Rebecca Paprott

Temporal changes in the prevalence of diagnosed diabetes, undiagnosed diabetes and prediabetes: findings from the German Health Interview and Examination Surveys in 1997-1999 and 2008-2011.

Nationally representative data on temporal changes in the prevalence of diagnosed diabetes, as well as undiagnosed diabetes and prediabetes, have been lacking in Germany as in most other European countries. We aimed to fill this gap using data from nationwide examination surveys of German adults.

Changes in diabetes care indicators: findings from German National Health Interview and Examination Surveys 1997–1999 and 2008–2011

Objectives To investigate changes in type 2 diabetes care indicators over time in Germany. Methods Adults aged 45–79 years with type 2 diabetes were identified from two national health examination surveys conducted in 1997–1999 (GNHIES98, n=333) and in 2008–2011 (DEGS1, n=526). We examined diabetes care indicators including treatment and preventive targets (glycemic control, blood pressure (BP), total cholesterol (TC), smoking, weight reduction, sports activity), self-management and care process measures (glucose self-monitoring, holding a diabetes passport, annual foot and eye examination; statin use), and the presence of diabetes-specific complications (diabetic nephropathy, retinopathy, neuropathy, diabetic foot, amputations) and comorbid cardiovascular disease (CVD) or chronic kidney disease (CKD). We calculated proportions of persons meeting these care indicators by survey and examined unadjusted and adjusted changes between surveys. Results Significant improvement (GNHIES98 vs DEGS1) over time was observed for glycated hemoglobin (HbA1c) <7.0% (53 mmol/mol) (32.4% vs 65.4%), BP <130/80 mm Hg (32.0% vs 47.2%), TC <190 mg/dL (13.5% vs 41.9%), statin use (11.7% vs 35.9%), eye (51.1% vs 78.4%) and foot (48.0% vs 61.4%) examination within the past 12 months, diabetes-specific complications (29.7% vs 21.8%), and CVD (44.5% vs 37.1%). Blood glucose self-monitoring significantly increased (37.4% vs 62.8%), while holding a diabetes passport did not change. Current smoking did not change and obesity rose, although sports activity significantly increased over time. Proportions of adults achieving combination goals of HbA1c, BP, TC, and smoking cessation were low in both surveys in spite of significant improvement. Conclusions In Germany, the quality of diabetes care improved over time. There is much room for improvement, in particular regarding preventive goals and diabetes self-management.

Residential traffic and incidence of Type 2 diabetes: the German Health Interview and Examination Surveys.

To investigate whether an indicator of overall traffic intensity is related to the risk of Type 2 diabetes in a nationwide cohort.

Association Between Hemoglobin A1c and All-Cause Mortality: Results of the Mortality Follow-up of the German National Health Interview and Examination Survey 1998

OBJECTIVE This study examined the association of HbA1c-defined glycemic status and continuous HbA1c with all-cause mortality. RESEARCH DESIGN AND METHODS The study population comprised 6,299 participants (aged 18–79 years) of the German National Health Interview and Examination Survey 1998, who were followed up for mortality for an average of 11.6 years. Glycemic status was defined as known diabetes (self-reported diagnosis or intake of antidiabetic medication) and based on HbA1c levels according to American Diabetes Association diagnostic criteria as undiagnosed diabetes (≥6.5% [≥48 mmol/mol]), prediabetes with very high (6.0–6.4% [42–46 mmol/mol]) or high diabetes risk (5.7–5.9% [39–41 mmol/mol]), and normoglycemia (<5.7% [<39 mmol/mol]). Associations between glycemic status and mortality were examined by Cox regression adjusting for age, sex, education, lifestyle factors, anthropometric measures, and history of chronic diseases (reference: normoglycemia). Spline models were fitted to investigate associations between continuous HbA1c and mortality among participants without known diabetes. RESULTS Excess mortality risk was observed for participants with known diabetes (hazard ratio 1.41 [95% CI 1.08–1.84]) and undiagnosed diabetes (1.63 [1.23–2.17]) but not for those with high (1.02 [0.80–1.30]) or very high diabetes risk (0.87 [0.67–1.13]). Spline models revealed a U-shaped association, with lowest risk at HbA1c levels 5.4–5.6% (36–38 mmol/mol) and a significantly increased risk at ≤5.0% (≤31 mmol/mol) and ≥6.4% (≥46 mmol/mol). CONCLUSIONS Unlike known and undiagnosed diabetes, HbA1c levels in the prediabetic range were not associated with an increased mortality risk. The observed U-shaped relationship adds to existing evidence that not only high but also low HbA1c levels might be associated with all-cause mortality.

Validation of the German Diabetes Risk Score among the general adult population: findings from the German Health Interview and Examination Surveys

Objective To evaluate the German Diabetes Risk Score (GDRS) among the general adult German population for prediction of incident type 2 diabetes and detection of prevalent undiagnosed diabetes. Methods The longitudinal sample for prediction of incident diagnosed type 2 diabetes included 3625 persons who participated both in the examination survey in 1997–1999 and the examination survey in 2008–2011. Incident diagnosed type 2 diabetes was defined as first-time physician diagnosis or antidiabetic medication during 5 years of follow-up excluding potential incident type 1 and gestational diabetes. The cross-sectional sample for detection of prevalent undiagnosed diabetes included 6048 participants without diagnosed diabetes of the examination survey in 2008–2011. Prevalent undiagnosed diabetes was defined as glycated haemoglobin ≥6.5% (48 mmol/mol). We assessed discrimination as area under the receiver operating characteristic curve (ROC-AUC (95% CI)) and calibration through calibration plots. Results In longitudinal analyses, 82 subjects with incident diagnosed type 2 diabetes were identified after 5 years of follow-up. For prediction of incident diagnosed diabetes, the GDRS yielded an ROC-AUC of 0.87 (0.83 to 0.90). Calibration plots indicated excellent prediction for low diabetes risk and overestimation for intermediate and high diabetes risk. When considering the entire follow-up period of 11.9 years (ROC-AUC: 0.84 (0.82 to 0.86)) and including incident undiagnosed diabetes (ROC-AUC: 0.81 (0.78 to 0.84)), discrimination decreased somewhat. A previously simplified paper version of the GDRS yielded a similar predictive ability (ROC-AUC: 0.86 (0.82 to 0.89)). In cross-sectional analyses, 128 subjects with undiagnosed diabetes were identified. For detection of prevalent undiagnosed diabetes, the ROC-AUC was 0.84 (0.81 to 0.86). Again, the simplified version yielded a similar result (ROC-AUC: 0.83 (0.80 to 0.86)). Conclusions The GDRS might be applied for public health monitoring of diabetes risk in the German adult population. Future research needs to evaluate whether the GDRS is useful to improve diabetes risk awareness and prevention among the general population.

All-cause mortality in adults with and without type 2 diabetes: findings from the national health monitoring in Germany

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

Temporal changes in predicted risk of type 2 diabetes in Germany: findings from the German Health Interview and Examination Surveys 1997–1999 and 2008–2011

Objective Over time, prevalence changes in individual diabetes risk factors have been observed for Germany and other European countries. We aimed to investigate the temporal change of a summary measure of type 2 diabetes risk in Germany. Design Comparison of data from two cross-sectional surveys that are about 12 years apart. Setting Two nationwide health examination surveys representative for the non-institutionalised population aged 18–79 years in Germany. Participants The study included participants without diagnosed diabetes from the national health examination surveys in 1997–1999 (n=6457) and 2008–2011 (n=6095). Outcome measures Predicted 5-year type 2 diabetes risk was calculated using the German Diabetes Risk Score (GDRS), which considers information on age, anthropometry, lifestyle factors, hypertension and family history of diabetes. Results Between the two survey periods, the overall age- and sex-standardised predicted 5-year risk of type 2 diabetes decreased by 27% from 1.5% (95% CI 1.4% to 1.6%) to 1.1% (1.0% to 1.2%). The decrease in red meat intake and waist circumference had the highest impact on the overall decrease in diabetes risk. In stratified analyses, diabetes risk decreased among both sexes and within strata of age and body mass index. Diabetes risk also decreased among highly educated persons, but remained unchanged among persons with a middle or low educational level. Conclusions Monitoring type 2 diabetes risk by a summary measure such as the GDRS could essentially contribute to interpret the dynamics in diabetes epidemiology.

Selecting and defining indicators for diabetes surveillance in Germany

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

Diabetes-Surveillance in Deutschland – Auswahl und Definition von Indikatoren

Vor dem Hintergrund einer hohen Anzahl Betroffener und der damit verbundenen gesundheitspolitischen Bedeutung wurde am Beispiel Diabetes mellitus mit dem Aufbau einer Public-Health-Surveillance am Robert Koch-Institut (RKI) begonnen. Für eine nachhaltige und vergleichbare Datenlage und zur Etablierung effizienter SurveillanceStrukturen wurde zunächst ein Set relevanter Indikatoren für die Diabetes-Surveillance definiert. Basierend auf umfangreichen Literaturrecherchen und anhand eines strukturierten Konsensusprozesses entstand ein abgestimmtes Indikatorenset, bestehend aus 30 Kernund 10 Zusatzindikatoren. Diese können den folgenden vier Handlungsfeldern zugeordnet werden: (1) Diabetes-Risiko reduzieren, (2) Diabetes-Früherkennung und Behandlung verbessern, (3) Diabetes-Komplikationen reduzieren, (4) Krankheitslast und Krankheitskosten senken. Neben den Primärdaten des RKI-Gesundheitsmonitorings sollen zukünftig auch Ergebnisse aus verfügbaren Sekundärdatenquellen in die Diabetes-Surveillance mit einfließen. Hierzu müssen die teilweise noch existierenden Barrieren bei der Nutzung vorhandener Datenquellen abgebaut sowie bestehende Datenlücken geschlossen werden. Perspektivisch soll das Indikatorenset kontinuierlich angepasst und auf weitere chronische Erkrankungen mit hoher Public-Health-Relevanz übertragen werden. PUBLIC HEALTH · SURVEILLANCE · DIABETES MELLITUS · INDIKATOREN · NCD

Erste Ergebnisse der Studie „Krankheitswissen und Informationsbedarfe – Diabetes mellitus (2017)“

Bislang ist wenig dazu bekannt, was Menschen in Deutschland zum Thema Diabetes wissen, welche Informationen sie sich wünschen, wo sie Informationen suchen und wie sie vorhandene Informationen einschätzen. Das Robert Koch-Institut (RKI) führte mit einem Schwerpunkt auf diesen Fragestellungen im Jahr 2017 den bundesweiten telefonischen Survey „Krankheitswissen und Informationsbedarfe – Diabetes mellitus (2017)“ in der Bevölkerung ab 18 Jahren durch. Insgesamt wurden 2.327 Personen ohne und 1.479 Personen mit diagnostiziertem Diabetes befragt. Erste Ergebnisse zeigen, dass 56,7 % der Befragten ohne Diabetes und 92,8 % der Befragten mit Diabetes ihr Diabeteswissen als sehr gut oder gut einschätzen. Befragte ohne Diabetes empfinden das größte Informationsbedürfnis zum Thema „Lebensstilanpassungen, Gesundheitsförderung und Prävention“, Befragte mit Diabetes zum Thema „Behandlung und Therapie“. Fast ein Drittel der Befragten ohne Diabetes hat sich schon einmal aktiv zu Diabetes informiert, am häufigsten über gedruckte Informationen. Für Menschen mit Diabetes ist die behandelnde (Haus-)Ärztin beziehungsweise der behandelnde (Haus-)Arzt die am häufigsten genannte Informationsquelle. In beiden Gruppen findet es etwa die Hälfte der Befragten schwierig, die Vertrauenswürdigkeit von Informationen zu Diabetes in den Medien einzuschätzen. Die Ergebnisse der Studie gehen in die vom RKI koordinierte Nationale Diabetes-Surveillance ein und werden von der Bundeszentrale für gesundheitliche Aufklärung zur Entwicklung von Strategien für eine verbesserte Information der Bevölkerung zum Thema Diabetes mellitus genutzt. DIABETES MELLITUS · TELEFONSURVEY · KRANKHEITSWISSEN · KRANKHEITSWAHRNEHMUNG · INFORMATIONSVERHALTEN