The Burden of Disease in Germany at the National and Regional Level

BACKGROUND

.Summary measures such as disability-adjusted life years (DALY) are becoming increasingly important for the standardized assessment of the burden of disease due to death and disability. The BURDEN 2020 pilot project was designed as an independent burden-of-disease study for Germany, which was based on nationwide data, but which also yielded regional estimates.

METHODS

DALY is defined as the sum of years of life lost due to death (YLL) and years lived with disability (YLD). YLL is the difference between the age at death due to disease and the remaining life expectancy at this age, while YLD quantifies the number of years individuals have spent with health impairments. Data are derived mainly from causes of death statistics, population health surveys, and claims data from health insurers.

RESULTS

In 2017, there were approximately 12 million DALY in Germany, or 14 584 DALY per 100 000 inhabitants. Conditions which caused the greatest number of DALY were coronary heart disease (2321 DALY), low back pain (1735 DALY), and lung cancer (1197 DALY). Headache and dementia accounted for a greater disease burden in women than in men, while lung cancer and alcohol use disorders accounted for a greater disease burden in men than in women. Pain disorders and alcohol use disorders were the leading causes of DALY among young adults of both sexes. The disease burden rose with age for some diseases, including cardiovascular diseases, dementia, and diabetes mellitus. For some diseases and conditions, the disease burden varied by geographical region.

CONCLUSION

The results indicate a need for age- and sex-specific prevention and for differing interventions according to geographic region. Burden of disease studies yield comprehensive population health surveillance data and are a useful aid to decision-making in health policy.

SARS-CoV-2 Transmissibility Within Day Care Centers-Study Protocol of a Prospective Analysis of Outbreaks in Germany

Introduction: Until today, the role of children in the transmission dynamics of SARS-CoV-2 and the development of the COVID-19 pandemic seems to be dynamic and is not finally resolved. The primary aim of this study is to investigate the transmission dynamics of SARS-CoV-2 in child day care centers and connected households as well as transmission-related indicators and clinical symptoms among children and adults. Methods and Analysis: COALA ("Corona outbreak-related examinations in day care centers") is a day care center- and household-based study with a case-ascertained study design. Based on day care centers with at least one reported case of SARS-CoV-2, we include one- to six-year-old children and staff of the affected group in the day care center as well as their respective households. We visit each child's and adult's household. During the home visit we take from each household member a combined mouth and nose swab as well as a saliva sample for analysis of SARS-CoV-2-RNA by real-time reverse transcription polymerase chain reaction (real-time RT-PCR) and a capillary blood sample for a retrospective assessment of an earlier SARS-CoV-2 infection. Furthermore, information on health status, socio-demographics and COVID-19 protective measures are collected via a short telephone interview in the subsequent days. In the following 12 days, household members (or parents for their children) self-collect the same respiratory samples as described above every 3 days and a stool sample for children once. COVID-19 symptoms are documented daily in a symptom diary. Approximately 35 days after testing the index case, every participant who tested positive for SARS-CoV-2 during the study is re-visited at home for another capillary blood sample and a standardized interview. The analysis includes secondary attack rates, by age of primary case, both in the day care center and in households, as well as viral shedding dynamics, including the beginning of shedding relative to symptom onset and viral clearance. Discussion: The results contribute to a better understanding of the epidemiological and virological transmission-related indicators of SARS-CoV-2 among young children, as compared to adults and the interplay between day care and households.

Are depressive symptoms associated with quality of care in diabetes? Findings from a nationwide population-based study

INTRODUCTION

We investigated whether the presence of depressive symptoms among adults with diagnosed diabetes is associated with adverse quality of diabetes care.

RESEARCH DESIGN AND METHODS

The study population was drawn from the German national health survey 'German Health Update' 2014/2015-European Health Interview Survey and included 1712 participants aged ≥18 years with self-reported diabetes during the past 12 months. Depressive symptoms in the past 2 weeks were assessed by the eight-item depression module of the Patient Health Questionnaire (PHQ-8), with PHQ-8 sum score values ≥10 indicating current depressive symptoms. We selected 12 care indicators in diabetes based on self-reported information on care processes and outcomes. Associations of depressive symptoms with those indicators were examined in multivariable logistic regression models with stepwise adjustments.

RESULTS

Overall, 15.6% of adults with diagnosed diabetes reported depressive symptoms, which were higher in women than in men (18.7% vs 12.9%). Adjusted for age, sex, education, social support, health-related behaviors, and diabetes duration, adults with depressive symptoms were more likely to report acute hypoglycemia (OR 1.81, 95% CI 1.13 to 2.88) or hyperglycemia (OR 2.10, 95% CI 1.30 to 3.37) in the past 12 months, long-term diabetes complications (OR 2.30, 95% CI 1.55 to 3.39) as well as currently having a diet plan (OR 2.14, 95% CI 1.39 to 3.29) than adults without depressive symptoms. Significant associations between depressive symptoms and other care indicators were not observed.

CONCLUSIONS

The present population-based study of adults with diagnosed diabetes indicates an association between depressive symptoms and adverse diabetes-specific care with respect to outcome but largely not to process indicators. Our findings underline the need for intensified care for persons with diabetes and depressive symptoms. Future research needs to identify underlying mechanisms with a focus on the inter-relationship between diabetes, depression and diabetes-related distress.

Seroepidemiological study on the spread of SARS-CoV-2 in Germany: Study protocol of the CORONA-MONITORING bundesweit' study (RKI-SOEP study)

The SARS-CoV-2 coronavirus has spread rapidly across Germany. Infections are likely to be under-recorded in the notification data from local health authorities on laboratory-confirmed cases since SARS-CoV-2 infections can proceed with few symptoms and then often remain undetected. Seroepidemiological studies allow the estimation of the proportion in the population that has been infected with SARS-CoV-2 (seroprevalence) as well as the extent of undetected infections. The ‘CORONA-MONITORING bundesweit’ study (RKI-SOEP study) collects biospecimens and interview data in a nationwide population sample drawn from the German Socio-Economic Panel (SOEP).

Participants are sent materials to self-collect a dry blood sample of capillary blood from their finger and a swab sample from their mouth and nose, as well as a questionnaire. The samples returned are tested for SARS-CoV-2 IgG antibodies and SARS-CoV-2 RNA to identify past or present infections.

The methods applied enable the identification of SARS-CoV-2 infections, including those that previously went undetected. In addition, by linking the data collected with available SOEP data, the study has the potential to investigate social and health-related differences in infection status. Thus, the study contributes to an improved understanding of the extent of the epidemic in Germany, as well as identification of target groups for infection protection.

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

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

Seroepidemiological study on the spread of SARS-CoV-2 in populations in especially affected areas in Germany - Study protocol of the CORONA-MONITORING lokal study

At a regional and local level, the COVID-19 pandemic has not spread out uniformly and some German municipalities have been particularly affected. The seroepidemiological data from these areas helps estimate the proportion of the population that has been infected with SARS-CoV-2 (seroprevalence), as well as the number of undetected infections and asymptomatic cases. In four municipalities which were especially affected, 2,000 participants will be tested for an active SARS-CoV-2 infection (oropharyngeal swab) or a past infection (blood specimen IgG antibody test). Participants will also be asked to fill out a short written questionnaire at study centres and complete a follow-up questionnaire either online or by telephone, including information on issues such as possible exposure, susceptability, symptoms and medical history. The CORONA-MONITORING lokal study will allow to determine the proportion of the population with SARS-CoV-2 antibodies in four particularly affected locations. This study will increase the accuracy of estimates regarding the scope of the epidemic, help determine risk and protective factors for an infection and therefore also identify especially exposed groups and, as such, it will be crucial towards planning of prevention measures.

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular risk-changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Corrigendum: Limitations in activities of daily living in old age in Germany and the EU - Results from the European Health Interview Survey (EHIS) 2

[This corrects the article on p. 48-56 in vol. 4.].

National trends in total cholesterol obscure heterogeneous changes in HDL and non-HDL cholesterol and total-to-HDL cholesterol ratio: a pooled analysis of 458 population-based studies in Asian and Western countries

BACKGROUND

Although high-density lipoprotein (HDL) and non-HDL cholesterol have opposite associations with coronary heart disease, multi-country reports of lipid trends only use total cholesterol (TC). Our aim was to compare trends in total, HDL and non-HDL cholesterol and the total-to-HDL cholesterol ratio in Asian and Western countries.

METHODS

We pooled 458 population-based studies with 82.1 million participants in 23 Asian and Western countries. We estimated changes in mean total, HDL and non-HDL cholesterol and mean total-to-HDL cholesterol ratio by country, sex and age group.

RESULTS

Since ∼1980, mean TC increased in Asian countries. In Japan and South Korea, the TC rise was due to rising HDL cholesterol, which increased by up to 0.17 mmol/L per decade in Japanese women; in China, it was due to rising non-HDL cholesterol. TC declined in Western countries, except in Polish men. The decline was largest in Finland and Norway, at ∼0.4 mmol/L per decade. The decline in TC in most Western countries was the net effect of an increase in HDL cholesterol and a decline in non-HDL cholesterol, with the HDL cholesterol increase largest in New Zealand and Switzerland. Mean total-to-HDL cholesterol ratio declined in Japan, South Korea and most Western countries, by as much as ∼0.7 per decade in Swiss men (equivalent to ∼26% decline in coronary heart disease risk per decade). The ratio increased in China.

CONCLUSIONS

HDL cholesterol has risen and the total-to-HDL cholesterol ratio has declined in many Western countries, Japan and South Korea, with only a weak correlation with changes in TC or non-HDL cholesterol.

Limitations in activities of daily living in old age in Germany and the EU - Results from the European Health Interview Survey (EHIS) 2

The health status of older people in Germany can be compared with the health of older people in other European Union (EU) Member States using data on the distribution of limitations in activities of daily living. This concept covers basic limitations in activities of daily living (ADL) such as eating, as well as limitations in instrumental activities of daily living (iADL) such as shopping and managing finances. The second wave of the European Health Interview Survey (EHIS 2) collected data on five ADLs and seven iADLs for people aged 65 or above. An ADL or iADL limitation was defined if a participant reported at least a lot of difficulty in at least one ADL or iADL, respectively. On average, 8.4% of the EU population reported an ADL limitation, with 25.2% reporting an iADL limitation. However, prevalences vary widely between EU Member States and are lower in Germany than the EU average (ADL limitation 6.3%, iADL limitation 14.0%). In general, women, people aged 75 or above, and lower education groups have a higher prevalence of ADL and iADL limitations.

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

BACKGROUND

The combined impact of multiple healthy behaviors on health exceeds that of single behaviors. This study aimed to estimate trends in the prevalence of a healthy lifestyle among adults in Germany.

METHODS

A data set of 18,058 adults aged 25-69 years from three population-based national health examination surveys 1990-92, 1997-99 and 2008-11 with complete information for five healthy behavior factors was used. A 'daily intake of both fruits and vegetables, 'sufficient physical exercise', 'no current smoking' and 'no current risk drinking' were assessed with self-reports and 'normal body weight' was calculated based on measured body weight and height. A dichotomous 'healthy lifestyle' indicator was defined as meeting at least four out of five healthy behaviors. Age-standardized prevalence was calculated stratified by sex, age groups (25-34, 35-44, 45-54 and 55-69 years) and education level (low, medium and high). Trends were expressed in relative change (RC) between 1990-92 and 2008-11.

RESULTS

In Germany, the overall prevalence of healthy lifestyle increased from 9.3% in 1990-92 to 13.5% in 1997-99 and to 14.7% in 2008-11 (RC: +58.1%). The prevalence increased among men and women and in all age groups, with the exception of men aged 45-54 years. The RC of increasing healthy lifestyle prevalence between 1990-92 and 2008-11 was stronger albeit on a higher level among women compared to men. Therefore, the gender difference in healthy lifestyle has increased, but age-related differences have overall decreased in this period. Among high educated men the prevalence of a healthy lifestyle increased between 1990-92 and 2008-11 from 10.6% to 16.3% (p = 0.01) and among high educated women from 16.4% to 30.3% and also among medium educated women (10.9 to 16.6, p<0.01), but no significant increase in healthy lifestyle prevalence was observed among men with low and medium education and among women with low education level.

CONCLUSIONS

The prevalence of a lifestyle with at least four out of five healthy behaviors markedly increased from 1990-92 to 2008-11. Nevertheless, additional health promotion interventions are needed to improve the number of combined healthy behavior factors and the awareness in the population that each additional healthy behavior factor leads to a further improvement in health, especially in men in the age-range 45 to 54 years, and among persons with low education level.

[Secondary prevention of coronary heart disease in women and men in Germany from 1997-1999 and from 2008-2011-Trend analysis with two national health population surveys]

BACKGROUND

The benefit of medicines in the secondary prevention of coronary heart disease (CHD) has been demonstrated in women and men. However, gender-specific differences have been observed in the prescription of these medicines. Information on trends in prevalence use in women and men from population-based studies are still lacking.

METHODS

Data of people aged 40-79 years with CHD from the national health interview and examination surveys for adults in Germany from 1997-1999 (GNHIES98, n = 411) and from 2008-2011 (DEGS1, n = 440) were analyzed. Trend analyses via multivariable regression models, taking into account relevant covariables, were used to calculate the prevalence of medicine use in secondary prevention of CHD between GNHIES98 and DEGS1. The following groups were considered: antiplatelet, statins, beta-receptor blockers, agents acting on the renin-angiotensin system (RAS blocker), calcium-channel blockers, and nitrate.

RESULTS

In one decade, the prevalence had increased for antiplatelet (24.0% vs. 59.6%), statins (18.5% vs. 56.2%), beta-receptor blockers (24.7% vs. 65.5%), and RAS blockers (31.6% vs. 69.0%). The prevalence of calcium-channel blockers (33.3% vs. 20.5%) and nitrate (40.6% vs. 10.1%) had decreased. In GNHIES98, men were more likely to use RAS blockers. Significant gender differences were found in DEGS1 only for angiotensin-converting-enzyme (ACE) inhibitors.

CONCLUSION

This study showed an improvement in the use of drugs for the secondary prevention of CHD in both sexes.

Associations between the use of specific psychotropic drugs and all-cause mortality among older adults in Germany: Results of the mortality follow-up of the German National Health Interview and Examination Survey 1998

Background

Use of psychotropic drugs is common among older adults. Population-based studies on the associations of psychotropic drug use with mortality are sparse.

Objectives

To investigate the associations between the use of specific psychotropic drug groups (opioids, antipsychotics, antidepressants and benzodiazepines) and all-cause mortality among community-dwelling older adults in Germany.

Methods

Participants of the German National Health Interview and Examination Survey 1998 were followed up for mortality from 1997 to 2011. Persons aged 60–79 years with complete data on psychotropic drug use at baseline and on mortality follow-up were considered as study population (N = 1,563). Associations between the use of opioids, antipsychotics, antidepressants and benzodiazepines and all-cause mortality were examined by Cox proportional hazards models adjusted for sociodemographics (sex, age, community size, region, socioeconomic status), life style (smoking, sports, risky alcohol drinking) and health conditions (obesity, disability, history of cardiovascular diseases, diabetes, hyperlipidemia, hypertension, any cancers, any mental disorders) at baseline.

Results

After a median follow-up of 11.4 years, 21, 18, 23 and 26 deaths were documented among those who used at baseline opioids (n = 39), antipsychotics (n = 30), antidepressants (n = 53) and benzodiazepines (n = 54) with an unadjusted mortality rate (MR) of 57.7, 59.1, 44.6 and 53.7 per 1000 person-years, respectively. Meanwhile, 400 deaths were documented among 1,406 nonusers of any of the above mentioned psychotropic drugs with a MR of 26.7 per 1000 person-years. The age and sex adjusted mortality rate ratios in comparison with nonusers were 2.20 (95% confidence intervals 1.42–3.41), 1.66(1.03–2.70), 1.56(1.06–2.28), and 1.57(1.07–2.31) for the use of opioids, antipsychotics, antidepressants and benzodiazepines, respectively. In the fully adjusted Cox models, use of opioids (hazardous ratio 2.04, 95% confidence intervals 1.07–3.89), antipsychotics (2.15, 1.11–4.15) and benzodiazepines (1.76, 1.09–2.82), but not antidepressants, were significantly associated with an increased risk of mortality.

Conclusions

Use of opioids, antipsychotics, benzodiazepines is significantly associated with an increased risk of all-cause mortality among community-dwelling older adults in Germany. Clinicians should be careful in prescribing these psychotropic drugs to older adults while patients already under psychotropic therapy should well balance the risks and benefits of drug use. Further studies with a larger sample size and information on specific indications for psychotropic drug use and mental comorbidities are required to confirm the findings of the present study.

Glycaemic status and depressive symptoms among adults in Germany: results from the German Health Interview and Examination Survey for Adults (DEGS1)

AIMS

To examine the association between glycaemic status and depressive symptoms in a nationwide sample of the adult population in Germany.

METHODS

We conducted a cross-sectional analysis of data from 6385 participants aged 18-79 years in the nationwide German Health Interview and Examination Survey for Adults 2008-2011 (DEGS1). Glycaemic status was classified as follows: diagnosed diabetes (self-reported diagnosis or receiving antidiabetes medication); undiagnosed diabetes (HbA_1c ≥48 mmol/mol [≥6.5%]); prediabetes (HbA_1c 39-47 mmol/mol [5.7-6.4%]); or normoglycaemia (HbA_1c <39 mmol/mol [<5.7%]). Current depressive symptoms were measured using the Patient Health Questionnaire depression scale (PHQ-9) and defined as elevated depressive symptoms (PHQ-9 score ≥10 points; dichotomous variable) and severity of depressive symptoms (PHQ-9 score, range 0-27 points; continuous variable). Associations of glycaemic status and HbA_1c with both depressive symptoms variables were analysed using multivariable logistic (elevated depressive symptoms) and linear (severity of depressive symptoms) regression models.

RESULTS

Compared with normoglycaemia, diagnosed diabetes, but not prediabetes or undiagnosed diabetes, was associated with elevated depressive symptoms (odds ratio 1.55, 95% CI 1.00-2.41) and severity of depressive symptoms (β coefficient 0.71, 95% CI 0.23-1.19) in models adjusting for sociodemographics and health behaviours. Associations were similar among people with diagnosed diabetes taking and not taking antidiabetes medication. Among people without diagnosed diabetes, no associations between HbA_1c and depressive symptoms were found.

CONCLUSIONS

Diagnosed diabetes, but not prediabetes, undiagnosed diabetes or HbA_1c , was associated with depressive symptoms among adults in Germany. Studies examining psychosocial and biological mechanisms that may potentially explain relationships between diagnosed diabetes and depressive symptoms are needed.

Implications of standardization of serum 25-hydroxyvitamin D data for the evaluation of vitamin D status in Germany, including a temporal analysis

BACKGROUND

Comparability of 25-hydroxyvitamin D (25(OH)D) measurements is hampered by method-related differences in measurement values. International standardization of laboratory assays has been suggested to solve this problem.

METHODS

As part of the European Commission-funded project 'Food-based solutions for optimal vitamin D nutrition and health through the life cycle' (ODIN), original measurements of serum 25(OH)D of three German national health surveys conducted between 1998 and 2011 have been standardized retrospectively. In these representative population-based samples including persons aged between 1 and 79 years, the original 25(OH)D values were compared with those after standardization. Mean values and prevalences of vitamin D deficiency, insufficiency, and sufficiency (25(OH)D levels < 30, 30- < 50, and > =50 nmol/l, respectively) were calculated by sex and age groups based on original and standardized 25(OH)D data.

RESULTS

In comparison to the original 25(OH)D levels, the standardized levels showed higher means overall and in age- and sex-specific analyses. After standardization, the prevalence of vitamin D deficiency was lower in all surveys while the prevalence of vitamin D sufficiency was higher. Nevertheless, even after standardization ~ 15% of adults and 12.5% of children had serum 25(OH)D levels < 30 nmol/l. Thus, the proportion of deficient vitamin D levels in the German population is still considerable.

CONCLUSIONS

The use of standardization of 25(OH)D levels has a substantial impact on estimates of the vitamin D status in Germany. Since clinical diagnostic, therapeutic and public health decision-making require valid and comparable data, standardization and calibration of commercial, clinical and research laboratory assays for 25(OH)D measurement should become common practice. Until then, researchers, health practitioners and policy makers should be aware of the peculiarities of the measurement methods when comparing and interpreting 25(OH)D levels.

Normative data for the Digit Symbol Substitution Test in a population-based sample aged 65-79 years: Results from the German Health Interview and Examination Survey for Adults (DEGS1)

OBJECTIVE

To provide normative data for the Digit Symbol Substitution Test (DSST) of the Wechsler Adult Intelligence Scale, 3rd edition (WAIS-III) in a population-based sample of community-dwelling older adults in Germany according to age, sex, and level of education.

METHOD

The sample comprised 1385 participants aged 65-79 years from the nationwide representative 'German Health Interview and Examination Survey for Adults' (DEGS1, 2008-2011). Participants with known cognitive impairment or dementia, other medical conditions affecting cognition, or currently using psychotropic drugs were excluded. Educational level was categorized as low, medium, and high according to the Comparative Analyses of Social Mobility in Industrial Nations (CASMIN) scale. Normative values for the DSST according to age, sex, and level of education were estimated by multiple linear regression using population weights.

RESULTS

Mean age was 71.1 years, 48.6% were men and low, medium, and high education levels were 62.8, 24.6, and 12.6%, respectively. Younger age, female sex, and higher level of education were significantly associated with higher DSST scores. Regression-based normative data for the DSST is provided according to age, sex, and level of education. In addition, a normative score calculator is provided.

CONCLUSIONS

These are the first age-, sex-, and education-specific normative data for older individuals for the DSST of the WAIS-III in Germany. These normative data will enable future population-level analyses on impaired cognitive function according to DSST.

Cognitive functioning in the general population: Factor structure and association with mental disorders-The neuropsychological test battery of the mental health module of the German Health Interview and Examination Survey for Adults (DEGS1-MH)

The objective of this study is to obtain population level data about cognitive functions and their association with mental disorders. We here report factor analytic and psychometric findings of a neuropsychological test battery and examine the association of current and past mental disorders with cognitive function in a large nationwide population-based sample of 18- to 79-year-old adults in Germany (n = 3,667) participating in the mental health module of the German Health Interview and Examination Survey for Adults 2008-2011. Confirmatory factor analysis confirmed verbal memory and executive function factors. Older age was strongly associated with lower verbal memory and executive function and with higher vocabulary scores. After adjustment for age, sex, and education, rather modest decrements were found for verbal memory (β = -.118, p = .002) and executive functions (β = -.191, p < .001) in participants with any current mental disorder (n = 442) compared to those without (n = 3,201). Small decrements in memory (β = -.064, p = .031) and executive function (β = -.111, p < .001) were found in participants with any mental disorder in the last 12 months but not in those with past (fully or partially remitted) mental disorders, compared to participants without a history of mental disorder. More fine-grained analyses of these data will investigate the complex interplay between cognition, health behaviors, and specific mental and somatic diseases.

Regional Differences in the Prevalence of Cardiovascular Disease

BACKGROUND

Cardiovascular disease continues to be the single most common cause of death and to account for the largest single portion of treatment costs in Germany. Reliable data on regional differences in the frequency of cardio - vascular disease are important for the planning of targeted care structures and preventive measures.

METHODS

Pooled data from the German Health Update (GEDA), a nationwide telephone health survey conducted in 2009, 2010 and 2012 (n = 62 214) were used to estimate the lifetime prevalence of major cardiovascular disease (self-reported medical diagnosis of myocardial infarction, other coronary heart disease, stroke, or congestive heart failure) in each of the German federal states. The influence of sociodemographic factors on regional prevalence differences was examined in adjusted logistic regression analyses. Prevalences were compared with mortality rates from cardiovascular disease that were obtained from cause-of-death statistics.

RESULTS

The lifetime prevalence of cardiovascular disease in Germany ranged from 10.0% in Baden-W¨rttemberg to 15.8% in Saxony-Anhalt. After adjustment for age, sex, socioeconomic status, and size of the communities of residence, nine of the other 15 states had significantly higher prevalences than Baden-W¨rttemberg, with odds ratios ranging from 1.26 (Hesse) to 1.55 (Saxony-Anhalt). Four of the five states that previously constituted the German Democratic Republic (East Germany) had above-average figures for prevalence and mortality.

CONCLUSION

There are relevant differences among the German federal states in the lifetime prevalence of major cardiovascular disease, which are only partly accounted for by differences in age and sex distribution, socioeconomic status, and community size.

Predicted 10-year risk of cardiovascular mortality in the 40 to 69 year old general population without cardiovascular diseases in Germany

AIMS

To estimate the 10-year risk of fatal cardiovascular disease (CVD) in the 40 to 69 year old general population in Germany stratified by sex and to analyze differences between socio-economic status (SES), region and community size in individuals without CVD. The analysis is based on the newly recalibrated SCORE Deutschland risk charts and considered other comorbidities for the classification of the high CVD risk group according to the guidelines of the European Society of Cardiology.

METHODS AND RESULTS

In 3,498 participants (40-69 years) from the German Health Examination Survey for Adults 2008-2011 (DEGS1) without a history of CVD (myocardial infarction, coronary heart disease, heart failure, stroke) we estimated the proportion with a low (SCORE <1%), moderate (SCORE 1-<5%) and high 10-year CVD mortality risk (SCORE ≥5% or diabetes, renal insufficiency, SBP/DPB ≥180/110 mmHg or cholesterol >8 mmol/l). The prevalence of low, moderate and high risk was 42.8%, 38.5% and 18.8% in men and 73.7%, 18.1% and 8.2% in women. The prevalence of high risk was significantly lower in women with a high compared to a low SES (3.3% vs. 11.2%) and in communities with ≥100.000 inhabitants compared to <20.000 inhabitants (5.4% vs.10.9%). There were no significant associations between predicted CVD mortality risk and SES or community size in men and regions in men and women. Among the high risk group, 58.2% of men and 9.8% of women had SCORE ≥5%, leaving the majority of women (60.1%) classified as high risks due to diabetes and SCORE <5%.

CONCLUSION

Our results suggest the persistence of socioeconomic disparities in predicted cardiovascular mortality in women and support the need of large-scale prevention efforts beyond individual lifestyle modification or treatment. Furthermore, the importance of additional comorbidities for the high risk group classification is highlighted.

Physical exercise and cognitive function across the life span: Results of a nationwide population-based study

OBJECTIVES

To examine cross-sectional and longitudinal associations between physical exercise and cognitive function across different age groups in a nationwide population-based sample of adults aged 18-79 years in Germany.

DESIGN

Cross-sectional/prospective.

METHODS

Cognitive function was assessed in the mental health module of the German Health Interview and Examination Survey for Adults (DEGS1-MH, 2009-2012, n=3535), using a comprehensive neuropsychological test battery. Cognitive domain scores for executive function and memory were derived from confirmatory factor analysis. Regular physical exercise in the last three months was assessed by self-report and defined as no exercise, <2 and ≥2h (hours) of exercise per week. A subgroup of DEGS1-MH participants who previously participated in the German National Health Interview and Examination Survey 1998 (GNHIES98, 1997-1999, n=1624) enabled longitudinal analyses with a mean follow-up of 12.4 years.

RESULTS

Compared to no exercise, more weekly physical exercise was associated with better executive function in cross-sectional (<2h: β=0.12; ≥2h: β=0.17; all p<0.001) and longitudinal analyses (<2h: β=0.14, p<0.001; ≥2h: β=0.15, p=0.001) using linear regression models adjusted for age, sex, education, smoking, alcohol consumption, fruit and vegetable consumption and obesity. Slightly weaker associations were found for memory in cross-sectional (<2h: β=0.08, p=0.009; ≥2h: β=0.08, p=0.026) and longitudinal analysis (<2h: β=0.09, p=0.036; ≥2h: β=0.08, p=0.114). There was no evidence of interaction between physical exercise and age.

CONCLUSIONS

Higher levels of physical exercise were associated with better executive function and memory in cross-sectional and longitudinal analyses with no evidence for differential effects by age.

Contribution of Established Stroke Risk Factors to the Burden of Stroke in Young Adults

BACKGROUND AND PURPOSE

As stroke in young adults is assumed to have different etiologies and risk factors than in older populations, the aim of this study was to examine the contribution of established potentially modifiable cardiovascular risk factors to the burden of stroke in young adults.

METHODS

A German nationwide case-control study based on patients enrolled in the SIFAP1 study (Stroke In Young Fabry Patients) 2007 to 2010 and controls from the population-based GEDA study (German Health Update) 2009 to 2010 was performed. Cases were 2125 consecutive patients aged 18 to 55 years with acute first-ever stroke from 26 clinical stroke centers; controls (age- and sex-matched, n=8500, without previous stroke) were from a nationwide community sample. Adjusted population-attributable risks of 8 risk factors (hypertension, hyperlipidemia, diabetes mellitus, coronary heart disease, smoking, heavy episodic alcohol consumption, low physical activity, and obesity) and their combinations for all stroke, ischemic stroke, and primary intracerebral hemorrhage were calculated.

RESULTS

Low physical activity and hypertension were the most important risk factors, accounting for 59.7% (95% confidence interval, 56.3-63.2) and 27.1% (95% confidence interval, 23.6-30.6) of all strokes, respectively. All 8 risk factors combined explained 78.9% (95% confidence interval, 76.3-81.4) of all strokes. Population-attributable risks of all risk factors were similar for all ischemic stroke subtypes. Population-attributable risks of most risk factors were higher in older age groups and in men.

CONCLUSIONS

Modifiable risk factors previously established in older populations also account for a large part of stroke in younger adults, with 4 risk factors explaining almost 80% of stroke risk.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00414583.

[Changes in the prevalence of statin use in Germany - findings from national health interview and examination surveys 1997-1999 and 2008-2011]

BACKGROUND

Evidence-based guideline recommendations on lipid lowering drug treatment, in particular statin treatment, play an essential role in the management of dyslipidemias and in the prevention of cardiovascular disease events. In Germany, statutory health insurance data provide information on time trends in the prescription of lipid lowering drugs. However, population-based data regarding changes in user prevalence according to socio-demographic and health-related characteristics are lacking. Based on data from national health interview and examination surveys for adults in Germany 1997-1999 (GNHIES98) and 2008-2010 (DEGS1), the present analysis aims to close this information gap with a particular focus on the use of statins.

METHODS

The study population consisted of 7,099 participants (GNHIES98) and 7,091 participants (DEGS1) aged 18 to 79 years at the time of the respective surveys. Primary data on medication use within 7 days prior to the survey were collected using standardized medication interviews and brown-bag drug review. Unique product identifiers on original drug containers were scanned and coded according to the latest version of the Anatomical Therapeutic Chemical (ATC) classification system. Medical history was obtained in computer-assisted personal interviews. A history of stroke or coronary heart disease (CHD) was assessed among persons aged 40 to 79 years only, and previous stroke or CHD were defined as cardiovascular disease. Obesity was defined as a body mass index (BMI) of ≥ 30kg/m²) based on calculation from standardized measures of body weight and height. Information on socio-demographic variables and type of health insurance was collected using standardized self-administered questionnaires. In cross-sectional descriptive analyses we calculated the prevalence of statin use (ATC codes: C10AA, C10BA, C10BX) by survey as well as the changes between surveys stratified according to relevant preexisting diseases and other co-variables. The association between survey period and statin use was analyzed in multivariable binary logistic regression models among persons aged 40 to 79 years. All results were weighted and standardized for the population of 2010.

RESULTS

Between the two survey periods 1997-1999 and 2008-2011, the prevalence of statin use increased from 3.2 % to 8.8 %. The increase was most pronounced for the age group 65 to 79 years (7.2 % vs. 26.9 %) and among persons with relevant preexisting conditions, such as CHD (19.1 % vs. 54.9 %), stroke (17.1 % vs. 50.1 %), diabetes mellitus (10.5 % vs. 33.2 %), and dyslipidemia (12.6 % vs. 27.8 %). Among persons aged 40 to 79 years, the prevalence of statin use significantly increased between the two surveys, independent of co-variables (Odds Ratio: 3.70; 95 % confidence interval [CI]: 2.92 to 4.70). This applied to persons with cardiovascular disease (5.17; 3.50 to 7.64) and without cardiovascular disease (2.76; 2.07 to 3.67).

CONCLUSION

The increase in the prevalence of statin use in Germany between the two national health surveys (1997-1999 and 2008-2011) reflects the implementation of current guideline recommendations without evidence for inequalities according to gender, education, type of health insurance or region of residence. These population-based data add to information on statin prescription obtained from statutory health insurance data. Limitations of survey-based information derive from potential misclassification and selection bias as well as large time gaps between the survey periods. Further studies are needed to examine why the observed prevalence of statin use among persons with cardiovascular morbidity lags behind current guideline recommendations for secondary cardiovascular prevention.

12-Month prevalence of coronary heart disease in Germany

The results of the GEDA 2014/2015-EHIS study demonstrate that during the last 12 months, 3.7% of women and 6.0% of men in Germany had coronary heart disease (CHD - defined as myocardial infarction, chronic consequences of myocardial infarction or angina pectoris). The 12-month prevalence of CHD in men and women under 45 years of age is well below 1.0%; however, the prevalence rises rapidly and disproportionately up to 16.0% among women and 24.1% among men aged 75 years and over. Women with a low level of education have a considerably higher prevalence of CHD (7.3%) compared to those with a high level of education (1.2%). Men show fewer education-related differences (6.5% versus 5.2%). As the indicators analysed here were first deployed as part of the 2014/2015 European Health Interview Survey (EHIS), no comparative data is available.

12-Month prevalence of stroke or chronic consequences of stroke in Germany

Stroke is the second most common cause of death globally and an important cause of disability in adults. According to the GEDA 2014/2015-EHIS study, 1.6% of adults (1.7% of women and 1.5% of men) in Germany had a stroke or chronic consequences of stroke during the past 12 months. For those aged under 55 years, the 12-month prevalence of these health problems remains well below 1% for both sexes, but then increases steeply and disproportionately to 6.3% for those aged 75 years and over. Prevalence among women with a low level of education (3.6%) is higher than among women with a high level of education (0.6%). Education has only a weak effect on prevalence among men. The indicator analysed here (12-month prevalence of stroke or chronic consequences of stroke) was developed for the European Health Interview Survey (EHIS) 2014/2015, which means that comparative data for Germany is not yet available.

Vitamin D and mortality: Individual participant data meta-analysis of standardized 25-hydroxyvitamin D in 26916 individuals from a European consortium

Background

Vitamin D deficiency may be a risk factor for mortality but previous meta-analyses lacked standardization of laboratory methods for 25-hydroxyvitamin D (25[OH]D) concentrations and used aggregate data instead of individual participant data (IPD). We therefore performed an IPD meta-analysis on the association between standardized serum 25(OH)D and mortality.

Methods

In a European consortium of eight prospective studies, including seven general population cohorts, we used the Vitamin D Standardization Program (VDSP) protocols to standardize 25(OH)D data. Meta-analyses using a one step procedure on IPD were performed to study associations of 25(OH)D with all-cause mortality as the primary outcome, and with cardiovascular and cancer mortality as secondary outcomes. This meta-analysis is registered at ClinicalTrials.gov, number NCT02438488.

Findings

We analysed 26916 study participants (median age 61.6 years, 58% females) with a median 25(OH)D concentration of 53.8 nmol/L. During a median follow-up time of 10.5 years, 6802 persons died. Compared to participants with 25(OH)D concentrations of 75 to 99.99 nmol/L, the adjusted hazard ratios (with 95% confidence interval) for mortality in the 25(OH)D groups with 40 to 49.99, 30 to 39.99, and <30 nmol/L were 1.15 (1.00–1.29), 1.33 (1.16–1.51), and 1.67 (1.44–1.89), respectively. We observed similar results for cardiovascular mortality, but there was no significant linear association between 25(OH)D and cancer mortality. There was also no significantly increased mortality risk at high 25(OH)D levels up to 125 nmol/L.

Interpretation

In the first IPD meta-analysis using standardized measurements of 25(OH)D we observed an association between low 25(OH)D and increased risk of all-cause mortality. It is of public health interest to evaluate whether treatment of vitamin D deficiency prevents premature deaths.

Changes in physical functioning among men and women aged 50-79 years in Germany: an analysis of National Health Interview and Examination Surveys, 1997-1999 and 2008-2011

Background

This study examines changes in physical functioning among adults aged 50-79 years in Germany based on data from two German National Health Interview and Examination Surveys conducted in 1997–1999 (GNHIES98) and 2008–2011 (DEGS1).

Methods

Using cross-sectional data from the two surveys (GNHIES98, n = 2884 and DEGS1, n = 3732), we examined changes in self-reported physical functioning scores (Short Form-36 physical functioning subscale (SF-36 PF)) by sex and age groups (50–64 and 65–79 years). Covariables included educational level, living alone, nine chronic diseases, polypharmacy (≥5 prescribed medicines), body mass index, sports activity, smoking and alcohol consumption. Multimorbidity was defined as ≥2 chronic diseases. Multivariable models were fitted to examine consistency of changes in physical functioning among certain subgroups and to assess changes in mean SF-36 PF scores, adjusting for changes in covariables between surveys.

Results

Mean physical functioning increased among adults aged 50–79 years between surveys in unadjusted analyses, but this change was not as marked among men aged 65–79 years who experienced rising obesity (20.6 to 31.5%, p = 0.004) and diabetes (13.0 to 20.0%, p = 0.014). Prevalence of multimorbidity and polypharmacy use increased among men and women aged 65–79 years. In sex and age specific multivariable analyses, changes in physical functioning over time were consistent across subgroups. Gains in physical functioning were explained by improved education, lower body mass index and improved health-related behaviours (smoking, alcohol consumption, sports activity) in women, but less so among men.

Conclusions

Physical functioning improved in Germany among adults aged 50–79 years. Improvements in the population 65–79 years were less evident among men than women, despite increases in multimorbidity prevalence among both sexes. Changes in health behaviours over time differed between sexes and help explain variations in physical functioning. Targeted health behaviour interventions are indicated from this study.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-016-0377-0) contains supplementary material, which is available to authorized users.

Mental disorders in adults with congenital heart disease: Unmet needs and impact on quality of life

OBJECTIVE

In adult congenital heart disease (ACHD), mental health status and quality of life become important issues due to improved life expectancy. Current literature provides conflicting data regarding mental health status in ACHD. Furthermore, none of the studies so far compared prevalence rates with a matched control group.

METHODS

The prevalence of mental disorders was assessed in 150 ACHD using a structured interview, and compared to 12-months estimates of the general German population. Quality of life (QoL) was measured with World Health Organization Quality of Life instrument. Furthermore, we related the diagnostic results of widely used screening instruments for depression (Beck Depression Inventory-2; BDI-2; Hospital Anxiety and Depression Scale; HADS) with clinical diagnoses, to receive optimal sensitivity and specificity values.

RESULTS

The prevalence of psychiatric disorders was significantly higher in ACHD than in the general population (48.0%; CI: 44.7-60.0 vs. 35.7%; CI: 33.5-37.9). Mood (30.7%; CI: 24.0-38.0 vs. 10.7%;CI:9.4-12.0) and anxiety disorders (28.0%; CI:22.0-36.7 vs. 16.8%; CI: 15.0-18.6) were the leading causes of psychiatric illness. Sixteen of 150 ACHD patients (10.7%) received specific treatment for psychiatric disorders before entering the study. Overall quality of life was independently and negatively associated with a diagnosis of major depression (p<0.001), alcohol dependency (p=0.004), nicotine dependency (p=0.036), and NYHA class (p=0.007). Accuracy of the HADS-D and BDI-2 as screening instruments was moderate (AUC 0.60-0.81), depending on the cut-off score used.

CONCLUSIONS

Psychiatric disorders, particularly mood and anxiety disorders are significantly more frequent in ACHD compared to the general population. However, these disorders are rarely diagnosed resulting in under treatment and loss of quality of life. Quality of life is independently associated with the existence of mood, anxiety and substance use disorders. When self-rating instruments (BDI-2, HADS) are used as screening instruments in ACHD care, lower cut-off values are recommended.

Association between vitamin D and depressive symptoms varies by season: Results from the German Health Interview and Examination Survey for Adults (DEGS1)

BACKGROUND

Findings from epidemiological studies regarding seasonal variations in the association between vitamin D status and depression are inconsistent.

METHODS

Cross-sectional analysis of data from 6331 participants aged 18-79 years in the nationwide representative German Health Interview and Examination Survey for Adults 2008-2011 (DEGS1). Associations between 25-hydroxy-vitamin-D (25(OH)D) serum levels in quartiles and current depressive symptoms as measured by the Patient Health Questionnaire depression module (PHQ-9) and defined as severity of depressive symptoms (PHQ-9 score, range 0-27 points) and elevated depressive symptoms (PHQ-9 score ≥10 points) were analysed using multivariable linear and logistic regression adjusted for sociodemographic, biological and lifestyle factors. Analyses were stratified by summertime (May to October) and wintertime (November to April) because of evidence for interaction with season (p≤0.01).

RESULTS

In crude analyses, vitamin D status was inversely associated with both depression outcomes in summertime but not in wintertime. After adjustment for potential confounders, a significant association with severity of depressive symptoms remained in summer, with 0.73 point lower PHQ-9 scores in the highest versus lowest quartile. The association between 25(OH)D quartiles and elevated depressive symptoms in summertime was less strong and no longer significant in fully adjusted models.

LIMITATIONS

Participants with severe depression may be underrepresented in DEGS1. Residual confounding cannot be excluded.

CONCLUSION

25(OH)D serum levels were inversely associated with current depressive symptoms in summer but not in wintertime. The fact that the association is stronger in summertime suggests that vitamin D deficiency may be a consequence rather than a cause of depression.

Regional Differences in the Prevalence of Cardiovascular Disease

BACKGROUND

Cardiovascular disease continues to be the single most common cause of death and to account for the largest single portion of treatment costs in Germany. Reliable data on regional differences in the frequency of cardio - vascular disease are important for the planning of targeted care structures and preventive measures.

METHODS

Pooled data from the German Health Update (GEDA), a nationwide telephone health survey conducted in 2009, 2010 and 2012 (n = 62 214) were used to estimate the lifetime prevalence of major cardiovascular disease (self-reported medical diagnosis of myocardial infarction, other coronary heart disease, stroke, or congestive heart failure) in each of the German federal states. The influence of sociodemographic factors on regional prevalence differences was examined in adjusted logistic regression analyses. Prevalences were compared with mortality rates from cardiovascular disease that were obtained from cause-of-death statistics.

RESULTS

The lifetime prevalence of cardiovascular disease in Germany ranged from 10.0% in Baden-W¨rttemberg to 15.8% in Saxony-Anhalt. After adjustment for age, sex, socioeconomic status, and size of the communities of residence, nine of the other 15 states had significantly higher prevalences than Baden-W¨rttemberg, with odds ratios ranging from 1.26 (Hesse) to 1.55 (Saxony-Anhalt). Four of the five states that previously constituted the German Democratic Republic (East Germany) had above-average figures for prevalence and mortality.

CONCLUSION

There are relevant differences among the German federal states in the lifetime prevalence of major cardiovascular disease, which are only partly accounted for by differences in age and sex distribution, socioeconomic status, and community size.

Time Trends in Cardiometabolic Risk Factors in Adults

BACKGROUND

Data from three representative health examination surveys in Germany were analyzed to examine secular trends in the prevalence and magnitude of cardiometabolic risk factors.

METHODS

The target variables were the following cardiometabolic risk factors: lack of exercise, smoking, obesity, systolic blood pressure, total cholesterol, serum glucose, self-reported high blood pressure, hyperlipidemia, and diabetes, and the use of antihypertensive, cholesterol-lowering, and antidiabetic drugs. 9347 data sets from men and 10 068 from women were analyzed. The calculated means and prevalences were standardized to the age structure of the German population as of 31 December 2010 and compared across the three time periods of the surveys: 1990-1992, 1997-1999, and 2008-11.

RESULTS

Over the entire period of observation (1990-2011), the mean systolic blood pressure fell from 137 to 128 mmHg in men and from 132 to 120 mmHg in women; the mean serum glucose concentration fell from 5.6 to 5.3 mmol/L in men and from 5.4 to 5.0 mmol/l in women; and the mean total cholesterol level fell from 6.2 to 5.3 mmol/L in both sexes. In men, smoking and lack of exercise became less common. On the other hand, the prevalence of use of antidiabetic, cholesterol-lowering, and antihypertensive drugs rose over the same time period, as did that of self-reported diabetes. The first of the three surveys (1990-1992) revealed differences between persons residing in the former East and West Germany in most of the health variables studied; these differences became less marked over time, up to the last survey in 2008-2011.

CONCLUSION

The cardiometabolic risk profile of the German adult population as a whole improved over a period of 20 years. Further in-depth analyses are now planned.

Proceedings of the International Workshop ‘From Global Burden of Disease Studies to National Burden of Disease Surveillance'

I1 Introduction and aims of the workshop

Christa Scheidt-Nave, Thomas Ziese, Judith Fuchs, Dietrich Plass

S1 History, concept, and current results of GBD for Germany

Tom Achoki, Katherine Leach-Kemon, Peter Speyer, William E. Heisel, Emmanuela Gakidou, Theo Vos

S2 Methodology of the GBD 2013 Study–Mortality, Morbidity, Risk-Factors

Mohammad Hossein Forouzanfar

S3 National burden of disease surveillance examples of good practice: the case of Public Health England

Jürgen C. Schmidt

S4 Critical aspects of the burden of disease methodology and country-specific challenges

Claudia E. Stein

S5 Non-communicable disease surveillance in Germany – public health and data challenges

Christa Scheidt-Nave, Elena von der Lippe, Benjamin Barnes, Markus Busch, Nina Buttmann-Schweiger, Judith Fuchs, Christin Heidemann, Klaus Kraywinkel, Enno Nowossadeck, Thomas Ziese

S6 Different approaches in estimating the burden of communicable diseases using the examples of the healthcare associated infections and influenza

Udo Buchholz, Matthias an der Heiden, Tim Eckmanns, Sebastian Haller

S7 Behavioral and environmental attributable risk estimation

Mohammad Hossein Forouzanfar

S8 Environmental Burden of Disease (EBD) in Germany – past achievements and future perspectives

Dietrich Plass, Myriam Tobollik, Dagmar Kallweit, Dirk Wintermeyer

C1 Conclusions of the workshop

Christa Scheidt-Nave, Thomas Ziese, Judith Fuchs, Dietrich Plass

Vitamin D deficiency in Europe: pandemic?

BACKGROUND

Vitamin D deficiency has been described as being pandemic, but serum 25-hydroxyvitamin D [25(OH)D] distribution data for the European Union are of very variable quality. The NIH-led international Vitamin D Standardization Program (VDSP) has developed protocols for standardizing existing 25(OH)D values from national health/nutrition surveys.

OBJECTIVE

This study applied VDSP protocols to serum 25(OH)D data from representative childhood/teenage and adult/older adult European populations, representing a sizable geographical footprint, to better quantify the prevalence of vitamin D deficiency in Europe.

DESIGN

The VDSP protocols were applied in 14 population studies [reanalysis of subsets of serum 25(OH)D in 11 studies and complete analysis of all samples from 3 studies that had not previously measured it] by using certified liquid chromatography-tandem mass spectrometry on biobanked sera. These data were combined with standardized serum 25(OH)D data from 4 previously standardized studies (for a total n= 55,844). Prevalence estimates of vitamin D deficiency [using various serum 25(OH)D thresholds] were generated on the basis of standardized 25(OH)D data.

RESULTS

An overall pooled estimate, irrespective of age group, ethnic mix, and latitude of study populations, showed that 13.0% of the 55,844 European individuals had serum 25(OH)D concentrations <30 nmol/L on average in the year, with 17.7% and 8.3% in those sampled during the extended winter (October-March) and summer (April-November) periods, respectively. According to an alternate suggested definition of vitamin D deficiency (<50 nmol/L), the prevalence was 40.4%. Dark-skinned ethnic subgroups had much higher (3- to 71-fold) prevalence of serum 25(OH)D <30 nmol/L than did white populations.

CONCLUSIONS

Vitamin D deficiency is evident throughout the European population at prevalence rates that are concerning and that require action from a public health perspective. What direction these strategies take will depend on European policy but should aim to ensure vitamin D intakes that are protective against vitamin D deficiency in the majority of the European population.

Changes in mean serum lipids among adults in Germany: results from National Health Surveys 1997-99 and 2008-11

Background

Monitoring of serum lipid concentrations at the population level is an important public health tool to describe progress in cardiovascular disease risk control and prevention. Using data from two nationally representative health surveys of adults 18–79 years, this study identified changes in mean serum total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and triglycerides (TG) in relation to changes in potential determinants of serum lipids between 1997–99 and 2008–11 in Germany.

Methods

Sex-specific multivariable linear regression analyses were performed with serum lipids as dependent variables and survey wave as independent variable and adjusted for the following covariables: age, fasting duration, educational status, lifestyle, and use of medication.

Results

Mean TC declined between the two survey periods by 13 % (5.97 mmol/l vs. 5.19 mmol/l) among men and by 12 % (6.03 mmol/l vs. 5.30 mmol/l) among women. Geometric mean TG decreased by 14 % (1.66 mmol/l vs. 1.42 mmol/l) among men and by 8 % (1.20 mmol/l vs. 1.10 mmol/l) among women. Mean HDL-C remained unchanged among men (1.29 mmol/l vs. 1.27 mmol/l), but decreased by 5 % among women (1.66 mmol/l vs. 1.58 mmol/l). Sports activity and coffee consumption increased, while smoking and high alcohol consumption decreased only in men. Processed food consumption increased and wholegrain bread consumption decreased in both sexes, and obesity increased among men. The use of lipid-lowering medication, in particular statins nearly doubled over time in both sexes. Among women, hormonal contraceptive use increased and postmenopausal hormone therapy halved over time. The changes in lipid levels between surveys remained significant after adjusting for covariables.

Conclusion

Serum TC and TG considerably declined over one decade in Germany, which can be partly explained by increased use of lipid-lowering medication and improved lifestyle among men. The decline in serum lipids among women, however, remains unexplained.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2826-2) contains supplementary material, which is available to authorized users.

Baseline participation in a health examination survey of the population 65 years and older: who is missed and why?

Background

Public health monitoring depends on valid health and disability estimates in the population 65+ years. This is hampered by high non-participation rates in this age group. There is limited insight into size and direction of potential baseline selection bias.

Methods

We analyzed baseline non-participation in a register-based random sample of 1481 inner-city residents 65+ years, invited to a health examination survey according to demographics available for the entire sample, self-report information as available and reasons for non-participation. One year after recruitment, non-responders were revisited to assess their reasons.

Results

Five groups defined by participation status were differentiated: participants (N = 299), persons who had died or moved (N = 173), those who declined participation, but answered a short questionnaire (N = 384), those who declined participation and the short questionnaire (N = 324), and non-responders (N = 301). The results confirm substantial baseline selection bias with significant underrepresentation of persons 85+ years, persons in residential care or from disadvantaged neighborhoods, with lower education, foreign citizenship, or lower health-related quality of life. Finally, reasons for non-participation could be identified for 78 % of all non-participants, including 183 non-responders.

Conclusion

A diversity in health problems and barriers to participation exists among non-participants. Innovative study designs are needed for public health monitoring in aging populations.

In vitro evaluation of nutrients that selectively confer a competitive advantage to lactobacilli

An assay was developed that tested the ability of Lactobacillus acidophilus to outcompete a challenge of Escherichia coli in a mixed culture containing different test nutrients. Using this assay, addition of fructo-oligosaccharide to the media allowed L. acidophilus to outcompete a challenge of E. coli, whereas in a mixed culture without the prebiotic the trend was reversed. Growth curves generated for E. coli in a single culture showed that fructo-oligosaccharide did not affect growth, indicating that the carbohydrate was not toxic to E. coli. This indicates that fructo-oligosaccharides may increase the ability of beneficial microbes to outcompete a pathogenic challenge. These results were confirmed using a skin simulant model that incorporates growth of the organisms at an air-surface interface to mimic the vulvar environment. It is possible to use a co-culture assay as an in vitro screening tool to define nutrients that confer a competitive advantage to beneficial flora specific to the female urogenital tract.

Twelve-months prevalence of mental disorders in the German Health Interview and Examination Survey for Adults - Mental Health Module (DEGS1-MH): a methodological addendum and correction

We recently published findings in this journal on the prevalence of mental disorders from the German Health Interview and Examination Survey for Adults Mental Health Module (DEGS1-MH). The DEGS1-MH paper was also meant to be the major reference publication for this large-scale German study program, allowing future users of the data set to understand how the study was conducted and analyzed. Thus, towards this goal highest standards regarding transparency, consistency and reproducibility should be applied. After publication, unfortunately, the need for an addendum and corrigendum became apparent due to changes in the eligible reference sample, and corresponding corrections of the imputed data. As a consequence the sample description, sample size and some prevalence data needed amendments. Additionally we identified a coding error in the algorithm for major depression that had a significant effect on the prevalence estimates of depression and associated conditions. This addendum and corrigendum highlights all changes and presents the corrected prevalence tables. Copyright © 2015 John Wiley & Sons, Ltd.

Modifiable cardiovascular risk factors in adults aged 40-79 years in Germany with and without prior coronary heart disease or stroke

Background

Control of modifiable cardiovascular disease (CVD) risk factors has substantially reduced CVD mortality, but risk factor levels in populations may change and need continuous monitoring. This study aims to provide current estimates of the prevalence of these risk factors in Germany according to sex and history of coronary heart disease (CHD) or stroke.

Methods

The analyses were based on data from the German Health Interview and Examination Survey for Adults (DEGS1; age 40–79 years, n = 5101), which is a cross-sectional population-based examination survey. CVD risk factors were defined according to recommendations in the European Guidelines on Cardiovascular Disease Prevention in Clinical Practice 2012.

Results

The mean age was 57 years and 52 % were female; 493 participants had prior CHD and 163 participants a prior stroke. The overall prevalence of behavioural risk factors ranged from 17.9 % for high risk alcohol consumption to 90 % for low vegetable intake. Blood pressure ≥ 140/90 mmHg was found in 21 % and 69 % had total cholesterol ≥ 5.0 mmol/l. Only 16 % met the targets for five behavioural factors combined (smoking, physical activity, fruit intake, alcohol intake and obesity), 13 % of those with and 16 % of those without CHD or stroke. The prevalences of most behavioural risk factors were higher among men compared to women.

Conclusions

There is a high prevention potential from modifiable cardiovascular risk factors in the general population aged 40–79 years in Germany and among those with prior CHD or stroke. Risk factors are often co-occurring, are interrelated and require combined educational, behavioral, medical and policy approaches.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1929-5) contains supplementary material, which is available to authorized users.

Vitamin D status among adults in Germany--results from the German Health Interview and Examination Survey for Adults (DEGS1)

Background

In 1998, more than half of the adult population in Germany had serum 25-hydroxy-vitamin-D [25(OH)D] levels below the common threshold of 50 nmol/l. Since then, there has been a lot of attention for vitamin D in the scientific community, the media and the general population and serum 25(OH)D levels may have increased as a consequence. With data from the ‘German Health Interview and Examination Survey for Adults’ (DEGS1) the current situation of vitamin D status can be analysed.

Methods

DEGS1, a national health survey among adults in Germany conducted by the Robert Koch Institute between 2008 and 2011, included 6,995 persons with available serum 25(OH)D levels. We calculated the proportion of participants with serum 25(OH)D levels <30 nmol/l, 30- < 50 nmol/l and > =50 nmol/l overall and according to age, season and latitude of residence as well as percentiles of serum 25(OH)D according to month of examination. Determinants of vitamin D status were analysed with multiple linear regression models.

Results

Mean serum 25(OH)D level was 45.6 nmol/l with no significant sex differences (p = 0.47). 61.6 % of the participants had serum 25(OH)D levels <50 nmol/l, 30.2 % had levels <30 nmol/l. During summer, half of the participants had levels > =50 nmol/l, during winter time, 25 % of the participants had levels <30 nmol/l. A significant latitudinal gradient was observed in autumn for men and in winter for women.

In multiple linear regression analyses, examination during winter time, residing in northern latitude, non-use of vitamin D supplements, low sport activity, high Body Mass Index (BMI) and high media consumption were independently and significantly associated with lower serum 25(OH)D levels in both sexes. In addition, among women, significant associations with lower 25(OH)D levels were observed for older age and lower socio-economic status, among men, for low vitamin D intake and more residential traffic.

Conclusions

Serum 25(OH)D levels below the threshold of 50 nmol/l are still common among adults in Germany, especially during winter and spring and in higher latitudes. Potentially modifiable factors of poorer vitamin D status are higher BMI, lack of sport activity and high media use.

Current major depressive syndrome measured with the Patient Health Questionnaire-9 (PHQ-9) and the Composite International Diagnostic Interview (CIDI): results from a cross-sectional population-based study of adults in Germany

BACKGROUND

Prevalence estimates for depression vary considerably by the type of assessment instrument, and there is limited information on their overlap in population-based samples. Our aim was to compare the Patient Health Questionnaire-9 (PHQ-9) with the Composite International Diagnostic Interview (CIDI) as measures for current major depressive syndrome (MDS) in a large population-based sample.

METHODS

Data derived from the mental health module of the nationwide cross-sectional German Health Interview and Examination Survey for Adults (DEGS1-MH) (n = 4483; age 18-79 years). MDS in the past two weeks was assessed (a) using the PHQ-9 diagnostic algorithm (PHQ-MDS) and (b) based on CIDI information about the latest symptom occurrence (recency) (CIDI-MDS). Prevalences, overall concordance and percentages of overlap of both MDS measures were determined. Prevalences of affirmed PHQ-9 depression symptoms and the mean and median PHQ-9 sum scores were analyzed per measure.

RESULTS

Prevalence of current MDS was 2.7% (95% CI: 2.0-3.6) for PHQ-MDS and 3.9% (95% CI: 3.1-5.0) for CIDI-MDS. The overall agreement between both measures was moderate (kappa: 0.43). Of all the participants, 1.5% (95% CI: 1.0-2.2) were classified as MDS cases by both measures, with 54.5% (95% CI: 42.7-65.9) of PHQ-MDS cases and 37.9% (95% CI: 27.8-49.1) of CIDI-MDS cases also being classified as MDS by the respective other MDS measure. However, 94.8% (95% CI: 93.6-95.8) of the participants were classified as non-MDS by both measures, with 97.5% (95% CI: 96.6-98.1) of non-PHQ-MDS and 98.7% (95% CI: 98.2-99.1) of non-CIDI-MDS being classified as non-MDS by the respective other MDS measure. The mean and median PHQ-9 sum score was higher in those with PHQ-MDS than in those with CIDI-MDS.

CONCLUSIONS

Both measures have a high level of agreement for ruling out current MDS, but the overlap in their classification of cases is moderate. Our results indicate that they cannot be interpreted as equal measures of the same construct, suggesting limited comparability of their prevalence estimates. However, further exploration of algorithms and correlates and a proper labeling of measures in epidemiological studies are required.

Association between hemoglobin A1c and all-cause mortality: results of the mortality follow-up of the German National Health Interview and Examination Survey 1998

OBJECTIVE

This study examined the association of HbA1c-defined glycemic status and continuous HbA1c with all-cause mortality.

RESEARCH DESIGN AND METHODS

The study population comprised 6,299 participants (aged 18-79 years) of the German National Health Interview and Examination Survey 1998, who were followed up for mortality for an average of 11.6 years. Glycemic status was defined as known diabetes (self-reported diagnosis or intake of antidiabetic medication) and based on HbA1c levels according to American Diabetes Association diagnostic criteria as undiagnosed diabetes (≥6.5% [≥48 mmol/mol]), prediabetes with very high (6.0-6.4% [42-46 mmol/mol]) or high diabetes risk (5.7-5.9% [39-41 mmol/mol]), and normoglycemia (<5.7% [<39 mmol/mol]). Associations between glycemic status and mortality were examined by Cox regression adjusting for age, sex, education, lifestyle factors, anthropometric measures, and history of chronic diseases (reference: normoglycemia). Spline models were fitted to investigate associations between continuous HbA1c and mortality among participants without known diabetes.

RESULTS

Excess mortality risk was observed for participants with known diabetes (hazard ratio 1.41 [95% CI 1.08-1.84]) and undiagnosed diabetes (1.63 [1.23-2.17]) but not for those with high (1.02 [0.80-1.30]) or very high diabetes risk (0.87 [0.67-1.13]). Spline models revealed a U-shaped association, with lowest risk at HbA1c levels 5.4-5.6% (36-38 mmol/mol) and a significantly increased risk at ≤5.0% (≤31 mmol/mol) and ≥6.4% (≥46 mmol/mol).

CONCLUSIONS

Unlike known and undiagnosed diabetes, HbA1c levels in the prediabetic range were not associated with an increased mortality risk. The observed U-shaped relationship adds to existing evidence that not only high but also low HbA1c levels might be associated with all-cause mortality.

Twelve-month prevalence, comorbidity and correlates of mental disorders in Germany: the Mental Health Module of the German Health Interview and Examination Survey for Adults (DEGS1-MH)

This paper provides up to date prevalence estimates of mental disorders in Germany derived from a national survey (German Health Interview and Examination Survey for Adults, Mental Health Module [DEGS1-MH]). A nationally representative sample (N = 5318) of the adult (18-79) population was examined by clinically trained interviewers with a modified version of the Composite International Diagnostic Interview (DEGS-CIDI) to assess symptoms, syndromes and diagnoses according to DSM-IV-TR (25 diagnoses covered). Of the participants 27.7% met criteria for at least one mental disorder during the past 12 months, among them 44% with more than one disorder and 22% with three or more diagnoses. Most frequent were anxiety (15.3%), mood (9.3%) and substance use disorders (5.7%). Overall rates for mental disorders were substantially higher in women (33% versus 22% in men), younger age group (18-34: 37% versus 20% in age group 65-79), when living without a partner (37% versus 26% with partnership) or with low (38%) versus high socio-economic status (22%). High degree of urbanization (> 500,000 inhabitants versus < 20,000) was associated with elevated rates of psychotic (5.2% versus 2.5%) and mood disorders (13.9% versus 7.8%). The findings confirm that almost one third of the general population is affected by mental disorders and inform about subsets in the population who are particularly affected.

Self-reported utilization of mental health services in the adult German population--evidence for unmet needs? Results of the DEGS1-Mental Health Module (DEGS1-MH)

This paper provides up-to-date data on service use for mental health problems and disorders among adults aged 18-79 years in Germany derived from the Mental Health Module of the German Health Interview and Examination Survey for Adults (DEGS1-MH; N=4483). Data are based exclusively on self-report. Respondents were examined by clinically trained interviewers with a modified version of the Composite International Diagnostic Interview DIA-X/M-CIDI to assess diagnoses according to the criteria of DSM-IV-TR. Service use, i.e. contact to mental health care services, due to mental health problems was assessed for the past 12 months and lifetime, by type of sector and type of institution. Among respondents with a 12-month diagnosis of a mental disorder, 23.5% of the women and 11.6% of the men reported any service use in the past 12 months. Service use depends on type of diagnosis, comorbidity and socio-demographic characteristics. Lowest 12-month utilization rates were found for substance use disorders (15.6%; lifetime use 37.3%), highest for psychotic disorders (40.5%; lifetime 72.1%). Further, a considerable time lap was found between disorder onset and subsequent service use among the majority of cases with anxiety and mood disorders. This paper provides self-reported epidemiological data on mental health service use in Germany, complementing administrative statistics and the predecessor mental health module of the German Health Interview and Examination Survey (GHS-MHS) from 1998. Despite considerable changes in the mental health field in Germany and the existence of a comprehensive mental health care system without major financial barriers, we find no indications of substantially higher utilization rates for mental disorders as compared to other comparable European countries. Further, no indications of major overall changes in utilization rates are apparent. To pinpoint areas with unmet needs, more detailed analyses of the data are needed taking into account type, frequency, and adequacy of service use and treatment of mental disorders. Appropriately matched comparisons with the GHS-MHS are needed to identify changes in patterns of utilization and interventions by type of disorder.

[Comorbidity of diabetes mellitus and depression in the general population in Germany]

OBJECTIVE

To assess the comorbidity of diabetes and depression in the adult general population of Germany.

METHODS

Data (n = 43 312) derived from the representative cross-sectional telephone survey "German Health Update (GEDA)". Information about diagnosed chronic somatic diseases including diabetes and diagnosed depression was available for residents in private households. Age- and sex-specific adjusted logistic regressions were used to examine the association between diabetes and depression.

RESULTS

12-month prevalences: diagnosed diabetes 7.4 %, diagnosed depression 6.7 %, comorbidity of both 0.8 %. An association of diabetes and depression was found in people < 50 years and in women aged 50 - 64 years. This association was dependent on the number of additional chronic diseases.

CONCLUSION

Comorbidity of diabetes and depression was quite rare. Yet according to our results every 10(th) adult with diagnosed diabetes gets a depression diagnosis and every 9(th) adult with diagnosed depression has known diabetes. Underestimation for men and older adults due to diagnostic bias is possible. The combination of diabetes and depression is relevant for medical care because of its health burden.