Association of the habitual dietary intake with the fatty liver index and effect modification by metabotypes in the population-based KORA-Fit study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is an emerging threat for public health with diet being a major risk factor in disease development and progression. However, the effects of habitual food consumption on fatty liver are still inconclusive as well as the proposed role of the individuals' metabolic profiles. Therefore, the aim of our study is to examine the associations between diet and NAFLD with an emphasis on the influence of specific metabotypes in the general population.

METHODS

A total of 689 participants (304 men and 385 women) of the KORA-Fit (S4) survey, a follow-up study of the population-based KORA cohort study running in the Region of Augsburg, Germany, were included in this analysis. Dietary information was derived from repeated 24-h food lists and a food frequency questionnaire. The intake of energy and energy-providing nutrients were calculated using the national food composition database. The presence of fatty liver was quantified by the fatty liver index (FLI), and metabotypes were calculated using K-means clustering. Multivariable linear regression models were used for the analysis of habitual food groups and FLI; for the evaluation of macronutrients, energy substitution models were applied.

RESULTS

A higher consumption of nuts and whole grains, and a better diet quality (according to Alternate Healthy Eating Index and Mediterranean Diet Score) were associated with lower FLI values, while the intake of soft drinks, meat, fish and eggs were associated with a higher FLI. The isocaloric substitution of carbohydrates with polyunsaturated fatty acids was associated with a decreased FLI, while substitution with monounsaturated fatty acids and protein showed increased FLI. Statistically significant interactions with the metabotype were observed for most food groups.

CONCLUSION

The consumption of plant-based food groups, including nuts and whole grains, and diet quality, were associated with lower FLI values, whereas the intake of soft drinks and products of animal origin (meat, fish, eggs) were associated with a higher FLI. The observed statistically significant interactions with the metabotype for most food groups could help to develop targeted prevention strategies on a population-based level if confirmed in independent prospective studies.

Anterior-wall and non-anterior-wall STEMIs do not differ in long-term mortality: results from the augsburg myocardial infarction registry

Background

Different ST-segment elevation myocardial infarction (STEMI) localizations go along with dissimilarities in the size of the affected myocardium, the causing coronary vessel occlusion, and the right ventricular participation. Therefore, this study aims to clarify if there is any difference in long-term survival between anterior- and non-anterior-wall STEMI.

Methods

This study included 2,195 incident STEMI cases that occurred between 2009 and 2017, recorded by the population-based Augsburg Myocardial Infarction Registry, Germany. The study population comprised 1.570 men and 625 women aged 25-84 years at acute myocardial infarction. The patients were observed from the day of their first acute event with an average follow-up period of 4.3 years, (standard deviation: 3.0). Survival analyses and multivariable Cox regression analyses were performed to examine the association between infarction localizations and long-term all-cause mortality.

Results

Of the 2,195 patients, 1,118 had an anterior (AWS)- and 1,077 a non-anterior-wall-STEMI (NAWS). No significant associations of the STEMI localization with long-term mortality were found. When comparing AWS with NAWS, a hazard ratio of 0.91 [95% confidence interval: 0.75-1.10] could be calculated after multivariable adjustment. In contrast to NAWS, AWS was associated with a greater <28 day mortality, less current or former smoking and higher creatine kinase-myocardial band levels (CK-MB) and went along with a higher frequency of impaired left ventricular ejection fraction (<30%).

Conclusions

Despite pathophysiological differences between AWS and NAWS, and identified differences in multiple clinical characteristics, no significant differences in long-term mortality between both groups were observed.

Sex-specific associations between systolic, diastolic and pulse pressure and hemostatic parameters in the population-based KORA-Fit study: a cross-sectional study

BACKGROUND

Several prior studies postulated an effect of hypertension on coagulation factors. However, population-based studies investigating the sex-specific associations between hypertension and hemostatic parameters are scarce. Therefore, we investigated the relationship between blood pressure and parameters of coagulation, namely activated partial thromboplastin time (aPTT), international normalized ratio (INR), fibrinogen, factor VIII, antithrombin III, protein C, protein S, and D-dimer in men and women from the general population.

METHODS

Based on 803 participants (376 men, 427 women) from the KORA-Fit Study the sex-specific relationship between systolic, diastolic, and pulse pressure and commonly measured coagulation factors were investigated using multivariable-adjusted linear regression models.

RESULTS

Hypertensive males had significantly higher median fibrinogen levels and factor VIII activity in comparison to normotensive males. There was a statistically significant difference between females with and without hypertension regarding the parameter fibrinogen, D-dimers, Protein S activity, and factor VIII activity. In multivariable linear regression analyses no significant association between systolic blood pressure, diastolic blood pressure, as well as pulse pressure and the investigated hemostatic parameters was found in men. In women, a significant positive association could be observed between systolic blood pressure and D-dimer level [β-estimate per mmHg increase 3.37 (95% CI 0.935-5.804; p = 0.007)] and between pulse pressure and D-dimer level [β-estimate per mmHg increase 5.351 (95% CI 1.772-8.930; p = 0.003)].

CONCLUSIONS

It appears that sex differences exist in the association between blood pressure parameters and commonly measured coagulation markers in the general population. Further studies are needed to identify the underlying causes.

Inflammatory plasma proteins predict short-term mortality in patients with an acute myocardial infarction

BACKGROUND

The aim of this study was to investigate the association between inflammatory markers and 28-day mortality in patients with ST-elevation myocardial infarction (STEMI).

METHODS

In 398 STEMI patients recorded between 2009 and 2013 by the population-based Myocardial Infarction Registry Augsburg, 92 protein biomarkers were measured in admission arterial blood samples using the OLINK inflammatory panel. In multivariable-adjusted logistic regression models, the association between each marker and 28-day mortality was investigated. The values of the biomarkers most significantly associated with mortality were standardized and summarized to obtain a prediction score for 28-day mortality. The predictive ability of this biomarker score was compared to the established GRACE score using ROC analysis. Finally, a combined total score was generated by adding the standardized biomarker score to the standardized GRACE score.

RESULTS

The markers IL-6, IL-8, IL-10, FGF-21, FGF-23, ST1A1, MCP-1, 4E-BP1, and CST5 were most significantly associated with 28-day mortality, each with FDR-adjusted (false discovery rate adjusted) p-values of < 0.01 in the multivariable logistic regression model. In a ROC analysis, the biomarker score and the GRACE score showed comparable predictive ability for 28-day mortality (biomarker score AUC: 0.7859 [CI: 0.6735-0.89], GRACE score AUC: 0.7961 [CI: 0.6965-0.8802]). By combining the biomarker score and the Grace score, the predictive ability improved with an AUC of 0.8305 [CI: 0.7269-0.9187]. A continuous Net Reclassification Improvement (cNRI) of 0.566 (CI: 0.192-0.94, p-value: 0.003) and an Integrated Discrimination Improvement (IDI) of 0.083 ((CI: 0.016-0.149, p-value: 0.015) confirmed the superiority of the combined score over the GARCE score.

CONCLUSIONS

Inflammatory biomarkers may play a significant role in the pathophysiology of acute myocardial infarction (AMI) and AMI-related mortality and might be a promising starting point for personalized medicine, which aims to provide each patient with tailored therapy.

Prognostic value of stress hyperglycemia ratio on short- and long-term mortality after acute myocardial infarction

AIMS

Prior studies demonstrated an association between hospital admission blood glucose and mortality in acute myocardial infarction (AMI). Because stress hyperglycemia ratio (SHR) has been suggested as a more reliable marker of stress hyperglycemia this study investigated to what extent SHR in comparison with admission blood glucose is associated with short- and long-term mortality in diabetic and non-diabetic AMI patients.

METHODS

The analysis was based on 2,311 AMI patients aged 25-84 years from the population-based Myocardial Infarction Registry Augsburg (median follow-up time 6.5 years [IQR: 4.9-8.1]). The SHR was calculated as admission glucose (mg/dl)/(28.7 × HbA1c (%)-46.7). Using logistic and COX regression analyses the associations between SHR and admission glucose and mortality were investigated.

RESULT

Higher admission glucose and higher SHR were significantly and nonlinearly associated with higher 28-day mortality in AMI patients with and without diabetes. In patients without diabetes, the AUC for SHR was significantly lower than for admission glucose (SHR: 0.6912 [95%CI 0.6317-0.7496], admission glucose: 0.716 [95%CI 0.6572-0.7736], p-value: 0.0351). In patients with diabetes the AUCs were similar for SHR and admission glucose. Increasing admission glucose and SHR were significantly nonlinearly associated with higher 5-year all-cause mortality in AMI patients with diabetes but not in non-diabetic patients. AUC values indicated a comparable prediction of 5-year mortality for both measures in diabetic and non-diabetic patients.

CONCLUSIONS

Stress hyperglycemia in AMI patients plays a significant role mainly with regard to short-term prognosis, but barely so for long-term prognosis, underlining the assumption that it is a transient dynamic disorder that occurs to varying degrees during the acute event, thereby affecting prognosis.

Physical activity, muscular strength, and polypharmacy among older multimorbid persons: Results from the KORA-Age study

The purpose of this study was to examine whether physical activity (PA) and muscular strength (MS) are related to polypharmacy. Our cross-sectional analysis was based on 711 patients with multimorbidity (MMB), aged 65-94 years, who participated in the KORA-Age study. Participants underwent a face-to-face interview and extensive physical examinations including anthropometric measurements, registration of chronic diseases, determination of health-related behaviors (smoking, alcohol intake, physical activity, etc.), collection of blood samples and measurement of hand-grip strength. PPha was defined as the use of >4 drugs and MMB as having ≥2 of 13 chronic diseases. Prevalence of PPha was 44.6% (n=317), and a significant difference was found in the number of drugs used between participants with and without PPha (7.2±2.1 vs 2.5±1.2, P<.001). Patients in the lower compared to the upper tertile of physical activity had a significantly increased odds to be on PPha (OR: 1.64, 95% CI: 1.05-2.56, P=.031) after controlling for age, gender, BMI, family status, education, alcohol intake, smoking habits, number of diseases, hs-CRP, and telomere length. On the contrary, no significant association between muscular strength and PPha was found (OR: 1.04, 95% CI: 0.66-1.63, P=.873) after multivariable adjustment. Among older persons with MMB, lower levels of physical activity, but not low muscular strength, are associated with higher odds of PPha. Increasing the levels of physical activity appears to be highly recommended in order to potentially reduce the risk of PPha among multimorbid persons aged 65 and older.

Low serum omentin levels in the elderly population with Type 2 diabetes and polyneuropathy

AIMS

To investigate the hypothesis that high serum levels of omentin, an adipokine with anti-inflammatory, insulin-sensitizing and cardioprotective properties, may be related to a lower risk of diabetic sensorimotor polyneuropathy.

METHODS

The association between serum omentin level and polyneuropathy was estimated in people aged 61-82 years with Type 2 diabetes (47 with and 168 without polyneuropathy) from the population-based KORA F4 study. The presence of clinical diabetic sensorimotor polyneuropathy was defined as bilateral impairment of foot vibration perception and/or foot pressure sensation. Omentin levels were determined by enzyme-linked immunosorbent assay.

RESULTS

Serum omentin level was inversely associated with polyneuropathy after adjustment for age, sex, height, waist circumference, hypertension, total cholesterol, smoking, alcohol intake and physical activity [odds ratio 0.45 (95% CI 0.21-0.98); P = 0.043]. Although omentin was positively correlated with adiponectin (r = 0.55, P < 0.0001) and inversely with tumour necrosis factor-α (r = -0.30, P = 0.019), additional adjustment for adiponectin and tumour necrosis factor-α had little impact on the association.

CONCLUSIONS

Serum levels of omentin are reduced in people with Type 2 diabetes and diabetic sensorimotor polyneuropathy, independently of established risk factors of polyneuropathy. This association is only partially explained by biomarkers of subclinical inflammation.

Association between muscular strength and inflammatory markers among elderly persons with cardiac disease: results from the KORA-Age study

Little is known about the association between muscle strength and inflammation in diseased individuals and particularly in cardiac patients. Thus, our purpose was to examine the association of muscular strength with the inflammatory status in older adults with and without cardiac disease. The cross-sectional analysis was based on 1079 adults aged 65-94 years, who participated in the KORA-Age study. Participants underwent an interview and extensive physical examinations including anthropometric measurements, registration of diseases and drug intake, determination of health-related behaviors, collection of blood samples for measurements of interleukin-6 and hs-CRP and muscle strength measurement using hand-grip dynamometry. Cardiac patients (n = 323) had higher levels of IL-6 and poorer muscle strength compared with older adults without cardiac disease. Among persons with cardiac diseases, muscle strength in the lower tertile compared to the upper tertile was significantly associated with increased odds of having elevated IL-6 levels (OR 3.53, 95 % CI 1.18-10.50, p = 0.024) after controlling for age, gender, body fat, alcohol intake, smoking status, diseases, medications and physical activity, whereas the association between muscle strength and hs-CRP remained borderline significant (OR 2.80, 95 % CI 0.85-9.24, p = 0.092). The same trends, with slightly lower odds ratios, were also observed in older adults without cardiac disease. Lower levels of muscular strength are associated with higher concentrations of IL-6 and hs-CRP in elderly individuals with and without cardiac disease suggesting a significant contribution of the muscular system in reducing low-grade inflammation that accompanies cardiac disease and aging.

A clinical screening score for diabetic polyneuropathy: KORA F4 and AusDiab studies

AIMS

Since screening for distal sensorimotor polyneuropathy (DSPN) in individuals with diabetes is being underused, our aim was to develop a clinical screening score for identifying individuals with DSPN.

METHODS

All participants with type 2 diabetes and aged 61-82 years from the German population-based KORA F4 Study (n=177) and the Australian population-based AusDiab Study (n=244) were combined into one study sample. Risk indicators of DSPN were identified and entered into a stepwise model-selection procedure, constructing two consecutive scores with increasing complexity (a base and clinical model).

RESULTS

The prevalence of DSPN was 18.2% (95% confidence interval (CI): 14.7-22.3). The base model comprised age (years), height (cm), weight (kg), pain or discomfort in the feet and/or legs (yes/no), and duration of diabetes (years), yielding an area under the receiver operating characteristics curve (AUC) of 0.80 (95% CI: 0.76-0.85). The clinical model additionally included diastolic blood pressure (mmHg) and serum creatinine levels (mmol/l). The AUC increased only marginally to 0.82 (0.77-0.87) (p for AUC comparison=0.188). The internal validation of the scores produced similar AUCs.

CONCLUSIONS

The screening scores developed in this study are a simple tool to differentiate between a high and low likelihood of having DSPN among individuals with type 2 diabetes.

The use of dietary supplements among older persons in southern Germany - results from the KORA-age study

OBJECTIVES

Current population-based surveys in Europe on the prevalence of dietary supplement (DS) use in older individuals are scarce. The aim of the present study was to investigate patterns, prevalence and determinants of non-herbal DS use in aged subjects. Furthermore, the intake amounts of vitamins and minerals from supplements were assessed.

DESIGN

Cross-sectional.

SETTING

Data on supplement use were available from an age- and sex-stratified random sample of the German population-based KORA (Cooperative Health Research in the Region of Augsburg)-Age study.

PARTICIPANTS

1,079 persons who were born in or before the year 1943.

MEASUREMENTS

Use of dietary supplements and medications during the last seven days was recorded in a face-to-face interview in 2009. Participants were asked to bring all packages of ingested preparations to the study center. Not only vitamin/mineral supplements, but also non-vitamin non-mineral non-herbal supplements and drugs containing vitamins and minerals were coded as DS.

RESULTS

The age-standardized prevalence of DS intake was 54.3% in women and 33.8% in men, respectively. The most commonly supplemented mineral and vitamin, respectively, was magnesium (31.9%) and vitamin D (21.5%) in women and magnesium (18.0%) and vitamin E (12.0%) in men. The highest intakes, compared to the German Dietary Reference Intakes, were reported for biotin, vitamin B6 and B1. Excessive intakes (equal or above the European Tolerable Upper Intake Levels (UL)) were observed especially for magnesium and vitamin E. 20.2% of the women and 32.5% of the men who took magnesium supplements regularly exceeded the UL for magnesium. In case of vitamin E this was true for 8.0% of the women and 13.6% of the men. Determinants of DS use were sex, education, smoking, physical activity, neurological diseases, and stroke.

CONCLUSION

A high proportion of the general population aged 65 years and older in Southern Germany uses DS, especially supplements containing vitamins/minerals. The supplementation of vitamin D can be regarded as favorable in this age group, whereas the excessive intakes of vitamin E might be a cause of concern.

Serum potassium is associated with prediabetes and newly diagnosed diabetes in hypertensive adults from the general population: the KORA F4-study

AIMS/HYPOTHESIS

Evidence suggests that low serum potassium concentrations or hypokalaemia induced by the intake of diuretics are associated with incident diabetes and increased risk for diabetes in persons with hypertension. We examined a possible association between serum potassium and prediabetes (defined as isolated impaired fasting glucose [i-IFG], isolated impaired glucose tolerance [i-IGT] or combined IFG/IGT), as well as known and newly diagnosed diabetes (NDD), in 32- to 81-year-old men and women with and without hypertension.

METHODS

This cross-sectional analysis was based on 2,948 participants in the Cooperative Health Research in the Region of Augsburg (KORA) F4 study conducted in 2006-2008 in southern Germany. Serum concentrations of potassium were measured by indirect potentiometry.

RESULTS

In the total sample there was no association between serum potassium concentrations and prediabetes. In hypertensive persons however serum potassium levels in the first and second quartile compared with the highest quartile were independently significantly associated with prediabetes after multivariable adjustment (OR for prediabetes, 2.02 [95% CI 1.27, 3.21] for quartile 2 and 2.00 [95% CI 1.27, 3.15] for quartile 1), while in persons without hypertension no association was found. In multinomial logistic regression analysis these findings could be confirmed. In hypertensive participants after multivariable adjustment the associations were statistically significant for i-IGT and NDD (i-IGT OR 1.23; NDD OR 1.41). However, in non-hypertensive persons, all associations between serum potassium levels and each of the categories of impaired glucose regulation were non-significant.

CONCLUSIONS/INTERPRETATION

Serum potassium levels were independently associated with prediabetes and NDD in hypertensive adults from the general population.

Evaluation of the Neuropad sudomotor function test as a screening tool for polyneuropathy in the elderly population with diabetes and pre-diabetes: the KORA F4 survey

BACKGROUND

Neuropad is a novel indicator test for sudomotor dysfunction, which has not been validated as a screening tool in a population-based study. This study aimed to evaluate the utility of Neuropad as a screening tool for distal symmetric polyneuropathy among elderly subjects with diabetes and pre-diabetes in the general population.

METHODS

Eligible subjects aged 61-82 years (n = 940) from the KORA F4 survey were examined, 201 of whom had diabetes and 231 had pre-diabetes (WHO 1999 criteria). Polyneuropathy was defined by the Michigan Neuropathy Screening Instrument (MNSI) score >3.

RESULTS

Polyneuropathy was diagnosed in 60 (29.9%) subjects with diabetes and in 45 (19.5%) subjects with pre-diabetes, respectively (p = 0.013). The sensitivity and negative predictive value of Neuropad (reading time: 10 min) for the diagnosis of polyneuropathy were moderately high, reaching 76.7% and 78.1% in subjects with diabetes and 57.8% and 76.5% in those with pre-diabetes, respectively. Conversely, the specificity and positive predictive value for the diagnosis of polyneuropathy were rather low: 35.5% and 33.6% in diabetic individuals and 33.3% and 17.3% in subjects with pre-diabetes, respectively. Use of the >2 cut-off and MNSI combined with monofilament examination did not improve the diagnostic performance of Neuropad.

CONCLUSIONS

In the elderly general population with diabetes and pre-diabetes, Neuropad has reasonable sensitivity but rather low specificity for the diagnosis of polyneuropathy. It is a useful simple and inexpensive tool to screen for and to exclude polyneuropathy as desired, while its low specificity implies that a longer reading time merits consideration.

Geographic variations in the frequency of thyroid disorders and thyroid peroxidase antibodies in persons without former thyroid disease within Germany

OBJECTIVE

To investigate regional variations in the frequency of undiagnosed thyroid disorders among 25- to 88-year-old men and women in two communities in the northeast and the south of Germany. In addition, autoantibodies to thyroperoxidase (TPO-Abs) and urinary iodine excretion were determined.

METHODS

Two population-based surveys of men and women using a common standardized protocol, the Study of Health in Pomerania (SHIP) in the northeast of Germany (2505 participants) and the Kooperative Gesundheitsforschung in der Region Augsburg (KORA) in the south of Germany (2316 participants), were compared with regard to the frequency of undiagnosed thyroid disorders.

RESULTS

Compared with the northeast of Germany, urinary iodine excretion and serum thyroid-stimulating hormone (TSH) levels were significantly higher in the south. The median urinary iodine concentration was 110 μg/l (64; 169 μg/l) in SHIP and 151 μg/l (97; 214 μg/l) in KORA, and the median TSH value was 0.81 mIU/l (0.56; 1.15 mIU/l) in SHIP and 1.22 mIU/l (0.84; 1.80 mIU/l) in KORA. The frequency of elevated TSH (TSH ≥ 2.12 mIU/l) was 4.3% in SHIP and 14.1% in KORA (P<0.001); the corresponding values for suppressed TSH (<0.25 mIU/l) were 3.5 and 1.7% (P<0.001). The proportion of ultrasonographic findings was 55.5% in SHIP and 68.0% in KORA. The frequency of serum TPO-Abs did not differ significantly between northeast and south Germany.

CONCLUSIONS

There were considerable regional disparities in the frequency of thyroid disorders within Germany. These differences can be explained not only by different regional histories of natural iodine deficiency but also by current differences in the iodine supply under an identical nationwide iodine fortification program.

[Multimorbidity and successful aging: the population-based KORA-Age study]

BACKGROUND

The objective of the KORA-Age research consortium is to assess the determinants and consequences of multimorbidity in the elderly and to look into reasons for successful aging in the general public.

PATIENTS AND METHODS

In the KORA-Age cohort study 9,197 persons were included who where born in the year 1943 or before and participants of previous KORA cohort studies conducted between 1984 and 2001 (KORA: Cooperative Health Research in the Region of Augsburg). The randomized intervention study KORINNA (Coronary infarct follow-up treatment in the elderly) tested a nurse-based case management program with 338 patients with myocardial infarct and included an evaluation in health economics.

RESULTS

A total of 2,734 deaths were registered, 4,565 participants submitted a postal health status questionnaire and 4,127 participants were interviewed by telephone (response 76.2% and 68.9% respectively). A gender and age-stratified random sample of the cohort consisting of 1,079 persons took part in a physical examination (response 53.8%).

CONCLUSION

The KORA-Age consortium was able to collect data in a large population-based sample and is contributing to the understanding of multimorbidity and successful aging.

Age at menarche is associated with prediabetes and diabetes in women (aged 32-81 years) from the general population: the KORA F4 Study

AIMS/HYPOTHESIS

The aim of this study was to examine the association between age at menarche and prediabetes as well as diabetes, considering confounding factors and the possible mediating role of adult obesity.

METHODS

This cross-sectional study analysed data on 1,503 women aged 32-81 years from the German population-based KORA (Cooperative Health Research in the Region of Augsburg, South Germany) F4 Study (2006-2008). Data were collected by standardised interviews, physical examinations, and whole blood and serum measurements, including administration of an OGTT in non-diabetic participants.

RESULTS

Of the 1,503 women, 226 showed a prediabetic state (impaired fasting glucose and/or impaired glucose tolerance) and 140 persons had diabetes (45 participants with previously undiagnosed diabetes and 95 with known diabetes). In Poisson regression analysis, age at menarche was significantly inversely associated with prediabetes or diabetes after adjustment for year of birth (RR 0.88; 95% CI 0.82, 0.94, p < 0.0001 per additional year of menarche) and after additional adjustment for a number of confounding factors (RR 0.88; 95% CI 0.83, 0.94, p = 0.0001). Further adjustment for current BMI slightly attenuated the association with prediabetes or diabetes (RR 0.89; 95% CI 0.83, 0.95, p = 0.0009), but the association remained clearly significant.

CONCLUSIONS/INTERPRETATION

Age at menarche seems to be inversely associated with prediabetes and diabetes independent of confounding factors including current BMI. Women at risk for diabetes might be identified by a history of young age at menarche.

Patient-reported symptoms in acute myocardial infarction: differences related to ST-segment elevation: the MONICA/KORA Myocardial Infarction Registry

OBJECTIVES

The early recognition of symptoms of myocardial infarction (MI) is crucial for patients with both ST-segment elevation (STEMI) and non-STEMI (NSTEMI). However, to date, only a few studies have examined the differences between patients with STEMI and NSTEMI with regard to the range of presenting MI symptoms.

DESIGN

The study population comprised 889 individuals with STEMI and 1268 with NSTEMI, aged 25-74, hospitalized with a first-time MI between January 2001 and December 2006 recruited from a population-based MI registry. The occurrence of 13 symptoms was recorded during a standardized patient interview.

RESULTS

Patients with STEMI were significantly younger, more likely to be smokers and less likely to have a history of hypertension or sleep disturbances prior to the acute MI (AMI) event than those with NSTEMI. A total of 50% of the patients attributed their experienced symptoms to the heart. Logistic regression modelling revealed that patients with STEMI were significantly more likely than patients with NSTEMI to complain of vomiting [odds ratio (OR) 2.34, 95% confidence interval (CI) 1.76-3.05], dizziness (OR 1.63, 95% CI 1.30-2.03) and diaphoresis (OR 1.49, 95% CI 1.23-1.81). Furthermore, patients with STEMI were less likely to experience dyspnoea (OR 0.81, 95% CI 0.68-0.98) or pain in the throat/jaw (OR 0.80, 95% CI 0.66-0.98).

CONCLUSIONS

Only half of all patients correctly attributed their symptoms to the heart. Patients with STEMI and NSTEMI showed differences regarding several presenting symptoms. Further research is needed to replicate our results, and public awareness of AMI symptoms needs to be improved.

Prediction models for incident type 2 diabetes mellitus in the older population: KORA S4/F4 cohort study

BACKGROUND

The aim was to derive Type 2 diabetes prediction models for the older population and to check to what degree addition of 2-h glucose measurements (oral glucose tolerance test) and biomarkers improves the predictive power of risk scores which are based on non-biochemical as well as conventional clinical parameters.

METHODS

Oral glucose tolerance tests were carried out in a population-based sample of 1353 subjects, aged 55-74 years (62% response) in Augsburg (Southern Germany) from 1999 to 2001. The cohort was reinvestigated in 2006-2008. Of those individuals without diabetes at baseline, 887 (74%) participated in the follow-up. Ninety-three (10.5%) validated diabetes cases occurred during the follow-up. In logistic regression analyses for model 1, variables were selected from personal characteristics and additional variables were selected from routinely measurable blood parameters (model 2) and from 2-h glucose, adiponectin, insulin and homeostasis model assessment of insulin resistance (HOMA-IR) (model 3).

RESULTS

Age, sex, BMI, parental diabetes, smoking and hypertension were selected for model 1. Model 2 additionally included fasting glucose, HbA(1c) and uric acid. The same variables plus 2-h glucose were selected for model 3. The area under the receiver operating characteristic curve significantly increased from 0.763 (model 1) to 0.844 (model 2) and 0.886 (model 3) (P<0.01). Biomarkers such as adiponectin and insulin did not improve the predictive abilities of models 2 and 3. Cross-validation and bootstrap-corrected model performance indicated high internal validity.

CONCLUSIONS

This longitudinal study in an older population provides models to predict the future risk of Type 2 diabetes. The OGTT, but not biomarkers, improved discrimination of incident diabetes.

Prevalence of undiagnosed diabetes and impaired glucose regulation in 35-59-year-old individuals in Southern Germany: the KORA F4 Study

AIMS

Limited data are available for European populations regarding the prevalence of diabetes and disturbed glucose metabolism in younger individuals. Our aim was to estimate the prevalence of diagnosed and undiagnosed diabetes, isolated impaired fasting glucose (i-IFG), isolated impaired glucose tolerance (i-IGT) and combined IFG/IGT in a population-based sample (n = 1653) from Southern Germany aged 35-59 years.

METHODS

Oral glucose tolerance tests were carried out in all non-diabetic participants of the KORA F4 Study (2006-2008). Diabetes, IGT and IFG were defined according to the 1999 World Health Organization diagnostic criteria. The original IFG criteria (6.1-6.9 mmol/l) were used as recommended by the European Diabetes Epidemiology Group.

RESULTS

The age-standardized prevalence was 2.2% for known diabetes, 2.0% for newly detected diabetes, 2.9% for i-IFG, 6.3% for i-IGT and 1.1% for combined IFG/IGT. About half of the cases with overt diabetes were undiagnosed in all age groups. The prevalence of i-IGT was approximately twice as high as that of i-IFG. The proportion of i-IGT varied between 3.2% (age group 35-44 years) and 11.8% (age group 55-59 years); the corresponding numbers for i-IFG were 1.1% and 5.9%. IFG/IGT was present in 1.2% of the total sample, and was most frequently found in the age group 55-59 years (2.4%). Overall, 16% of the study population had either diabetes or abnormalities of glucose metabolism.

CONCLUSIONS

The study reveals for the first time a high prevalence of impaired glucose regulation in the younger and middle-aged German population. The detection of disturbed glucose metabolism or diabetes needs to be improved.

Incidence of Type 2 diabetes in the elderly German population and the effect of clinical and lifestyle risk factors: KORA S4/F4 cohort study

AIMS

To determine the incidence of Type 2 diabetes in an elderly population in Germany and its association with clinical and lifestyle factors.

METHODS

Oral glucose tolerance tests (OGTT, World Health Organization criteria) were carried out in a random sample of 1353 subjects (age group 55-74 years; 62% response) in Augsburg (Southern Germany) (1999-2001). The cohort was re-investigated in 2006-2008. Of those individuals without diabetes (baseline), 887 (74%) participated in the follow-up.

RESULTS

Ninety-three (10.5%) developed diabetes during the 7-year follow-up period {standardized incidence rates [95% confidence interval (CI)] per 1000 person-years: total 15.5; 12.6, 19.1; men 20.2; 15.6, 26.1; women 11.3; 7.9, 16.1}. In both sexes, those who developed diabetes were slightly older, were more obese, had a more adverse metabolic profile (higher glucose values, HbA(1c), fasting insulin, uric acid, and triglycerides) and were more likely to have hypertension at baseline than were participants remaining free of diabetes (P < 0.05). On stepwise logistic regression, age, parental diabetes, body mass index, uric acid, current smoking, HbA(1c) and fasting and 2-h glucose (OGTT) were strong predictors of diabetes incidence. The risk of diabetes was higher in subjects with isolated impaired glucose tolerance (odds ratio 8.8; 95% CI 5.0, 15.6) than in isolated impaired fasting glucose (4.7; 2.2, 10.0), although the difference did not reach statistical significance.

CONCLUSIONS

For the first time, we have estimated the incidence of Type 2 diabetes in an elderly German cohort and demonstrated that it is among the highest in Europe. The OGTT appears to be useful in identifying individuals with high Type 2 diabetes risk. Our results support a role of smoking in the progression to diabetes.

Differences in trends in estimated incidence of myocardial infarction in non-diabetic and diabetic people: Monitoring Trends and Determinants on Cardiovascular Diseases (MONICA)/Cooperative Health Research in the Region of Augsburg (KORA) registry

AIMS/HYPOTHESIS

One major objective of the St Vincent Declaration was to reduce the excess risk of myocardial infarction in patients with diabetes mellitus. We estimated the trend of the incidence and relative risk of myocardial infarction in the diabetic and non-diabetic populations in southern Germany from 1985 to 2006.

METHODS

Using data from the Monitoring Trends and Determinants on Cardiovascular Diseases (MONICA)/Cooperative Health Research in the Region of Augsburg (KORA) Project in southern Germany, we ascertained all fatal and non-fatal first myocardial infarctions between 1985 and 2006 (n = 14,891, age 25-74 years). We estimated the diabetic and the non-diabetic populations using data on diabetes prevalence from surveys, and evaluated incidence of myocardial infarction in the two estimated populations. To test for time trends, we fitted Poisson regression models.

RESULTS

Of individuals with first myocardial infarction, 71% were male and 28% known to have diabetes. In the non-diabetic population, myocardial infarction incidence decreased by about 1.5% to 2.0% per year. A comparable decrease was seen in the population of diabetic women. However, in the population of diabetic men, incidence of myocardial infarction increased by about 1% per year. Over the whole study period, myocardial infarction incidence decreased by 34% and 27% in non-diabetic men and women respectively (RR 0.66, 95% CI 0.59-0.74 and 0.73, 0.62-0.87 respectively). In diabetic women, it decreased by 27% (RR 0.73, 0.61-0.88), whereas in diabetic men, it increased by 25% (RR 1.25, 1.07-1.45).

CONCLUSIONS/INTERPRETATION

Our results suggest that the St Vincent goal of reducing excess cardiovascular morbidity in diabetic individuals has not been achieved and that the situation in men has actually got worse.

20-year trends in clinical characteristics, therapy and short-term prognosis in acute myocardial infarction according to presenting electrocardiogram: the MONICA/KORA AMI Registry (1985-2004)

OBJECTIVES

To examine the extent to which evidence-based beneficial therapy is applied in practice, whether this is changing over time and is associated with improved outcomes.

BACKGROUND

Randomized trials have proved efficacy of several treatments for acute myocardial infarction (AMI) with ST-elevation (STEMI), non-ST-elevation (NSTEMI) and bundle branch block (BBB).

DESIGN AND SETTING

We prospectively examined all 6748 consecutive patients with AMI aged 25-74 years hospitalized in the study region's major clinic stratified into four time-periods: 1985-1989 (n = 1622), 1990-1994 (n = 1588), 1995-1999 (n = 1450) and 2000-2004 (n = 2088).

RESULTS

The increase in numbers of AMI in the last period was mainly, but not exclusively driven by NSTEMI cases. Evidence-based pharmacological therapy increased steeply over time. Invasive procedures increased mainly in the last period with percutaneous coronary intervention and coronary artery bypass graft performed in 30% and 15% in 1998 and 66.0% and 22%, respectively, in 2004. In-hospital complications and 28-day-case fatality decreased significantly from period 1 to period 4 in all patients with AMI. Marked reductions in 28-day-case fatality were mostly seen in BBB patients during the last period (25.3% vs. 10.3%, P < 0.001). Of interest, the odds in 28-day-case fatality reduction was diminished after correction for recanalization therapy (from 0.35, 95% CI: 0.16-0.74 to 0.52, 95% CI: 0.19-1.45).

CONCLUSIONS

Over the past 20 years, there were substantial changes in pharmacological and interventional therapies in AMI accompanied by reductions in in-hospital complications and 28-day-case fatality in all infarction types with marked reductions in 28-day-case fatality in BBB patients. The latter observation may mainly be because of the increased use of interventional therapy.

Beta-blocker use and risk of fractures in men and women from the general population: the MONICA/KORA Augsburg cohort study

Use of beta-blockers is associated with a reduced risk of fractures in middle-aged and older subjects from the general population.

INTRODUCTION

The present prospective population-based study investigated the association between use of beta-blockers and incidence of any fracture.

METHODS

The study was based on 1,793 persons 55 to 74 years of age who participated in one of the three MONICA Augsburg surveys between 1984 and 1995. Subjects were without any fracture at baseline. Incident fractures were assessed using a health questionnaire. Hazard ratios (HRs) were estimated from Cox proportional hazard models.

RESULTS

During a mean follow-up of 10.7 years, there occurred 263 incident fractures. beta-blocker users were older, were significantly more likely to be obese, to drink no alcohol, to have hypertension or diabetes, to use thiazides and statins, and to be physically inactive. The use of beta-blockers was associated with a lower risk of any fracture (HR 0.57; 95% CI = 0.36-0.90) after adjustment for age, sex and survey. Further adjustment for body mass index and education years only slightly attenuated the relationship (HR 0.60; 95% CI = 0.38-0.95) and additional adjustment for a variety of further risk factors did not attenuate the association (HR 0.60; 95% CI = 0.37-0.96).

CONCLUSION

Use of beta-blockers was associated with a reduced risk of fractures in middle-aged and older subjects from the general population.

Association between the intake of vitamins and trace elements from supplements and C-reactive protein: results of the MONICA/KORA Augsburg study

OBJECTIVE

To examine the association between plasma concentrations of C-reactive protein (CRP) and the intake of vitamins and trace elements from supplements possibly related to inflammation such as vitamin C, vitamin E, carotenoids, selenium and zinc.

DESIGN

Cross-sectional study using data from the Monitoring of Trends and Determinants in Cardiovascular Disease/Cooperative Health Research in the Region of Augsburg (MONICA/KORA) Survey 1994/95.

SETTING

Region of Augsburg, Southern Germany.

SUBJECTS

Population-based sample of 2045 women and 2172 men, aged 25-74 years.

RESULTS

Intake of dietary supplements containing vitamins and trace elements was associated with lower CRP levels in women. Especially vitamin E in combination with other vitamins like vitamin C, vitamin B(1), B(2), B(6), B(12), niacin, folic acid, pantothenic acid and selenium, was significantly associated with lower CRP levels. Odds ratios for elevated CRP levels (>3.0 mg/l) after multivariable adjustment were 0.57 (95% confidence interval (CI): 0.37, 0.89) for the intake of vitamin E and 0.57 (95% CI: 0.35, 0.91) for the intake of multivitamins, defined as taking three or more different vitamins. These associations were not seen in men. Intake of vitamin C, carotenoids or zinc was not significantly associated with levels of CRP in both men and women.

CONCLUSIONS

Our data indicate that the intake of certain vitamins and trace elements from supplements is associated with lower CRP concentrations in women. Thus, intake of these micronutrients could influence the inflammatory process underlying the pathogenesis of atherosclerosis. Specific dose response relationships and the best combinations of vitamins and trace elements have to be determined in further studies.

[Epidemiology of hypertension in Germany. Selected results of population-representative cross-sectional studies]

BACKGROUND AND OBJECTIVES

The mortality rate from cardiovascular disease is higher in northern than southern Germany. To illuminate this further current epidemiological data on arterial hypertension were obtained and compared with previously collected data.

METHODS

The results were based on interview and measurement data of 25- to 64 year-old participants in the Study of Health in Pomerania (SHIP-0 1997 - 2001; n = 3,042), and three population-representative surveys in the region of Augsburg, Southern Germany (MONICA S2 1989/90 n = 3,966; MONICA S3 1994/95 n = 3,916; S4 1999-2001 [KORA-2000 n = 3,464]). Hypertension was defined according to the WHO/ISH guidelines as blood pressure levels of > or =140/90 mmHg or antihypertensive medication given the subjects with known hypertension. Antihypertensive medication was classified as recommended by the German Hypertension Society.

RESULTS

Currently, 57 % (95 % confidence intervall [CI] 54-59 %) of men and 32 % (CI 30-35) of women in Pomerania had hypertension compared to 36 % (CI 34-38 %) and 23 % (CI 21-25 %) in KORA-2000 with some decreases since MONICA S2 und S3. Although a significantly higher prevalence was found in the north than in the south, the medical care was equally poor in both regions: 44-46 % of men and 29-31 % of women were not aware of their hypertension. Among the hypertensives, only 26-31 % of males and 44-48 % of females were being treated for hypertension, mostly with beta blockers, ACE-inhibitors, calcium antagonists, diuretics and AT(1)-antagonists, at least half being given just one of these drugs. Fewer than half of the treated hypertensives were normotensive, regardless of the antihypertensive drug group that was given.

CONCLUSION

As the overall situation regarding the treatment of hypertension remains inadequate, an aggressive approach to applying the evidence-based guidelines is essential. The underlying causes of this unacceptable degree of hypertension control requires further intensive investigation.

Influence of antihypertensive therapy and blood pressure control on left ventricular geometry and function in subjects with type II diabetes: The Augsburg Diabetes Family Study

Cross-sectional data often fail to show beneficial effects of antihypertensive therapy in patients with hypertension. We, therefore, examined the influence of hypertension control on left ventricular (LV) structure in diabetic persons separated into those having and not having any known cardiovascular disease (CVD) symptoms. The study population consisted of 394 subjects with type II diabetes. According to the presence of CVD, subjects were classified as symptomatic (N=181) or asymptomatic (N=213). In addition, three groups were differentiated: controlled hypertensives (CHs), that is, known hypertension with normal blood pressure (BP), uncontrolled hypertensives (UHs), that is, elevated BP regardless of antihypertensive medication, and normotensives (Ns). Symptomatic subjects showed a significantly higher prevalence of LV hypertrophy (LVH) (34.5 vs 23.4%, P<0.02). In contrast to symptomatic subjects where hypertension control status had no further significant impact on LV geometry, a considerable impact on preservation of normal LV geometry was observed in asymptomatic persons (LVH of 30, 15 and 18% in UH, CH and N, respectively, P<0.001). Control of hypertension in early diabetes seems especially to prevent the development of concentric hypertrophy (24 vs 11% in UH vs CH, P<0.04). In conclusion, in subjects with diabetes and CVD, the prevalence of LV structural abnormalities is very high. Although in this population-based study setting, in the latter group BP control does not seem to positively influence LV mass and function, hypertension control in still asymptomatic diabetic persons is beneficial and has a considerable impact on preservation of normal LV geometry.

Serum gamma-glutamyltransferase and risk of type 2 diabetes mellitus in men and women from the general population

OBJECTIVES

To examine gender-specific associations between gamma-glutamyltransferase (GGT) and incident type 2 diabetes mellitus in a representative population-based sample in Germany.

DESIGN

Prospective population-based study.

METHODS

The study was based on 1851 men and 1836 women (aged 25-64 years) who participated in the first Monitoring Trends and Determinants on Cardiovascular Diseases (MONICA) Augsburg Survey 1984/1985, and who were free of diabetes at baseline. Incident cases of type 2 diabetes were assessed using follow-up questionnaires in 1987/1988, 1997/1998 and 2002/2003 and were validated with medical records. Gender-specific hazard ratios (HRs) were estimated from Cox proportional hazard models.

RESULTS

A total of 172 cases of incident type 2 diabetes amongst men and 109 amongst women were registered during a mean follow-up period of 14.7 years. In both sexes the risk of type 2 diabetes increased with increasing levels of serum GGT. After multivariable adjustment HRs for incident type 2 diabetes across GGT categories (<25th, <50th, <75th, <87.5th and > or =87.5th percentiles) were 1.0, 1.81, 2.37, 3.41 and 4.24 (P-value for trend <0.0001) in men and 1.0, 1.42, 1.48, 1.95 and 2.41 (P-value for trend 0.0179) in women. Obesity appeared to be more strongly associated with type 2 diabetes in women with GGT equal or greater than the median compared to women with GGT below the median. However, in men the association between obesity and type 2 diabetes was almost identical in the two groups.

CONCLUSIONS

The GGT is an important predictor for incident type 2 diabetes in men and women from the general population.

[Case-cohort studies: an effective design for the investigation of biomarkers as risk factors for chronic diseases--demonstrated by the example of the MONICA/KORA Augsburg Case-Cohort Study 1984-2002]

As it is often not possible to determine specific measures of exposure in all participants of a prospective cohort study due to financial or other restrictions, new study designs have been developed. The aim of these designs is to obtain valid results even though expensive measurements are restricted to a limited number of participants of the original cohort study. The case-cohort study is a design that has recently become interesting as an alternative to the well known nested case-control study. The following article describes the case-cohort design considering as an example data from the MONICA/KORA Augsburg cohort study 1984-2002 and the outcomes of type 2 diabetes mellitus and acute myocardial infarction. Furthermore, results obtained in the full cohort for selected exposures are compared with results obtained in the case-cohort study.