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Background While life expectancy (LE) is rising, years lived with severe health impairments especially due to chronic diseases also increase. Diabetes is one of the major chronic diseases with high potential for co-morbidity and premature deaths needing life-long care. Therefore, information about loss in LE and healthy life years (HLY) in people with diabetes compared to people without diabetes is essential for assessing the burden of diabetes. Methods Data on all-cause mortality rates for the general population of Germany in 2014 was drawn from the Federal Statistical Office; mortality rate ratios for people with diabetes compared to people without diabetes were based on claims data from about 70 million people covered by statutory health insurances in 2014. Data of three nationwide health telephone surveys conducted among adults in Germany 2009-2012 (n ∼ 60,000) were used to assess severe health impairments defined as self-reported limitations in daily activities due to diseases for at least six months in people with and without diabetes. Based on these figures, estimates on LE and HLY could be calculated by sex and 5-year age-groups for people with and without diabetes aged ≥ 30 years. Results In both sexes and in all 5-year age-groups, LE and HLY were substantially lower for people with than for people without diabetes. For example, among women in the age group 30-34 years, LE and HLY estimates were 48.0 and 36.4 years for those with diabetes compared to 54.9 and 47.6 years for those without diabetes; in men, these figures were estimated as 42.6 and 32.4 years for those with diabetes compared to 50.3 and 44.1 years for those without diabetes. Differences in LE and HLY between people with and without diabetes attenuated with increasing age. Conclusions The present study revealed substantial reductions in LE and HLY related to diabetes and underlines the importance of integrating both figures in a national diabetes surveillance. Key messages There are substantial differences in life expectancy and healthy life years between people with and without diabetes. Specific intervention and prevention activities should be implemented to tackle disability in persons with diabetes.

Background Patient-assessed quality of chronic illness care is important to guide medical care for patients with diabetes and other complex chronic diseases, but information from epidemiological studies is scarce. Thus, we examined self-assessed quality of care among adults with type 2 diabetes (T2D) based on a population-based design. Methods The study population was drawn from a nationwide survey on diabetes-related knowledge and information needs conducted in Germany in 2017 and included participants aged ≥18 years with known type 2 diabetes (T2D) in the last 12 months (n = 1,328). A German short version of the “Patient assessment of chronic illness care (PACIC-DSF)” consisting of 9 items based on 5-point Likert scale was applied to assess self-reported quality of care in diabetes which was operationalized by a standardized PACIC sum score ranging from 1 to 5. Linear regression with different stages of adjustment was applied to assess the association of basic characteristics and diabetes-related factors with the PACIC score. Results Quality of care was assessed less favorably by women than by men (PACIC score: 2.38 vs. 2.47) overall and decreased along with age. The PACIC score significantly increased in participants with insulin use (β = 0.16, p = 0.024), ever participating in a diabetes education program (β = 0.33, p Conclusions Self-assessed quality of care by adults with known T2D from this population-based study is moderate and seems lower compared to findings from clinical studies. Key messages An active involvement of people with type 2 diabetes into the implementation of care is essential and may contribute to improved self-perceived quality of care. To identify and overcome obstacles in diabetes care based on the patient’s perspective remains a public health challenge.

Background Non-communicable diseases (NCD) are a major public health challenge in Germany and throughout the world. The epidemiology of diabetes, in particular type 2 diabetes, exemplifies the need for effective prevention and control. To support policy making with actionable evidence, the Robert Koch Institute (RKI) is developing a diabetes surveillance system for Germany serving as model for NCD surveillance. Methods First, we consented a conceptual framework and key indicators among experts and stakeholders based on an extensive literature review including national and international NCD surveillance systems. After prioritization of indicators applying a two-step Delphi method, we identified data sources for sustainable surveillance including data from nationwide RKI health surveys as well as external data such as claims or registry data. Lastly, in cooperation with stakeholders we developed first dissemination products. Results During concept phase, we identified 40 indicators ranging from risk factors, disease incidence and prevalence to quality of care, mortality and burden of disease. During implementation, suitable data sources and results on temporal trends have been obtained for a large part of the indicators. For dissemination we developed a website with interactive visualization of results supported by an explainer video on YouTube. Additionally, we prepared a printed diabetes report summarizing and interpreting key findings for a broader audience, including health politicians and public health researchers. Conclusions We demonstrated the feasibility of the systematic collection and analysis of health data to describe the disease and care situation of diabetes in Germany. The methodology and data sources of indicators can be transferred to further NCDs and shared risk factors are already depicted. Next steps are to close remaining data gaps and to advance dissemination products in collaboration with our stakeholder network tailored to their information needs. Key messages Considering available health data, we showed the feasibility of implementing a diabetes surveillance system for Germany providing reliable information on disease dynamics for various stakeholders. The knowledge on methodology and data sources gained establishing a diabetes surveillance system can be extended to other noncommunicable diseases.

Background The Global Activity Limitation Indicator (GALI) is part of the Minimum European Health Module and has been shown to be a valid indicator of functional limitations. The present study aims to identify determinants of GALI prevalence among adults in Europe. Methods We used data from the European Health Interview Survey (EHIS) Wave 2 which included adults aged 15 years and older and was conducted between 2013 and 2015 in all European Union member states. We examined patterns regarding age, sex, education and chronic diseases. After excluding some inconsistencies in the data the sample size was 284,732 respondents from 26 countries. When making comparisons across countries one has to bear in mind that the data was collected through different modes, the indicators were obtained through various instruments and in some countries interviews were conducted not always with the target person, but with a proxy person. Results Our findings revealed that age and education are very strong determinants of functional limitation in all countries. Sex showed to be mostly non-significantly associated, however in some Eastern and Southern countries it plays a significant role. The additional factors examined showed less consistent picture. While chronic diseases with stronger disease burden were associated with higher limitation, diseases that are well treatable (like high blood pressure) showed in some countries strong associations with functional limitation while in others there was no clear relationship. Conclusions Having in mind the aging of the population, the problem with the functional limitation in higher ages will increase furthermore. This is an issue which should be taken into account in health promotion policies. The role of chronic diseases and their association with disability cannot be neglected. Prevention policies should put more effort in identifying earlier the vulnerable population (e.g. less educated) and promote health care initiatives. Key messages Age and education are strong determinants of functional limitation across all European countries. Sex showed inconsistent patterns. Functional limitation is in general strongly associated with chronic disease. However, differences in Europe were found with regard to some specific conditions.

Background Diabetes mellitus is a non-communicable disease with high public health relevance in Germany. Therefore, the Robert Koch Institute startetd to establish a national diabetes surveillance system in Germany in 2016. Essential part of a surveillance system is the dissemination of health information to the relevant stakeholders to facilitate its translation into action. Methods For the development of the dissemination strategy, different sources of information were used. First, an online-survey combined with structured web-research explored dissemination approaches in the international context. Secondly, a workshop with public health experts from seven countries highlighted best practice examples. Based on this information, a dissemination strategy was developed in close alignment with the scientific advisory board of the diabetes surveillance including experts from politics, prevention research, regional health reporting, physicians/diabetologists and public health scientists. Results Three main questions were identified to be considered in the dissemination of health information: Which audience group is addressed? Which content is relevant to this group? What is the preferred format to communicate the information? Therefore, a diabetes report will be generated focusing on health policy makers summarizing the key information on the disease dynamic. A website containing all information including a visualization tool should facilitate access for stakeholders. Additionally, awareness needs to be raised using social media, classical media and direct interactions with relevant stakeholders. Conclusions In alignment with different stakeholder groups, the diabetes surveillance developed a dissemination strategy considering international best practice examples and innovative ideas for health data visualization. The next steps are to refine the dissemination strategy based on feedback from the different stakeholder groups to ensure the use of the provided information. Key messages A dissemination strategy for the diabetes surveillance has been developed in a participatory approach including experts from various stakeholder groups. Next steps include the refinement of the dissemination strategy and its formats based on stakeholders feedback requirements.

Introduction Heavy cigarette smoking is more frequent in men than in women. So far, little is known whether this sex-specific difference in cigarette consumption is modified by age at smoking onset, sociodemographical, and lifestyle factors. Therefore, we aimed to identify sex-specific characteristics associated with heavy daily cigarette smoking. Methods The study population consisted of 3,178 daily smokers aged 25-74 years from the population-based MONICA/KORA Augsburg surveys conducted between 1984 and 1995. Subjects consuming at least 20 cigarettes daily were defined as heavy smokers. Multivariate logistic regression was used to identify sociodemographical, smoking-related, and lifestyle characteristics of heavy smokers. Results A number of 1,576 subjects (49.6%) were identified as heavy smokers. Men were significantly more often heavy smokers than women with the exception of those women who have started smoking at an early age. Multivariate logistic regression revealed early age at smoking onset determines heavy smoking in women but not in men. While younger age at study examination and low educational level was associated with heavy smoking in men only, current employment was associated with heavy smoking in women only. Moreover, living alone, high alcohol or coffee consumption, and low physical leisure activity were associated with heavy smoking behavior in both sexes. Survey, obesity and parental history of smoking showed no association with heavy smoking. Conclusions The present study revealed sex-specific differences in heavy smoking by age at smoking onset, which was not shown before so far. These findings should be further investigated and addressed in future prevention campaigns.

Background: Among the numerous emerging biomarkers, high-sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) have received widespread interest, and a large database has been accumulated on their potential role as predictors of cardiovascular risk. The concentrations of inflammatory biomarkers, however, are influenced, among other things, by physiological variation, which is the natural within-individual variation occurring over time. Implementation of hsCRP and IL-6 measurement into clinical practice requires data on the reliability of such measurements. Methods: We serially measured hsCRP and IL-6 concentrations in up to 6 blood samples taken at monthly intervals from 200 post–myocardial infarction patients who participated in the AIRGENE study. Results: The mean (SD) of the ln-transformed plasma concentrations (in milligrams per liter for hsCRP and nanograms per liter for IL-6) for all participants over all samples was 0.16 (1.04) for hsCRP and 0.76 (0.57) for IL-6, with no significant differences between men and women. The within-individual and analytical variance component for the ln-transformed hsCRP data was 0.37, and the between-individual variance component was 0.73. For the ln-transformed IL-6 data, these values were 0.11 and 0.22, respectively. A substantial part of the total variation in plasma hsCRP and IL-6 concentrations was explained by the between-individual variation (as a percentage of the total variance, 66.1% for the ln-transformed hsCRP data and 66.2% for the ln-transformed IL-6 data). For both markers, 2 measurements were needed to reach a sufficient reliability. Conclusions: Our results demonstrate considerable stability and good reproducibility for serial hsCRP and IL-6 measurements. Thus, there should be no major concern about misclassification in clinical practice if at least 2 subsequent measurements are taken.

Background: An increased plasma concentration of the endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine (ADMA) predicts adverse clinical outcome in patients with coronary heart disease. We investigated the association between plasma concentrations of ADMA and risk in initially healthy smoking and nonsmoking men.Methods: Participants for this nested case-control study came from the population-based Monitoring of Trends and Determinants in Cardiovascular Disease/Kooperative Gesundheitsforschung in der Region Augsburg study. ADMA was measured by liquid chromatography–tandem mass spectrometry in 88 men with incident coronary events (fatal and nonfatal myocardial infarction and sudden cardiac death) and 254 age-matched controls, with a median (interquartile range) follow-up of 6.2 (3.3–7.9) years.Results: After adjustment for potential confounders, the relative risk for a future coronary event was 2.00 [95% confidence interval (CI) 1.27–3.16; P = 0.003] for smokers compared with nonsmokers and 1.35 (95% CI 0.78–2.33; P = 0.282) for the top vs the bottom tertile of the ADMA distribution. In cases and controls, lower ADMA plasma concentrations were observed in smokers. Analysis of ADMA-associated risk in smokers and nonsmokers separately revealed substantial differences: the adjusted relative risk for future coronary events (top vs bottom tertile of the ADMA distribution) was 0.48 (95% CI 0.16–1.46; P = 0.198) in smokers and 2.40 (95% CI 1.14–5.08; P = 0.021) in nonsmokers. Exposure of human endothelium-derived EAhy 926 cells to tobacco smoke enhanced expression of the ADMA metabolizing enzyme dimethylarginine dimethylaminohydrolase 2 and reduced ADMA concentration.Conclusions: In apparently healthy men, increased ADMA predicts the risk for coronary events in nonsmokers, but not in smokers. This may be explained in part by an alteration of ADMA metabolism by tobacco smoke.

Background: Railway suicides strongly impact psychological and socioeconomic aspects of the railway company, its employees and possible eye witnesses. We aimed to assess the incidence of railway suicides compared with the total burden of suicides in Germany and its time trend over a 10-year observation period. Methods: From 1991 to 2000, a total of 8653 fatal railway suicides were recorded by the national central registry of all passenger accidents on the German railway net. To assess time trends, the average annual percentage change (AAPC) of the number of suicides was estimated using Poisson regression. Adjustments were made for two age groups and measures of availability. Results: Railway suicides accounted for 7.0% (annual range 5.0–7.9%) of all suicides in Germany. The time trend of the number of suicides by all means declined, with a significant stronger decline for older subjects [AAPC −2.2; 95% confidence intercal (CI) −3.0 to −1.5; and −4.2; 95% CI −5.2 to −3.0]. An AAPC of 1.8% (95% CI 0.1–3.4) indicated an increasing time trend of the number of railway suicides for subjects aged ≤65 years, whereas, in contrast, fatal incidences for subjects aged >65 years exhibited a strong decrease (AAPC −6.2%; 95% CI −10.9 to −1.3). Conclusions: The present study demonstrates different time trends for railway suicides compared with all suicides. It underlines the urgent need for amplified research efforts in the particular field of railway suicides. Further examinations are recommended, in particular concerning possible reasons for this suicidal method.

Background In several studies an increased risk for development of breast cancer, malignant lymphoma and neoplasms of the kidney as second primary cancers in patients with cutaneous melanomas was discussed. Objectives To determine the risk for development of second primary neoplasms in patients with cutaneous melanomas. Methods A prospective study was performed between 1977 and 1992 to evaluate the occurrence of second primary malignancies in 4597 patients (2083 men, 2514 women) with invasive cutaneous melanomas, diagnosed and treated at the Department of Dermatology and Allergology, Ludwig-Maximilians-University, Munich, Germany. Results During a median follow-up of 7·2 years, 296 of 4597 patients (6·4%) developed one or more neoplasms at the time of or subsequent to the diagnosis of the first cutaneous melanoma. More than half of these patients developed one or more further melanomas (152, 3·3%). Cancers of the breast, prostate, colon, rectum and kidney occurred less frequently. Statistical calculations revealed a 33·8-fold increased risk for the development of a second melanoma in the entire group [relative risk 38·5 for men (95% CI, 30·4–48·1), 29·0 for women (95% CI, 22·0–37·5)]. Moreover, a significantly increased risk for the development of kidney carcinoma in men was found [relative risk 3·5 (95% CI, 1·4–7·2)]. Conclusions Thorough follow-up and skin examination in patients with cutaneous melanomas is recommended for early detection of other primary melanomas. Furthermore, ultrasound examinations routinely performed in melanoma patients for the detection of melanoma metastases may also be of value for early detection of kidney carcinomas in male patients.