Type 2 diabetes mellitus in Augsburg--an epidemiological overview

This article provides an overview of the prevalence of type 2 diabetes and the antidiabetic treatment over a 17 year study period. The causes of the disease and the impact of diabetes on cardiovascular disease (CVD) morbidity are discussed. Furthermore, changes in lifestyle and risk factor profile in persons with diabetes are reported. We present data from the MONICA/KORA surveys S1-S4 conducted between 1984/85 and 1999/2001 in the region of Augsburg, Southern Germany and the Augsburg Myocardial Infarction Registry. Contrary to most studies from other countries, in the 25 to 74 year old Augsburg population the prevalence of known diabetes did not increase over the last years. Obesity and decreased physical activity are the two main lifestyle related risk factors for type 2 diabetes. Recently, further modifiable risk factors such as smoking and hypertension have been associated with the development of type 2 diabetes in the Augsburg population. Consistent with recommendations to intensify glucose control in diabetic persons the diabetes treatment continuously improved during the study period. However, health status of persons with diabetes is far from optimal in the Augsburg population suggesting that recommendations for primary prevention of CVD in diabetic persons were not sufficiently put into practice until 1999/2001. Furthermore, data from the MONICA/KORA Augsburg Myocardial infarction registry underline the challenge that in particular men and women with diabetes should receive intensive preventive interventions proven to reduce CVD risk. In conclusion, data from the MONICA/KORA Augsburg studies suggest that it should become an important public health priority to prevent diabetes mellitus.     

The prevalence of contact allergy differed between population-based and clinic-based data

OBJECTIVE: Epidemiologic evidence on contact allergy (CA) largely relies on clinical studies. However, the effects of the selection process until consultation as patient are largely unclear. STUDY DESIGN AND SETTING: Prevalences of contact allergy to important allergens estimated from the population-based nested case-control study "KORA Allergy Study" in Augsburg, Germany (a subsample from the third MONICA survey in 1997/1998, n=1141), were compared with proportions found in the Department of Dermatology of the Augsburg Municipal Hospital in patients of similar age patch tested between 1997 and 2000 (n=555). Prevalences were standardized for sex, age, and atopic dermatitis as potential confounders. RESULTS: Among the 25 substances tested, the fragrance mix (MONICA, estimated from the KORA Allergy Study: 11.4%, hospital: 12.9%) and nickel (MONICA: 9.9%, hospital: 12.9%) were the most common allergens. Larger differences between prevalences were noted particularly with ingredients of topicals used to treat varicose ulcers-a speciality of the Augsburg department, which is also reflected by comparing the department with the whole Information Network of (n =40) Departments of Dermatology (IVDK). CONCLUSION: This locally matched comparison illustrates the differential effect of selection until presentation in dermatological departments.     

Fractures in the elderly--a challenge for prevention and health promotion--results from the KORA fracture study Augsburg

Fractures of the appendicular bones are frequent and can cause a loss of the ability for independent living, depending on age and fracture localisation. They affect both sexes at different times and in different ways. The basic epidemiology for Germany of this injury resp. disease and knowledge regarding medium-term health-related consequences has been provided by work done in the context of the KORA Augsburg Fracture Study 1998, a follow-up of older participants of the third MONICA Augsburg survey S3 (1994/95) and through further research in the past years. Results of a validation study support the value of questionnaire-based patients recall of fractures and their location. It could be shown that age, gender, time since fracture and impaired walking have the greatest predictive value among a number of factors. Limitations of physical function are apparent especially during the first two years after a fragility fracture. After five years functional capacity of survivors equals the functional capacity of control persons of the same age. These population-representative and validated data support model-based cost-effective strategies of population-orientated disease prevention and health promotion. An age and gender-specific approach (gender mainstreaming) is mandatory.     

Nimmt die gesundheitliche Ungleichheit zu?

The analyses focused on time trends in health inequalities in the 25 to 64-year-old population of Augsburg. The analyses are based on four independent cross-sectional surveys from the MONICA/KORA study covering 15 years: 1984/1985 (n?=?4,022), 1989/1990 (n?=?3,966), 1994/1995 (n?=?3,916) and 1999/2000 (n?=?3,492). Socioeconomic status (SES) was assessed by educational level and per capita household income with separate analyses for each of these two variables. Both absolute and relative health inequalities were calculated. The results showed that inequalities in self-rated health did not change very much (with some indications for increasing inequalities). However, concerning smoking the results clearly pointed towards increasing health inequalities (for example concerning relative inequalities among women by educational level: significant increase from survey to survey of about 20?%). The prevalence of obesity was increased in all SES groups but the inequalities did not change very much. These time trends show that the efforts aimed at reducing health inequalities should be intensified.     

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.     

The association of antihypertensive treatment patterns and adverse lipid effects in population-based studies

We investigated the relationship between antihypertensive drug treatment of hypertensives and their mean serum lipid concentrations in population based studies in Germany. Data from three surveys (Luebeck Blood Pressure Study (LBS) of 1984, MONICA Augsburg Survey I of 1984/85, MONICA Augsburg Survey II of 1989/90), obtained on random samples of the population aged 25–64 years, were used for cross-sectional analyses. Moreover, prospective analyses were carried out on participants of the MONICA Augsburg cohort study of 1987/88 (3-year-follow-up of the MONICA Survey I). Blood pressure, non-fasting serum total cholesterol and HDL-cholesterol, and body height and weight were measured under strictly standardized conditions. Interview data were available on medical history including medication use, and on smoking and alcohol consumption. In cross-sectional and prospective analyses treated male and female hypertensives in each population had significantly lower crude mean HDL-C concentrations than untreated hypertensives, borderliners, or normotensives. Differences in mean HDL-C between untreated and treated hypertensives were attenuated but still significant after control of confounders and ranged from 1.8 to 6.1 mg/dl (i.e. in relative terms, −3.4 to −12.9%) in men and from 3.6 to 9.4 mg/dl (−5.7 to −14.9%) in women. By contrast, crude and multivariate associations of antihypertensive treatment with non-HDL-C (total minus HDL-C) levels were inconsistent and not significant. The inverse association of drug therapy with HDL-C was confirmed by prospective analyses in the MONICA cohort study supporting a causal relationship. Treatment patterns in a community (prevalence of prescribed drug classes) correlated with the magnitude and significance of HDL-C effects. Despite the diversity of brands and substances used, treated hypertensives consistently had the lowest HDL-C levels of all blood pressure strata strata in population. We assume this to indicate permanent, common and rathther substantial HDL-C effects of present antihypertensive treatment patterns. Mass treatment of hypertension may suffer sizable reductions in the overall benefit as a consequence of the observed associations. We suggest that from a public health point of view this aspect should be given more attention.     

Psychosocial factors as risk for coronary heart disease--status with special reference to the KORA platform

Psychosocial factors derived from concepts in health psychology and psychopathology are subject of extensive research to assess their power to predict a future coronary artery disease event in apparently healthy subjects. However, bio-behavioural factors have not been implemented in current guidelines of scoring schemes for calculating the risk of coronary events. The presented data were derived from the population-based MONICA Augsburg studies (S1-S3) conducted between 1984 and 1995. The psychosocial data set was available in approximately 13,000 subjects. The KORA follow-up study assessed the vital status for all participants (except for 56 persons) in 1998. Until then, 772 participants (531 men, 241 women) had died. The depressive symptomatology was derived from the von Zerrssen affective symptom check list combining 24 single symptom items with scores ranging from 0 to 3. Risks of total mortality and myocardial infarction were estimated from Cox proportional hazard ratio (HR) models adjusted for age and survey and multiple risk factors. Male participants with high scores in depression exhibited a significantly increased risk in total mortality (adjusted HR: 1.55; 95 % CI: 1.28 - 1.83, p < 0.0001) and for fatal and non-fatal coronary events (adjusted HR: 1.36; 95 % CI: 1.02 - 1.81, p < 0.035). Female participants reported higher values in depression scores; however, depression was not predictive for subsequent total mortality and fatal and non-fatal events in females. Depression in men yielded a significant interaction with obesity and increased levels of C-reactive protein (CRP). The inclusion of psychosocial factors, as demonstrated for depression, is likely to improve prediction of future adverse cardiovascular and total mortality. These factors may also play a crucial role in genotype-phenotype interaction.     

Contemplating to quit current smoking status: differences in behavioural and psychosocial patterns in a population-based cohort of current smokers

BACKGROUND: Smokers actively considering to quit smoking were compared with hard-core smokers completely unwilling to change smoking habits with respect to psychosocial variables. METHODS: A total of 3,229 current regular smokers aged 25-74 years were drawn from three population-based MONICA/KORA Augsburg surveys conducted between 1984 and 1995. Among them, 592 (8.4%) subjects were defined as active contemplators (AC) and 776 (22.6%) as immotives (IM). Multivariate logistic regression analysis stratified by sex was used to identify active contemplators. RESULTS: No differences between ACs and IMs were observed for sex and age. Active contemplating in females was strongly mediated by impaired self-rated health [Odds ratio (OR) 2.29; 95% CI 1.42-3.69] and somatic complaints (OR 2.10; 95% CI 1.29-3.48). For men, depression (OR 2.49; 95% CI 1.64-3.79) and not living alone (OR 2.20, 95% CI 1.51-3.20) promoted being AC. Long-term survival was impaired for IM compared to AC. The odds ratio for smoking cessation of ACs compared to IMs was 1.77 (95% CI 1.25-2.50). CONCLUSIONS: Sex-specific differences in factors associated with the intention to quit smoking were observed and may lead to sex-specific targets in prevention strategy. IMs may be victims of a conceited healthy smoker effect triggered by the absence of disabling body or affective symptoms.     

KORA-gen--resource for population genetics, controls and a broad spectrum of disease phenotypes

KORA-gen is a resource for genetic epidemiological research, based on the KORA platform (Cooperative Health Research in the Region of Augsburg). Biosamples and phenotypic characteristics as well as environmental parameters of 18,000 adults from Augsburg and the surrounding counties are available. The age range of the participants was 25 to 74 years of recruitment and is 30 to 90 years in 2005. KORA-gen can be used by external partners. Interested parties can inform themselves interactively via internet about the available data and the rules of access. The genotypic data base is a common resource of all partners.     

The MONICA project. A WHO research project in cardiovascular diseases

The MONICA Project is an international research program coordinated by WHO. It aims at studying the relationships of simultaneous temporal variations during a 10-year period a) of a morbidity index (acute myocardial infarction) and of the risk factors levels and b) of mortality indexes (lethality of acute infarction and coronary mortality) and of the medical care level. The study of the relationships will take into account the temporal variations measured in the numerous centers participating in the Project. It uses the methodology of registers completed by population studies and studies among patient cohorts. The whole methodology is standardized by a permanent quality control. A French participation (MONICA-France Project) includes 3 registers (Bas-Rhin, Haute-Garonne, Lille) with a national coordination and an autonomous analysis. The MONICA Project must provide public health information and should suggest hypotheses, but it must also be a "tool for research".     

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.     

The diabetes epidemic in the elderly population in Western Europe: data from population-based studies

Valid epidemiologic data on type 2 diabetes in the elderly population are scarce in the European Region despite its enormous human and economic burden. The aim was to assess population-based data on type 2 diabetes and impaired glucose regulation (IGR) from surveys carried out in Western Europe since 1990 using oral glucose tolerance tests, and to discuss the possible impact of risk factors on geographic variation, in particular, obesity and physical activity. In the decade below 60 years of age, about 10 % of the population had known or newly diagnosed diabetes in European surveys. In the age group 70 to 79 years, average total diabetes prevalence was about one quarter. IGR prevalences also increased with age, reaching a maximum of 25 % (men) to 30 % (women) above 70 years of age. There was a wide variation of total diabetes prevalence in the elderly population in Western European countries, however, without clear geographical pattern. Whereas age- and sex-specific prevalences for total diabetes in the German KORA Survey S4 (1999/2001) (Augsburg) were comparable to the European average, IGR prevalences were higher in Augsburg (60-69 years: KORA: men: 30.2 %, women: 22.4 % Europe: men: 21.2 %, women: 19.0 %). Thus, there is a huge reservoir for future diabetes cases in the elderly population in Germany. Differences at the population level were found for obesity, nutrition, and sedentary lifestyle in Western Europe. Comparative studies on the predictive values of obesity, physical activity, and nutrition and possible interactions with genetic markers in European populations are of interest in the future.     

Association between domains of physical activity and all-cause,cardiovascular and cancer mortality

Few studies have investigated the independent effects of domain-specific physical activity on mortality. We sought to investigate the association of physical activity performed in different domains of daily living on all-cause, cardiovascular (CVD) and cancer mortality. Using a prospective cohort design, 4,672 men and women, aged 25–74 years, who participated in the baseline examination of the MONICA/KORA Augsburg Survey 1989/1990 were classified according to their activity level (no, light, moderate, vigorous). Domains of self-reported physical activity (work, transportation, household, leisure time) and total activity were assessed by the validated MOSPA (MONICA Optional Study on Physical Activity) questionnaire. After a median follow-up of 17.8 years, a total of 995 deaths occurred, with 452 from CVD and 326 from cancer. For all-cause mortality, hazard ratios and 95% confidence interval (HR, 95% CI) of the highly active versus the inactive reference group were 0.69 (0.48–1.00) for work, 0.48 (0.36–0.65) for leisure time, and 0.73 (0.59–0.90) for total activity after multivariable adjustments. Reduced risks of CVD mortality were observed for high levels of work (0.54, 0.31–0.93), household (0.80, 0.54–1.19), leisure time (0.50, 0.31–0.79) and total activity (0.75, 0.55–1.03). Leisure time (0.36, 0.23–0.59) and total activity (0.62, 0.43–0.88) were associated with reduced risks of cancer mortality. Light household activity was related to lower all-cause (0.82, 0.71–0.95) and CVD (0.72, 0.58–0.89) mortality. No clear effects were found for transportation activities. Our findings suggest that work, household, leisure time and total physical activity, but not transportation activity, may protect from premature mortality.     

The influence of depressive mood on activities of daily living and health care utilization in the elderly--the MEMO study on the KORA platform Augsburg

Depression has a high prevalence in the general population and is often found as a comorbid condition in patient population with specific diseases. Little is known about health care resource use and depression impact on the daily life of community dwelling elderly. We assessed the prevalence of depression among 380 participants of the Memory and Morbidity in Augsburg Elderly Study, performed in 1997/98, a follow up project of the 1989/90 Augsburg MONICA survey S2, and evaluated the association with activities of daily living and health care utilisation. The prevalence of depressive symptoms severe enough to classify for manifest depression was 10.4 %. Women were twice as often affected. Participants with depression had a 3-fold higher probability for general practioner visits during the preceeding 4 weeks and were 3 to 4-fold more likely to have restrictions in their daily activities. In this study depression is associated with strong impairments in the daily life and more physician contacts of those affected.     

Epidemiology in Germany—general development and personal experience

Did you ever hear about epidemiology in Germany? Starting from an epidemiological desert the discipline has grown remarkably, especially during the last 10–15 years: research institutes have been established, research funding has improved, multiple curriculae in Epidemiology and Public Health are offered. This increase has been quite steep, and now the epidemiological infrastructure is much better. Several medium-sized and even big population cohorts are ongoing, and the number and quality of publications from German epidemiologists has reached a respectable level. My own career in epidemiology started in the field of environmental health. After German reunification I concentrated for many years on environmental problems in East Germany and observed the health benefits after improvement of the situation. Later, I concentrated on population-based cohorts in newborns (GINI/LISA) and adults (KORA, German National Cohort), and on biobanking. This Essay describes the development in Germany after worldwar 2, illustrated by examples of research results and build-up of epidemiological infractructures worth mentioning.     

Switching sickness funds and risk compensation mechanisms in the statutory health insurance system in Germany--empirical results from the cooperative health research in the region of Augsburg (KORA)

Since 1996, all citizens of the Federal Republic of Germany who are insured in the statutory health insurance system are entitled to switch their sickness fund. The rationale of this regulation was to strengthen elements of competition in this system in order to stimulate the sickness funds to improve the efficiency of health care and to respond to consumers' preferences. Simultaneously, to avoid the implicit incentives for sickness funds to engage in risk selection, a risk compensation mechanism was introduced, including as morbidity-related risk adjusters age, sex and incapacity to work. Based on the KORA survey S4 (1999/2001) we take the case of switching behaviour in the region of Augsburg, and analyse whether this risk adjustment scheme was working effectively. The results show that persons changing their sickness fund were characterised by a comparatively smaller burden of chronic diseases and by a less frequent utilization of inpatient health care. Under these conditions, differences in the contribution rates do not accurately reflect differences in the performance and efficiency of sickness funds. Moreover, the migration of good risk to sickness funds with favourable contribution rates threatens the principle of financial solidarity. Therefore, the system of risk equalisation has to be developed towards measuring the risk volume borne by the sickness funds more precisely than hitherto.     

Increases in heart rate during an air pollution episode

This paper assesses whether air pollution increases resting heart rates in 2,681 men and women aged 25-64 years who participated in the MONICA (monitoring of trends and determinants in cardiovascular disease) Augsburg cohort. Increases in heart rate were observed during the air pollution episode in January 1985 compared with non-episode days adjusted for cardiovascular risk factors and meteorologic parameters. Consistently, heart rates were also elevated at high concentrations of sulfur dioxide, total suspended particulates, or carbon monoxide. Acceleration in heart rates indicates an altered autonomic control of the heart in association with air pollution, which may contribute to the observed health effects in association with air pollution.     

Social epidemiology: Definition,history, and research examples

Social epidemiology is a branch of epidemiology that focuses particularly on the effects of social-structural factors on states of health. Social epidemiology assumes that the distribution of advantages and disadvantages in a society reflects the distribution of health and disease. It proposes to identify societal characteristics that affect the pattern of disease and health distribution in a society and to understand its mechanisms. The central and initial question of social epidemiology to be answered is what effect do social factors have on individual and population health. However, the new focus on this theme using current epidemiological methods is a relatively recent phenomenon. There are several significant concepts in the field of social epidemiology: 1) the bio-psychosocial paradigm, 2) the population perspective, 3) use of new statistical approaches such as multilevel analysis, and 4) significance of theory. The relationship between social class and health has been a major research field since the beginning of public health history. Many studies have identified the disparities in health among social classes and developed several theories, such as social selection theory and socio-biological translation theory. However, despite the long history of this research field, the effect of social class on health is not yet fully understood. Income distribution and health is a relatively new field within social epidemiology. Three possible mechanisms for the consequences of income distribution on health are 1) disinvestment of human capital, 2) disinvestment of social capital, and 3) psychological process. Refining theories of income distribution is a major challenge in research on income distribution.