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People who have diabetes require regular medical care. The views of patients about the quality of their care are becoming increasingly relevant when it comes to chronic diseases such as diabetes. As part of the nationwide study Disease Knowledge and Information Needs - Diabetes mellitus (2017), data on self-assessed quality of care by people with diagnosed diabetes was collected using the Patient Assessment of Chronic Illness Care - DAWN short form (PACIC-DSF, scale 1 to 5) and analysed for respondents aged 45 years or above. The average score for quality of care was 2.47 and was lower for women than for men (2.33 vs 2.58). The respondents assessed the quality of their care as being worse with rising age and size of the population in their residential area. No significant differences were observed by education group. Overall, people with diabetes in Germany consider the quality of their care to be moderate, which indicates a need for improvement in care.

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.

IntroductionTo identify characteristics of people with undiagnosed type 2 diabetes (T2D) among adults in Germany.Research design and methodsThe study population comprised participants aged 40–79 years of the German Health Interview and Examination Survey for Adults 2008–2011. Glycemic status was categorized as undiagnosed T2D (glycated hemoglobin A1c (HbA1c) ≥48 mmol/mol (6.5%), n=135), diagnosed T2D (n=518) and normoglycemia (HbA1cResultsThe prevalence of undiagnosed T2D was 2.9% (95% CI 2.2% to 3.9%) at an overall prevalence of 12.3% (11.0% to 13.6%) of persons with undiagnosed or diagnosed T2D. In multivariable analyses, factors associated with undiagnosed as well as diagnosed T2D in comparison to normoglycemia were older age (OR 1.04, 95% CI 1.01 to 1.06, per year, for undiagnosed T2D; OR 1.08, 1.07 to 1.10 for diagnosed T2D), male sex (3.33, 2.18 to 5.07; 1.91, 1.43 to 2.56), obesity (3.47, 2.17 to 5.56; 2.68, 2.04 to 3.52), hypertension (1.66, 1.09 to 2.53; 2.04, 1.42 to 2.95) and parental history of diabetes (2.04, 1.24 to 3.35; 3.16, 2.30 to 4.34). Variables independently associated with undiagnosed T2D but not diagnosed T2D included living alone (2.20; 1.36 to 3.56) and not seeing a doctor within the past year (2.57; 1.34 to 4.93). People with undiagnosed T2D were further younger and more likely to be male sex and reside in the western part of Germany than people with diagnosed T2D.ConclusionApart from major known risk factors of diabetes, characteristics specific to undiagnosed diabetes among adults in Germany will serve to inform the national education and communication strategy on diabetes mellitus in Germany.

Diabetes mellitus ist eine nichtubertragbare Krankheit von hoher Public-Health-Relevanz. In Deutschland verfugbare Daten werden bislang nicht ausreichend fur eine zielorientierte Analyse und Bereitstellung von Ergebnissen genutzt. Ziel ist der Aufbau einer nationalen Diabetes-Surveillance am Robert Koch-Institut (RKI). Erarbeitet wird ein wissenschaftliches Rahmenkonzept mit 4 Handlungsfeldern und 40 Indikatoren auf Basis von Literaturreviews und strukturiertem Expertenkonsens. Es erfolgt eine Bestandsaufnahme zu verfugbaren Datenquellen und nachhaltiger Nutzbarkeit zur Abbildung der Indikatoren nach soziodemografischen Kriterien, zeitlichen Veranderungen und regionalen Unterschieden. Handlungsfeld 1 umfasst 10 Indikatoren zur Primarpravention von Diabetes. Die Handlungsfelder 2 bis 4 enthalten 30 Prozess- und Ergebnisindikatoren zur Sekundarpravention von Diabetes. Essenzielle Datenquellen sind bundesweite RKI-Gesundheitssurveys, Abrechnungs‑/Versorgungsdaten, amtliche Statistiken und Typ-1-Diabetes-Register. Erste Analysen zeigen eine Verbesserung in Prozessen und Ergebnissen. Bei patientennahen Indikatoren weisen die Ergebnisse auf Verbesserungspotenziale hin. Verbleibende Datenlucken und Nutzungsbarrieren bestehen bezuglich des Gestationsdiabetes und diabetesassoziierter Komplikationen. Analysen zu sozialen und regionalen Unterschieden sind bislang nicht uberall moglich. Die Diabetes-Surveillance ermoglicht systematische und fortlaufende Analysen zur Epidemiologie und Krankheitslast von Diabetes in Deutschland und kann als Entscheidungshilfe fur die Planung und Umsetzung von Masnahmen dienen. Datengrundlagen sowie Print- und Online-Produkte fur eine zeitnahe und adressatengerechte Ergebnisdarstellung mussen kontinuierlich weiterentwickelt werden.

ObjectiveWhether participation in structured diabetes self-management education programs (DSME) for participants with diabetes mellitus is associated with a healthy lifestyle in routine care apart from randomized-controlled studies remains unclear and is this studies’ research question.Research design and methodsWe identified 1300 persons with diabetes mellitus drawn from the cross-sectional population-based analysis German Health Update 2014/2015 (GEDA 2014/2015), which integrated the modules of the European Health Interview Survey (EHIS) wave 2. Of those, 816 were ever-DSME participants and 484 never-participants. We conducted multivariable weighted logistic regression analyses for lifestyle differences comparing ever-DSME and never-DSME participants. Lifestyle was defined by physical activity (PA), current smoking, fruit/vegetable consumption and body mass index (BMI). Age, sex, socioeconomic status, living together, limitation due to health problems for at least for 6 months, self-efficacy and attention to one’s health were included as confounders in the regression models.ResultsEver-DSME participants engaged significantly more often in cycling at least 1 day per week (OR 1.62, 95% CI: 1.15–2.30) and performed significantly more often aerobic endurance training of 150 min per week (including walking: OR 1.42, 95% CI: 1.03–1.94, without walking: OR 1.48, 95% CI: 1.08–2.03) compared with never-DSME participants. Ever-DSME participants were significantly more often ex-smoker compared with never-DSME participants (OR 1.39, 95% CI: 1.03–1.88). DSME attendance was not significantly associated with current smoking, BMI and fruit or vegetable consumption.ConclusionDSME participation is associated with a moderately healthier lifestyle particularly for PA even in routine healthcare. Study results emphasize the importance of a broadly dissemination of DSME access for nationwide diabetes healthcare. Future studies should adjust for DSME participation when investigating lifestyle in persons with diabetes.

Diabetes mellitus and other noncommunicable diseases (NCDs) represent an emerging global public health challenge. In Germany, about 6.7 million adults are affected by diabetes according to national health surveys, including 1.3 million with undiagnosed diabetes. Complications of diabetes result in an increasing burden for individuals and society as well as enormous costs for the health care system. In response, the Federal Ministry of Health commissioned the Robert Koch Institute (RKI) to implement a diabetes surveillance system and the Federal Center for Health Education (BZgA) to develop a diabetes prevention strategy. In a two-day workshop jointly organized by the RKI and the BZgA, representatives from public health institutes in seven countries shared their expertise and knowledge on diabetes prevention and surveillance. Day one focused on NCD surveillance systems and emphasized both the strengthening of sustainable data sources and the timely and targeted dissemination of results using innovative formats. The second day focused on diabetes prevention strategies and highlighted the importance of involving all relevant stakeholders in the development process to facilitate its acceptance and implementation. Furthermore, the effective translation of prevention measures into real-world settings requires data from surveillance systems to identify high-risk groups and evaluate the effect of measures at the population level based on analyses of time trends in risk factors and disease outcomes. Overall, the workshop highlighted the close link between diabetes prevention strategies and surveillance systems. It was generally stated that only robust data enables effective prevention measures to encounter the increasing burden from diabetes and other NCDs.

Zusammenfassung Hintergrund und Ziele Seit Jahren steigt die Prävalenz des Diabetes mellitus (DM) an. Aufgrund des Krankheitsbildes wird mit steigender Bedeutung rehabilitativer Leistungen gerechnet. In diesem Beitrag wird die Inanspruchnahme medizinischer Rehabilitation von 2006 bis 2013 untersucht. Methodik Die Sekundärdatenanalyse basiert auf einem scientific use file. DM wird gemäß ICD-10 (E10-E14) definiert. Die Verläufe werden roh, altersstandardisiert und stratifiziert nach Alter und Geschlecht dargestellt. Die Inanspruchnahmen und Prävalenzen pro Bundesland werden korreliert. Ergebnisse Die standardisierte Inanspruchnahme stieg von 2006 bis 2013 bei Männern von 170 auf 204,4 und Frauen von 99 auf 123,6 je 100 000. Während sie bei unter 60-Jährigen rückläufig ist, stieg sie in der Altersgruppe der 60–64-Jährigen um zirka 80%. Die Inanspruchnahme korreliert positiv (r=0,64) mit der bevölkerungsbezogenen Prävalenz. Schlussfolgerung Aufgrund des zunehmend späteren Renteneintritts wächst die Bedeutung rehabilitativer Leistungen bei Personen mit DM.

Unzureichend behandelt kann die Stoffwechselerkrankung Diabetes mellitus zu schwerwiegenden Folgeerkrankungen fuhren. Nationale und internationale Analysen zeigen einen kontinuierlichen Anstieg der Diabetespravalenz uber die letzten Jahre. Am Robert Koch-Institut (RKI) wird derzeit eine Nationale Diabetes-Surveillance aufgebaut, die das Diabetesgeschehen indikatorenbasiert unter Nutzung von Primar- und Sekundardaten kontinuierlich abbilden soll. Ziel des Bund-Lander-Gesprachs war es, die Bundeslander fruhzeitig in die Konzeption der Diabetes-Surveillance einzubinden und die Bedarfe der Gesundheitsberichterstattung (GBE) der Lander zu berucksichtigen. Das RKI lud alle Vertreter der Lander-GBE zu einem Gesprach nach Berlin ein. Dies war bereits das zweite Bund-Lander-Gesprach im Rahmen der Diabetes-Surveillance. Ein kontinuierlicher Austausch in Form regelmasiger Bund-Lander-Gesprache wird angestrebt.

Epidemiologische Daten belegen, dass Diabetes mellitus in Deutschland wie in vielen anderen Landern eine hohe Public-health-Relevanz hat. Am Robert Koch-Institut (RKI) wird derzeit eine Nationale Diabetes-Surveillance aufgebaut, die das Diabetesgeschehen indikatorenbasiert unter Nutzung von Primar- und Sekundardaten kontinuierlich abbilden soll. Ziel des Workshops war es, eine Bestandsaufnahme verfugbarer Sekundardatenquellen vorzunehmen und Dateninhalte, Datenzugange, Analysebeispiele sowie Moglichkeiten einer verstetigten Nutzung fur die Diabetes-Surveillance zu diskutieren.

Background The role of an individual’s social network satisfaction (SNS) in the association of social isolation or living alone and incident type 2 diabetes (T2D) is unclear. We assessed the association of SNS with incident T2D and analysed potential modifications of the SNS-T2D association by social isolation or living alone. Methods The study population (N = 6839 aged 25–74 years without diabetes at baseline) derived from the prospective population-based MONICA/KORA study (1989–2009). Social network satisfaction was assessed by a single item. Cox regression was used to estimate hazard ratios (HR) for SNS separately in men and women. Results In men with low SNS, risk for incident T2D increased significantly (HR: 2.15, 95% CI: 1.33–3.48, p value 0.002). After additional adjustments for social isolation or living alone, the risk for incident T2D was still significant, albeit less pronounced (HRs 1.85 or 2.05, p values 0.001 or 0.004). The interaction analysis showed an increased T2D risk effect for low SNS compared to high SNS in women living in a partnership (HR: 2.11, 95% CI: 1.00–4.44, p value for interaction: 0.047) and for moderate SNS compared to high SNS in socially connected women (1.56, 1.01–2.39, 0.010). Conclusions Further research is needed to address the complexities of the perception of social relationships and social interactions, or interdependence, especially when another major public health issue such as T2D is concerned. Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4323-7) contains supplementary material, which is available to authorized users.

ZusammenfassungBei der Versorgung von Personen mit Diabetes mellitus im erwerbsfähigen Alter können rehabilitative Maßnahmen die Behandlung stärken. In der Richtlinie des Disease-Management-Programms (DMP) für Typ-2-Diabetes (T2D) wird diese Behandlungsoption ausdrücklich benannt. Mit Forschungsdaten der Rentenversicherung wird gezeigt, dass bei Rehabilitanden mit T2D und DMP-Einschreibung die Chance auf eine spätere Erwerbsminderungsrente unabhängig von relevanten Kovariablen um 23% niedriger liegt als ohne DMP-Einschreibung.

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.

The connection between social disadvantage and the presence of known diabetes and specific risk factors is well documented. This article summarises the results from the Robert Koch Institute examination surveys that were conducted between 1997 and 1999 as well as 2008 and 2011 to address social inequality – operationalised by level of education – with regard to prevalences of known and unknown diabetes, risk of diabetes and care of diabetes as well as their development over time. Both survey periods showed that the low education group has higher prevalences of known and unkown diabetes as well as a higher risk of developing diabetes within the next five years compared to the medium and high education group. Over time, prevalence tended to increase for known diabetes and to decrease for unknown diabetes for all education groups. For the 5-year diabetes risk, only the high education group showed a clear decrease over time. The chosen indicators of diabetes care indicated no clear differences between education groups and an improvement of diabetes care over time. For some indicators of care (foot examination, statins), improvements were only seen in the low education group. In conclusion, social inequalities in the prevalence of known and unknown diabetes as well as in diabetes risk remain in Germany; for the indicators of care, however, no clear education gradient is evident. Over time, inequality regarding the prevalence of diabetes has not increased further. However, with regard to diabetes risk, inequality has become slightly more evident. For individual care indicators, improvements are limited to specific education groups.

BACKGROUND Evidence suggests that mobile health app use is beneficial for the prevention and management of type 2 diabetes (T2D) and its associated complications; however, population-based research on specific determinants of health app use in people with and without T2D is scarce. OBJECTIVE This cross-sectional study aimed to provide population-based evidence on rates and determinants of health app use among adults with and without T2D, thereby covering a prevention perspective and a diabetes management perspective, respectively. METHODS The study population included 2327 adults without a known diabetes diagnosis and 1149 adults with known T2D from a nationwide telephone survey in Germany conducted in 2017. Rates of smartphone ownership and health app use were estimated based on weighted sample proportions. Among smartphone owners, determinants of health app use were identified for both groups separately in multivariable logistic regression models. Sociodemographic factors, diabetes-related factors or indicators, psychological and health-related factors, and physician-provided information were selected as potential determinants. RESULTS Among participants without known diabetes, 74.72% (1690/2327) were smartphone owners. Of those, 49.27% (717/1690) used health apps, most often to improve regular physical activity. Among participants with T2D, 42.26% (481/1149) were smartphone owners. Of those, 41.1% (171/481) used health apps, most commonly to target a healthy diet. Among people without known diabetes, determinants significantly (all P values PP=.004, respectively), overweight or obesity (ORs 1.58; PPP=.045), former or current smoking (ORs 1.51; P=.002 and 1.58; PPP=.002), and having received health advice from a physician (OR 1.48; PP=.04 and 0.23; PP=.007), female gender (OR 1.61; P=.02), and using a glucose sensor in addition or instead of a glucose meter (OR 2.74; P=.04) were significantly positively associated with health app use. CONCLUSIONS In terms of T2D prevention, age, diabetes-related risk factors, psychological and health-related factors, and medical health advice may inform app development for specific target groups. In addition, health professionals may encourage health app use when giving advice on health behaviors. Concerning T2D management, only a few determinants seem relevant for explaining health app use among people with T2D, indicating a need for more future research on which people with T2D use health apps and why.

Background High-sensitivity C-reactive protein (hsCRP) is a sensitive biomarker of systemic inflammation and is related to the development and progression of cardiometabolic diseases. Beyond individual-level determinants, characteristics of the residential physical and social environment are increasingly recognized as contextual determinants of systemic inflammation and cardiometabolic risks. Based on a large nationwide sample of adults in Germany, we analyzed the cross-sectional association of hsCRP with residential environment characteristics. We specifically asked whether these associations are observed independent of determinants at the individual level. Methods Data on serum hsCRP levels and individual sociodemographic, behavioral, and anthropometric characteristics were available from the German Health Interview and Examination Survey for Adults (2008–2011). Area-level variables included, firstly, the predefined German Index of Socioeconomic Deprivation (GISD) derived from the INKAR (indicators and maps on spatial and urban development in Germany and Europe) database and, secondly, population-weighted annual average concentration of particulate matter (PM10) in ambient air provided by the German Environment Agency. Associations with log-transformed hsCRP levels were analyzed using random-intercept multi-level linear regression models including 6,768 participants aged 18–79 years nested in 162 municipalities. Results No statistically significant association of PM10 exposure with hsCRP was observed. However, adults residing in municipalities with high compared to those with low social deprivation showed significantly elevated hsCRP levels (change in geometric mean 13.5%, 95%CI 3.2%-24.7%) after adjusting for age and sex. The observed relationship was independent of individual-level educational status. Further adjustment for smoking, sports activity, and abdominal obesity appeared to markedly reduce the association between area-level social deprivation and hsCRP, whereas all individual-level variables contributed significantly to the model. Conclusions Area-level social deprivation is associated with higher systemic inflammation and the potentially mediating role of modifiable risk factors needs further elucidation. Identifying and assessing the source-specific harmful components of ambient air pollution in population-based studies remains challenging.

BACKGROUND Epidemiological studies show that high circulating cystatin C is associated with risk of cardiovascular disease (CVD), independent of creatinine-based renal function measurements. It is unclear whether this relationship is causal, arises from residual confounding, and/or is a consequence of reverse causation. OBJECTIVES The aim of this study was to use Mendelian randomization to investigate whether cystatin C is causally related to CVD in the general population. METHODS We incorporated participant data from 16 prospective cohorts (n = 76,481) with 37,126 measures of cystatin C and added genetic data from 43 studies (n = 252,216) with 63,292 CVD events. We used the common variant rs911119 in CST3 as an instrumental variable to investigate the causal role of cystatin C in CVD, including coronary heart disease, ischemic stroke, and heart failure. RESULTS Cystatin C concentrations were associated with CVD risk after adjusting for age, sex, and traditional risk factors (relative risk: 1.82 per doubling of cystatin C; 95% confidence interval [CI]: 1.56 to 2.13; p = 2.12 x 10(-14)). The minor allele of rs911119 was associated with decreased serum cystatin C (6.13% per allele; 95% CI: 5.75 to 6.50; p = 5.95 x 10(-211)), explaining 2.8% of the observed variation in cystatin C. Mendelian randomization analysis did not provide evidence fora causal role of cystatin C, with a causal relative risk for CVD of 1.00 per doubling cystatin C (95% CI: 0.82 to 1.22; p = 0,994), which was statistically different from the observational estimate (p = 1.6 x 10(-5)). A causal effect of cystatin C was not detected for any individual component of CVD. CONCLUSIONS Mendelian randomization analyses did not support a causal role of cystatin C in the etiology of CVD. As such, therapeutics targeted at lowering circulating cystatin C are unlikely to be effective in preventing CVD. (C) 2016 The Authors. Published by Elsevier Inc. on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license.

OBJECTIVE: This study aimed to examine prospectively the influence of exposure to job insecurity during working life on subjective well-being (SWB) after retirement, an association which has not been studied to date. METHOD: Data were derived from the prospective population-based MONICA/KORA study conducted in southern Germany. Participants were recruited and data were collected during three independent surveys between 1984-1995 (T1) and followed up in 2009 (T2). The study sample consisted of 1801 employed participants (1146 male/ 655 female) aged 41-72 years at T1 and ≥65 years at T2, without missing data. Self-administered questionnaires and clinical examinations were used to assess job insecurity and risk factors at T1 and SWB at T2. Mean follow-up was 19.6 years. Logistic regression analyses were performed to determine the association of job insecurity with SWB after retirement. We accounted for an extensive set of sociodemographic, lifestyle-, health- and work-related risk factors. RESULTS: At T1, 39.5% of the participants reported job insecurity, which was associated with a 1.40-fold [95% confidence interval (95% CI) 1.08-1.82] risk of low SWB at T2 in models adjusted for sociodemographic and lifestyle- and health-related conditions at T1. Additional adjustment for a set of work-related risk factors at T1 had little effect on this association. CONCLUSIONS: Exposure to job insecurity at midlife was associated with low SWB in retirement, even after controlling for an extensive set of risk factors. This shows that the negative effects of unstable working conditions might persist well into retirement, long after cessation of employment.

Arbeitsbedingte Stressoren wirken sich auf die Gesundheit von Arbeitnehmern aus. Arbeitsunsicherheit, die Ungewissheit in Bezug auf einen unfreiwilligen Arbeitsplatzverlust (quantitative Arbeitsunsicherheit) oder einer unfreiwilligen Veranderung der Arbeitsbedingungen (qualitative Arbeitsunsicherheit) gilt als ein solcher arbeitsbedingter Stressor. Durch die Zunahme an befristeten Arbeitsverhaltnissen und eine wachsende Zahl an Veranderungen innerhalb von Organisationen wachst auch die Zahl der verunsicherten Arbeitnehmer. In einer Befragung zu Arbeitsbedingungen in der Europaischen Union aus dem Jahr 2010 berichteten 16 % der Befragten Arbeitsunsicherheit. Eine Fulle an empirischen Arbeiten hat einen Zusammenhang zwischen Arbeitsunsicherheit und seelischer (z. B. Depression) sowie korperlicher (z. B. koronare Herzerkrankungen) Gesundheit festgestellt. Bislang fehlen jedoch erprobte Interventionsansatze zur Reduktion von Arbeitsunsicherheit und deren gesundheitlichen Folgen. Neben Grundlagen zu Arbeitsunsicherheit werden hier mogliche Ansatzpunkte der Verhaltnis- und Verhaltenspravention, sowie moderierende Faktoren in der Beziehung zwischen Arbeitsunsicherheit und Gesundheit, dargelegt.

Der Suizid ist ein multifaktorielles Geschehen, zu dem auch aversive Bedingungen am Arbeitsplatz sowie eine hohe berufliche Belastung beitragen konnen. Im Allgemeinen geht man davon aus, dass Berufsgruppen mit leichtem Zugang zu Suizidmitteln (Medikamente, Waffen) einerseits und einem hohen Stressfaktor andererseits ein besonders hohes Risiko fur Suizid haben. Insbesondere medizinische Berufe, waffentragende Berufe (Polizei, Militar), Banker sowie Land- und Forstwirte haben im Vergleich zur Allgemeinbevolkerung ein erhohtes Suizidrisiko. Suizidpraventionsprogramme am Arbeitsplatz bestehen hauptsachlich aus Ausbildung und Training des einzelnen Mitarbeiters wie auch der Fuhrungsebene, um das Wissen uber Suizid und dessen Risikofaktoren zu vertiefen, dem Unterstutzen eines sozialen Netzwerkes unter den Angestellten, der Kooperation von internen und externen Ressourcen, z. B. durch enge Zusammenarbeit zwischen Betriebsarzten, Allgemeinarzten und/oder Spezialisten, Screening nach und Hilfsangebote fur Risikopersonen sowie dem Erschweren des Zugangs zu Suizidmitteln. Es bedarf weiterer Forschung, um berufsspezifische Risikofaktoren zu verstehen und Programme zu entwickeln, die in die Arbeitswelt integriert werden konnten.

Menschen sind in ihrer Arbeitsumgebung vielfältigen Belastungen ausgesetzt, die auch Gesundheitsrisiken einschließen. Zu den aversiven psychosozialen Arbeitsplatzbedingungen, die als KHK-Risikofaktoren qualifizieren, gehören Arbeitsstress, Arbeitsplatzunsicherheit, Arbeitsplatzverlust und Überforderung durch Mehrarbeit und Überstunden. Zu den zentralen psycho-neurophysiologischen Vermittlungswegen, über die aversive Stressbedingungen am Arbeitsplatz zu pathologischen Veränderungen im Körper führen, zählen das autonome, das endokrine und das immunologische System. Aversive Synergismen durch Akkumulation weiterer psychosozialer Risikofaktoren (wie andauernde familiäre Konflikte) sind wahrscheinlich. Psychosoziale berufliche Belastungsfaktoren sollten in die Anamnese berufstätiger Patienten einbezogen werden. Eine Therapie zielt auf eine Förderung von personalen Bewältigungsressourcen.

Significance Diseases of the aging are the leading cause of morbidity and mortality. Elucidating the molecular mechanisms through which modifiable factors, such as psychosocial stress, confer risk for aging-related disease can have profound implications. By combining studies in humans with experiments in cells, we show that aging and stress synergize to epigenetically upregulate FKBP5, a protein implicated in stress physiology. Higher FKBP5 promotes inflammation by activating the master immune regulator NF-κB, whereas opposing FKBP5, either genetically or pharmacologically, prevents the effects on NF-κB. Further, the aging/stress-related epigenetic signature of FKBP5 is associated with history of myocardial infarction, a disease linked to inflammation. These findings provide molecular insights into stress-related disease, pointing to biomarker and treatment possibilities., Aging and psychosocial stress are associated with increased inflammation and disease risk, but the underlying molecular mechanisms are unclear. Because both aging and stress are also associated with lasting epigenetic changes, a plausible hypothesis is that stress along the lifespan could confer disease risk through epigenetic effects on molecules involved in inflammatory processes. Here, by combining large-scale analyses in human cohorts with experiments in cells, we report that FKBP5, a protein implicated in stress physiology, contributes to these relations. Across independent human cohorts (total n > 3,000), aging synergized with stress-related phenotypes, measured with childhood trauma and major depression questionnaires, to epigenetically up-regulate FKBP5 expression. These age/stress-related epigenetic effects were recapitulated in a cellular model of replicative senescence, whereby we exposed replicating human fibroblasts to stress (glucocorticoid) hormones. Unbiased genome-wide analyses in human blood linked higher FKBP5 mRNA with a proinflammatory profile and altered NF-κB–related gene networks. Accordingly, experiments in immune cells showed that higher FKBP5 promotes inflammation by strengthening the interactions of NF-κB regulatory kinases, whereas opposing FKBP5 either by genetic deletion (CRISPR/Cas9-mediated) or selective pharmacological inhibition prevented the effects on NF-κB. Further, the age/stress-related epigenetic signature enhanced FKBP5 response to NF-κB through a positive feedback loop and was present in individuals with a history of acute myocardial infarction, a disease state linked to peripheral inflammation. These findings suggest that aging/stress-driven FKBP5–NF-κB signaling mediates inflammation, potentially contributing to cardiovascular risk, and may thus point to novel biomarker and treatment possibilities.

Background There is evidence for a seasonal pattern of suicides with peaks in spring and early summer; however, only a limited number of studies has investigated whether daily changes in meteorological variables may trigger suicides. Methods Daily fatal suicide (N = 10,595) and meteorological data were available for four Bavarian cities and ten counties (Germany) for 1990–2006. City/county-specific immediate, delayed and cumulative effects of air temperature, sunshine duration, and cloud cover on suicides were analyzed using a time-stratified case-crossover approach; city/county-specific effects were then combined using random effects meta-analysis. Potential effect modifiers were specific weather conditions, personal or regional characteristics, and season. Results A 5 °C increase in air temperature on the day before a suicide compared to the control days was associated with a 5.7% (95% confidence interval (CI): 0.6; 11.0) higher suicide risk. Further, the suicide risk was 6.5% (95% CI: 0.2; 13.3) higher on days with low/medium cloud cover (0–6 oktas) compared to days with high cloud cover (7–8 oktas). While daily changes in temperature were not associated with suicides in spring, we found a higher suicide risk in summer, autumn, and winter in association with temperature increases. The effects of cloud cover were strongest in summer and autumn and on days with temperature above the median (>8.8 °C). Sunshine duration was not associated with suicides. Conclusion We found a higher risk for suicides in association with short-term increases in air temperature on the day before the event compared to the control days and on days with low to medium cloud cover. This may highlight times when people are more likely to commit suicide.

Background Random glucose is widely measured in epidemiological studies and in the clinical setting when standardized fasting protocols and oral glucose tolerance testing or HbA1c measuring are not feasible. The relationship between random glucose and all-cause mortality has hardly been studied so far and was examined in the present study. Methods We ascertained mortality status among 5955 persons aged 18–79 years and free of known diabetes when participating in the German National Health Interview and Examination Survey 1998 (mean observation time 11.7 years, 458 deaths). Cox regression was applied to analyze the association of random serum glucose with all-cause mortality taken potential confounders into account. Relative mortality risks were estimated as hazard ratios (HRs) with 95% confidence intervals (CIs) modeling random glucose as categorical or continuous variable. Results Compared to random glucose levels of 4.3

Aging and psychosocial stress are associated with increased inflammation and disease risk, but the underlying molecular mechanisms are poorly understood. Because both aging and stress are also associated with lasting epigenetic changes, a plausible hypothesis is that stress exposure along the lifespan could confer disease risk by epigenetically deregulating molecules involved in inflammatory processes. Here, by combining large-scale analyses in human cohorts with mechanisticin vitroinvestigations, we found that FKBP5, a protein implicated in stress physiology, contributes to these relations. Across independent human cohorts (total n=3,131), aging and stress-related phenotypes were synergistically associated with epigenetic derepression ofFKBP5. These age/stress-related epigenetic effects were recapitulated in anin vitromodel of replicative senescence, whereby we exposed replicating human fibroblasts to stress (glucocorticoid) hormones. Unbiased genome-wide analyses in human blood linked higherFKBP5mRNA with a proinflammatory profile and altered NF-κB-related gene networks. Accordingly, experiments in immune cells showed thatFKBP5overexpression promotes inflammation by strengthening the interactions of NF-κB regulatory kinases, whereas opposing FKBP5 either by genetic deletion (CRISPR/Cas9-mediated) or selective pharmacological inhibition prevented the effects on NF-κB. Further, the age/stress-related epigenetic signature enhancedFKBP5responsivity to NF-κB through a positive feedback loop and was present in individuals with a history of acute myocardial infarction, a disease state linked to peripheral inflammation. These findings suggest that FKBP5-NF-κB signaling mediates inflammation associated with aging and stress, potentially contributing to cardiovascular risk, and may thus point to novel biomarker and treatment possibilities.SignificanceDiseases of the aging are the leading cause of morbidity and mortality. Elucidating the molecular mechanisms through which modifiable factors, such as psychosocial stress, confer risk for aging-related disease can have profound implications. Here, by combining studies in humans with experiments in cells, we find that aging and stress synergize to epigenetically derepress FKBP5, a protein implicated in stress physiology. Higher FKBP5 promotes inflammation by activating the master immune regulator NF-κB, whereas opposing FKBP5 – either genetically or pharmacologically– prevents the effects on NF-κB. Further, the age/stress-related epigenetic signature ofFKBP5is associated with history of myocardial infarction, a disease state linked to inflammation. These findings provide molecular insights into stress-related disease and may point to novel biomarker and treatment possibilities.

Erratum to: Bundesgesundheitsbl (2018) https://doi.org/10.1007/s00103-018-2793-0 The original publication of this article contained an error in the list of the authors, in which the contributing author Christian Schmidt was missing. The full list of authors has now been updated. The original article …

Background Evidence-based policy measures need non-interest-guided information about the health status of a population and the diseases that affect the population the most. In such cases, a national burden of disease study can provide reliable insights at the regional level. Aim This article presents the potential of the BURDEN 2020 project and its expected outcome for Germany at the national and regional level. Methods The BURDEN 2020 project uses several indicators including years of life lost (YLL) to cover the impact of mortality and years lived with disability (YLD) to cover morbidity. The sum of both is the measure of population health called disability adjusted life years (DALY). Results The study ranks individual diseases and risk factors based on their impact on population health. The burden of disease approach is assumed to be sensitive to subnational differences and may generate immediate benefits for regional planning. The BURDEN 2020 study will pilot a national burden of disease study for Germany that will later be transformed into a continuous data processing and visualization tool. This is done by using, modifying and supplementing the methodology employed by the Global Burden of Disease (GBD) study to better fit the needs of health policy in Germany. This study is aimed at calculating the disease burden for up to 17 preselected diseases. Furthermore, the estimates of burden of disease are attributed to a selected set of risk factors. Conclusion The Burden 2020 study will provide the results of a new, health-related data processing system to the public. This includes a noninterest-guided presentation of the burden of disease (DALY) in Germany at the national and regional level.

Over the last years the prevalence of diabetes mellitus (DM) has risen. Due to the disease pattern an increasing importance of rehabilitation services is assumed as well. This article contributs to the debate by analyising the use of medical rehabilitations from 2006 to 2013.The secondary data analysis is based on a scientific use file. DM is defined according to ICD-10 (E10-E14). The trends stratified by age and gender are displayed crude and standardized per 100.000. The use will be correlated with the population-based prevalence on the level of federal states.The standardized use rose from 2006 to 2013 in men from 170 to 204.4 and woman from 99 to 123.6 per 100.000. While it declined for people under 60 years old, it rose by about 80% in the age group of the 60-64 year-olds. The use correlated positively (r=0.64) with the population-based prevalence.As a result of increasingly late retierment, the importance of rehabilitation services in people with DM incesases.Seit Jahren steigt die Prävalenz des Diabetes mellitus (DM) an. Aufgrund des Krankheitsbildes wird mit steigender Bedeutung rehabilitativer Leistungen gerechnet. In diesem Beitrag wird die Inanspruchnahme medizinischer Rehabilitation von 2006 bis 2013 untersucht.Die Sekundärdatenanalyse basiert auf einem scientific use file. DM wird gemäß ICD-10 (E10-E14) definiert. Die Verläufe werden roh, altersstandardisiert und stratifiziert nach Alter und Geschlecht dargestellt. Die Inanspruchnahmen und Prävalenzen pro Bundesland werden korreliert.Die standardisierte Inanspruchnahme stieg von 2006 bis 2013 bei Männern von 170 auf 204,4 und Frauen von 99 auf 123,6 je 100 000. Während sie bei unter 60-Jährigen rückläufig ist, stieg sie in der Altersgruppe der 60–64-Jährigen um zirka 80%. Die Inanspruchnahme korreliert positiv (r=0,64) mit der bevölkerungsbezogenen Prävalenz.Aufgrund des zunehmend späteren Renteneintritts wächst die Bedeutung rehabilitativer Leistungen bei Personen mit DM.

Mainly because of the large number of people affected and associated significant health policy implications, the Robert Koch Institute (RKI) is developing a public health surveillance system using diabetes as an example. In a first step to ensure long-term and comparable data collection and establish efficient surveillance structures, the RKI has defined a set of relevant indicators for diabetes surveillance. An extensive review of the available literature followed by a structured process of consensus provided the basis for a harmonised set of 30 core and 10 supplementary indicators. They correspond to the following four fields of activity: (1) reducing diabetes risk, (2) improving diabetes early detection and treatment, (3) reducing diabetes complications, (4) reducing the disease burden and overall costs of the disease. In future, in addition to the primary data provided by RKI health monitoring diabetes surveillance needs to also consider the results from secondary data sources. Currently, barriers to accessing this data remain, which will have to be overcome, and gaps in the data closed. The RKI intentends to continuously update this set of indicators and at some point apply it also to further chronic diseases with high public health relevance.

Efficacy of treatment of working-age patients with diabetes mellitus can be increased by rehabilitative measures. This treatment option is explicitly mentioned in the guidelines of the disease management program (DMP) for type 2 diabetes (T2D). With research data from the pension insurance fund, it is shown that for rehabilitation patients with T2D and DMP enrolment, the chance of disability pension is 23% lower than without DMP enrolment, irrespective of relevant covariates.Bei der Versorgung von Personen mit Diabetes mellitus im erwerbsfähigen Alter können rehabilitative Maßnahmen die Behandlung stärken. In der Richtlinie des Disease-Management-Programms (DMP) für Typ-2-Diabetes (T2D) wird diese Behandlungsoption ausdrücklich benannt. Mit Forschungsdaten der Rentenversicherung wird gezeigt, dass bei Rehabilitanden mit T2D und DMP-Einschreibung die Chance auf eine spätere Erwerbsminderungsrente unabhängig von relevanten Kovariablen um 23% niedriger liegt als ohne DMP-Einschreibung.

Background/aim Researchers worldwide have reported a seasonal pattern of suicides with peaks in spring and early summer; however, only a limited number of studies has evaluated whether meteorological variables may trigger suicides. We therefore aimed to investigate the association between short-term changes of meteorological variables and suicides in Bavaria, Germany, for the period 1990–2006. Methods Daily suicide and meteorological data were available for four Bavarian cities and ten counties. Immediate, delayed and cumulative effects of air temperature, sunshine duration, cloud cover, relative humidity as well as precipitation on suicides were analysed using a confounder-adjusted time-stratified case-crossover approach. In further analysis, we explored potential effect modifications by specific weather conditions (air temperature Results A 5°C increase in air temperature was associated with a 4.1% (95%-confidence interval: 0.97; 7.4%) and 5.1% (2.0; 8.4%) higher suicide risk on the same day and with a delay of one day, respectively. Further, the suicide risk was 6.2% (0.6; 12.2%) higher on days with low/medium cloud cover (0–6 oktas) compared to days with high cloud cover (7–8 oktas). Temperature effects with a lag of one day were more pronounced in individuals older than 65 years (9.9% (4.3; 15.8%)). While temperature was not associated with suicides in spring we found positive associations in summer, autumn, and winter. The effects of cloud cover were strongest in summer and autumn and on days with temperature above the median (>8.8°C). The other meteorological variables were not significantly associated with suicides. Conclusion We found a higher risk for suicides in association with short-term increases in air temperature and on days with low to medium cloud cover. This may highlight time periods when people are more likely to commit suicide.

Objective To estimate age-specific and sex-specific all-cause mortality among adults with and without type 2 diabetes (T2D) in Germany. Research design and methods The German National Health Interview and Examination Survey 1998 (GNHIES98) included a mortality follow-up (median follow-up time 12.0 years) of its nationwide sample representative of the population aged 18–79 years. After exclusion of participants with type 1 diabetes, age- and sex-stratified mortality rates (MR) were calculated for 330 GNHIES98 participants with diagnosed T2D (self-reported diagnosis or antidiabetic medication), 245 with undiagnosed T2D (no diagnosed T2D, glycated hemoglobin A1c ≥6.5% (≥48 mmol/mol)), and 5975 without T2D. Mortality rate ratios (MRR) comparing MR of persons with and without T2D were estimated. Age-/sex-standardized MR and MRR were calculated including persons aged 45 years or older. MRR were used to estimate the number of years of life lost (YLL) due to diagnosed diabetes in 2010. Results Over 75 994 person-years, 73 persons with undiagnosed T2D, 103 with diagnosed T2D, and 425 persons without T2D died. MRR were significantly higher in younger age groups, except for analyses limited to women or diagnosed T2D. Age- and sex-standardized MRR (95% CI) among persons aged 45 years or older were 1.96 (1.41 to 2.71) for undiagnosed, 1.68 (1.26 to 2.23) for diagnosed, and 1.82 (1.45 to 2.28) for total (undiagnosed or diagnosed) T2D. Sex-stratified analysis revealed similar age-standardized MRR for undiagnosed (1.56 (0.79 to 3.06)) and diagnosed T2D (1.56 (1.03 to 2.37)) among women, and a higher age-standardized MRR for undiagnosed (2.06 (1.43 to 2.97)) than diagnosed T2D (1.70 (1.10 to 2.63)) among men. YLL due to diagnosed diabetes in Germany in 2010 were 164 600 (35 000 to 279 300) among women and 169 900 (28 300 to 328 300) among men. Conclusions In Germany, age- and sex-standardized all-cause mortality is almost twice as high for adults with T2D as for adults without T2D. The T2D-associated excess risk of mortality appears to be most pronounced in younger adults and among men unaware of their T2D.

Insufficiently treated diabetes mellitus can lead to severe comorbidities. National and international analyses show a continuous increase in diabetes prevalence over the last decades. Currently, an indicator-based national diabetes surveillance system is implemented at the Robert Koch Institute (RKI) to monitor and report on diabetes development on the basis of available primary and secondary data. The aim of the meeting was to go into deeper discussions and to integrate expectations and expertise of the federal states into the design of the national surveillance system. A close collaboration between the RKI and the federal states is intended.