Gert Mensink

Health-enhancing physical activity during leisure time amongadults in Germany

Self-reported data from the GEDA 2014/2015-EHIS study was used to calculate the level of compliance among adults in Germany with the World Health Organization’s (WHO) recommendations on physical activity. The WHO’s recommendations distinguish between ‘aerobic activity’ and ‘muscle-strengthening activity’. In Germany, 42.6% of women and 48.0% of men reported that they conduct at least 2.5 hours of aerobic physical activity per week, and therefore meet the WHO’s recommendation on this form of activity. A higher level of education among women and men of all ages is associated with a higher frequency of meeting the WHO’s recommendations on aerobic activity. In addition, 27.6% of women and 31.2% of men conduct muscle-strengthening activity at least twice a week, thereby meeting the WHO’s recommendations on this form of activity. About one fifth of women (20.5%) and one quarter of men in Germany (24.7%) meet both of these recommendations. In summary, the results point to the value of encouraging people to conduct more physical activity during their leisure time. In fact, inactive people who begin to follow the WHO’s recommendations can significantly reduce their long-term risk of premature mortality. PHYSICAL ACTIVITY · PHYSICAL ACTIVITY RECOMMENDATIONS · ADULTS · GERMANY · HEALTH MONITORING Introduction Physical activity is defined as any bodily movement generated by the skeletal muscles that requires more energy to be consumed than the basal metabolic rate [1]. Health-enhancing physical activity includes aerobic activity (endurance activity) such as cycling, jogging, playing football or swimming that increases breathing and heart rate and is undertaken without interruption for at least 10 minutes [2]. Aerobic activity provides an important contribution to the maintenance and recovery of the health of the cardiovascular and metabolic system [3, 4]. Muscle-strengthening activity such as strength training, Pilates and yoga is also beneficial to health, as it increases the performance and health of the human musculoskeletal system, skeletal muscles, joints, bones, tendons and ligaments [2, 4]. In contrast, a lack of physical activity increases the risks of developing the most important non-communicable diseases such as heart disease, type 2 diabetes mellitus, and breast and colorectal cancer, and it also reduces life expectancy [5]. According to the 2015 Global Burden of Disease Study, physical inactivity in Germany contributes to a significant reduction in life expectancy and quality of life. Specifically, physical inactivity was found to be linked to 10% of the years lost due to coronary heart disease, 17% of the years lost due to diabetes mellitus, 15% of the years lost due to colorectal Journal of Health Monitoring Health-enhancing physical activity during leisure time among adults in Germany Journal of Health Monitoring 2017 2(2) FACT SHEET 36 cancer and 10% of the years lost due to breast cancer [6]. As insufficient levels of physical activity are associated with disease, the World Health Organization (WHO) formulated the goal of reducing the prevalence of insufficient physical activity (defined as less than 2.5 hours of moderateto vigorous-intensity physical activity per week) as part of the Global Action Plan for the Prevention and Control of Non-Communicable Diseases 20132020. The aim is to ensure that levels of insufficient physical activity are 10% lower than 2010 levels by 2025 [7]. Indicator The WHO’s recommendations on physical activity differentiate between ‘aerobic activity’ and ‘muscle-strengthening activity’ [2, 8]. Adherence to these recommendations among the population in Germany [8] was assessed with the validated German version of the European Health Interview Survey – Physical Activity Questionnaire (EHIS-PAQ) used for the German Health Update (GEDA 2014/2015-EHIS) survey [9, 10]. As part of this study, respondents were asked about the duration of the physical activity they undertake during a typical week, in the form of both moderate-intensity aerobic physical activity conducted during leisure time and cycling used for transportation, as well as the number of days a week during which they undertake muscle-strengthening activities. Details about the way in which these indicators were constructed have been published elsewhere [10]. The following describes the proportion of respondents who conduct at least moderate-intensity aerobic activities for at least 2.5 hours a week (the first part of the WHO’s recommendations on physical activity), as well as those who conduct muscle-strengthening activities on at least two days a week (the second part of the WHO’s recommendations), and the proportion of those who meet both parts of the WHO’s recommendations (2.5 hours of aerobic activity, as well as muscle-strengthening activities twice a week). The figures are stratified according to gender, age, level of education and federal state. A difference between these groups is interpreted as statistically significant where confidence intervals do not overlap. The analyses are based on data from 22,959 participants aged 18 years and above (12,511 women, and 10,448 men) with valid EHIS-PAQ data. The calculations were carried out using a weighting factor that corrects for deviations within the sample from the structure of the German population (as of 31 December 2014) with regard to gender, age, community type and education. The community type reflects the degree of urbanisation and corresponds to the regional distribution in Germany. The International Standard Classification for Education (ISCED) was used to ensure the respondents’ responses on education were comparable [11]. A detailed description of the methodology applied in GEDA 2014/2015EHIS can be found in the article German Health Update: New data for Germany and Europe in issue 1/2017 of the Journal of Health Monitoring. Results and discussion According to results from the GEDA 2014/2015-EHIS study, 42.6% of women and 48.0% of men meet the WHO’s recommendation on aerobic activity (Tables 1 and Table 2). 56.7% of men aged between 18 and 29 meet GEDA 2014/2015-EHIS Data holder: Robert Koch Institute Aims: To provide reliable informa tion about the population’s health status, health-related behaviour and health care in Germany, with the possibility of a European comparison Method: Questionnaires completed on paper or online Population: People aged 18 years and above with permanent residency in Germany Sampling: Registry office sample; randomly selected individuals from 301 communities in Germany were invited to participate Participants: 24,016 people (13,144 women; 10,872 men) Response rate: 26.9% Study period: November 2014 July 2015 Data protection: This study was undertaken in strict accordance with the data protection regulations set out in the German Federal Data Protection Act and was approved by the German Federal Commissioner for Data Protection and Freedom of Information. Participation in the study was voluntary. The participants were fully informed about the study’s aims and content, and about data protection. All participants provided written informed consent. More information in German is available at www.geda-studie.de Journal of Health Monitoring Health-enhancing physical activity during leisure time among adults in Germany Journal of Health Monitoring 2017 2(2) FACT SHEET 37 the WHO’s recommendations on aerobic activity; the same can be said of around 45% of men in other age groups. Among women, compliance with the recommendations is highest in the 45-to-64 age group (47.8%). No uniform pattern can be observed among women in terms of age distribution. A smaller proportion of women (27.6%) and men (31.2%) meet the WHO’s recommendation on muscle-strengthening activity. About one fifth of women (20.5%) and one quarter of men (24.7%) meet both recommendations. An association exists between level of education and health-enhancing aerobic physical activity among women Table 1 Health-enhancing physical activity during leisure time among women according to age and educational status (n=12,511) Source: GEDA 2014/2015-EHIS 42.6% of women and 48.0% of men in Germany meet the World Health Organization’s recommendations on aerobic activity by undertaking at least 2.5 hours of aerobic physical activity per week. and men of all age groups: the proportion of adults who meet the recommendations on physical activity is lower in groups with lower levels of education compared to those with the higher levels of education (Table 1 and Table 2). The proportion of women in Thuringia who meet the recommendations on aerobic activity is below the national average; in Hamburg, it is above the national average. The proportion of men in Mecklenburg-West Pomerania and Saxony who meet the recommendations on aerobic activity is below the national average; in Bremen, it is above the national average (Figure 1). Women Aerobic activity at least 2.5 hours per week Muscle-strengthening activity at least 2 times a week Aerobic and muscle-strengthening activity recommendations compliance % (95% CI) % (95% CI) % (95% CI) Women total 42.6 (41.3-43.9) 27.6 (26.7-28.6) 20.5 (19.6-21.4) 18-29 Years 45.2 (42.3-48.2) 34.5 (32.1-37.0) 25.8 (23.6-28.2) Low education 40.1 (34.2-46.3) 29.5 (24.3-35.3) 21.9 (17.2-27.3) Medium education 44.4 (40.6-48.2) 35.8 (32.6-39.1) 26.0 (23.1-29.1) High education 55.0 (49.6-60.2) 35.6 (31.5-40.0) 29.3 (25.1-33.8) 30-44 Years 38.8 (36.7-41.0) 21.1 (19.5-22.9) 16.3 (14.8-17.9) Low education 34.2 (27.7-41.5) 12.7 (8.9-17.7) 11.1 (7.5-16.1) Medium education 36.7 (34.0-39.5) 20.2 (18.1-22.5) 15.0 (13.1-17.1) High education 46.4 (42.9-49.8) 28.1 (25.0-31.3) 22.3 (19.5-25.4) 45-64 Years 47.8 (46.0-49.6) 29.4 (27.9-30.9) 22.7 (21.3-24.2) Low education 44.3 (39.7-49.1) 26.1 (22.5-30.1) 20.0 (16.7-23.7) Medium education 46.5 (44.3-48.8) 29.3 (27.4-31.2) 22.4 (20.6-24.2) High education 55.0 (51.5-58.3) 32.7 (30.2-35.4) 26.2 (23.8-28.7) ≥ 65 Years 36.5 (34.0-39.1) 26.

Gesundheitsfördernde körperliche Aktivität in der Freizeitbei Erwachsenen in Deutschland

Auf Basis der Selbstangaben in GEDA 2014/2015-EHIS wurde die Einhaltung der Bewegungsempfehlungen der Weltgesundheitsorganisation (WHO) bei Erwachsenen in Deutschland ermittelt. Die Empfehlungen unterscheiden zwischen „Ausdaueraktivitäten“ und „Aktivitäten zur Muskelkräftigung“. 42,6 % der Frauen und 48,0 % der Männer geben an, mindestens 2,5 Stunden pro Woche aerobe körperliche Aktivität auszuüben und erreichen dadurch die WHO-Empfehlung zur Ausdaueraktivität. Für alle Altersgruppen bei Frauen und Männern gilt: Je höher der Bildungsstand, desto häufiger wird die WHO-Empfehlung zur Ausdaueraktivität erreicht. 27,6 % der Frauen und 31,2 % der Männer erreichen die WHO-Empfehlung für muskelkräftigende Aktivitäten mindestens zweimal pro Woche. Beide Empfehlungen erreichen etwa ein Fünftel der Frauen (20,5 %) und ein Viertel der Männer (24,7 %). Insgesamt weisen die Ergebnisse auf ein hohes Potenzial für die Bewegungsförderung in der Freizeit hin. Inaktive Personen, die beginnen sich den Empfehlungen entsprechend zu bewegen, können langfristig das Risiko frühzeitiger Sterblichkeit deutlich reduzieren. KÖRPERLICHE AKTIVITÄT · BEWEGUNGSEMPFEHLUNGEN · ERWACHSENE · DEUTSCHLAND · GESUNDHEITSMONITORING Einleitung Als körperliche Aktivität wird jede Bewegung definiert, die durch die Skelettmuskulatur erzeugt wird und den Energieverbrauch über den Grundumsatz anhebt [1]. Zu gesundheitsfördernden Aktivitäten gehören einerseits aerobe körperliche Aktivitäten (Ausdaueraktivitäten) wie Radfahren, Joggen, Fußballspielen oder Schwimmen, die eine erhöhte Atemund Herzfrequenz erzeugen und über einen Zeitraum von mindestens 10 Minuten ohne Unterbrechung ausgeübt werden [2]. Diese Aktivitäten leisten einen wichtigen Beitrag zur Erhaltung bzw. Wiedererlangung der Gesundheit des Herz-Kreislaufund Stoffwechselsystems [3, 4]. Andererseits wirken auch Aktivitäten zur Muskelkräftigung wie Krafttraining, Pilates oder Yoga gesundheitsfördernd, da diese die Leistungsfähigkeit und Gesundheit des Bewegungsapparates, der Skelettmuskeln, Gelenke, Knochen, Sehnen und Bänder fördern [2, 4]. Körperliche Inaktivität erhöht das Risiko für die wichtigsten nicht-übertragbaren Erkrankungen wie Herz-Kreislauf-Erkrankungen, Diabetes mellitus Typ 2, Brustund Darmkrebs und reduziert die Lebenserwartung [5]. Nach der Global Burden of Disease Study 2015 trägt körperliche Inaktivität in Deutschland zu einer erhebAutorinnen und Autoren: Jonas D. Finger, Gert B.M. Mensink, Cornelia Lange, Kristin Manz Journal of Health Monitoring · 2017 2(2) DOI 10.17886/RKI-GBE-2017-027 Robert Koch-Institut, Berlin Journal of Health Monitoring Gesundheitsfördernde körperliche Aktivität in der Freizeit bei Erwachsenen in Deutschland

Socioeconomic Correlates and Determinants of Cardiorespiratory Fitness in the General Adult Population: a Systematic Review and Meta-Analysis

BackgroundThis review aims to (1) consolidate evidence regarding the association between socioeconomic status (SES) and cardiorespiratory fitness (CRF), (2) conduct a meta-analysis of the association between SES and CRF using methodologically comparable data, stratified by sex, and (3) test whether the association varies after adjustment for physical activity (PA).MethodsA systematic review of studies from MEDLINE, EMBASE, Latin American and Caribbean Health Sciences (LILACS), Scientific Electronic Library Online (ScIELO), and Cochrane Library without time or language restrictions, which investigated associations between SES and CRF. Risk of bias within studies was assessed using a customized quality assessment tool. Results were summarized in table format and methodologically similar studies were synthesized using meta-analysis of Hedges’ g effect sizes. Synthesized results were appraised for cross-study bias. Results were tested for the impact of PA adjustment using meta-regression.ResultsCompared to individuals with low education, both men and women showed higher CRF among individuals with high education (men 0.12 [0.04–0.20], women 0.19 [0.02–0.36]), while participants with medium education showed no significant difference in CRF (men 0.03 [− 0.04–0.11], women 0.09 [− 0.03–0.21]). Adjustment for PA did not significantly impact the association between education and CRF.ConclusionsThere is fair evidence for an association between high levels of education and increased CRF. This could have implications for monitoring, of health target compliance and of chronic disease risk among higher risk populations, to detect and prevent non-communicable diseases (NCDs) and to diminish social health inequalities.Trial RegistrationPROSPERO, CRD42017055456

Konsum zuckerhaltiger Erfrischungsgetränke bei Kindern undJugendlichen in Deutschland – Querschnittergebnisse ausKiGGS Welle 2 und Trends

Ein hoher Konsum zuckerhaltiger Getränke wird mit der Entwicklung von Adipositas, Diabetes mellitus Typ II und weiteren chronischen Krankheiten in Verbindung gebracht. Mit den Daten aus KiGGS Welle 2 (2014 – 2017) wird der aktuelle Konsum zuckerhaltiger Erfrischungsgetränke bei 3bis 17-Jährigen in Deutschland dargestellt. Insgesamt trinken 13,7 % der Mädchen und 17,6 % der Jungen einbis dreimal und 3,3 % der Mädchen beziehungsweise 4,7 % der Jungen viermal oder häufiger am Tag zuckerhaltige Erfrischungsgetränke. Die Konsumhäufigkeit steigt mit zunehmendem Alter und ist bei Kindern und Jugendlichen mit niedrigem sozioökonomischen Status (SES) höher als bei Gleichaltrigen mit hohem SES. Der Anteil der Heranwachsenden, die täglich zuckerhaltige Erfrischungsgetränke trinken, hat sich gegenüber der KiGGS-Basiserhebung (2003 – 2006) verringert. ERFRISCHUNGSGETRÄNKE · GETRÄNKEKONSUM · GESUNDHEITSSURVEY · KINDER UND JUGENDLICHE · KIGGS Hintergrund Als Risikofaktor für Übergewicht und Adipositas steht der Konsum zuckerhaltiger Getränke in den letzten Jahren vermehrt im wissenschaftlichen und politischen Fokus [1]. Der hohe Konsum von zuckerhaltigen Erfrischungsgetränken bei Kindern und Jugendlichen zeigt in vielen Studien einen Zusammenhang mit einer Gewichtszunahme [2]. Eine ausreichende Flüssigkeitsaufnahme ist zwar wichtig, wird der Bedarf jedoch überwiegend über zuckerhaltige Erfrischungsgetränke gedeckt, kann dies langfristig zu einer Gewichtszunahme führen. Es werden relativ hohe Energiemengen aufgenommen, ohne entsprechend zur Sättigung beizutragen. Wird diese zusätzliche Kalorienzufuhr in der Energiebilanz nicht ausgeglichen, kann langfristig Übergewicht entstehen. Ein hoher Konsum von zuckerhaltigen Erfrischungsgetränken erhöht auch das Risiko eines Diabetes mellitus Typ II [3]. Durch den Konsum steigt der Blutzuckerspiegel schnell an und eine erhöhte Menge Insulin wird ausgeschüttet. Es kommt zu größeren Schwankungen des Blutzuckerspiegels, was die insulinbildenden Zellen in der Bauchspeicheldrüse langfristig schädigen kann. Daneben ist der Konsum zuckerhaltiger Getränke eine Belastung für die Zähne, da der Zucker sowie die den Erfrischungsgetränken vielfach zugesetzte Säure den Zahnschmelz angreifen und die Bildung von Karies fördern kann [4]. Darüber hinaus weisen Studien darauf hin, dass ein Zusammenhang zwischen der Zufuhr von zuckerhaltigen Getränken und einer VerrinJournal of Health Monitoring · 2018 3(1) DOI 10.17886/RKI-GBE-2018-007 Robert Koch-Institut, Berlin Gert B. M. Mensink, Anja Schienkiewitz, Martina Rabenberg, Anja Borrmann, Almut Richter, Marjolein Haftenberger Robert Koch-Institut, Berlin Abteilung für Epidemiologie und Gesundheits-

Alcohol consumption and cardiorespiratory fitness in five population-based studies:

Background Poor cardiorespiratory fitness is a risk factor for cardiovascular morbidity. Alcohol consumption contributes substantially to the burden of disease, but its association with cardiorespiratory fitness is not well described. We examined associations between average alcohol consumption, heavy episodic drinking and cardiorespiratory fitness. Design The design of this study was as a cross-sectional population-based random sample. Methods We analysed data from five independent population-based studies (Study of Health in Pomerania (2008–2012); German Health Interview and Examination Survey (2008–2011); US National Health and Nutrition Examination Survey (NHANES) 1999–2000; NHANES 2001–2002; NHANES 2003–2004) including 7358 men and women aged 20–85 years, free of lung disease or asthma. Cardiorespiratory fitness, quantified by peak oxygen uptake, was assessed using exercise testing. Information regarding average alcohol consumption (ethanol in grams per day (g/d)) and heavy episodic drinking (5+ or 6+ drinks/occasion) was obtained from self-reports. Fractional polynomial regression models were used to determine the best-fitting dose-response relationship. Results Average alcohol consumption displayed an inverted U-type relation with peak oxygen uptake (p-value<0.0001), after adjustment for age, sex, education, smoking and physical activity. Compared to individuals consuming 10 g/d (moderate consumption), current abstainers and individuals consuming 50 and 60 g/d had significantly lower peak oxygen uptake values (ml/kg/min) (β coefficients = −1.90, β = −0.06, β = −0.31, respectively). Heavy episodic drinking was not associated with peak oxygen uptake. Conclusions Across multiple adult population-based samples, moderate drinkers displayed better fitness than current abstainers and individuals with higher average alcohol consumption.

Work-related physical activity among adults in Germany

In GEDA 2014/2015-EHIS the prevalence of work-related physical activity was estimated based on respondents’ self-reported data. 47.5% of women and 47.2% of men mostly sit or stand during work. The highest proportion of people who mostly sit or stand during work is found among 18to 29-year-old women (55.5%) and men aged 30 to 44 (50.2%). A significantly higher proportion of men (14.8%) than women (3.2%) have jobs involving mostly heavy manual labour. For both genders, the higher a person’s level of education, the more likely it is that physical activity during work is limited to sitting or standing. The results highlight great potential to promote physical activity. PHYSICAL INACTIVITY · WORK · SITTING · ADULTS · HEALTH MONITORING Introduction Physical activity is any movement by the skeletal muscles that increases the body’s energy expenditure beyond the basal metabolic rate (BMR) [1]. Physically non-demanding activities performed whilst sitting or standing hardly raise energy expenditure beyond the BMR [2]. Sitting for long hours, as is normal in office jobs, constitutes a risk factor for non-communicable diseases [3, 4]. According to current estimates, the general mortality risk for adults increases by 2% for every hour spent sitting per day [4]. Where employment involves physical activity, such as for example in agriculture, work-related physical activity is often a person’s greatest expenditure of energy, as working days usually comprise eight-hour shifts [5]. Whilst work-related physical activity has health benefits, these are not as great as the health benefits of aerobic physical exercise during leisure time [6-8]. The reason is that work-related physical activity is often repetitive, and usually involves working overhead and carrying heavy objects. This can increase muscular strength, yet hardly improves aerobic endurance capacity [9-11]. Endurance capacity improves during aerobic leisure activities such as jogging and swimming, and is particularly important with regard to preventing non-communicable diseases (such as cardiovascular diseases, certain types of cancer or diabetes) and their underlying cardiometabolic risk factors (such as hypertension, lipometabolic disorders and obesity) [12]. Due to the high relevance of physical inactivity as a contributing factor to disease development, the World Health Organization (WHO), in its Global Action Plan for the Prevention and Control of Non-Communicable-Diseases 2013-2020, established the goal of a 10% relative reduction in prevalence of insufficient physical activity by 2025 (compared with 2010) [13]. Authors: Jonas D. Finger, Gert B. M. Mensink, Cornelia Lange, Kristin Manz Journal of Health Monitoring · 2017 2(2) DOI 10.17886/RKI-GBE-2017-039 Robert Koch Institute, Berlin Journal of Health Monitoring Journal of Health Monitoring 2017 2(2) FACT SHEET 29 Work-related physical activity among adults in Germany Indicator Using a validated German version of the European Health Interview Survey – Physical Activity Questionnaires (EHISPAQ), the German Health Update (GEDA 2014/2015EHIS) survey for the first time measured work-related physical activity [14, 15]. In GEDA 2014/2015-EHIS, respondents were asked: ‘When you work, what best describes what you do? (a) mostly sitting or standing; (b) mostly walking or tasks of moderate physical effort; (c) mostly heavy labour or physically demanding work, or (d) not performing any working tasks.’ Work, here, encompasses not only paid but also unpaid work (for example, studying or housework). Respondents were asked to select only one answer. For the purpose of the analysis presented here, these four answers on work-related physical activity for the 18-to-64 age group were stratified by gender, age group, level of education and federal state. A statistically significant difference between groups is assumed when confidence intervals do not overlap. The analyses are based on the data received from 18,026 participants of working age, aged 18-to-64 (10,146 women and 7,880 men) with valid data in EHIS-PAQ. Calculations were carried out using a weighting factor that corrects for deviations within the sample from the German population (as of 31 December 2014) with regard to gender, age, community type and education. The community type accounts for the degree of urbanisation and reflects the regional distribution in Germany. The International Standard Classification for Education (ISCED) was used to ensure that the responses provided on educational levels were comparable [16]. A detailed description of the methodology applied in the GEDA 2014/2015-EHIS study can be found in the article German Health Update – New data for Germany and Europe in issue 1/2017 of the Journal of Health Monitoring. Results and discussion Nearly half of all women (47.5%) and men (47.2%) of working age (18 to 64) stated that they sit or stand most of the time during work and therefore spend many hours per day physically inactive. Among women, the prevalence of work-related physical inactivity (mostly sitting or standing) is highest in the 18-to-29 age group (55.5%) (Table 1). Among men, it is highest in the 30-to-44 age group (50.2%) (Table 2). Compared with women, men nearly five times as often reported being employed in jobs that involve mostly heavy manual labour. The observed regional and educational differences in work-related physical activity are stronger among men than among women (Table 1 and Table 2; Figure 1). In all age groups, men with higher levels of education responded nearly twice as often as men with lower levels of education that they mostly sit or stand during work. The highest value for mostly sitting or standing during work was found in 30to 44-year-old men with higher education levels (79.7%). Conversely, men with lower education levels are seven times as likely to state that their work implies heavy manual labour than those with higher levels of education. The same is true for women: the higher their level of education, the more likely they are to work sitting or standing. For women in Hamburg, the amount of work-related physical inactivity is statistically significantly higher than the German average. For men in Thuringia, MecklenGEDA 2014/2015-EHIS Data holder: Robert Koch Institute Aims: To provide reliable informa tion about the population’s health status, health-related behaviour and health care in Germany, with the possibility of a European comparison Method: Questionnaires completed on paper or online Population: People aged 18 years and above with permanent residency in Germany Sampling: Registry office sample; randomly selected individuals from 301 communities in Germany were invited to participate Participants: 24,016 people (13,144 women; 10,872 men) Response rate: 26.9% Study period: November 2014 July 2015 Data protection: This study was undertaken in strict accordance with the data protection regulations set out in the German Federal Data Protection Act and was approved by the German Federal Commissioner for Data Protection and Freedom of Information. Participation in the study was voluntary. The participants were fully informed about the study’s aims and content, and about data protection. All participants provided written informed consent. More information in German is available at www.geda-studie.de Journal of Health Monitoring Work-related physical activity among adults in Germany Journal of Health Monitoring 2017 2(2) FACT SHEET 30 Table 2 Physical activity during work among men according to age and educational status (n=7,880) Source: GEDA 2014/2015-EHIS Table 1 Physical activity during work among women according to age and educational status (n=10,146) Source: GEDA 2014/2015-EHIS Roughly 47.5% of women and 47.2% of men mostly sit or stand during work. Women Mostly sitting or standing (physical inactivity) Mostly walking or tasks of moderate physical effort Mostly heavy labour or physically demanding work Not performing any working tasks % (95% CI) % (95% CI) % (95% CI) % (95% CI) Women total 47.5 (46.1-49.0) 40.6 (39.0-42.1) 3.2 (2.8-3.7) 8.7 (8.0-9.5) 18-29 Years 55.5 (52.6-58.4) 33.7 (30.9-36.7) 3.9 (2.9-5.0) 6.9 (5.6-8.6) Low education 43.5 (36.9-50.4) 36.5 (30.0-43.5) 3.3 (1.6-6.6) 16.7 (12.5-22.0) Medium education 55.9 (52.1-59.5) 34.9 (31.3-38.6) 4.9 (3.6-6.6) 4.4 (3.1-6.1) High education 73.0 (67.9-77.6) 23.9 (19.6-28.8) 0.8 (0.3-2.1) 2.3 (1.2-4.4) 30-44 Years 49.5 (47.0-51.9) 42.2 (39.7-44.8) 2.9 (2.3-3.8) 5.4 (4.3-6.8) Low education 29.7 (23.7-36.6) 50.1 (42.8-57.5) 6.3 (3.5-11.0) 13.8 (9.2-20.3) Medium education 46.3 (43.2-49.3) 45.7 (42.5-48.8) 3.1 (2.3-4.1) 5.0 (3.9-6.5) High education 67.8 (63.9-71.4) 29.7 (26.2-33.4) 0.7 (0.4-1.4) 1.8 (1.1-3.0) 45-64 Years 42.7 (40.8-44.6) 42.7 (40.8-44.6) 3.1 (2.6-3.7) 11.5 (10.5-12.7) Low education 24.2 (20.6-28.1) 52.9 (48.5-57.1) 3.8 (2.5-5.9) 19.1 (15.8-22.9) Medium education 41.7 (39.3-44.0) 43.8 (41.5-46.1) 3.4 (2.7-4.3) 11.2 (9.8-12.7) High education 62.5 (59.5-65.3) 29.9 (27.4-32.7) 1.4 (0.9-2.1) 6.2 (4.8-8.0) Total (women and men) 47.3 (46.1-48.6) 35.6 (34.5-36.7) 9.0 (8.3-9.8) 8.0 (7.5-8.6) Men Mostly sitting or standing (physical inactivity) Mostly walking or tasks of moderate physical effort Mostly heavy labour or physically demanding work Not performing any working tasks % (95% CI) % (95% CI) % (95% CI) % (95% CI) Men total 47.2 (45.6-48.8) 30.7 (29.3-32.0) 14.8 (13.5-16.1) 7.4 (6.6-8.3) 18-29 Years 46.4 (43.5-49.3) 30.4 (27.5-33.5) 16.7 (14.3-19.5) 6.4 (5.0-8.2) Low education 35.4 (29.1-42.3) 31.6 (25.9-37.9) 18.0 (13.4-23.6) 15.0 (10.7-20.7) Medium education 44.2 (40.6-47.9) 33.4 (29.5-37.5) 18.9 (15.5-22.7) 3.5 (2.6-4.9) High education 77.1 (71.2-82.1) 14.8 (11.0-19.8) 5.1 (3.2-8.1) 2.9 (1.0-8.0) 30-44 Years 50.2 (47.6-52.9) 30.0 (27.7-32.4) 15.9 (13.9-18.0) 3.9 (2.8-5.4) Low education 28.2 (21.4-36.1) 37.5 (29.9-45.9) 24.1 (17.7-31.9) 10.2 (6.3-16.2) Medium education 39.3 (36.0-42.6) 36.0 (32.7-39.4) 20.8 (18.0-23.9) 4.0 (2.6-6.0) High education

Fruit consumption among adults in Germany

Eating fruit is part of a healthy diet and can help prevent various chronic diseases. According to GEDA 2014/2015EHIS data, 54.2% of women and 38.1% of men eat fruit daily. 38.0% of women and 25.5% of men aged 18 to 29 years eat fruit daily; and in the age group of 65 and older this figure rises to 72.6% for women and 61.1% for men. In the age groups under 65, women with higher levels of education are more likely to eat fruit every day, for men this correlation applies only to those aged between 45 and 64. In Brandenburg, Mecklenburg-West Pomerania, Saxony, Saxony-Anhalt and Thuringia, the proportion of women and men who eat fruit daily is higher than the German average, and in Bavaria and Saarland the proportion of men who eat fruit daily is lower than the German average. FRUIT · ADULTS · INTERVIEW SURVEY · HEALTH MONITORING · GERMANY Introduction Fruit includes the edible fruits and seeds of mostly perennial plants. Like vegetables, there are many different types of fruit and due to global trade the market in Germany is continuously expanding. Fruit can be subdivided into groups such as pomaceous fruit, berries or citrus fruit. Whereas vegetables are usually eaten at meals, fruit is often a dessert or eaten as a snack between meals. Fruit is an important source of vitamins, minerals, trace elements, phytochemicals and fibre, yet has only little fat. Due to the variety of biologically active substances, eating fruit is associated with a number of health benefits. Beyond a high nutrient density, most fruit have high water contents and are therefore relatively low in calories [1]. Moreover, people who eat high quantities of fruit usually eat smaller amounts of physiologically less beneficial foods. A low energy content combined with high satiety means that eating lots of fruit and vegetables can contribute to maintain weight and to prevent obesity [1, 2]. Convincing evidence shows that eating high amounts of fruit and vegetables can help prevent, or positively influence the course, of coronary heart disease, high blood pressure and stroke [1, 3-5]. Probably, eating lots of fruit and vegetables also has a prophylactic effect on various cancers; the observed correlation with the overall cancer risk, however, is low [1, 6-9]. Consuming large amounts of fruit and vegetables is, according to a recent meta-analysis, associated with a lower overall mortality risk, in particular due to a lower cardiovascular mortality risk [8]. For some time now, this has been reflected in the implementation of various health-policy measures aimed at encouraging people to eat more fruit and vegetables. Journal of Health Monitoring Fruit consumption among adults in Germany Journal of Health Monitoring 2017 2(2) FACT SHEET 44 The ‘5 a day’ campaign, which recommends that people eat five portions of fruit and vegetables every day, is prob ably one of the most well-known. A portion of fruit or vegetables may occasionally be replaced by a smoothie or a glass of fruit or vegetable juice; however, the fruit or vegetable content of these drinks should be no less than 100%. A portion is defined as a handful of fruit or vege tables [10, 11]. Indicator Sufficient consumption of fruit and vegetables is a key element in a balanced and healthy diet. A population representative assessment of fruit consumption as an indicator of a healthy diet is therefore highly relevant for health policy. GEDA 2014/2015-EHIS assessed the frequency of people’s fruit consumption by asking: ‘How often do you eat fruit, including freshly pressed juices?’, with the possible answers ‘once or more a day’, ‘4 to 6 times a week’, ‘1 to 3 times a week’, ‘less than once a week’ and ‘never’. For the purpose of the analysis presented here, these answers were summarised into three categories (once or more a day, at least once a week and less than once a week). The results were stratified according to gender, age group, education and federal state. A statistically significant difference between groups is assumed when confidence intervals do not overlap. The analyses are based on the data received from 23,947 participants aged 18 and above (13,104 women and 10,843 men) with valid information on fruit consumption. Calculations were carried out using a weighting factor that corrects for deviations within the sample from the German population (as of 31 December 2014) with regard to gender, age, district type and education. The district type accounts for the degree of urbanisation and reflects the regional distribution in Germany. The International Standard Classification for Education (ISCED) was used to improve the comparability of the responses provided on educational levels [12]. A detailed description of the methodology applied in the GEDA 2014/2015-EHIS study can be found in the article German Health Update – New data for Germany and Europe published in issue 1/2017 of the Journal of Health Monitoring. Results and discussion The German Nutrition Society (DGE) recommends eating fruit and vegetables every day [10]. In Germany, many adults do not fulfil this recommendation. According to GEDA 2014/2015-EHIS, 54.2% of women and 38.1% of men eat fruit daily. Thus considerably more women than men eat fruit daily (Table 1 and Table 2). In the GEDA 2012 survey, 69.5% of women and 48.0% of men reported eating fruit daily [13]. Figures for vegetable consumption have also seen a similarly strong decline and this could be partly related to changes in the survey methodology (2014/2015: self-administered questionnaires; 2012: telephone interviews), as well as to different phrasing of questions and possible answers. GEDA 2012 respondents were asked on the telephone ‘How often do you eat fruit?’ and given the response options ‘every day’, ‘at least once a week’, ‘less than once a week’ and ‘never’. In GEDA 2014/2015-EHIS the question was formulated in writing as shown in the Indicator section. In GEDA 2012, people might have been inclined to answer GEDA 2014/2015-EHIS Data holder: Robert Koch Institute Aims: To provide reliable informa tion about the population’s health status, health-related behaviour and health care in Germany, with the possibility of a European comparison Method: Questionnaires completed on paper or online Population: People aged 18 years and above with permanent residency in Germany Sampling: Registry office sample; randomly selected individuals from 301 communities in Germany were invited to participate Participants: 24,016 people (13,144 women; 10,872 men) Response rate: 26.9% Study period: November 2014 July 2015 Data protection: This study was undertaken in strict accordance with the data protection regulations set out in the German Federal Data Protection Act and was approved by the German Federal Commissioner for Data Protection and Freedom of Information. Participation in the study was voluntary. The participants were fully informed about the study’s aims and content, and about data protection. All participants provided written informed consent. More information in German is available at www.geda-studie.de Journal of Health Monitoring Fruit consumption among adults in Germany Journal of Health Monitoring 2017 2(2) FACT SHEET 45 ‘every day’ even if they only actually consumed fruit five or six times per week. The answer categories in GEDA 2012 may have partly led to the higher reported fruit consumption as compared to GEDA 2014/2015-EHIS. Daily consumption of fruit among women and men increases with age: Whereas only 38.0% of women and 25.5% of men aged 18 to 29 eat fruit daily, in the age group of 65 and older, the figures are 72.6% for women and 61.1% for men. Previous surveys also registered an increase in fruit consumption with age [13, 14]. Daily consumption of fruit is particularly widespread among the 65-years and older (Table 1 and Table 2). This could be Table 1 Fruit consumption among women according to age and educational status (n=13,104) Source: GEDA 2014/2015-EHIS 54% of women and 38% of men eat fruit daily. due to the fact that people in this age group are more concerned both with their health and following a healthy diet. Moreover, they are less likely to be employed and, therefore, have more time to choose, buy and prepare their own food.They also cook more often every day or nearly every day than younger people [15]. In the age groups up to 65, women with higher levels of education eat significantly more often fruit every day. For men, a similar correlation between education and fruit consumption is seen only in the 45-to-65 age group. In Bavaria and Saarland, the proportion of men who consume fruit daily is significantly lower than the German Women Once or more a day At least once a week Less than once a week % (95% CI) % (95% CI) % (95% CI) Women total 54.2 (53.0-55.3) 38.5 (37.4-39.6) 7.3 (6.7-8.0) 18-29 Years 38.0 (35.5-40.7) 50.8 (48.0-53.5) 11.2 (9.5-13.2) Low education 33.7 (27.4-40.7) 50.7 (44.3-57.1) 15.6 (11.6-20.5) Medium education 37.5 (34.3-40.8) 51.8 (48.3-55.3) 10.7 (8.6-13.3) High education 47.1 (42.1-52.2) 46.2 (41.1-51.4) 6.7 (4.3-10.2) 30-44 Years 44.3 (42.0-46.6) 45.6 (43.3-47.9) 10.1 (8.7-11.7) Low education 38.6 (32.0-45.6) 45.5 (38.2-52.9) 15.9 (11.3-22.0) Medium education 40.6 (37.7-43.5) 48.4 (45.5-51.3) 11.1 (9.2-13.2) High education 56.7 (53.6-59.8) 38.5 (35.6-41.6) 4.7 (3.4-6.6) 45-64 Years 53.7 (51.9-55.5) 39.5 (37.8-41.2) 6.8 (6.0-7.8) Low education 52.8 (48.5-57.2) 38.0 (33.9-42.3) 9.2 (7.1-11.7) Medium education 51.0 (48.7-53.3) 41.9 (39.7-44.2) 7.1 (5.9-8.5) High education 63.5 (60.9-66.1) 32.6 (30.0-35.3) 3.9 (3.0-5.0) ≥ 65 Years 72.6 (70.5-74.7) 24.1 (22.3-26.1) 3.3 (2.5-4.3) Low education 70.1 (66.4-73.4) 25.8 (22.6-29.2) 4.2 (2.8-6.2) Medium education 73.7 (70.9-76.3) 23.5 (21.1-26.2) 2.8 (1.9-4.1) High education 77.9 (73.1-82.0) 20.2 (16.1-25.0) 2.0 (1.0-4.0) Total (women and men) 46.3 (45.4-47.3) 43.1 (42.1-44.0) 10.6 (10.0-11.3) CI=confidence interval Journal of Health Monitoring Journal of Health Monitoring 201

Arbeitsbezogene körperliche Aktivität bei Erwachsenenin Deutschland

Die Prävalenz arbeitsbezogener körperlicher Aktivität wurde auf Basis von Selbstangaben in GEDA 2014/2015-EHIS geschätzt. 47,5 % der Frauen und 47,2 % der Männer sitzen oder stehen vorwiegend während der Arbeit. Der Anteil derjenigen, die während der Arbeit vorwiegend sitzen oder stehen, ist mit 55,5 % bei Frauen in der Altersgruppe 18 bis 29 Jahre am höchsten. Bei den Männern findet sich der größte Anteil mit 50,2 % in der Altersgruppe 30 bis 44 Jahre. Der Anteil derjenigen, die vorwiegend schwere körperliche Arbeit verrichten, ist bei Männern mit 14,8 % deutlich höher als bei Frauen mit 3,2 %. Je höher der Bildungsstand, desto häufiger beschränkt sich bei Männern und Frauen die körperliche Aktivität während der Arbeit auf Sitzen oder Stehen. Die Ergebnisse weisen auf ein hohes Potenzial für Bewegungsförderung hin. KÖRPERLICHE INAKTIVITÄT · ARBEIT · SITZEN · ERWACHSENE · GESUNDHEITSMONITORING Einleitung Als körperliche Aktivität wird jede Bewegung definiert, die durch die Skelettmuskulatur produziert wird und den Energieverbrauch über den Grundumsatz anhebt [1]. Bei leicht anstrengenden Tätigkeiten, die sitzend oder stehend ausgeführt werden, geht dagegen der Energieverbrauch nicht wesentlich über den Grundumsatz hinaus [2]. Langanhaltendes Sitzen, wie beispielsweise bei Bürotätigkeiten, stellt einen Risikofaktor für die Entstehung nichtübertragbarer Erkrankungen dar [3, 4]. Laut einer aktuellen Schätzung erhöht sich das Risiko allgemeiner Sterblichkeit bei Erwachsenen mit jeder Stunde sitzender Tätigkeit am Tag um 2 % [4]. Beinhaltet die berufliche Tätigkeit körperliche Aktivitäten, wie beispielsweise in der Landwirtschaft, nimmt diese arbeitsbezogene körperliche Aktivität häufig den größten Anteil am täglichen Gesamtenergieverbrauch ein, da diese bei Berufstätigen üblicherweise für 8 Stunden an Werktagen ausgeübt wird [5]. Die arbeitsbezogene körperliche Aktivität kann gesundheitsfördernd wirken, allerdings in geringerem Maße als sportliche Aktivität in der Freizeit [6 – 8]. Dies lässt sich dadurch begründen, dass arbeitsbezogene körperliche Aktivität häufig einseitige Belastung, Überkopfarbeit und Tragen schwerer Gegenstände beinhaltet, wodurch zwar die Kraftfähigkeit verbessert werden kann, jedoch kaum die Ausdauerleistungsfähigkeit [9 – 11]. Die Ausdauerleistungsfähigkeit, die durch Freizeitsport wie Joggen und Schwimmen trainiert wird, ist aber besonders wirksam im Hinblick auf die Vermeidung nichtübertragbarer Krankheiten Autorinnen und Autoren: Jonas D. Finger, Gert B. M. Mensink, Cornelia Lange, Kristin Manz Journal of Health Monitoring · 2017 2(2) DOI 10.17886/RKI-GBE-2017-026 Robert Koch-Institut, Berlin Hier gelangen Sie zum Journal of Health Monitoring 2017/2: »Gesundheitsverhalten in Deutschland und Europa« kapitelweise Journal of Health Monitoring Arbeitsbezogene körperliche Aktivität bei Erwachsenen in Deutschland

Overweight and obesity among adults in Germany

Body weight and height, as well as associated indicators like overweight and obesity, are widespread factors used to describe the health of a population. Over the past decades, the prevalence of overweight and obesity has increased worldwide and has reached significant public health relevance. According to self-reported data on body weight and body height in the GEDA 2014/2015-EHIS study, 54.0% of adults in Germany are overweight or obese (defined as having a body mass index – BMI – of 25 kg/m2 or higher). Men are more often affected by overweight than women, with 43.3% of men having a BMI between 25 kg/m2 and 30 kg/m2, compared to women (28.8%). In Germany, the prevalence of obesity (BMI greater or equal to 30 kg/m2) is 18.1%; there is no significant difference between women and men. The prevalence of overweight, including obesity, is higher among women and men with increasing age. Although the prevalence of overweight, including obesity, has remained at a high level in recent years, the prevalence of obesity has increased compared to the GEDA 2010 study. OVERWEIGHT · OBESITY · SELF-REPORTING · HEALTH MONITORING · GERMANY Introduction Persons are defined as overweight if their body weight exceeds a certain level for a given body height. Excessive overweight is referred to as obesity and classified as a disease by the World Health Organization (WHO) [1]. Obesity is a risk factor linked to chronic diseases such as type 2 diabetes mellitus [2], cardiovascular diseases [3] and some types of cancer [4]. It is also associated with a higher risk of premature death [5, 6]. Finally, obesity and the associated comorbidities are a major challenge to the health system and present an important public health problem not only in Germany but also worldwide. Against this background, the WHO developed the Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-2020. One of the 9 voluntary global non-communicable diseases targets addresses the prevalence of obesity. The rise in diabetes and obesity prevalence should be halted until 2025 on the 2010 levels [7]. In accordance to the WHO Global Action Plan, the revision of the Sustainable Development Strategy 2016 of the Federal Government of Germany has the target that until 2030 the proportion of people with obesity in Germany does no longer increase [8]. Indicator Body Mass Index (BMI) is the most commonly used measure to define overweight and obesity. It is calculated as the ratio of a person’s body weight to the square of his body height (kg/m2); it is thus relatively easy to Authors: Anja Schienkiewitz, Gert B. M. Mensink, Ronny Kuhnert, Cornelia Lange Journal of Health Monitoring · 2017 2(2) DOI 10.17886/RKI-GBE-2017-038 Robert Koch Institute, Berlin Journal of Health Monitoring Overweight and obesity among adults in Germany Journal of Health Monitoring 2017 2(2) FACT SHEET 21 calculate and to use as a reference measure for individuals as well as study populations. The BMI is no direct measure of body fat as it cannot distinguish between body fat and muscle mass. However, research has shown that at the group level BMI shows a high correlation with direct measurements used to determine body fat. A high BMI can therefore act as an indicator of a high level of body fat. According to the WHO classification system, adults with a BMI of less than 18.5 kg/m2 are considered to be underweight. A BMI between 18.5 kg/m2 and less than 25 kg/m2 is defined as normal weight, a BMI between 25 kg/m2 and under 30 kg/m2 as overweight and a BMI of 30 kg/m2 or more as obese [1]. In order to calculate BMI, studies collect data on body weight and body height either through direct measurement or self-reporting. Self-reporting often leads to underestimated body weights and overestimated body heights compared with directly measured values. A BMI calculated through self-reported information thus tends to be lower than those gained through direct measurements [9]. The prevalence presented here based on the German Health Update (GEDA) study series used self-reported data. Therefore, the prevalence observed in this study differs from the prevalence calculated using data from direct measurements gathered for the National Health Interview and Examination Surveys conducted by the Robert Koch Institute, including the 1998 German National Health Interview and Examination Survey (GNHIES98) and the German Health Interview and Examination Survey for Adults (DEGS1) [10].According to DEGS1 the prevalence of obesity in the age group 18 and 79 years is 23.9% among women and 23.3% among men. For the direct comparison of obesity prevalence from different data sources, such as DEGS1 and GEDA 2014/2015-EHIS, it should be taken into account that the obesity prevalence from self-reported data is lower. Furthermore, comparisons from GEDA 2014/2015EHIS with previous GEDA waves need to take into account the fact that sampling methods and types of questionnaire (self-administered questionnaire versus telephone interview) have been changed. As part of the GEDA 2014/2015-EHIS study, respondents were asked: ‘How tall are you without shoes (in cm)?’. The question on body weight was: ‘How much do you weigh without clothes and shoes (in kg)? Pregnant women should provide their weight before they became pregnant.’ The tables present the prevalence of underweight, normal weight, overweight, obesity as well as overweight including obesity among the German population aged 18 years and older. The results are stratified according to gender, age and level of education, and for obesity additionally, by gender and federal state. The analyses are based on data from 23,791 participants aged 18 years and older (13,006 women and 10,785 men) with valid data on body weight and height. The calculations were carried out using a weighting factor that corrects for deviations within the sample from the German population (as of 31 December 2014) with regard to gender, age, district type and education. The district type accounts for the degree of urbanisation and reflects the regional distribution in Germany. The International Standard Classification for Education (ISCED) was used to ensure that the responses provided on GEDA 2014/2015-EHIS Data holder: Robert Koch Institute Aims: To provide reliable informa tion about the population’s health status, health-related behaviour and health care in Germany, with the possibility of a European comparison Method: Questionnaires completed on paper or online Population: People aged 18 years and above with permanent residency in Germany Sampling: Registry office sample; randomly selected individuals from 301 communities in Germany were invited to participate Participants: 24,016 people (13,144 women; 10,872 men) Response rate: 26.9% Study period: November 2014 July 2015 Data protection: This study was undertaken in strict accordance with the data protection regulations set out in the German Federal Data Protection Act and was approved by the German Federal Commissioner for Data Protection and Freedom of Information. Participation in the study was voluntary. The participants were fully informed about the study’s aims and content, and about data protection. All participants provided written informed consent. More information in German is available at www.geda-studie.de Journal of Health Monitoring Journal of Health Monitoring 2017 2(2) FACT SHEET 22 Overweight and obesity among adults in Germany Table 1 Underweight, normal weight, overweight and obesity among women according to age and educational status (n=13,006) Source: GEDA 2014/2015-EHIS 47% of women and 62% of men in Germany are overweight or obese; 18% of adults are obese. educational levels were comparable [11]. A detailed description of the methodology applied in the GEDA 2014/2015-EHIS study can be found in the article German Health Update – New data for Germany and Europe in issue 1/2017 of the Journal of Health Monitoring. Results and discussion The results of the GEDA 2014/2015-EHIS study indicate that 46.7% of women and 61.6% of men in Germany have a BMI of more than 25 kg/m2 and are thus overweight or obese. 28.8% of women and 43.3% of men have a BMI between 25 kg/m2 and less than 30 kg/m2, and 18.1% of adults are obese (Table 1 and Table 2). Overall, the prevalence of overweight, including obesity, has remained high in recent years. In 2012, 45.8% of women and 59.7% of men were overweight or obese [12]. The GEDA 2014/2015-EHIS data show no significant difference between women and men, with the preva lence increasing by two percentage points compared to 2010 [12]. The current prevalence and trends in obesity is similar as observed in the German Microcensus which also Women Underweight Normal weight Overweight Obesity Overweight including obesity* % (95% CI) % (95% CI) % (95% CI) % (95% CI) % (95% CI) Women total 2.9 (2.5-3.3) 50.4 (49.3-51.6) 28.8 (27.8-29.8) 18.0 (17.1-18.9) 46.7 (45.6-47.9) 18-29 Years 7.5 (6.2-9.0) 66.4 (63.7-68.9) 16.5 (14.5-18.7) 9.7 (8.3-11.3) 26.2 (23.8-28.6) Low education 10.9 (7.4-15.8) 56.7 (50.6-62.6) 19.3 (14.9-24.6) 13.1 (9.3-18.1) 32.4 (26.9-38.4) Medium education 6.5 (5.2-8.2) 67.5 (64.1-70.8) 16.3 (13.8-19.3) 9.6 (7.9-11.6) 25.9 (23.0-29.1) High education 5.4 (3.5-8.3) 77.3 (72.6-81.4) 12.3 (9.5-15.7) 5.0 (3.3-7.5) 17.3 (13.9-21.3) 30-44 Years 2.4 (1.8-3.1) 56.1 (53.7-58.5) 24.2 (22.2-26.3) 17.3 (15.4-19.4) 41.5 (39.1-43.9) Low education 2.1 (0.8-5.8) 34.5 (28.4-41.1) 31.9 (25.7-38.8) 31.5 (24.7-39.2) 63.4 (56.6-69.6) Medium education 2.1 (1.4-3.0) 55.2 (52.2-58.2) 25.3 (22.8-28.0) 17.4 (15.2-19.9) 42.7 (39.6-45.8) High education 3.0 (2.0-4.6) 70.6 (67.5-73.5) 17.3 (15.0-19.9) 9.1 (7.2-11.4) 26.4 (23.7-29.3) 45-64 Years 1.6 (1.2-2.0) 48.3 (46.6-50.0) 30.5 (28.9-32.2) 19.6 (18.3-21.1) 50.1 (48.4-51.9) Low education 1.4 (0.7-2.9) 43.3 (39.0-47.8) 33.1 (28.9-37.6) 22.2 (18.7-26.0) 55.3 (50.9-59.5) Medium education 1.6 (1.2-2.1) 46.9 (44.8-49.1) 30.4 (28.4-32.5) 21.1 (19.3-22.9) 51.5 (49.3-53.