Individual and area-level determinants associated with C-reactive protein as a marker of cardiometabolic risk among adults: Results from the German National Health Interview and Examination Survey 2008-2011.

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.

Time trends in incidence and mortality of respiratory diseases of high public health relevance in Germany.

Respiratory diseases are major causes of disease burden and mortality throughout the world. In Germany, alongside acute respiratory infections (ARI), chronic lung diseases - including lung cancer, chronic obstructive pulmonary disease (COPD), and asthma - are of particular socioeconomic importance. ARI incidence rates differ significantly according to age, season and year. They are recorded as weekly consultation rates as reported by selected outpatient and inpatient care facilities. Between 2009 and 2016, the highest incidence rates of severe acute respiratory infection (SARI) were recorded among young children in outpatient (9.4%) and inpatient (0.2%) care. Mortality rates for ARI are also subject to seasonal and annual fluctuations. However, the official statistics on causes of death, which lead to estimates of more than 17,000 annual deaths, provide an inadequate measure of death rates because chronic underlying illnesses are often recorded as the cause of death rather than a more recently acquired acute infection. Therefore, the excess mortality caused by ARI needs to be assessed in the context of influenza outbreaks. Regarding lung cancer, COPD and asthma, the long-term time trends in disease incidence and mortality rates are of particular interest from a health policy perspective. Analyses of data from the official statistics on causes of death for the years 1998 through 2015 show that mortality rates for lung cancer and COPD decreased on average by 1.8% and 1.1% per year respectively, among men, whereas among women they increased by 2.5% (lung cancer) and 2.3% (COPD) annually. Nevertheless, more men than women died of lung cancer or COPD in 2015 in Germany: 29,378 men and 15,881 women died from lung cancer, and 17,300 men and 13,773 women died from COPD. During the same period, the asthma mortality rates decreased on average by 8.3% annually among women and by 11.2% annually among men, and the absolute number of deaths came down to 659 among women and 393 among men. Lung cancer incidence rates have been at similar levels as lung cancer death rates since 1998. No such data are available on time trends in COPD or asthma incidence rates. Coordinated surveillance of respiratory diseases needs to be expanded within the framework of international action plans for disease prevention.

German health interview and examination survey for adults (DEGS) - design, objectives and implementation of the first data collection wave.

BACKGROUND: The German Health Interview and Examination Survey for Adults (DEGS) is part of the recently established national health monitoring conducted by the Robert Koch Institute. DEGS combines a nationally representative periodic health survey and a longitudinal study based on follow-up of survey participants. Funding is provided by the German Ministry of Health and supplemented for specific research topics from other sources. METHODS/DESIGN: The first DEGS wave of data collection (DEGS1) extended from November 2008 to December 2011. Overall, 8152 men and women participated. Of these, 3959 persons already participated in the German National Health Interview and Examination Survey 1998 (GNHIES98) at which time they were 18-79 years of age. Another 4193 persons 18-79 years of age were recruited for DEGS1 in 2008-2011 based on two-stage stratified random sampling from local population registries. Health data and context variables were collected using standardized computer assisted personal interviews, self-administered questionnaires, and standardized measurements and tests. In order to keep survey results representative for the population aged 18-79 years, results will be weighted by survey-specific weighting factors considering sampling and drop-out probabilities as well as deviations between the design-weighted net sample and German population statistics 2010. DISCUSSION: DEGS aims to establish a nationally representative data base on health of adults in Germany. This health data platform will be used for continuous health reporting and health care research. The results will help to support health policy planning and evaluation. Repeated cross-sectional surveys will permit analyses of time trends in morbidity, functional capacity levels, disability, and health risks and resources. Follow-up of study participants will provide the opportunity to study trajectories of health and disability. A special focus lies on chronic diseases including asthma, allergies, cardiovascular conditions, diabetes mellitus, and musculoskeletal diseases. Other core topics include vaccine-preventable diseases and immunization status, nutritional deficiencies, health in older age, and the association between health-related behavior and mental health.

Assessment of environmental and socio-economic stress.

Since long, socio-economic status, often expressed as an index, is known to correlate with health outcomes like behavioural problems. We constructed a new index that encapsulated not only economic and social but also environmental stressors (ESES), using data of the German Health Interview and Examination Survey for Children and Adolescents, a nation-wide representative surveillance of 17,641 participants aged between 0-17 years. Different factors were selected to account for socio-economic stress (low parental education, low household income, low occupational status of the householder), domestic stress (living in large cities, exposure to tobacco smoke at home, crowded housing, mouldy walls), and prenatal stress (maternal smoking during pregnancy, drinking alcohol during pregnancy). Prior to the calculation of ESES, the different factors were multiplied by weights which were estimated by multivariate linear regression on a number of health outcomes. ESES was then used to predict emotional and social problems (SDQ scores). The resulting ORs were compared with those obtained for an established socio-economic index (SEI). ESES was superior to SEI as it could more clearly identify children and adolescents with emotional or social problems. Different types of stressors (i.e. socio-economic stress, domestic stress and prenatal stress) contributed independently to emotional and social problems.