmonary capillary wedge pressure (PCWP)). HDF assessment included left ventricular (LV) longitudinal, systolic peak and impulse, systolic/diastolic transition, E-wave deceleration as well as A-wave acceleration forces. Two patients were lost to 24 months follow-up evaluating cardiovascular mortality and hospitalisation (CVH).

Results

HDF assessment revealed impairment of LV longitudinal force in HFpEF (15.8 vs. 18.3, p=0.035) attributable to impairment of systolic peak (38.6 vs 51.6, p=0.003) and impulse (20.8 vs. 24.5, p=0.009) forces as well as late diastolic filling (−3.8 vs −5.4, p=0.029). Impairment of early diastolic filling could be observed in HFpEF patients identified at rest only but not stress (7.7 vs. 9.9, p=0.004). Impaired systolic peak was associated to CVH (HR 0.95, p=0.016) and superior for CVH prediction compared to LV global longitudinal strain (AUC 0.76 vs. 0.61, p=0.048).

Conclusions

Assessment of HDF reveals impairment of LV systolic and diastolic function in HFpEF. The value of systolic HDF assessment exceeded that of conventional deformation imaging for CVH prediction.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Centre for Cardiovascular Research

Impact of prediabetes and type 2 diabetes mellitus on cardiac function in the general population

Introduction

Prediabetes and type 2 diabetes mellitus (T2DM) are risk factors for heart failure (HF). The association of prediabetes and T2DM to different forms of functional left ventricular impairment and their impact on clinical outcome in the general population needs to be further investigated. In this context, little is known about the prevalences of prediabetes and different HF subtypes in the general population, especially in Europe.

Purpose

To investigate the prevalence and clinical impact of prediabetes and type 2 diabetes mellitus (T2DM) on functional cardiac disorder (FCD).

Methods

The participants of the Gutenberg Health Study sample (15,010 subjects, 35–74 years) were stratified in individuals with euglycaemia, prediabetes and T2DM based on clinical information and HbA1c level. FCD included asymptomatic systolic and diastolic dysfunction, symptomatic systolic and diastolic heart failure, asymptomatic diastolic dysfunction and preserved left ventricular ejection fraction (EF), asymptomatic diastolic dysfunction and reduced EF, asymptomatic preserved diastole and reduced EF, symptomatic heart failure with preserved EF (HFpEF) and symptomatic heart failure with reduced EF HFrEF). Using structured follow-up clinical outcome was assessed.

Results

Overall, 14,870 individuals were included in the present analysis. Among them, 9,426 individuals were categorized in the euglycaemia group, 4,128 participants had prediabetes and in 1,316 individuals T2DM was present. Prevalence of FCD increased from euglycaemia (19.6%) over prediabetes (33.3%) to T2DM (46.8%, p&lt;0.0001). Prevalence of symptomatic HF was increased in patients with T2DM (euglycaemia 2.8%, prediabetes 5.9%, T2DM 11.9%). T2DM was associated with reduced EF (β −0.63, 95% CI −0.99 to −0.26, P=0.00088) and elevated E/E' (β 0.08, 95% CI 0.06 to 0.10, P&lt;0.0001), whereas prediabetes was associated to elevated E/E' (β 0.02, 95% CI 0.01 to 0.03, P=0.0029). Prediabetes and T2DM revealed increased prevalences of FCD (13%, 18%), asymptomatic diastolic dysfunction with preserved EF (prediabetes: 14%, T2DM: 11%), symptomatic heart failure (prediabetes: 46%, T2DM: 70%) and HFpEF (prediabetes: 49%, T2DM: 82%). With prediabetes and T2DM all-cause mortality was elevated in presence and absence of FCD, only T2DM was also a risk factor for cardiovascular mortality with and without FCD. Within a 5-years follow-up, T2DM was an independent risk factor for the development of FCD, asymptomatic diastolic dysfunction with reduced ejection fraction, symptomatic heart failure and HFrEF. Prediabetes was not an independent risk factor for FCD.

Conclusions

In the general population, a high prevalence of asymptomatic FCD is present. Coexisting FCD and prediabetes as well as T2DM result in increased mortality elucidating the need for early detection and prevention of DM development, especially with regard to numerous asymptomatic people concerned. T2DM, but not prediabetes, is a risk factor for incident FCD.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The Gutenberg Health Study is supported by the government of Rheinland-Pfalz (`Stiftung Rheinland-Pfalz für Innovation'), the research programmes `Wissen schafft Zukunft' and the Centre forTranslational Vascular Biology (CTVB) of the Johannes Gutenberg-University of Mainz, Germany, and its contract with Boehringer Ingelheim and Philips Medical Systems including an unrestricted grant forthe Gutenberg Health Study. P.S.W. and J.H.P. are funded by the Federal Ministry of Education and Research (BMBF 01EO1503). P.S.W. and T.M. are principal investigators of the German Center for Cardiovascular Research (DZHK). P.S.W. is principal investigator of the DIASyM research core (BMBF 161L0217A).

Lower levels of vWF are associated with lower risk of cardiovascular disease

Objective

The current study was undertaken to prospectively explore whether having low levels of von Willebrand factor (vWF) antigen and vWF activity reduce the risk for cardiovascular disease and death.

Methods

VWF antigen and vWF activity were measured by enzyme-linked immunosorbent assay and an immunological-based assay, respectively, in a subsample of 4857 individuals aged between 35 and 74 years old, enrolled between April 2007 and October 2008 in the population-based Gutenberg Health Study. VWF antigen and activity below the 20th percentile was set as a measure of "low vWF." Adjusted robust Poisson regression models were used to analyze the relation between low vWF and the incidence of cardiovascular disease (CVD). Consequent adjusted cox regression models as well as cumulative incidence plots were calculated to explore the relation between all-cause and cardiovascular mortality and low vWF.

Results

VWF activity levels <20th percentile (i.e., <76.2%) were associated with a decreased relative risk for CVD (RR: 0.59, 95% CI: 0.37-0.95), despite adjusting for age and sex. After adjusting for levels of F-VIII, the association persisted (RR: 0.60, 95% CI: 0.36-0.99). The cumulative incidence plots demonstrated that vWF antigen <20th percentile significantly correlated with decreased cardiovascular mortality. VWF antigen<20th percentile (i.e., <83%) was significantly associated with lower risk of all-cause mortality, despite adjusting for clinical factors (RR: 61, 95% CI: 0.41-0.91).

Conclusion

The study demonstrated that having low vWF activity levels were associated with a lower risk for CVD. Additionally, it revealed a decreased risk of cardiovascular and all-cause mortality in individuals with low levels of vWF antigen, shining new light on vWF as a potential target for novel therapies.

The association of smoking and smoking cessation with prevalent and incident symptoms of depression, anxiety, and sleep disturbance in the general population

BACKGROUND

Smoking is a well-established risk factor for chronic non-communicable diseases. However, the relationship between cigarette smoking and the risk of developing mental health conditions remains largely elusive. This study examined the relationship between cigarette smoking as well as smoking cessation and prevalent and incident symptoms of depression, anxiety, and sleep disturbance in the general population.

METHODS

In a cohort of 15,010 individuals from the Gutenberg Health Study (aged 35-74 years at enrollment), prevalent (at baseline from 2007 to 2012) and incident symptoms (at follow-up from 2012 to 2017) of depression, anxiety, and sleep disturbance were determined by validated questionnaires and/or medical records. Smoking status, pack-years of smoking in current and former smokers, and years since quitting smoking in former smokers were assessed by a standardized computer-assisted interview.

RESULTS

In multivariable logistic regression models with comprehensive adjustment for covariates, smoking status was independently associated with prevalent and incident symptoms of depression (Patient Health Questionnaire-9 ≥ 10), whereas this association was weaker for anxiety (Generalized Anxiety Disorder Scale-2 ≥ 3) and sleep disturbance (Patient Health Questionnaire-9 > 1). Among current and former smokers, smoking ≥30 or ≥10 pack-years, respectively, yielded in general the highest effect estimates. Smoking cessation was weakly associated with the prevalence and incidence of all outcomes, here consistent associations were observed for prevalent symptoms of depression.

LIMITATIONS

The observational nature of the study does not allow for causal inferences.

CONCLUSIONS

The results of the present study suggest that cigarette smoking is positively and that smoking cessation is negatively associated with symptoms of common mental health conditions, in particular of depression.

Relationships between coagulation factors and thrombin generation in a general population with arterial and venous disease background

Background

The current study aims to identify the relationships between coagulation factors and plasma thrombin generation in a large population-based study by comparing individuals with a history of arterial or venous thrombosis to cardiovascular healthy individuals.

Methods

This study comprised 502 individuals with a history of arterial disease, 195 with history of venous thrombosis and 1402 cardiovascular healthy individuals (reference group) from the population-based Gutenberg Health Study (GHS). Calibrated Automated Thrombography was assessed and coagulation factors were measured by means of BCS XP Systems. To assess the biochemical determinants of TG variables, a multiple linear regression analysis, adjusted for age, sex and antithrombotic therapy, was conducted.

Results

The lag time, the time to form the first thrombin, was mainly positively associated with the natural coagulant and anti-coagulant factors in the reference group, i.e. higher factors result in a longer lag time. The same determinants were negative for individuals with a history of arterial or venous thrombosis, with a 10 times higher effect size. Endogenous thrombin potential, or area under the curve, was predominantly positively determined by factor II, VIII, X and IX in all groups. However, the effect sizes of the reported associations were 4 times higher for the arterial and venous disease groups in comparison to the reference group.

Conclusion

This large-scale analysis demonstrated a stronger effect of the coagulant and natural anti-coagulant factors on the thrombin potential in individuals with a history of arterial or venous thrombosis as compared to healthy individuals, which implicates sustained alterations in the plasma coagulome in subjects with a history of thrombotic vascular disease, despite intake of antithrombotic therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12959-022-00392-0.

Prevalence and Risk Factors of Advanced Liver Fibrosis in a Population-Based Study in Germany

The prevalence of liver disease, and especially of advanced liver fibrosis, in the German population is poorly defined. The aim of the study was to explore liver enzymes and surrogate scores of hepatic steatosis and advanced hepatic fibrosis in a population-based cohort study in Germany. In the cross-sectional population-based Gutenberg Health study, data of 14,950 participants enrolled between 2007 and 2012 were captured and analyzed. The distribution of alanine aminotransferase (ALT), aspartate aminotransferase (AST), gamma-glutamyltransferase (GGT), fatty liver index (FLI), and Fibrosis-4 (FIB-4) score, as well as the underlying risk factors, were assessed by regression models. Elevated liver enzymes in this population-based sample were seen in 19.9% for ALT, 12.8% for AST, and 14% for GGT. Risk factors for liver disease included alcohol use and the presence of the metabolic syndrome, which were both risk factors associated with increased liver enzymes. The FLI suggested that 37.5% of the population exhibited hepatic steatosis and 1.1% of patients exhibited a FIB-4 above the upper cutoff, while 19.2% were in the intermediate range. Interestingly, advanced fibrosis was significantly more frequent in men compared with women (FIB-4: 1.5% vs. 0.6% [P < 0.0001]; NFS: 3.6% vs. 1.9% [P < 0.0001]). In addition, age was a relevant risk factor for exhibiting a noninvasive surrogate score suggestive of advanced fibrosis in the current study population. Conclusion: Elevated liver enzymes were seen in almost a fifth of the German population. At the population-based level, the prevalence of advanced fibrosis was estimated at 1% in Germany.