Population-based Cohort Study In Germany Research Articles

8.G. Scientific session: The German National Cohort (NAKO): Current state, follow up data collection and selected results

Abstract This workshop aims to give an overview on current state and selected results of the German National Cohort (NAKO). NAKO is the largest, multidisciplinary population-based cohort study in Germany. The overall aims of NAKO are: 1) to elucidate pathways to major chronic diseases such as diabetes, cancer, cardiovascular, pulmonary, neuro-psychiatric, and infectious diseases, focusing on determinants and exposures (e.g., socioeconomic, psychosocial, behavioural, occupational, and environmental factors); 2) to assess regional differences; and to improve prevention and early detection of disease. Between 2014 and 2019 more than 205,000 men and women aged 20-74 years at baseline were recruited in 18 study centres across Germany. During their examination participants underwent an extensive programme including a face-to-face interview, self-administered, computer-based questionnaires, in-depth biomedical examinations, and the collection of various bio-samples. In addition, at 5 study centres a subgroup of almost 31,000, received whole-body magnet resonance imaging (MRI). In 4-5 year intervals, all study participants are re-invited for examination at the study centres. The first re-examination started in October 2018 and will be finished in July 2024. In parallel the pilot phase for the second re-examination will start in May 2024. The programme for both re-examinations is similar to the baseline programme. Thereby, longitudinal information on changes in risk factor profiles and in vascular, cardiac, metabolic, neurocognitive, pulmonary and sensory function is collected. During the COVID-19 pandemic two supplemental questionnaires focusing on pandemic-related aspects were provided to all NAKO participants at two different time points. The first COVID-19 questionnaire collected data on more than 160,000 participants during the first COVID-19-related lockdown in Spring 2020. The questionnaire included questions on general state of health, Sars-CoV-2 symptoms, changes in psychosocial, socioeconomic, and behavioural factors (e.g., physical activity). The workshop session consists of four presentations. The first presentation will provide insights into the extensive examination programme of NAKO, will give a short overview on the current state and plans for follow-up of data collection. In addition, it will briefly inform about possibilities to get access to NAKO data. Furthermore, the workshop will include three presentations on selected results of NAKO to demonstrate its broad research scope. The presentations will focus on the following topics: 1) cardiovascular disease and sex differences according to socioeconomic position, 2) cognitive functioning according to income, employment and living alone, 3) physical activity and changes during the COVID-19 pandemic. Key messages • Due to the large sample size, and the broad research scope, NAKO provides an excellent resource to scientists form different research disciplines and enforces interdisciplinary collaborations. • The workshop will be informative to researchers who are planning to work with NAKO data as data access within the European Union/the European Economic Area is open since spring 2024.

8.D. Workshop: The German National Cohort (NAKO): Design, current state, and selected results

Abstract This workshop aims to provide an overview on the current state and on selected results of the German National Cohort (NAKO) - the largest multidisciplinary, population-based cohort study in Germany. The session will include one overview presentation and three presentations on selected topics: use of secondary and registry data, environmental exposures, and COVID-19. NAKO aims to investigate the development and aetiology of diseases, and to identify risk factors and enhance early detection and prevention of diseases with a focus on diabetes, cancer, cardiovascular, pulmonary, neurological, psychiatric, and infectious diseases. Between 2014 and 2019, 205,415 participants aged 20-74 years were recruited and examined at 18 study centres across Germany. During their visit to the study centre, they participated in an extensive examination programme including a face-to-face interview, self-administered, computer-based questionnaires, in-depth biomedical examinations, and the collection of various bio-samples. In addition, a subgroup of 30,861 participants received whole-body Magnet Resonance Imaging (MRI) with a focus on brain and cardiac structures, the musculoskeletal system, and body fat distribution. All study participants are re-invited for examinations at the study centres at 4-5 year intervals. The programme for the first re-examination is similar to the baseline programme to detect changes in risk factor profiles and in vascular, cardiac, metabolic, neurocognitive, pulmonary and sensory function. By 31.03.23, 100,822 participants were re-examined, including 14,950 with MRI re-examination. A third examination will start in 2024. Additional information on morbidity, drug use, health care utilization, rehabilitation, cancer diagnoses and therapies, as well as employment and occupational history is obtained by record linkage with secondary data from health insurance companies, the statutory pension insurance, the unemployment fund, as well as through cancer registries and mortality follow-up. Information on environmental exposures (e.g., air pollution, traffic noise, climatic conditions) is linked to residential addresses of the participants to analyse the association with health and development of chronic diseases and to elucidate long-term effects of environmental stressors on health and disease. Two supplemental questionnaires focusing on COVID-19 pandemic-related aspects were provided to all NAKO participants. The second COVID-19 questionnaire was offered online between October 2022 and February 2023 and included questions on general state of health, psychosocial factors, Sars-CoV-2 and long-/post COVID symptoms. It was completed by > 110,000 NAKO participants. Due to its large sample size, the broad examination programme and the longitudinal design, NAKO provides a valuable resource for epidemiologic research and international scientific cooperations. Key messages • The workshop provides information on current state, and selected results of NAKO to facilitate harmonization of data collection between cohort studies and cooperations between scientists. • The workshop will be informative for researchers aiming to work with NAKO data as data access within the European Union is expected to be possible by the end of 2023.

The German National Cohort (NAKO): Design, current state, and further follow-up data collection

Abstract The German National Cohort (NAKO) is the largest population-based cohort study in Germany and provides a central resource for epidemiologic research. NAKO aims to investigate the development and aetiology of diseases, and to identify risk factors and enhance early detection and prevention of diseases with a focus on diabetes, cancer, cardiovascular, pulmonary, neurological, psychiatric, and infectious diseases. Between 2014 and 2019, overall 205,415 participants aged 20-74 years were recruited and examined at 18 study centres across Germany. During their visit to the study centre, they participated in an extensive examination programme including a face-to-face interview, self-administered, computer-based questionnaires, broad biomedical examinations (e.g., blood pressure, electrocardiograms, oral glucose tolerance tests) and provision of bio-samples (blood, urine, stool, saliva, nasal swabs). In addition, a subgroup of 30,861 participants received whole-body Magnet Resonance Imaging (MRI) with a focus on brain, heart, the musculoskeletal system, and body fat distribution. All study participants are re-invited for examinations at the study centres at 4-5 year intervals. The programme of the first re-examination is similar to the baseline programme in order to detect changes in risk factor profiles and in vascular, cardiac, metabolic, neurocognitive, pulmonary and sensory function. By 31.03.23, 100,822 participants were re-examined, including 14,950 with MRI re-examination. A third examination will start in 2024. Data collection is standardized, and central quality control and data cleaning is performed. For more complex data (e.g., echocardiography, accelerometry), competence units process the data and derive variables on exposure, functions, and disease. Due to its large sample size, the in-depth examination programme and the longitudinal design, NAKO provides an excellent source for better understanding of determinants for health and disease at the population level.

The effect of population-based blood pressure screening on long-term cardiometabolic morbidity and mortality in Germany: A regression discontinuity analysis.

Hypertension represents one of the major risk factors for cardiovascular morbidity and mortality globally. Early detection and treatment of this condition is vital to prevent complications. However, hypertension often goes undetected, and even if detected, not every patient receives adequate treatment. Identifying simple and effective interventions is therefore crucial to fight this problem and allow more patients to receive the treatment they need. Therefore, we aim at investigating the impact of a population-based blood pressure (BP) screening and the subsequent "low-threshold" information treatment on long-term cardiovascular disease (CVD) morbidity and mortality. We examined the impact of a BP screening embedded in a population-based cohort study in Germany and subsequent personalized "light touch" information treatment, including a hypertension diagnosis and a recommendation to seek medical attention. We pooled four waves of the KORA study, carried out between 1984 and 1996 (N = 14,592). Using a sharp multivariate regression discontinuity (RD) design, we estimated the impact of the information treatment on CVD mortality and morbidity over 16.9 years. Additionally, we investigated potential intermediate outcomes, such as hypertension awareness, BP, and behavior after 7 years. No evidence of effect of BP screening was observed on CVD mortality (hazard ratio (HR) = 1.172 [95% confidence interval (CI): 0.725, 1.896]) or on any (fatal or nonfatal) long-term CVD event (HR = 1.022 [0.636, 1.641]) for individuals just above (versus below) the threshold for hypertension. Stratification for previous self-reported diagnosis of hypertension at baseline did not reveal any differential effect. The intermediate outcomes, including awareness of hypertension, were also unaffected by the information treatment. However, these results should be interpreted with caution since the analysis might not be sufficiently powered to detect a potential intervention effect. The study does not provide evidence of an effect of the assessed BP screening and subsequent information treatment on BP, health behavior, or long-term CVD mortality and morbidity. Future studies should consider larger datasets to detect possible effects and a shorter follow-up for the intermediate outcomes (i.e., BP and behavior) to detect short-, medium-, and long-term effects of the intervention along the causal pathway.

Consistent Inverse Associations of Total, "Bioavailable", Free, and "Non-Bioavailable" Vitamin D with Incidence of Diabetes among Older Adults with Lower Baseline HbA1c (≤6%) Levels.

Background: Serum 25-hydroxyvitamin (25(OH)D) levels are inversely associated with risk of diabetes. The “free hormone hypothesis” suggests potential effects to be mainly related to concentrations of “bioavailable” and free rather than total 25(OH)D. We assessed associations of serum concentrations of vitamin D-binding protein (VDBP), as well as total “bioavailable”, complementary “non-bioavailable”, and free 25(OH)D, with the risk of developing diabetes among non-diabetic older adults in a large population-based cohort study in Germany. Methods: We included 4841 non-diabetic older adults aged 50–75 years at the baseline exam from the ESTHER cohort conducted in Saarland, Germany, in 2001–2002. Concentrations of “bioavailable” and free 25(OH)D were derived from serum concentrations of VDBP, total 25(OH)D, and albumin. Incidence of diabetes was ascertained during up to 14 years of follow-up. Associations were quantified by multivariable Cox proportional hazards regression models with comprehensive confounder adjustment. Results: During a median follow-up of 10.6 years, 837 non-diabetic participants developed diabetes. We observed similar inverse associations with developing diabetes for VDBP (hazard ratio (HR) for lowest versus highest quintile: 1.37, 95% confidence interval (CI): 1.09, 1.72), total 25(OH)D (HR: 1.31, 95% CI: 1.03, 1.66), and “non-bioavailable” 25(OH)D (HR: 1.30, 95% CI: 1.02, 1.65). Associations were smaller and statistically insignificant for “bioavailable” and free 25(OH)D. However, associations of total “non-bioavailable”, “bioavailable”, and free 25(OH)D with incidence of diabetes were much stronger among, and essentially restricted to, participants with lower baseline HbA1c (≤6%) levels. Conclusions: This large prospective cohort study of older Caucasian adults, in agreement with results from randomized trials and Mendelian randomization studies, supports a protective effect of vitamin D against development of diabetes. The “free hormone theory” may not be relevant in this context. However, our results underline the importance of adequate vitamin D status among those who have not yet shown any sign of impaired glucose tolerance.

Quality of life and sleep in individuals with irritable bowel syndrome according to different diagnostic criteria and inflammatory bowel diseases: A comparison using data from a population-based survey.

A proportion of irritable bowel syndrome (IBS) affected patients does not fulfil Rome criteria despite considerable impairment similarly to that in patients with organic gastrointestinal diseases.This investigation aims to examine differences regarding Mental (MQoL), Physical Quality of Life (PQoL), and sleep between IBS according to Rome III (IBS Rome), clinically defined IBS, inflammatory bowel diseases (IBD), and non-IBS/non-IBD individuals. Data from SHIP-Trend (Study of Health in Pomerania, 2008-2012), a population-based cohort study in Germany, were used. Response was 50.1% (N = 4420). Prevalence was 3.5% for IBS Rome (95% confidence interval (CI): 3.0-4.1%, n =148), 0.6% for clinically defined IBS (CI: 0.4-0.9%, n=27), and 0.8% for IBD (CI: 0.6 - 1.1%, n = 34). Individuals with IBS Rome (4.54 (CI: -5.92; -3.17)) and clinically defined IBS (4.69 (CI: -7.82; -1.56)) had lower scores for MQoL compared to the non-IBS/non-IBD group. PQoL scores were lowered in IBS Rome (6.39 (CI: -7.89; -4.88)) and IBD (5.37 (CI: -8.51; -2.22)), but not in clinically defined IBS compared to the non-IBS/non-IBD group. IBS Rome was the only gastroenterological condition with higher odds of sleeping problems (odds ratio (OR) "falling asleep": 1.74; CI: 1.29; 2.36; OR "remaining asleep": 1.73; CI: 1.26; 2.38). IBS Rome is associated with reduced MQoL, PQoL, and sleep problems. Clinically defined IBS is associated only with reduced MQoL. Heterogeneity within IBS affected patients should be considered in clinical routine and screening for daily life impairment should be performed.

Prevalence of corneal arcus and associated factors in a German population-Results from the Gutenberg Health Study.

PurposeWe aimed to determine the prevalence of corneal arcus and to identify associated factors in the general population of Germany.MethodsThe Gutenberg Health Study (GHS) is a population-based cohort study in Germany, which includes an ophthalmological assessment. Refraction, distance-corrected visual acuity, non-contact tonometry and anterior segment imaging were performed for the five-year follow-up examination. Anterior segment photographs were graded for the presence of corneal arcus. Prevalence estimates were computed, and multivariable logistic regression analysis was applied to determine associated factors for corneal arcus including sex, age, spherical equivalent, central corneal thickness, intraocular pressure (IOP), socio-economic status, smoking, BMI, systolic and diastolic arterial blood pressure, HbA1c, HDL-C, LDL-C, triglyceride, and lipid modifying agents.ResultsA total of 9,850 right and 9,745 left eyes of 9,858 subjects (59.2±10.8 years), 49.0% females were included in this cross-sectional analysis. 21.1% of men (95%-CI: 20.0%– 22.3%) had a corneal arcus in at least one eye, and 16.9% (95%-CI: 15.9%– 18.0%) of women. In multivariable analyses, the presence of corneal arcus was associated with male gender (OR = 0.54 for female, p<0.0001), higher age (OR = 2.54 per decade, p<0.0001), smoking (OR = 1.59, p<0.0001), hyperopia (OR = 1.05 per diopter, p<0.0001), thinner cornea (OR = 0.994 per μm, p<0.0001), higher IOP (OR = 1.02, p = 0.039), higher HDL-C-level (OR = 2.13, p<0.0001), higher LDL-C-level (OR = 1.21, p<0.0001), and intake of lipid modifying agents (OR = 1.26, p = 0.0001). Arcus was not associated with socio-economic status, BMI, arterial blood pressure, and HbA1c.ConclusionsCorneal arcus is a frequent alteration of the cornea in Germany and is associated with ocular parameters and systemic parameters of dyslipidemia.

Sleep-related difficulties in healthy children and adolescents

BackgroundAs sleep-related difficulties are a growing public health concern, it is important to gain an overview of the specific difficulty areas of the most vulnerable individuals: children. The current descriptive study presents the prevalence of sleep-related difficulties in two large samples of healthy children and adolescents and outlines the effects of age, gender, and socioeconomic status (SES) on various sleep-related difficulties.MethodsParticipants were 855 4–9 year-old children (child sample) and 1,047 10–17 year-old adolescents (adolescent sample) participating 2011–2015 in the LIFE Child study, a population-based cohort study in Germany. Parents of the child participants completed the Children’s Sleep Habits Questionnaire (CSHQ), whereas adolescents self-administered the Sleep Self Report (SSR). Familial SES was determined by a composite score considering parental education, occupational status, and income. Multiple regression analyses were carried out to address the research question.ResultsAmong 4−9 year-old children, the mean bedtime was reported to be 8 p.m., the mean wake-up time 7 a.m., and sleep duration decreased by 14 min/year of age. 22.6 % of the children and 20.0 % of the adolescents showed problematic amounts of sleep-related difficulties. In the child sample, bedtime resistance, sleep onset delay, sleep-related anxiety, night waking, and parasomnia were more frequent in younger than older children. In the adolescent sample, difficulties at bedtime were more frequent among the younger adolescents, whereas daytime sleepiness was more prominent in the older than the younger adolescents. Considering gender differences, sleep-related difficulties were more frequent among boys in the child sample and among girls in the adolescent sample. Lower SES was associated with increased sleep-related difficulties in the adolescent, but not the child sample.ConclusionsThe present results report sleep-related difficulties throughout both childhood and adolescence. Gender differences can already be observed in early childhood, while effects of SES emerge only later in adolescence. The awareness for this circumstance is of great importance for pediatric clinicians who ought to early identify sleep-related difficulties in particularly vulnerable individuals.

Neonatal Outcome After Preeclampsia and HELLP Syndrome: A Population-Based Cohort Study in Germany.

Aim: To analyze short term outcomes of very low birth weight infants (VLBWI) born preterm after maternal preeclampsia and HELLP syndrome within the German Neonatal Network.Methods: The German Neonatal Network is a large population-based cohort study enrolling VLBWI since 2009. Two thousand six hundred and fifty two infants below 32 weeks of gestation born after maternal preeclampsia or HELLP syndrome and 13,383 infants born prematurely for other causes between 2009 and 2018 were included in our analysis. Descriptive statistics and multinomial regression models including preeclampsia and HELLP syndrome were performed for short-term outcome measures such as intracerebral hemorrhage, necrotizing enterocolitis requiring surgery, bronchopulmonary dysplasia, retinopathy of prematurity, periventricular leukomalacia, persistent ductus arteriosus requiring surgery, blood culture positive sepsis and death.Results: After adjustment for confounding variables, preterm birth due to preeclampsia or HELLP syndrome was associated with a reduced risk for intracerebral hemorrhage (OR 0.73, 95% CI 0.60–0.89), necrotizing enterocolitis requiring surgery (OR 0.35 95% CI 0.15–0.82), periventricular leukomalacia (OR 0.61 95% CI 0.40–0.92), and death (OR 0.72 95% CI 0.55–0.96) as compared to other causes of preterm birth.Conclusions: The indication for preterm birth has an impact on neonatal outcome in preterm infants born below 32 weeks. This notion should be included when counseling the families.

Associations between self-reported sleep characteristics and incident mild cognitive impairment: The Heinz Nixdorf Recall Cohort Study

Associations of sleep characteristics with mild cognitive impairment (MCI) have been examined in cross-sectional, but rarely in longitudinal studies. Incident MCI and sleep characteristics were assessed in 1,890 participants of the first and second follow-up of the Heinz Nixdorf Recall study, a population-based cohort study in Germany (age at first follow-up 50−80 years, mean follow-up 5.2 years). MCI was assessed with extensive cognitive tests. Sleep questionnaires including PSQI (Pittsburgh Sleep Quality Index) were used to assess sleep quality, sleep disturbances, time asleep, and time in bed. Relative risks (RR) of developing MCI when exposed to sleep characteristics were assessed in regression models adjusted for sociodemographic and cardiovascular risk factors. Poor sleep quality (PSQI > 5) (RR = 1.43, 95% CI: 1.12−1.82, fully adjusted, reference: PSQI ≤ 5) and difficulties initiating sleep (almost nightly versus never) (RR = 1.40, 0.94−2.08) were associated with incident MCI. For time in bed, the risk of MCI was increased for ≤ 5 hours (RR = 2.86, 1.24─6.60, reference:7 to <8 hours). In this longitudinal study with older participants, MCI risk was increased in persons with poor sleep quality, difficulties initiating sleep, and short time in bed.

The Prevalence of Visual Impairment in the Adult Population.

The distribution of visual impairment is an indicator of the health status of the population and for the frequency of diseases of the eye. The Gutenberg Health Study (GHS) is a population-based cohort study in Germany concerning adults aged 35 to 74. 15 010 subjects from the Mainz-Bingen region underwent general medical and ophthalmological examination, with measurement of the distance-corrected visual acuity in each eye separately. As per the World Health Organization criteria, visual impairment was defined as an acuity below 0.3 in the better eye, and blindness as an acuity below 0.05. All patients who were found to be visually impaired or blind underwent further individual study with clinical history-taking, split-lamp examination, and fundus photography. Data from 14 687 subjects were evaluated. The mean age of the partici- pants was 55.0 years (standard deviation, 11.1 years). The prevalence of visual im- pairment was 0.37% (95% confidence interval [0.28; 0.49]) (n = 55) and was higher in women (0.44%) than in men (0.31%). Blindness was present in 0.05% [0.03; 0.11] (n = 8) of the subjects. The prevalence of visual impairment from age 65 on- ward was 0.79%, three times higher than in the younger age groups. 54.5% of the visually impaired subjects had multiple underlying ophthalmological pathologies. The causes of visual impairment are manifold. Loss of vision is often the combined effect of multiple pathological factors. The etiology of visual impair- ment is thus a more complex matter than is commonly assumed.

Decline in ankle-brachial index is stronger in poorly than in well controlled diabetes: Results from the Heinz Nixdorf Recall cohort study

Background and aimsThe ankle-brachial index (ABI) is a marker of atherosclerosis and a diagnostic criterion for peripheral arterial disease (PAD). We studied the association between HbA1c and ABI in subjects with and without diabetes. MethodsIn the Heinz Nixdorf Recall Study, a population-based cohort study in Germany (N = 4,814, age 45–75 years), ABI was measured at baseline, at 5- and 10-year follow-up. Subjects with ABI <0.9, ABI >1.4 or self-reported PAD at baseline were excluded from analyses. In 3199 participants, we assessed associations between HbA1c and incident PAD (ABI < 0.9) and change in ABI, respectively, using logistic and linear regression models. Subjects without diabetes, with HbA1c < 5.7% were used as reference group. ResultsCompared to the reference group, 10-year decline in ABI was −0.066 (95% confidence interval: −0.117; −0.016) and −0.021 (−0.063; 0.021) in subjects with poorly (≥7.0% HbA1c) and well (<7.0% HbA1c) controlled previously known diabetes; −0.010 (−0.054; 0.034) in those with newly detected diabetes diagnosed by HbA1c ≥ 6.5%, and −0.005 (−0.023; 0.013) in those without diabetes, with HbA1c 5.7–6.4%. For poorly controlled diabetes, odds ratios for low ABI (<0.9) were 3.5 (1.6–7.9), and 3.1 (1.3–7.0) after 5- and 10-year follow-up, respectively. The incidence of Mönckeberg disease (ABI > 1.4) was low (6/288 (2.4%) over 5 years). ConclusionsDecline in ABI was stronger in poorly than well-controlled diabetes. Subjects with newly detected diabetes diagnosed by the new HbA1c criterion (≥6.5%) did not show an increased decline in ABI over 10 years.

Risk Profiles for Care Dependency: Cross-Sectional Findings of a Population-Based Cohort Study in Germany.

Background: Rising life expectancy in Western societies is accompanied by a rising incidence of care dependency (CD) among older people. Objective: The aim of the study was to examine which health-related and social determinants were associated with CD. Method: We used cross-sectional data from the first follow-up (N = 1,699) of a prospective, population-based cohort study of older participants (≥70 years). CD was assessed if participants required substantial assistance in at least two activities of daily living for 90+ minutes daily. Multivariate logistic regressions were applied. Results: Participants’ mean age was 82 years; 18.9% were care-dependent. CD was significantly associated with older age, urinary incontinence, stroke, falls, cancer, diabetes, education level, having no partner, limited mobility, and limited physical activity. Discussion: Our research highlights the importance of promoting mobility, even in care-dependent people. Further research should investigate the role of partnership in terms of the prevention and delay of CD.

Associations of metabolically healthy obesity with prevalence and progression of coronary artery calcification: Results from the Heinz Nixdorf Recall Cohort Study

Background and aimsThere is controversy on the potentially benign nature of metabolically healthy obesity (MHO), i.e., obese persons with few or no metabolic abnormalities. So far, associations between MHO and coronary artery calcification (CAC), a measure of subclinical atherosclerosis, have mainly been studied cross-sectionally in Asian populations. We assessed cross-sectional and longitudinal MHO CAC associations in a Caucasian population. Methods and resultsIn the Heinz Nixdorf Recall Study, a population-based cohort study in Germany, CAC was assessed by electron-beam tomography at baseline and at 5-year follow-up. For cross-sectional and longitudinal analyses, we included 1585 participants free of coronary heart disease at baseline, with CAC measurements at baseline and at follow-up, and with either normal weight (BMI 18.5–24.9 kg/m2) or obesity (BMI ≥30.0 kg/m2) at baseline. We used four definitions of MHO. In our main analysis, we defined obese persons as metabolically healthy if they met ≤1 of the NCEP ATP III criteria for the definition of the metabolic syndrome – waist circumference was not taken into account because of collinearity with BMI.Persons with MHO had a higher prevalence of CAC than metabolically healthy normal weight (MHNW) persons (prevalence ratio = 1.59 (95% confidence interval 1.38–1.84) for the main analysis). Persons with MHO had slightly larger odds of CAC progression than persons with MHNW (odds ratios ranged from 1.17 (0.69–1.99) to 1.48 (1.02–2.13) depending on MHO definition and statistical approach). ConclusionOur analyses on MHO CAC associations add to the evidence that MHO is not a purely benign health condition.

Sleep characteristics and progression of coronary artery calcification: Results from the Heinz Nixdorf Recall cohort study

Background and aimsSleep characteristics are associated with incident cardiovascular diseases (CVD), but there is a lack of studies on the association between sleep characteristics and incidence/progression of coronary artery calcification (CAC). MethodsIn the Heinz Nixdorf Recall Study, a population-based cohort study in Germany, CAC was assessed by electron-beam tomography at baseline and at 5-year follow-up. In an analysis set of 3043 subjects (age at baseline 45–74 years; 47% men), we fitted logistic and linear regression models to assess associations between self-rated sleep characteristics (nocturnal and total sleep duration; napping; various sleep disorders) and CAC incidence/CAC progression. Progression was measured as 5-year progression factor, as categories of absolute CAC change, and additionally characterized as rapid or slow compared to an extrapolation of baseline CAC values. ResultsWe observed barely any association between sleep characteristics and CAC progression regardless of the chosen statistical approach; associations between sleep and CAC incidence were slightly larger, e.g., the geometric mean of the 5-year CAC progression factor was 6.8% (95% confidence interval: −9.5; 25.9) larger for ≤5 h, 2.9% (−7.3; 14.3) larger for 5.1–6.9 h and 7.1% (−2.4; 15.7) smaller for ≥7.5 h total sleep compared to 7- <7.5 h total sleep. For subjects with any regular sleep disorder, the geometric mean of the 5-year CAC progression was 3.5% (−4.7; 11.2) smaller compared to subjects without any regular sleep disorder. ConclusionsIn this German cohort study, sleep characteristics were barely associated with CAC progression.

Progression of coronary artery calcification is stronger in poorly than in well controlled diabetes: Results from the Heinz Nixdorf Recall Study

AimTo assess associations between HbA1c and progression of coronary artery calcification (CAC) in persons with and without diabetes. MethodsIn the Heinz Nixdorf Recall Study, a population-based cohort study in Germany (N=3453, aged 45–74years), CAC was assessed by electron-beam tomography at baseline and at 5-year follow-up. At baseline, participants were divided into five groups: poorly (HbA1c≥7.0%) and well (HbA1c<7.0%) controlled previously known diabetes (group I/II); no previously known diabetes with HbA1c ≥6.5% (group III), HbA1c 5.7–6.4% (group IV), and HbA1c <5.7% (group V). We fitted linear, logistic and robust Poisson regression models to assess associations between diabetes group and PF5 (factor by which CAC after 5-year follow-up is larger than baseline CAC), and categories of CAC change, respectively. ResultsRelative to group V, adjusted percentage increase of the geometric mean of PF5 (95% CI) was: 69.1% (33.9%;113.6%), 15.4% (−5.6%;41.1%), −4.1% (−22.2%;18.2%), 4.2% (−5.4%;14.8%) for groups I–IV, respectively. The corresponding odds ratios for annual CAC increase ≥100 Agatston units (reference: <10) were 10.0 (4.8;20.6), 4.0 (2.1;7.6), 1.5 (0.7;3.2), and 1.1 (0.7;1.8). ConclusionsIn known diabetes, CAC progression was stronger in poor diabetes control. For newly detected diabetes diagnosed by HbA1c ≥6.5%, associations with CAC progression were weak.

Invitation to cervical cancer screening does increase participation in Germany: Results from the MARZY study.

The effect of different invitation models on participation in cervical cancer screening (CCS) was investigated in a randomized population-based cohort study in Germany. Participants were randomly selected via population registries and randomized into intervention Arm A (invitation letter) and Arm B (invitation letter and information brochure) or control Arm C (no invitation). The intervention and control arms were compared with regard to 3-year participation and the two invitation models were compared between intervention arms. Of the 7,758 eligible women aged 30-65 years, living in the city of Mainz and in the rural region of Mainz-Bingen, 5,265 were included in the analysis. Differences in proportions of women attending CCS were investigated and logistic regression was performed to analyze various factors influencing participation. In the intervention group, 91.8% participated in CCS compared to 85.3% in the control group (p < 0.0001), with a 6.6 percentage point increase in participation [95% confidence interval (CI) 4.6-8.6] and an adjusted odds ratio (OR) of 2.69 (95% CI 2.15-3.37). Effect estimators increased to 21.9 percentage points (95% CI 16.7-27.1) and an OR of 3.64 (95% CI 2.74-4.82), respectively, when women who participated in screening annually were excluded from the analysis. The invitation letter was particularly effective among women with lower school education, migrant women and older women. No difference in participation was found between the intervention Arm A and Arm B. An accompanying information brochure did not motivate more women to undergo CCS. However, a written invitation statistically significantly increased participation in CCS in Germany.

Associations among sleep disturbances, nocturnal sleep duration, daytime napping, and incident prediabetes and type 2 diabetes: the Heinz Nixdorf Recall Study

ObjectivePoor sleep quality as well as short and long sleep duration has been linked to type 2 diabetes. In addition to confirmational analyses, we examined the impact of daytime napping on incident diabetes, and we assessed associations between sleep characteristics and incident prediabetes. MethodsIn a subgroup of the Heinz Nixdorf Recall Study, a population-based cohort study in Germany (N = 2962; age 45–75 years, without history of cancer, stroke, or cardiovascular diseases), diabetes at baseline and at 5-year follow-up was assessed by self-report and measurement of serum glucose levels. Prediabetes was defined as impaired fasting glucose (6.1–6.9 mmol/L). A sleep questionnaire was used to assess difficulties falling asleep, difficulties maintaining sleep, early morning arousal, and duration of nocturnal and daytime sleep. ResultsIn adjusted regression models, short (≤5 hours) and long (≥7.5 hours) sleepers were at greater risk for diabetes (relative risk [RR] = 1.56, 95% confidence interval [CI] = 1.02–2.39, and 1.40, 95% CI = 1.01–1.96, respectively [reference: 7 hours]). Moreover, the prevalence of any regular sleep disorder was associated with incident diabetes (RR = 1.30, 95% CI = 1.01–1.68), and with incident prediabetes (RR = 1.31, 95% CI = 1.00–1.72). Regular daytime nappers had no increased risk of incident diabetes (RR = 1.00, 95% CI = 0.70–1.41). ConclusionThis study shows that people with regular sleep disorders, people with short and long sleep duration, but not regular daytime nappers are at increased risk of diabetes. Furthermore, regular sleep disorders are associated with an increased risk of prediabetes.

Body mass index and leukocyte telomere length dynamics among older adults: Results from the ESTHER cohort

ObjectiveTelomere length (TL) has been proposed as a biomarker of ageing, which might be used to identify individuals at higher risk of age-related diseases. Obesity is a well-known risk factor for several diseases. This study aims to analyse the associations of BMI with TL and the rate of TL change in older adults. MethodsLeukocyte TL (LTL) was measured by quantitative PCR in blood samples of 3600 older adults aged 50–75years obtained at the baseline examination of a population-based cohort study in Germany. For longitudinal analyses, measurements were repeated in blood samples obtained at 8-year follow-up from 1000 participants. Multivariate linear regression models were used to estimate associations of BMI with LTL and changes in LTL over time. ResultsLTL was inversely associated with age (r=−0.090, p<0.0001). BMI and LTL associations varied according to age (p for interaction=0.021). BMI was significantly inversely associated with LTL in those younger than 60years (−6basepairs per 1kg/m2 difference in BMI). In particular, weight gain during adulthood was inversely associated with LTL in a dose–response manner in this age group, with those having gained ≥30kg having significantly shorter telomeres (−209basepairs) than those who maintained their weight. No clear patterns were observed between any of BMI-related variables and the rate of LTL change. ConclusionsOur cross-sectional analysis supports suggestions that weight gain during adulthood and obesity may contribute to shorter telomere length below 60years of age, but this relationship could not be shown longitudinally.

Smoking habits and leukocyte telomere length dynamics among older adults: Results from the ESTHER cohort

Background & aimsLeukocyte telomere length (LTL) shortens with age and short LTL has been associated with increased mortality and increased risk for some age-related outcomes. This study aims to analyse the associations of smoking habits with LTL and rate of LTL change per year in older adults. MethodsLTL was measured by quantitative PCR at baseline in 3600 older adults, who were enrolled in a population-based cohort study in Germany. For longitudinal analyses, measurements were repeated in blood samples obtained at 8-year follow-up from 1000 participants. Terminal Restriction Fragment analysis was additionally performed in a sub-sample to obtain absolute LTL in base pairs. Multivariate linear regression models were used to estimate associations of smoking habits with baseline LTL and changes in LTL over time. ResultsLTL was inversely associated with age (r=−0.090, p<0.0001). Women had longer LTL than men (p<0.0001). Smoking was inversely associated with LTL. On average, current smokers had 73 base pairs (BP) shorter LTL compared to never smokers. Smoking intensity and pack-years of smoking were also inversely associated with LTL, and a positive association was observed with years since smoking cessation. Slower LTL attrition rates were observed in ever smokers over 8years of follow-up. ConclusionsOur cross-sectional analysis supports suggestions that smoking might contribute to shortening of LTL but this relationship could not be shown longitudinally. The overall rather small effect sizes observed for smoking-related variables suggest that LTL reflects smoking-related health hazards only to a very limited extent.