The Berlin-Brandenburg Air Study-A Methodological Study Paper of a Natural Experiment Investigating Health Effects Related to Changes in Airport-Related Exposures

Objectives: This paper presents the study design of the Berlin-Brandenburg Air study (BEAR-study). We measure air quality in Berlin and Brandenburg before and after the relocation of aircraft (AC) traffic from Tegel (TXL) airport to the new Berlin-Brandenburg airport (BER) and investigate the association of AC-related ultrafine particles (UFP) with health outcomes in schoolchildren. Methods: The BEAR-study is a natural experiment examining schoolchildren attending schools near TXL and BER airports, and in control areas (CA) away from both airports and associated air corridors. Each child undergoes repeated school-based health-examinations. Total particle number concentration (PNC) and meteorological parameters are continuously monitored. Submicrometer particle number size distribution, equivalent black carbon, and gas-phase pollutants are collected from long-term air quality monitoring stations. Daily source-specific UFP concentrations are modeled. We will analyze short-term effects of UFP on respiratory, cardiovascular, and neurocognitive outcomes, as well as medium and long-term effects on lung growth and cognitive development. Results: We examined 1,070 children (as of 30 November 2022) from 16 schools in Berlin and Brandenburg. Conclusion: The BEAR study increases the understanding of how AC-related UFP affect children's health.

Short-term exposure to ultrafine and fine particulate matter with multipollutant modelling on heart rate variability among seniors and children from the CorPuScula (coronary, pulmonary, sanguis) longitudinal study in Germany

Background

Short-term exposure particulate matter with a diameter of 10 µm or less (PM10) and fine particulate matter (PM2.5) has been associated with heart rate variability (HRV), but exposure to ultrafine particles (UFP) has been less well examined. We investigated the associations between the HRV outcomes and short-term exposure to UFP, PM10 and PM2.5 among school-aged children and seniors.

Methods

CorPuScula (Coronary, Pulmonary and Sanguis) is a longitudinal, repeated-measure panel study conducted in 2000-2002 in Munich, Germany including 52 seniors (58-94 years old) with 899 observations and 50 children (6-10 years old) with 925 observations. A 10-min resting electrocardiogram was performed to assess resting HRV outcomes [Standard Deviation of Normal to Normal Intervals (SDNN), Root Mean Square of Successive Differences between Normal Heartbeats (RMSSD), Low Frequency power (LF), High Frequency power (HF), ration between low and high frequency (LF/HF)]. UFP and PM exposures were measured near the care home and school yard for seniors and children, respectively. Mean exposures during the day of examination (9-21 h) as well as 3-h, 12-h, 24-h, one-day, and two-day lags were assessed. Linear mixed-effect models were used to investigate the associations between short-term air pollution and HRV outcomes separately in children and seniors. The models were adjusted for sex, age, weather conditions (temperature, precipitation, and water vapor pressure), BMI, lifestyle and medical information. Two and multipollutant models adjusted for NO2 and O3 were performed.

Results

Among seniors, we observed increases in SDNN, LF, HF and LF/HF ratio after short-term exposure to UFP (hourly and daily lags) in contrast to decreases in SDNN and RMSSD after exposure to PM10. Associations were generally robust to two- and multipollutant adjustment. Among children, we observed increases of the LF/HF ratio after short-term exposures to UFP at lags 12 and 24 h. In contrast, we observed decreases of the ratio after exposure to PM2.5 and PM10. Results were largely unchanged for multipollutant modelling, however we found a more pronounced increase in SDNN and LF/HF (UFP lag 12 and 24 h) after adjusting for NO2.

Conclusions

Overall, among seniors, we observed associations of UFP and PM10 exposure with sympathetic responses of the ANS, which play an important role in sudden heart attacks or arrhythmia. Among children we found more inconsistent associations between UFP and a delayed increase in HRV. Adjusting for co-pollutants including NO2 and O3 yielded robust results.

Global Prevalence of Prediabetes

OBJECTIVE

To estimate the global, regional, and national prevalence of prediabetes, defined by impaired glucose tolerance (IGT) or impaired fasting glucose (IFG).

RESEARCH DESIGN AND METHODS

We reviewed 7,014 publications for high-quality estimates of IGT (2-h glucose, 7.8-11.0 mmol/L [140-199 mg/dL]) and IFG (fasting glucose, 6.1-6.9 mmol/L [110-125 mg/dL]) prevalence for each country. We used logistic regression to generate prevalence estimates for IGT and IFG among adults aged 20-79 years in 2021 and projections for 2045. For countries without in-country data, we extrapolated estimates from countries with available data with similar geography, income, ethnicity, and language. Estimates were standardized to the age distribution for each country from the United Nations.

RESULTS

Approximately two-thirds of countries did not have high-quality IGT or IFG data. There were 50 high-quality studies for IGT from 43 countries and 43 high-quality studies for IFG from 40 countries. Eleven countries had data for both IGT and IFG. The global prevalence of IGT in 2021 was 9.1% (464 million) and is projected to increase to 10.0% (638 million) in 2045. The global prevalence of IFG in 2021 was 5.8% (298 million) and is projected to increase to 6.5% (414 million) in 2045. The 2021 prevalence of IGT and IFG was highest in high-income countries. In 2045, the largest relative growth in cases of IGT and IFG would be in low-income countries.

CONCLUSIONS

The global burden of prediabetes is substantial and growing. Enhancing prediabetes surveillance is necessary to effectively implement diabetes prevention policies and interventions.

Association of long-term air pollution and ambient noise with cognitive decline in the heinz nixdorf recall study

Little is known about the impact of long-term ambient air pollution (AP) and noise exposure on change in cognitive function over years in the elderly. In this study, we wanted to examine the association between long-term exposure to AP and noise with the rate of cognitive decline in a population aged 50 and older and susceptible groups with mild cognitive impairment or at a genetically higher risk of Alzheimer's disease (Apolipoprotein E ε4 positive). Participants in the German population-based Heinz Nixdorf Recall study carried out five neuropsychological tests. Individual tests scores at the first (T₁ = 2006-2008) and second (T₂ = 2011-2015) follow-up for each test were used as outcomes after standardization using predicted means adjusted for age and education. Global cognitive score (GCS) was defined as sum of five standardized scores of individual tests. Long-term exposures to particulate matter (PM_2.5, PM₁₀, PM_2.5 absorbance), accumulation mode particle number (PN_acc), a proxy of ultrafine particles, and nitrogen dioxide were estimated by the land-use regression and chemistry transport models. Noise exposures were assessed as outdoor weighted nighttime road traffic noise (L_night) means. We performed linear regression analyses adjusted for sex, age, individual and neighborhood socio-economic status, and lifestyle variables. Effect modification in vulnerable groups was estimated using multiplicative interaction terms between exposure and a modifier. Overall, 2554 participants (49.5% men, median age is 63 (IQR = 12)) were included. We found weak associations between higher exposure to PM₁₀ and PM_2.5 with faster decline in the immediate verbal memory test. Adjustment for potential confounders and for co-exposures did not change the results. We saw no effects on GCS, and no effect of noise exposure. In susceptible groups, higher AP and noise exposure were tended to be associated with faster decline in GCS. Our results suggest that AP exposure may accelerate cognitive decline in older ages, particularly in susceptible groups.

PHQ-9, CES-D, health insurance data-who is identified with depression? A Population-based study in persons with diabetes

AIMS

Several instruments are used to identify depression among patients with diabetes and have been compared for their test criteria, but, not for the overlaps and differences, for example, in the sociodemographic and clinical characteristics of the individuals identified with different instruments.

METHODS

We conducted a cross-sectional survey among a random sample of a statutory health insurance (SHI) (n = 1,579) with diabetes and linked it with longitudinal SHI data. Depression symptoms were identified using either the Centre for Epidemiological Studies Depression (CES-D) scale or the Patient Health Questionnaire-9 (PHQ-9), and a depressive disorder was identified with a diagnosis in SHI data, resulting in 8 possible groups. Groups were compared using a multinomial logistic model.

RESULTS

In total 33·0% of our analysis sample were identified with depression by at least one method. 5·0% were identified with depression by all methods. Multinomial logistic analysis showed that identification through SHI data only compared to the group with no depression was associated with gender (women). Identification through at least SHI data was associated with taking antidepressants and previous depression. Health related quality of life, especially the mental summary score was associated with depression but not when identified through SHI data only.

CONCLUSION

The methods overlapped less than expected. We did not find a clear pattern between methods used and characteristics of individuals identified. However, we found first indications that the choice of method is related to specific underlying characteristics in the identified population. These findings need to be confirmed by further studies with larger study samples.

IDF Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045

AIMS

To provide global, regional, and country-level estimates of diabetes prevalence and health expenditures for 2021 and projections for 2045.

METHODS

A total of 219 data sources meeting pre-established quality criteria reporting research conducted between 2005 and 2020 and representing 215 countries and territories were identified. For countries without data meeting quality criteria, estimates were extrapolated from countries with similar economies, ethnicity, geography and language. Logistic regression was used to generate smoothed age-specific diabetes prevalence estimates. Diabetes-related health expenditures were estimated using an attributable fraction method. The 2021 diabetes prevalence estimates were applied to population estimates for 2045 to project future prevalence.

RESULTS

The global diabetes prevalence in 20-79 year olds in 2021 was estimated to be 10.5% (536.6 million people), rising to 12.2% (783.2 million) in 2045. Diabetes prevalence was similar in men and women and was highest in those aged 75-79 years. Prevalence (in 2021) was estimated to be higher in urban (12.1%) than rural (8.3%) areas, and in high-income (11.1%) compared to low-income countries (5.5%). The greatest relative increase in the prevalence of diabetes between 2021 and 2045 is expected to occur in middle-income countries (21.1%) compared to high- (12.2%) and low-income (11.9%) countries. Global diabetes-related health expenditures were estimated at 966 billion USD in 2021, and are projected to reach 1,054 billion USD by 2045.

CONCLUSIONS

Just over half a billion people are living with diabetes worldwide which means that over 10.5% of the world's adult population now have this condition.

IDF diabetes Atlas: Global estimates of undiagnosed diabetes in adults for 2021

AIMS

To provide up-to-date estimates of undiagnosed diabetes mellitus (UDM) prevalence - both globally, and by region/country, for the year 2021.

METHODS

Data sources reporting diabetes prevalence were identified through a systematic search in the peer-reviewed and grey literature. The prevalence of undiagnosed diabetes was estimated from the data from each country where data was available. For countries without in-country data, the prevalence of undiagnosed diabetes was approximated by extrapolating the average of the estimates from countries with data sources within the same International Diabetes Federation (IDF) region and World Bank income grouping. We then applied these stratified prevalence estimates of UDM from each country to the number of adults in each strata and summed the counts to generate the number of adults with UDM (aged 20-79 years) for 215 countries and territories.

RESULTS

In 2021, almost one in two adults (20-79 years old) with diabetes were unaware of their diabetes status (44.7%; 239.7 million). The highest proportions of undiagnosed diabetes (53.6%) were found in the Africa, Western Pacific (52.8%) and South-East Asia regions (51.3%), respectively. The lowest proportion of undiagnosed diabetes was observed in North America and the Caribbean (24.2%).

CONCLUSIONS

Diabetes surveillance needs to be strengthened to reduce the prevalence of UDM, particularly in low- and middle-income countries.

Cumulative long-term recurrence of diabetic foot ulcers in two cohorts from centres in Germany and the Czech Republic

AIMS

Our aim was to comprehensively estimate the incidence of diabetic foot ulcer (DFU) recurrence and corresponding risk factors in two cohorts.

METHODS

Prospective data from patients with active DFU from two diabetes centres in Germany (GER, n = 222) and the Czech Republic (CZ, n = 99) were analysed. Crude cumulative incidences were obtained. Additionally, time to recurrence and risk factors were investigated using multivariate Cox models.

RESULTS

69%(154) of patients in GER and 70%(69) in CZ experienced at least one DFU recurrence; 25%(56) in DEU and 15%(15) in CZ died; 5%(11) and 9%(9) were lost to follow-up. The crude cumulative incidence in the first year was 28% in GER and 25% in CZ; 68%/70% within ten years, and 69%/70% in 15 years. In GER, renal replacement therapy was associated with shorter time to recurrence (HR = 3.71, 95%CI:1.26-10.87); no history of DFU before the index lesion with longer time to recurrence (HR = 0.62, 0.42-0.92). In CZ, type 2 diabetes (HR = 2.57, 1.18-5.62) and index ulcer treatment by minor amputation (HR = 2.11, 1.03-4.33) were associated with shorter time to recurrence.

CONCLUSIONS

Cumulative DFU recurrence was approximately 70% in 15 years in both cohorts. We found a significantly higher risk of future recurrence in patients having a consecutive ulcer compared with the first ever ulcer.

Global and regional estimates and projections of diabetes-related health expenditure: Results from the International Diabetes Federation Diabetes Atlas, 9th edition

AIMS

Diabetes and its complications have a significant economic impact on individuals and their families, health systems and national economies.

METHODS

The direct health expenditure of diabetes was calculated relying on the following inputs: diagnosed and undiagnosed diabetes prevalence estimates, United Nations population estimates, World Health Organization health expenditure per capita and ratios of health expenditure for people with diabetes compared to people without diabetes.

RESULTS

The estimated global direct health expenditure on diabetes in 2019 is USD 760 billion and is expected to grow to a projected USD 825 billion by 2030 and USD 845 billion by 2045. There is a wide variation in annual health expenditures on diabetes. The United States of America has the highest estimated expenditure with USD 294.6 billion, followed by China and Brazil, with USD 109.0 billion and USD 52.3 billion, respectively. The age group with the largest annual diabetes-related health expenditure is 60-69 years with USD 177.7 billion, followed by 50-59 years, and 70-79 years with USD 173.0 billion and USD 171.5 billion, respectively. Slightly higher diabetes-related health expenditure is seen in women than in men (USD 382.6 billion vs. USD 377.6 billion, respectively). The same difference is expected to be present in 2030 and 2045.

CONCLUSIONS

There were large disparities between high-, middle- and low-income countries with total health expenditures in high-income countries being over 300 times those in low-income countries. The ratio for annual direct health expenditure per person between these groups of countries is more than 38-fold.

Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition

AIMS

To provide global estimates of diabetes prevalence for 2019 and projections for 2030 and 2045.

METHODS

A total of 255 high-quality data sources, published between 1990 and 2018 and representing 138 countries were identified. For countries without high quality in-country data, estimates were extrapolated from similar countries matched by economy, ethnicity, geography and language. Logistic regression was used to generate smoothed age-specific diabetes prevalence estimates (including previously undiagnosed diabetes) in adults aged 20-79 years.

RESULTS

The global diabetes prevalence in 2019 is estimated to be 9.3% (463 million people), rising to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045. The prevalence is higher in urban (10.8%) than rural (7.2%) areas, and in high-income (10.4%) than low-income countries (4.0%). One in two (50.1%) people living with diabetes do not know that they have diabetes. The global prevalence of impaired glucose tolerance is estimated to be 7.5% (374 million) in 2019 and projected to reach 8.0% (454 million) by 2030 and 8.6% (548 million) by 2045.

CONCLUSIONS

Just under half a billion people are living with diabetes worldwide and the number is projected to increase by 25% in 2030 and 51% in 2045.

External validation of type 2 diabetes computer simulation models: definitions, approaches, implications and room for improvement-a protocol for a systematic review

BACKGROUND

Type 2 diabetes mellitus (T2DM), a highly prevalent chronic disease, puts a large burden on individual health and health care systems. Computer simulation models, used to evaluate the clinical and economic effectiveness of various interventions to handle T2DM, have become a well-established tool in diabetes research. Despite the broad consensus about the general importance of validation, especially external validation, as a crucial instrument of assessing and controlling for the quality of these models, there are no systematic reviews comparing such validation of diabetes models. As a result, the main objectives of this systematic review are to identify and appraise the different approaches used for the external validation of existing models covering the development and progression of T2DM.

METHODS

We will perform adapted searches by applying respective search strategies to identify suitable studies from 14 electronic databases. Retrieved study records will be included or excluded based on predefined eligibility criteria as defined in this protocol. Among others, a publication filter will exclude studies published before 1995. We will run abstract and full text screenings and then extract data from all selected studies by filling in a predefined data extraction spreadsheet. We will undertake a descriptive, narrative synthesis of findings to address the study objectives. We will pay special attention to aspects of quality of these models in regard to the external validation based upon ISPOR and ADA recommendations as well as Mount Hood Challenge reports. All critical stages within the screening, data extraction and synthesis processes will be conducted by at least two authors. This protocol adheres to PRISMA and PRISMA-P standards.

DISCUSSION

The proposed systematic review will provide a broad overview of the current practice in the external validation of models with respect to T2DM incidence and progression in humans built on simulation techniques.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017069983 .

IDF Diabetes Atlas: Global estimates for the prevalence of diabetes for 2015 and 2040

AIM

To produce current estimates of the national, regional and global impact of diabetes for 2015 and 2040.

METHODS

A systematic literature review was conducted to identify data sources on the prevalence of diabetes from studies conducted in the period from 1990 to 2015. An analytic hierarchy process was used to select the most appropriate studies for each country, and estimates for countries without data were modelled using extrapolation from similar countries that had available data. A logistic regression model was used to generate smoothed age-specific estimates, which were applied to UN population estimates.

RESULTS

540 data sources were reviewed, of which 196 sources from 111 countries were selected. In 2015 it was estimated that there were 415 million (uncertainty interval: 340-536 million) people with diabetes aged 20-79years, 5.0 million deaths attributable to diabetes, and the total global health expenditure due to diabetes was estimated at 673 billion US dollars. Three quarters (75%) of those with diabetes were living in low- and middle-income countries. The number of people with diabetes aged 20-79years was predicted to rise to 642 million (uncertainty interval: 521-829 million) by 2040.

CONCLUSION

Diabetes prevalence, deaths attributable to diabetes, and health expenditure due to diabetes continue to rise across the globe with important social, financial and health system implications.

IDF Diabetes Atlas estimates of 2014 global health expenditures on diabetes

AIMS

To estimate health expenditures due to diabetes in 2014 for the world and its regions.

METHODS

Diabetes-attributable health expenditures were estimated using an attributable fraction method. Data were sourced from International Diabetes Federation (IDF) estimates of diabetes prevalence, UN population projections, WHO annual health expenditure reports, and estimates of the cost ratio of people with and without diabetes. Health expenditures were calculated in both US dollars (USD) and international dollars (ID).

RESULTS

The average health expenditure per person with diabetes worldwide in 2014 was estimated to range from USD 1583 (ID 1742) to USD 2842 (ID 3110). The estimated annual global health expenditure attributable to diabetes ranged from USD 612 billion (ID 673 billion) to USD 1099 billion (ID 1202 billion). Together, the North America and Caribbean Region and the Europe Region were responsible for over 69% of the costs, and less than 10% of the costs were from the Africa Region, South East Asia Region, and Middle East and North Africa Region combined. The North America and Caribbean Region had the highest annual spending per person with diabetes (USD 7984 [ID 8040.39]), while the South East Asia Region had the lowest annual spending per person with diabetes (USD 92 [ID 234]).

CONCLUSIONS

Diabetes imposes a large economic burden on health care systems across the world, yet varies across world regions. Diabetes prevention and effective management of diabetes should be a public health priority to reduce the financial burden.