Stefanie Braig

The impact of education on risk factors and the occurrence of multimorbidity in the EPIC-Heidelberg cohort

BackgroundIn aging populations, the prevalence of multimorbidity is high, and the role of socioeconomic status and its correlates is not well described. Thus, we investigated the association between educational attainment and multimorbidity in a prospective cohort study, taking also into account intermediate factors that could explain such associations.MethodsWe included 13,781 participants of the Heidelberg cohort of the European Prospective Investigation into Cancer and Nutrition (EPIC), who were 50–75 years at the end of follow-up. Information on diet and lifestyle was collected at recruitment (1994–1998). During a median follow-up of 8.7 years, information on chronic conditions and death were collected.ResultsOverall, the prevalence of multimorbidity (>= 2 concurrent chronic diseases) was 67.3%. Compared to the highest educational category, the lowest was statistically significantly associated with increased odds of multimorbidity in men (OR = 1.43; 95% CI 1.28–1.61) and women (OR = 1.33; 95% CI 1.18–1.57). After adjustment, the positive associations were attenuated (men: OR = 1.28; 95% CI 1.12–1.46; women: OR = 1.16; 95% CI 0.99–1.36). Increasing BMI was more strongly than smoking status an intermediate factor in the association between education and multimorbidity.ConclusionIn this German population, the prevalence of multimorbidity is high and is significantly associated with educational level. Increasing BMI is the most important predictor of this association. However, even the fully adjusted model, i.e. considering also other known risk factors for chronic diseases, could not entirely explain socio-economic inequalities in multimorbidity. Educational level should be considered in the development and implementation of prevention strategies of multimorbidity.

Determinants of maternal hair cortisol concentrations at delivery reflecting the last trimester of pregnancy

Hair cortisol concentrations (HCC) are emerging as a promising marker of chronic psychosocial stress. However, limited information on relevant correlates of this biomarker in late pregnancy is available. In the Ulm SPATZ Health Study mothers were recruited between 04/2012 and 05/2013 shortly after delivery in the University Medical Center Ulm, Germany. Cortisol concentrations of N=768 participants were determined by HPLC-MS/MS in the scalp-near 3cm of maternal hair reflecting stress exposure over the preceding three months. Sociodemographic characteristics, pregnancy-related variables and comorbidities were assessed. We conducted bivariate and multiple linear regression analyses using log transformed HCC. In bivariate analyses, significantly higher cortisol concentrations were found in obese compared to normal weight (b=0.32, p<0.001) and smoking as opposed to non-smoking mothers (b=0.34, p=0.002). Conversely, primary C-section was associated with lower HCC compared to spontaneous delivery. Besides, a strong impact of season of delivery with significantly higher HCC in summer and autumn as opposed to winter (both bs=0.58, p<0.001) was found. Further determinants of HCC were maternal education, number of persons in the household, premature delivery and hair characteristics. In a mutually adjusted model, all but education, multiple jobholding, hair characteristics and premature delivery remained statistically significant. Maternal hair cortisol in the last trimester of pregnancy is determined by many factors. Delivery mode, body mass index and season of delivery should be considered when investigating the association between HCC and further outcomes in mothers shortly after delivery.

Infant atopic eczema and subsequent attention-deficit/hyperactivity disorder – A prospective birth cohort study

Comorbidity between childhood atopic eczema (AE) and attention‐deficit/hyperactivity disorder (ADHD) has been observed, but temporal relationships remain unclear.

The impact of social status inconsistency on cardiovascular risk factors, myocardial infarction and stroke in the EPIC-Heidelberg cohort

BackgroundSocial inequalities in cardiovascular diseases are well documented. Yet, the relation of social status inconsistency (having different ranks in two or more status indicators like education, occupational position or income) and medical conditions of heart or vessels is not clear. Status inconsistency (SI) is assumed to be stressful, and the association of psychosocial distress and health is well known. Therefore, we aimed to analyze the relationship between cardiovascular diseases (CVD) and status inconsistency. Another target was to assess the influence of behaviour related risk factors on this association.Methods8960 men and 6070 women, aged 45-65 years, from the EPIC-Heidelberg cohort (European Prospective Investigation into Cancer and Nutrition) were included. Socio-economic status was assessed by education/vocational training and occupational position at recruitment. During a median follow-up of 8.7 years, information on CVD was collected.ResultsCompared to status consistent subjects, men who were in a higher occupational position than could be expected given their educational attainment had a nearly two-fold increased incidence of CVD (Odds Ratio (OR) = 1.8, 95% Confidence Interval (CI) = 1.5; 2.4, adjusted for age). Smoking behaviour and BMI differed significantly between those who had adequate occupational positions and those who did not. Yet, these lifestyle factors, as opposed to age, did not contribute to the observed differences in CVD. No association of cardiovascular diseases and status inconsistency was found for women or in cases where education exceeded occupational position.ConclusionsStatus inconsistent men (occupational position > education) had a higher risk of cardiovascular diseases than status consistent men. However, harmful behaviour did not explain this relationship.

The Association of Hair Cortisol with Self-Reported Chronic Psychosocial Stress and Symptoms of Anxiety and Depression in Women Shortly after Delivery.

BACKGROUND Psychosocial stress during pregnancy including anxiety and depression is known to have adverse health effects on newborns. However, measuring these psychological constructs is complex with psychological, endocrinological, and physiological systems being affected. Hair cortisol concentrations (HCC), assumed to reflect long-term endocrine consequences of stress exposure, represent a promising instrument for epidemiological research. However, the association between HCC and questionnaire-based instruments is unclear. METHODS In the Ulm SPATZ Health Study, mothers were recruited shortly after delivery in the University Medical Centre Ulm, Germany between April 2012 and May 2013. HCC of 768 participants were determined in scalp-near 3 cm maternal hair segments, assumed to reflect cortisol exposure over the last trimester of pregnancy. Chronic stress, anxiety, and depressive symptomatology were self-reported in questionnaire-based instruments. Spearman correlation coefficients between HCC and these instruments as well as means of HCC in highly and low stressed subgroups were calculated. RESULTS HCC were not correlated with self-reported chronic stress, anxiety, or depressive symptomatology. Furthermore, the investigation of sub-populations did not reveal substantial differences of HCC across highly and low stressed women. CONCLUSIONS HCC were not found to correlate with self-reports of chronic stress, anxiety, or depressive symptomatology. Among other things, these findings could reflect problems with questionnaire-based assessments obtained shortly after delivery such as recall bias and/or suggest that associations between cortisol secretion and psychosocial stress are difficult to detect due to, e.g. a strong physiological increase of cortisol in the last trimester.

Maternal prenatal stress and child atopic dermatitis up to age 2 years: the Ulm SPATZ Health Study

Evidence linking maternal psychosocial stress during pregnancy to subsequent child atopic dermatitis (AD) is growing, but the definition of AD is diverse and results are inconsistent. We aimed to analyze the relationship between stress and AD using alternative measurements of stress and AD.

Age-specific influence of wheezing phenotypes on pre-adolescent and adolescent health-related quality of life

Asthma is associated with diminished health‐related quality of life (HRQoL). Particularly in adolescence, asthma may be under‐diagnosed and undertreated or poorly managed. Therefore, we aimed to determine the association between childhood wheezing phenotypes rather than asthma and adolescent HRQoL in children aged 10–17 yr.

Client satisfaction with substance abuse treatment. Baseline results from the IQMS study conducted in seven counselling centres

SummaryObjectives:Our study was carried out to evaluate client satisfaction with substance abuse treatment before introducing a quality management (QM) program.Methods:Between October and November 2004 a complete sample of 247 substance abusers completed a self-administered questionnaire in seven counselling centres in Baden- Württemberg (Germany). Routine data from the counselling centres were also included. Analyses were conducted by using chi2-tests, logistic regression models adjusted for covariates and t-tests for paired samples.Results:Our results suggested a high client satisfaction with counselling and highly rated positive effects of counselling. The satisfaction with the treatment in hospitals for substance abuse was significantly lower. Patients felt that there was lack of appropriate information in hospitals. There seems to be room for improvement particularly in the cooperation between General Practitioners and counselling centres as well as between hospitals for substance abuse and aftercare institutions.Conclusions:To increase the quality of care for addicts particularly the exchange of information and the transfer of patients between different institutions involved in care should be improved.

Health-related quality of life does not mediate the protective effect of farming on asthma and allergic disease.

To the Editor, Recently, children living on a farm were shown to have higher health-related quality of life (HRQOL) than their rural peers (1). Data from the same cross-sectional GABRIEL Advanced Surveys indicate that HRQOL does not explain the protective effect of exposure to farming environments on asthma and allergic disease (2). However, the authors suggested that the relationship between allergic diseases and HRQOL is likely to be bidirectional and needs to be assessed prospectively. We have conducted yearly follow-ups in one study centre (Ulm, Baden-W€ urttemberg, southern Germany) of the GABRIEL Advanced Surveys from 2010 to 2012. Of the 2,248 children aged 6–10 yr assessed at baseline in 2006/2007, 2,035 (90.5%) provided data on HRQOL at baseline and the incidence of asthma or allergic disease in at least one of the follow-ups. Ulm University’s Ethics Committee approved the study. To ease comparison, we chose definitions identical to those reported by St€ ocklin et al.(2). Children living on a farm currently run by their parents or other relatives were classified as farm children; all others were non-farm children. Asthma was defined as reports of wheeze, the use of an asthma inhaler, or a doctor’s diagnosis of asthma at least once or wheezy bronchitis more than once. Hay fever was defined as reports of a runny nose accompanied by itchy or watery eyes or a doctor’s diagnosis of hay fever. Atopic dermatitis was assessed by reports of a doctor’s diagnosis only. We excluded children with reports of asthma (n = 373), hay fever (n = 236), and atopic dermatitis (n = 309) at baseline. The cumulative incidence (reports of the respective disease in at least one follow-up) over the 5-yr follow-up period was computed. Children’s HRQOL at baseline was reported by parents and measured by the KINDL-R(3). Due to the complex survey design(4), we modeled stratified weighted logistic regressions. All statistical analyses were performed using SAS 9.2 (The SAS Institute, Cary, NC, USA). Table 1 shows the protective ‘farm effect’ on the cumulative incidence of asthma, hay fever, and atopic dermatitis, the latter not being statistically significant. Adjustment for the set of confounders predefined by St€ ocklin et al.(2) had no substantial effect. Additional adjustment for HRQOL did not alter the point estimates for the protective ‘farm effect’ on the incidence of asthma, hay fever, and atopic dermatitis. This indicates that HRQOL does not mediate the protective ‘farm effect’ (Table 1). Furthermore, the incidence of hay fever and atopic dermatitis was higher in subjects with low compared with high HRQOL. However, this difference did not reach statistical significance for any of the disease outcomes. Besides, the effect size of this association was rather small, making a relevant mediation of the much larger ‘farm effect’ on allergic disease incidence by HRQOL unlikely. For completeness, the addition of farming status to the adjusted model left the association between HRQOL and asthma or allergic disease unchanged excluding mediation by exposure to farming environments. Our prospective study design allowed us to eliminate the effect of prevailing asthma or allergic disease on reported HRQOL. We were thus able to investigate the other suggested direction of effect, that is, the effect of psychosocial factors on

Short-term goal attainment of in-patient rehabilitation in Germany and long-term risk of early retirement in patients with musculoskeletal diseases: results from a prospective 5-year follow-up study

Purpose: Occupational consequences of musculoskeletal disorders (MSDs) are consistently found in epidemiological studies. The aim of this study was to evaluate the prognostic value of various short-term rehabilitation outcome parameters on early retirement in Germany. Method: In a prospective multi-centre cohort study of self-rated patient status, physician chosen therapy goals and attainment were measured by means of standardized questionnaires at the beginning and end of medical rehabilitation. Information with regard to disability was collected by self-report over a 5-year follow-up period. Results: We included 1268 MSD patients aged 45–57 who underwent a 3-week, multidisciplinary, in-patient rehabilitation programme in 10 rehabilitation centres in Southern Germany between January and December 2001. During follow-up (mean duration: 3.9 years) 117 (9%) patients received a disability pension. After adjustment for sex, age and patient outcomes, risk for early retirement was significantly increased for patients with only partial success with respect for the therapy goals pain reduction (HR 1.95), improvement in spine motility (HR 1.6) and improvement of muscle strength (HR 2.3). Patients who did not have the therapy goal were at the same risk as patients with full goal achievement. Conclusions: Clinicians’ rating of short-term therapy outcome might be of prognostic relevance of MSD patients’ long-term employment status. Implications for Rehabilitation Short-term therapy success in pain therapy, spine motility and improvement in muscle strength during in-patient rehabilitation can help preserve long-term working capacity. Clinician’s rating is an independent predictor for long-term working capacity. Assessment of rehabilitation outcome is a contribution to quality control.