[Strengthening Public and Global Health in Germany - an Appraisal of the Statement "Public Health in Germany" by the German Scientific Academies from June 16th 2015]. / Public und Global Health in Deutschland stärken - Eine Einordnung der Stellungnahme "Public Health in Deutschland" der wissenschaftlichen Akademien vom 16.6.2015.

In June 2015 the scientific academies "Leopoldina" and "acatech" and the union of the German academies of sciences and humanities published a statement on public and global health in Germany. The statement contains many valuable albeit generic and well-known recommendations. The few specific recommendations focus on centralizing research while weakening the role of universities and on the relative increase of research on public health genomics. These recommendations are not based on empirical or theoretical analyses and risk subverting successful developments of the recent past. To actually strengthen public and global health in Germany the existing institutions need to be backed up while designated funding of public and global health needs to be extended.

[Is there an Association between Prevention Campaign Knowledge and Sun Protection Behaviour of Parents for their Children? Results of a Parent Survey]. / Gibt es einen Zusammenhang zwischen der Kenntnis von Sonnenschutzkampagnen und dem Sonnenschutz von Kindern durch ihre Eltern? Ergebnisse einer Elternbefragung.

AIM: The aims of this study are to assess prevalence of awareness of sun protection campaigns among parents in Bavaria, Germany, to analyse the impact of sociodemographic factors on campaign knowledge and the association between parental campaign knowledge and sun protection behaviour in their children. METHODS: A cross-sectional survey was undertaken in 2010-2011 in Bavaria, Germany, with parents of 4,579 children aged 5-6 years (response rate 61%). RESULTS: Prevalence of knowledge of sun protection campaigns is 13% among parents in Germany and independent of sociodemographic factors. Ignorance of sun protection campaigns is associated with inadequate sun protection behaviour in children independent of sociodemographic and exposure characteristics. CONCLUSION: Awareness of sun protection campaigns is low among parents. Knowledge of adequate sun protection behaviour should be further increased at the population level in Germany independently of sociodemographic status.

Fruit and vegetable consumption and BMI change in primary school-age children: a cohort study.

BACKGROUND/OBJECTIVES: Healthy eating behaviours, such as increasing fruit and vegetable consumption (FVC), are frequently used as a target or outcome measure in obesity prevention interventions. The goal of this study was to demonstrate replacement of high-caloric foods/drinks by FVC and changes in body mass index (BMI) z-score associated with FVC. SUBJECTS/METHODS: Anthropometric measurements of 1252 children (51.0% girls) were taken before school entrance (age 6 years) and repeated in the fourth grade (age 10 years). At the same time, parents were asked about their children's diet using a questionnaire. RESULTS: In longitudinal analysis, changes in FVC were not significantly correlated with changes of other nutritional habits, such as consumption of sweets and high-caloric drinks. BMI gain tended to be lower (nonsignificant) in children with increasing fruit consumption compared to those with decreasing fruit consumption. An opposite (nonsignificant) tendency was observed for vegetable consumption and BMI gain. CONCLUSIONS: Although beneficial for other health outcomes, the evidence for FVC replacing high-energy foods and thereby reducing BMI gain is weak and could not be substantiated in this study. This might be partially due to the limitation in dietary assessment.

[The impact of migration background on children's secondhand smoke exposure. A cross-sectional study within the health monitoring units (GME) in Bavaria, Germany]. / Die Bedeutung des Migrationshintergrundes für die Tabakrauchbelastung von Kindern. Eine Querschnittstudie im Rahmen der Gesundheits-Monitoring-Einheiten (GME) in Bayern.

AIM OF THE STUDY: Differences in children's secondhand smoke (SHS) exposure were examined by migration-specific characteristics, socioeconomic factors and living conditions, as well as with regard to the parents SHS knowledge and SHS attitudes. STUDY POPULATION AND METHODS: Data from 5,336 pre-school children (29% migrants) were collected in a cross-sectional study in 2008/2009 in Germany through parental questionnaire (response rate: 61%). Using multiple logistic regression, the association of migration background and children's SHS exposure was analysed. RESULTS: Children with a migration background are at an increased risk of SHS exposure in their homes. Multivariate analyses show that adjusting for socioeconomic factors and parental knowledge of how to protect their children from SHS reduces the estimates of migration background significantly. Compared to children without migration background, the chance of SHS exposure for children with migration background is still increased (OR [95% CI]: 1.57 [1.23-2.01]). Children of Turkish-speaking families, compared to children from German-speaking families, are most often burdened by SHS (3.05 [2.18-4.26]). CONCLUSION: Migrant-sensitive tobacco prevention in selected risk groups is necessary to provide support for creating smoke-free homes for children.

Phthalates in German daycare centers: occurrence in air and dust and the excretion of their metabolites by children (LUPE 3).

Phthalates have been used for decades in large quantities, leading to the ubiquitous exposure of the population. In an investigation of 63 German daycare centers, indoor air and dust samples were analyzed for the presence of 10 phthalate diesters. Moreover, 10 primary and secondary phthalate metabolites were quantified in urine samples from 663 children attending these facilities. In addition, the urine specimens of 150 children were collected after the weekend and before they went to daycare centers. Di-isobutyl phthalate (DiBP), dibutyl phthalate (DnBP), and di-2-ethylhexyl phthalate (DEHP) were found in the indoor air, with median values of 468, 227, and 194ng/m(3), respectively. In the dust, median values of 888mg/kg for DEHP and 302mg/kg for di-isononyl phthalate (DiNP) were observed. DnBP and DiBP were together responsible for 55% of the total phthalate concentration in the indoor air, whereas DEHP and DiNP were responsible for 70% and 24% of the total phthalate concentration in the dust. Median concentrations in the urine specimens were 44.7µg/l for the DiBP monoester, 32.4µg/l for the DnBP monoester, and 16.5µg/l and 17.9µg/l for the two secondary DEHP metabolites. For some phthalates, we observed significant correlations between their concentrations in the indoor air and dust and their corresponding metabolites in the urine specimens using bivariate analyses. In multivariate analyses, the concentrations in dust were not associated with urinary metabolite excretion after controlling for the concentrations in the indoor air. The total daily "high" intake levels based on the 95th percentiles calculated from the biomonitoring data were 14.1µg/kg b.w. for DiNP and 11.9µg/kg b.w. for DEHP. Compared with tolerable daily intake (TDI) values, our "high" intake was 62% of the TDI value for DiBP, 49% for DnBP, 24% for DEHP, and 9% for DiNP. For DiBP, the total daily intake exceeded the TDI value for 2.4% of the individuals. Using a cumulative risk-assessment approach for the sum of DEHP, DnBP, and DiBP, 20% of the children had concentrations exceeding the hazard index of one. Therefore, a further reduction of the phthalate exposure of children is needed.

[Situation and perspectives of public health in Germany--research and teaching. Position paper of the German Public Health Association]. / Situation und Perspektiven von Public Health in Deutschland--Forschung und Lehre. Positionspapier der Deutschen Gesellschaft für Public Health e. V.

This position paper of the German Public Health Association describes current situation and perspectives of public health in Germany with emphasis on research and teaching. It outlines those measures necessary for strengthening of public health research in Germany.

[Breast-feeding training programme as intervention approach at the hospital level: results of evaluation of the first phase of the STELLA study]. / Personalschulung als Interventionsansatz auf Klinikebene zur Stillförderung: Evaluationsergebnisse der ersten Phase der STELLA-Studie.

BACKGROUND: The health-promoting short- and long-term effects of breast-feeding are supported by a vast scientific literature. The Bavarian prospective cohort study 2005/2006 showed regional variations of breast-feeding rates. Furthermore, improvement in counselling mothers, particularly with regard to prevention and handling of breast-feeding problems, has a great potential for health promotion. The objective of this study is to promote breast-feeding in maternity clinics by improving the surrounding conditions. STUDY DESIGN: A clinic-based and community-related intervention trial was carried out in Lower Bavaria as a model region with below average breast-feeding rates. (1) INTERVENTION: an advanced training of maternity ward professionals of 10 hospitals and after-care midwives was performed from May until December 2008. The training programme was based on the WHO/UNICEF criteria of the "Ten Steps to Successful Breastfeeding" to deepen the breast-feeding knowledge and to improve the breast-feeding management. (2) EVALUATION: A singular assessment of the advanced training programme was undertaken concerning an increase of knowledge and the practicability in clinical everyday life by participants; improvements of the maternity wards were assessed via structural interviews with maternity ward staff before and after intervention. RESULTS: Approximately 85% (n=378) of the staff of the 10 maternity clinics attended the training course. The survey after the training programme (response rate 83%) indicated that more than 80% of the participants stated to have learned something new and to be able to use the knowledge acquired for their own practice. Results of the clinic interviews showed a transfer of training contents into clinical work routines. Improvements at interview date were shown best for bonding (all 10 maternity clinics), for additional feeding (8 maternity clinics) as well as for 24-h rooming-in and mother counselling (7 maternal clinics each). CONCLUSION: Training of maternity ward professionals accounts for baby-friendly conditions in maternity clinics. Most willingness for improvements was shown by maternity ward staff particularly for bonding between mother and child as well as for additional feeding. Considerable differences between the hospitals were observed for the promotion of infant formulas before and after the intervention.

[Children of single mothers: health risks and environmental stress]. / Kinder alleinerziehender Frauen in Deutschland: Gesundheitsrisiken und Umweltbelastungen.

BACKGROUND AND AIM: In Germany the risk for relative poverty has increased profoundly during the last 15 years, especially among single parent families. As poverty is often associated with bad health we examined the physical and mental health as well as health-related behaviour, housing and environmental conditions in children with lone mothers versus children in couple families. STUDY POPULATION AND METHODS: In 3 cross-sectional surveys conducted during 2004-2007 in 3 cities and 3 rural areas in Bavaria data on 19 039 pre-school children (47% female) were collected. Health, behaviour and exposure assessment was based on parental reports. The 18 327 cases with complete information on family status were analysed. 10% of the children grew up with single mothers. RESULTS: Single mothers evaluated the general state of health of their children more often as moderate to very poor than couple parents (OR [95% CI]: male: 1.37 [1.07-1.77], female 1.77 [1.33-2.35]). Sons with single mothers were more often obese (1.44 [1.09-1.90]). They scored significantly higher in the SDQ total difficulties score (1.94 [1.44-2.62]), on the emotional problem scale (1.91 [1.40-2.59]) as well as on the hyperactivity scale (1.82 [1.35-2.47]) compared to boys from couple families. No difference was found in prosocial behaviour. Girls with single mothers revealed more often conduct problems 1.36 [1.02-1.81] compared to those from couple families. They also showed a significantly higher prevalence of asthma (2.06 [1.29-3.30]). Children living with their single mothers were less often members of sports clubs and the boys were less physical active. No difference was found regarding the consumption of fruits and vegetables. Single mother family was associated with children's environmental tobacco smoke exposure at home (2.03 [1.79-2.29]). Single mothers perceived higher environmental exposures to noise and air pollution, suffered more often from a lack of accessible green spaces in the neighbourhood and reported a higher traffic load on the residential street. CONCLUSION: Children with single mothers reveal increased health risks and live under significantly poorer housing and environmental conditions. Further analyses are necessary to identify the mediating factors.

Different age-specific incidence and remission rates in pre-school and primary school suggest need for targeted obesity prevention in childhood.

BACKGROUND: School entry marks a tremendous change in the children's life style, which might well be relevant for the emergence of overweight. Previous studies suggested a dramatic increase in the prevalence of overweight during this age. OBJECTIVE: To compare the age-specific balance between the incidence and remission of overweight between pre-school and primary school age children. DESIGN: We combined the data of three studies that had been conducted within the setting of the compulsory school entry health examination in different parts of Germany: one covering retrospective cohort data from age 2 to school entry (n=5045), one prospective data from school entry to fourth grade (n=1235) and one comprising both (n=1194). We assessed the rates of incidence and remission of overweight and obesity from age 2 to school entry and from school entry to fourth grade. RESULTS: In pre-school age, the pooled incidence for overweight was 8.2% (95% confidence interval: 7.5, 8.9) compared with a remission rate of 62.6% (58.4, 66.7), yielding a prevalence at school entry of 10.7% (9.9, 11.5). In primary school age, the pooled incidence for overweight increased to 14.6% (13.1, 16.1), whereas the remission rate was reduced to 17.7% (13.8, 22.3), yielding a prevalence of 23.7% (22.0, 25.4) in fourth grade. A similar pattern was observed for obesity. CONCLUSIONS: While high remission rates balance incident overweight in pre-school years, the dramatic increase in the prevalence of overweight and obesity in primary school years reflects a higher incidence and even more a lower remission rate. Obesity prevention programs in primary school age are mandatory and need to address primary and secondary prevention elements.

[Influence of environmental noise on sleep quality and sleeping disorders-implications for health]. / Einfluss von Umweltlärm auf Schlafqualität und Schlafstörungen und Auswirkungen auf die Gesundheit.

Environmental noise is a well-known risk factor influencing sleep-wake behavior and sleep quality. Epidemiologic studies have shown that environmental noise is regarded as the most annoying environmental factor. Noise causes modifications in physiologic and mental functions and may result in health outcomes like elevated blood pressure and ischemic heart disease. Reactions to high sound levels during sleep are decreased sleep intensity, arousals, and increased stress hormone secretion. Effects of poor sleep quality are reduced cognitive performance, tiredness, and psychosomatic symptoms. Long-term consequences of recurrent sleep loss due to environmental noise may be heart disease and increased medication intake. Arousals occur especially due to single noise events and intermittent noise. Laboratory and field studies showed no habituation of physiologic parameters to high sound levels. Sleep is especially sensitive to noise; therefore, sound levels during nighttime should be much lower than during daytime.

[Excessive media comsumption and behavioural problems--a cross-sectional study on pre-school children]. / Exzessiver Medienkonsum und Verhaltensauffälligkeiten--eine Querschnittstudie bei Vorschulkindern.

OBJECTIVE: The aim of this study was to assess the association between excessive media consumption (TV, video games usw) of more than three hours per day and behavioural problems in 5- to 6-year-old children. METHODS: Data from 5 155 preschool children were collected within the second health monitoring units (GME survey) during 2005/2006 in Bavaria, Germany. Parentally reported behavioural problems ('normal', 'borderline' or 'abnormal') were assessed from the Strengths and Difficulties Questionnaire. Daily media consumption was assessed for both weekend and weekdays and classified into three categories (rarely, medium, excessive). A multivariate logistic regression analysis was performed to control potential confounders. RESULTS: Boys showed more abnormal values on the total difficulties score of the SDQ than girls (8.2 vs. 4.1). Boys were more often excessive media consumers than girls. The association between excessive media consumption and abnormal values on the SDQ was significant in girls (OR: 2.2; 95% CI: 1.3-3.7) for both total difficulties score and subscales in the multivariate analysis. In boys, however, this association was less pronounced (OR: 1.5; 95% CI: 1.0-2.1) and not consistently significant for all subscales. CONCLUSION: Our study has shown a significant association between excessive media consumption and abnormal SDQ values, especially among 5- to 6-year-old girls, but which is less pronounced in boys. Parents of preschool children with excessive media consumption should be informed and the children should undergo a screening for behavioural problems.

[Tobacco prevention at the regional level, Bavaria as an example]. / Tabakprävention auf Landesebene. Das Beispiel Bayern.

Tobacco consumption is one of the most relevant behavior-based health risks. It has been estimated that there are 14,000-18,000 tobacco-related deaths each year in Bavaria, Germany. Thus, efficient tobacco prevention, which involves measures of behavior-oriented as well as of condition-oriented prevention at the Federal State level, is a priority objective of prevention politics in Bavaria. Measures of behavior-oriented prevention account for the fact that tobacco prevention affects private lifestyles, where statutory provisions may not be effectual. However, smoking bans have achieved the creation of smoke-free living spaces especially for children and adolescents. In the long term, it is essential to enhance evaluation of tobacco prevention, to pay more attention to sustainability of approved projects, and to ensure a smoke-free environment for children and adolescents. The Bavarian health program "Gesund.Leben.Bayern." is an important platform for this.

Exposure to secondhand tobacco smoke and child behaviour - results from a cross-sectional study among preschool children in Bavaria.

AIM: To evaluate the association of postnatal exposure to secondhand tobacco smoke on childhood behavioural problems after taking maternal smoking during pregnancy into account. METHODS: In a cross-sectional survey of preschool children in Bavaria, exposure to secondhand tobacco smoke in the child's home was assessed via a parent questionnaire. The Strength and Difficulties Questionnaire (SDQ) was applied to assess child's behaviour. The association with secondhand tobacco smoke exposure was assessed for 'probable' outcomes of the problem subscales and of prosocial behaviour. RESULTS: Among 5494 children (48% female), the SDQ indicated behavioural problems in up to 11%. After adjustment for socioeconomic factors, low birth weight and maternal smoking before and during pregnancy, a dose-response relationship with exposure to secondhand tobacco smoke was observed regarding hyperactivity/inattention (odds ratio compared to 'none' was 1.35 for 'low/medium' and 2.39 for 'high' exposure, 95% confidence intervals 1.02-1.78 and 1.62-3.53, respectively) as well as for conduct problems (OR 1.68 (1.37-2.06) and 1.93 (1.39-2.68)). CONCLUSION: Secondhand tobacco smoke exposure at home appears to be associated with an increased risk of behavioural problems among preschool children. Prevention of behavioural problems may be a further reason to target secondhand tobacco smoke exposure in children.

[Smoking bans in public places: current epidemiological evidence of cardiovascular health impacts at the population level]. / Rauchverbote in öffentlichen Räumen: Aktuelle epidemiologische Evidenz für kardiovaskuläre Gesundheitseffekte auf Bevölkerungsebene.

During the past years smoking bans in public places including hospitality venues have been introduced in several countries. Up to now, eight ecological studies on hospital admission rates due to acute myocardial infarction or coronary events after introduction of a smoking ban in the United States, Canada, and Italy have been published. This article reviews these studies and discusses their significance and potential sources of error from an epidemiological point of view. The chronological order of reduction in acute myocardial infarction rates following the smoking ban, the consistency of this association in several countries, and the biological plausibility because of the known acute cardiovascular effects of secondhand smoke suggest a causal association. Thus, if this turns out to be true public smoking bans will be a very effective public health measure.

[Dietary intake of non-dioxin-like polychlorinated biphenyls (PCB) in Bavaria, Germany. Results from the Integrated Exposure Assessment Survey (INES)]. / Nahrungsbedingte Zufuhr von nicht-dioxinähnlichen polychlorierten Biphenylen (PCB) in Bayern. Ergebnisse von INES (Integrated Exposure Assessment Survey).

Polychlorinated biphenyls (PCB) were widely used in numerous industrial and commercial applications in high quantities in the past. Based on their persistence in the environment, their tendency to accumulate in the organism and their specific health effects, PCBs have to be assessed as critical substances. Because the dietary intake was assumed to be the main intake route, the Integrated Exposure Assessment Survey (INES) aimed to measure the recent exposure to PCBs in Germany. The study consisted of 10 female and 10 male participants living in Munich and surroundings. The participants collected dietary duplicates of all food consumed and prepared as for consumption over 7 consecutive days. Altogether the 6 non-dioxin-like PCB congeners 28, 52, 101, 138, 153 and 180 ndl-PCB or, respectively, indicator PCB and furthermore the congener 118 were detected using a gas chromatographic method. Dietary intake was calculated using the amount of food eaten daily and the results from the duplicates. Using the sum of PCB 138, 153 and 180 multiplied by 4, the daily intake ranged from 4.0 to 24.1 ng/kg b.w. (median: 9.5 ng/kg b.w.). On the contrary, the daily intake was 2.9 to 20.6 ng/kg b.w. (median: 11.2 ng/kg b.w.) if the sum of the 6 indicator PCBs multiplied by factor 2 was used for quantification. No sex-related difference of the dietary intake was observable. Overall, it can be concluded that the dietary PCB intake has further decreased in the last years in Germany. At present, the toxicological database is not suitable to assess the risks coming solely from the non-dioxin-like PCBs because it is not possible to differentiate between non dioxin-like and dioxin-like effects in toxicological studies. Nevertheless, a further reduction of PCB exposure via food by searching for possible sources is needed.

[Secondhand smoke in hospitality venues. Exposure, body burden, economic and health aspects in conjunction with smoking bans]. / Tabakrauch in gastronomischen Einrichtungen. Exposition, innere Belastung, ökonomische und gesundheitliche Aspekte im Zusammenhang mit Rauchverboten.

Secondhand smoke was classified by national and international organisations as a known cause of cancer in humans and has many adverse health effects, especially cardiovascular diseases and lung tumours. Global studies have clearly shown that hospitality venues have the highest levels of indoor air pollution containing different substances that are clearly carcinogenic--such as tobacco-related chemicals--compared with other, smoke-free indoor spaces. Data from the human biomonitoring of non-smoking employees in the food service industry confirm this high exposure level. Non-smokers exposed to secondhand smoke in these environments are at increased risk for adverse health effects. The consistent protection of non-smokers in public places such as restaurants and bars through a smoking ban results in a significant reduction of the pollutants in the air (mostly > 90%) and clearly reduces the internal body burden for users and employees. Furthermore, health complaints by non-smoking employees are reduced and the higher risk for lung tumours of employees in the food service industry compared with the general population can be effectively reduced as well. According to current standards of knowledge, other measures such as spatial separation of smoking areas or the use of mechanical venting systems do not achieve a comparably high and effective pollutant reduction under field conditions. Studies concerning the economic effects of prohibiting smoking in public places conducted in various countries have shown that beverage-focused gastronomic enterprises experience a short-term down trend but that food-focused gastronomic enterprises do not experience any negative or even positive effects. The positive effects of a ban on smoking in public places on the general population are a decline in cigarette consumption and the reduction of secondhand smoke exposure by non-smokers. Smoking bans in hospitality venues are not necessarily linked with a shift of the tobacco consumption to private rooms and an associated increase of secondhand smoke exposure. A comprehensive smoking ban in public spaces without exemption is therefore an easy and targeted measure for gastronomic enterprises from a health perspective.

[An interventional study to improve breast-feeding conditions in obstetric clinics of a model region in Bavaria]. / Eine Interventionsstudie zur Verbesserung von Stillbedingungen in Geburtskliniken einer Modellregion in Bayern.

Breastfeeding is influenced amongst other aspects by the support of the medical staff in clinics. Therefore WHO and UNICEF have implemented the programme "ten steps to successful breastfeeding" and the certificate "Baby friendly hospital" to promote breastfeeding in clinics. When the study "Breastfeeding in Bavaria" was started only two clinics in Bavaria were certified as baby friendly. In a Bavarian region where breastfeeding rates were significantly lower than in other regions an intervention study will be conducted. The aim of the study is to educate the clinic staff in the support of breastfeeding mothers. This paper describes the aims and methods of this intervention study.

[Gender in epidemiology. State of discussion and perspectives]. / Gender in der Epidemiologie. Diskussionsstand und Perspektiven.

Against the background of sex-specific and sex-comparative approaches in health research, this article aims to clarify to what extent the category sex/gender with its biological dimensions (sex) and social dimensions (gender) has systematically and conceptually been consider ed in epidemiology and which methods have been developed. Epidemiologic research has been criticized for routinely controlling statistically for age and sex but often ignoring aspects of gender. Inadequate consideration of sex/gender may result in systematic errors (gender bias), on the one hand, if sex/gender is ignored as an important variable, and, on the other hand, if differences between men and women are assumed when there are actually similarities. There are examples of adequate consideration of gender in exposure assessment, analysis of social position or modelling of interactions in current articles of scientific journals. How ever, epidemiologic reference books and textbooks as well as university training in epidemiology show that the category sex/gender has not been integrated with both dimensions sex and gender into the currently predominating thought style of epidemiology. For the further development of valid epidemiologic research clarification of terms, generation of unambiguous concepts and sophisticated statistical tools are necessary. This is the only way to succeed in analysing the complex interactions between sex-linked biology and gender relations.