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203

Original communication

Prevalence of cardiovascular risk


factors among 28,000 employees
Martin Scheerbauma,1, Constantin Langenbacha,1, Petra Scheerbaum1,
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Franziska Heidemann1, Henrik C. Rieß1, Hagen Heigel2, Sebastian E. Debus1


and Christian-Alexander Behrendt1
a
These authors contributed equally to this paper
1
Department of Vascular Medicine, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
2
Heigel GmbH, Hanstedt, Germany

Summary: Background: Cardiovascular diseases are the leading cause of death in Germany. The knowledge of causal risk fac-
tors and their distribution is of utmost importance to design screening programs. Probands and methods: In this cross-section-
al study design we used STROBE criteria to achieve the highest comparability possible. Anthropometric measures (height and
weight), total cholesterol, glucose level, and blood pressure were measured. Probands’ history was collected by using a stand-
ardized questionnaire. The data was age- and gender-adjusted for the working population 16 to 70 years of age, derived from
the micro census, the 1 %-sample census of the German statistical office. For each study year weight factors were calculated.
Logistic regression analysis was conducted regarding the cardiovascular risk factors: smoking, arterial hypertension, diabetes,
hypercholesterolemia, and obesity. Results: Between 2006 and 2015 a total of 28,293 employees took part in the ongoing com-
pany screenings. The mean age was 42.3 years for both sexes (median: 43 years). The mean body mass index (BMI) was 25.6 kg/
m2 (men: 26.5 kg/m2, women: 24.7 kg/m2). A history of hypertension was present in 16 % of the employees (men: 17.8 %, women:
13.8 %). Of the respondents 2 % suffered from diabetes (men: 2.4 %, women: 1.6 %). Lipid-lowering drugs were taken by 2.8 % of
all employees (3.6 % men and 1.9 % women). 23.3 % of the men and women indicated to be active smokers. In the regression
analysis obesity was associated with a four times higher risk of hypertension and a three times higher risk of elevated glucose
levels, thus manifesting as main contributor for vascular diseases. Meanwhile the risk for obesity was 140 % higher in probands
who are former smokers. Conclusions: We regard obesity as the number one cardiovascular risk which should be assessed by
various medical, legislative, and socio-economic actions to limit future mortality and health-care costs in Germany.

Keywords: Cardiovascular risk factors, obesity, blood pressure, diabetes, smoking, employees

Introduction In recent years some authors already took a closer look


into the adolescent population [5–7]. The risk factor obesity
Cardiovascular diseases are the leading cause of death in is of special interest, since it is a rising risk factor that can be
Germany. The knowledge of causal risk factors and their influenced by the individuals themselves [8]. Therefore,
distribution in suitable target populations is of utmost im- since the early 2000’s, programs have been launched to pre-
portance to design evidence-based screening programs. In vent further growth of obesity among the US population [9].
2014, 338,056 deaths in Germany had been caused by car- There is a lot of data on children, adolescents, and el-
diovascular preconditions, thus summing up to 38.9 % of derly, but a group often overlooked is the employed popu-
all deaths in Germany [1]. lation between 18 and 65 years of age. Some studies fo-
The risk factors for cardiovascular diseases were first de- cused on younger adults, especially in the military services
scribed in the Framingham heart study [2, 3]. Today, the [10], but their focus mostly is not on the cardiovascular
established risk factors are smoking, arterial hypertension, risk assessment. Apart from that, only few data exist on
hypercholesterolemia, diabetes, and obesity. These factors the German population [11]. The closest approach in estab-
cause arteriosclerosis, which is the main pathophysiologic lishing some kind of registry of the German population is
entity of vascular damage. Arteriosclerosis causes diseases the DEGS1-Study which focuses on the current health-sta-
such as peripheral artery disease, myocardial infarction or tus of the German population [12]. So far, the authors of
carotidal artery stenosis. The crux of arteriosclerosis is its the on-going study managed to include 8,152 probands.
long presence until the onset of the related diseases [4]. As of today, there has been no continuous screening of
Therefore, detection of the prevalence of cardiovascular cardiovascular risk factors within all age groups of the Ger-
risk factors in younger population groups seems important. man population. Our aim was to investigate the prevalence

© 2017 Hogrefe Vasa (2017), 46 (3), 203–210


https://doi.org/10.1024/0301-1526/a000611
204 M. Scheerbaum et al., Cardiovascular risk factors in Germany

and possible correlation of cardiovascular risk factors in Total cholesterol: For total cholesterol, we included
the German working population, especially since the num- n  =   27,342 cases. The critical values of 190  mg/dl (for
ber of obese citizens in Germany is rising [7]. In order to hypercholesterolemia) as well as of 240 mg/dl (for severe
reach as much probands as possible, we collaborated with hypercholesterolemia) were used [15, 16].
the German company Heigel GmbH which conducts em-
ployee-screenings in German companies. This group of Elevated glucose level: Elevated glucose level was con-
employees seems to be quite unknown, hence the rate of sidered when probands had not eaten for at least eight
physician consultations is minimal. We managed to in- hours and reached a glucose level higher than 125 mg/dl or
clude 27,476 probands in our cross-sectional analysis. if the time period of not eating was between two to eight
hours and the glucose level exceeded 200 mg/dl [17].
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Elevated blood pressure: The arterial blood pressure was


Probands and methods measured indirectly and non-invasive (Korotkoff method)
after a rest period of five minutes prior to measurement.
The STROBE criteria were used throughout this study. Elevated blood pressure was diagnosed, when systolic
Furthermore, we adjusted our sub headlines in the meth- blood pressure ≥ 140  mmHg and/or diastolic blood pres-
ods and results section according to the structure of the sure ≥ 90 mmHg was measured [18].
STROBE criteria [13].
Smoking status: Active smokers have smoked at least 100
cigarettes, former smokers have smoked at least 100 ciga-
Source of data and setting rettes and quitted at least 12 months ago; non-smokers
have never smoked.
Heigel GmbH provides a voluntary cardiovascular screen-
ing program for employees in Germany. The services has
been offered to companies with employees ranging from Composite variables
150 to 65,000. The operational fields of the companies used in regression analyses
ranged from financial services to different branches of en-
gineering companies as well as publishing services. The • Hypercholesterolemia: Total cholesterol ≥ 190  mg/dl
employees underwent the screening in a standardized measured and/or use of lipid lowering drugs
form. Licensed physicians conducted the examination at • Elevated glucose level: elevated glucose level meas-
the company site by using point of care diagnostics which ured and/or diabetes (in the history)
were provided by Heigel throughout all screenings. The • Elevated blood pressure: systolic blood pressure
participation had been voluntary for the employees. The ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg
screenings were financed by the companies themselves. and/or high blood pressure (in the history)
We used the anonymized medical data of all conducted
screenings from 2006 until 2015 to form a cross-sectional
analysis of this 10-year time frame. Statistical analysis

Data were analysed using the statistical package for social


Study population sciences (SPSS 23.0 for Windows). The data were age- and
gender-adjusted for a working population 16 to 70 years of
Between 2006 and 2015 a total of 28,293 employees par- age, derived from the micro census, the 1 %-sample cen-
ticipated in the ongoing company screenings. After plausi- sus of the German statistical office. For each study year
bility checks, 27,476 participants aged 16 to 70 years were weight factors were calculated which later were used for
included in the cross-sectional analyses. Each participant additional analyses.
was monitored and interviewed just once and corresponds Missing or implausible values lead to exclusion of the
to one case and consequently to one data set entry. entire case. Outliers were defined as missing. Therefore,
the total number of probands varies with each risk factor.

Definitions of the quantitative variables Statistical analyses were conducted regarding the car-
diovascular risk factors: smoking, arterial hypertension,
Anthropometric measures (height and weight), total choles- diabetes, hypercholesterolemia, and obesity. Differences
terol, glucose level, and blood pressure were measured by with p-value  < 0.05 were classified as statistically signifi-
the licensed physician using on site diagnostics. Patient his- cant. For tables with descriptive statistics, the number of
tory was collected by using a standardized questionnaire. cases had to be at least n > 10, otherwise the field in the ta-
ble was marked with *. For all analyses, only cases with at
Obesity: Probands with a body mass index (BMI) of 30 kg/ least n ≥ 30 for all values of the investigated variables were
m2 or higher were declared as obese [14]. included. The prevalence of the risk factors, which mani-

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M. Scheerbaum et al., Cardiovascular risk factors in Germany 205

fested differently in gender and age, were tested on statis- higher prevalence of both forms of hypercholesterolemia
tical significance using contingency tables. Significance than men (p < 0.001).
level was identified with Chi-square and its p-values. The
means of BMI and total cholesterol were obtained by the Lipid lowering drugs
use of analysis of variance. The significant differences be- The use of lipid lowering medication rose with age (Fig-
tween the age groups were examined with the Scheffé-Test ure 1 panel C). In 49.6 % of the probands, who already
and the gender differences were tested using the t-test. used lipid lowering drugs, hypercholesterolemia was ob-
The logistic regression analysis was applied to identify the served (men: 44.2 %, women: 61.4 %); for 15.5 % we even
effect of the cardiovascular risk factors (obesity, hypercho- detected a severe hypercholesterolemia (men: 12.9 %,
lesterolemia, elevated glucose level, and elevated blood women: 21.4 %).
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pressure) on each other when further covariates (sex, age,


and smoking status) were involved. The logistic regression Diabetes and elevated glucose levels
stepwise model was applied, while only the independent Only 0.5 % of all probands showed elevated glucose lev-
variables regarding the covariates with a significance level els (men: 0.6 %, women: 0.3 %). But the rate of employ-
of at least p < 0.05 were considered. ees with a history of diabetes rose with age (Figure 1 panel
D). Interestingly, only 61.9 % of the probands with a his-
tory of diabetes used antidiabetic drugs (men: 65.1 %,
women: 56.2 %).
Results Elevated glucose levels were found in 14.9 % of probands
who had a history of diabetes. Within this group 19.6 % of
Characteristics of the study population the diabetic probands showed elevated glucose levels de-
spite using antidiabetic medication. In comparison, only
A total of 27,476 probands were included in the cross-sec- 7.8 % of the diabetic probands, who did not use antidiabet-
tional data analysis. After adjustments for gender and age, ic medication, showed elevated glucose levels. Probands
the distribution was 53.8 % men and 46.2 % women. The who had no history of diabetes showed elevated glucose
mean age was 42.3 years for both sexes (median: 43 years). levels in only 0.2 % (men: 0.3 %, women: 0.1 %).
The mean BMI was 25.6 kg/m2 (men: 26.5 kg/m2, women:
24.7  kg/m2). Further baseline characteristics are summa- Elevated blood pressure
rized in Table I. Of all probands 36.8 % showed elevated blood pressure,
2.1 % showed severe levels of hypertension (≥ 180 mmHg.
Obesity Systolic and/or ≥ 110 mmHg diastolic). The prevalence of
The average BMI of men in each age group was signifi- known hypertension increased with age, in men as well as
cantly higher than the BMI of women (p < 0.001) (Figure 1 in women (p  < 0.001). Men showed significantly higher
panel A). For both sexes, there was a significant increase prevalence of known hypertension than women in all age
of average BMI in the age groups 16–29 and 50–59 years groups (Figure 2 panel A).
(p < 0.001). Between the sixth and eighth life decade there Of the employees with a history of known arterial hy-
was no significant increase. pertension 78.1 % took antihypertensive drugs (Figure 2
The prevalence of obesity was higher in men than in panel B). The use of antihypertensive drugs increased con-
women in each age group. The number of obese employ- tinuously with age.
ees increased with every age group continuously. The rate Interestingly, 63.3 % of the probands who used antihy-
of adipose employees rose from 6.8 % (men: 8.2 %, wom- pertensive drugs showed elevated blood pressure levels in
en: 5.2 %) in the group of 16–29-year-olds to 19.8 % (men: our examination. Of those, 5.2 % even showed severely el-
21.4 %, women: 17.6 %) in the group of 60-years and older. evated levels. The probands with a history of hypertension,
who did not use antihypertensive drugs, showed elevated
Total cholesterol blood pressure levels in 74.3 % of the examinations, 8 %
The average total cholesterol was 195.1 mg/dl. The choles- even showed severely elevated levels (Figure 2 panel D).
terol level in women was with 200.2 mg/dl on average sig- The prevalence of unknown hypertension increased con-
nificantly higher than in men (190.8  mg/dl) (p  < 0.001) tinuously and significantly with age for both sexes (p < 0.001)
(Figure 1 panel B). We observed gender differences in the (Figure 2 panel C), thus rising up to 59.3 % for men and
means: while men already in a younger age showed an in- 50.9 % for women in the group of the 60-to-70-year olds.
crease, reaching the maximum mean at the age of 50,
women showed a rather late onset of increase after meno- Smoking
pause, reaching their maximum in their 60’s. Overall 23.3 % of the probands indicated to be active smok-
For half of the working population (50.9 %) hypercho- ers. Whereas 25 % of men were former smokers, 51.8 %
lesterolemia was detected (men: 47.1 %, women: 55.4 %). had never smoked. In women, 19.9 % were former smok-
In total 15 % were affected by severe hypercholesterolemia ers and 56.8 % had never smoked.
at a level above 240  mg/dl (men: 13 %, women: 17.4 %). For men and women, the percentage of active smokers
Women in the age group 16–29 and 50+ had a significant decreased with age (Figure 3 panel A), while the percent-

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206 M. Scheerbaum et al., Cardiovascular risk factors in Germany

Table I. Baseline characteristics of study population. 27,476 employees met the eligibility criteria and were included.

Characteristics Total Men Women (p-value)


Mean age ± SD, y 42.3 ± 11.8 42.4 ± 11.8 42.2 ± 11.8

Median age, y 43 43 43
Mean height ± SD, cm 174.3 ± 9.4 180.3 ± 7.2 167.4 ± 6.5 p < 0.001
Mean weight ± SD, kg 78.3 ± 16.0 86.2 ± 13.7 69.1 ± 13.5 p < 0.001
Mean BMI ± SD, kg/m2 25.6 ± 4.3 26.5 ± 3.8 24.7 ± 4.6 p < 0.001
Obesity, % 13.8 15.4 12.0 p < 0.001
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Hypercholesterolemia
Total cholesterol ≥ 190 mg/dl, % 50.9 47.1 55.4 p < 0.001
Total cholesterol ≥ 240 mg/dl, % 15.0 13.0 17.4 p < 0.001
Use of lipid lowering drugs, % 2.8 3.6 1.9 p < 0.001
Diabetes/elevated glucose level
History of diabetes, % 2.0 2.4 1.6 p < 0.001
Use of antidiabetic medicine, % 1.3 1.6 0.9 p < 0.001
Elevated glucose level (tested), % 0.5 0.6 0.3 p < 0.001
Blood pressure
History of arterial hypertension, % 16,0 17.8 13.9 p < 0.001
Use of antihypertensive drugs, % 12.5 13.8 10.9 p < 0.001
Elevated blood pressure (tested), % 36.8 42.1 30.7 p < 0.001
Smoking status
Active smoker, % 23.3 23.3 23.3 n. s.
Former smoker, % 22.6 25.0 19.9 p < 0.001

SD: standard deviation; BMI: body mass index.

age of former smokers rose for each age group (Figure 3 vs. 14.7 %, women: 49.5 % vs. 11.2 %). Meanwhile 6.5 % of
panel B). the obese employees had a history diabetes. This is five
times higher than in the non-obese group (1.3 %) (men:
6.2 % vs. 1.7 %, women: 6.8 % vs. 0.9 %).
Correlation and regression analysis Sex, age, smoking status, elevated blood pressure as
well as hypercholesterolemia were used as covariates in
Hypercholesterolemia the regression analysis. Obesity lead to a threefold in-
Obese employees suffered significantly more often from creased risk of elevated glucose levels (OR 3.17, 95 %-CI
hypercholesterolemia than those with regular weight. But 2.65–3.79, p < 0.001). Probands with elevated blood pres-
in the regression analysis with sex, age, smoking status, sure had a twofold higher risk of elevated glucose levels
and elevated blood pressure as covariates, obesity showed than probands without elevated blood pressure (OR 2.19,
no significant effect on hypercholesterolemia (ESM 1). 95 %-CI 1.77–2.71, p < 0.001).
Only elevated blood pressure correlated with hypercholes- In obese women, compared to non-obese women, the
terolemia (OR 1.34, 95 %-CI 1.27–1.42, p  < 0.001). When risk of elevated glucose level was higher (OR 4.66, 95 %-CI
analysed and stratified for gender, still no significant rela- 3.47–6.26, p < 0.001) than in men (OR 2.51, 95 %-CI 2.0–
tion to hypercholesterolemia could be detected. The effect 3.14, p < 0.001). The effect of elevated blood pressure re-
of high blood pressure remained (men: OR 1.36, 95 %-CI mained (ESM 1).
1.26–1.47, p < 0.001, women: OR 1.32, 95 %-CI 1.20–1.44, The regression analysis showed an increased risk of ele-
p < 0.001). In men, former smokers also had a moderately vated glucose levels for male active smokers (OR 1.43,
increased risk (OR 1.14, 95 %-CI 1.04–1.25; p  < 0.01) of 95 %-CI 1.07–1.90, p < 0.05) and male former smokers (OR
having hypercholesterolemia. 1.46, 95 %-CI 1.15–1.86, p < 0.01), whereas both active and
former female smokers were associated with a reduced
Elevated glucose levels risk (OR 0.66, 95 %-CI 0.45–0.98, p < 0.05 and OR 0.63,
In total 43.1 % of the probands who had a history of diabe- 95 %-CI 0.44–0.92, p < 0.05).
tes were obese, while only 13 % of the probands without a
history of diabetes showed signs of obesity (men: 39.4 %

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M. Scheerbaum et al., Cardiovascular risk factors in Germany 207
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Figure 1. Upper left (A): means of body mass index (BMI) by gender and age groups (n = 27,476). Upper right (B): means of total cholesterol meas-
ured in mg/dl by gender and age groups (n=27,342). Bottom left (C): use of lipid lowering drugs as proportion (%) by gender and age groups
(n = 27,130). Bottom right (D): history of diabetes as proportion (%) by gender and age groups (n = 27,130).

Elevated blood pressure Discussion


Sex, age, smoking status, hypercholesterolemia, and elevat-
ed glucose levels were the covariates in the regression analy- In our cross-sectional analysis we found that the main risk
sis. Obesity increased the risk of elevated blood pressure factor for a cardiovascular disease, which highly probable
(OR 3.85, 95 %-CI 3.53–4.21, p < 0.001). Obese women (OR adds to further risk factors, is obesity. The fact that obesity
4.36, 95 %-CI 3.81–5.0, p < 0.001) had a fourfold higher risk is one of the main contributors to vascular diseases is not
of elevated blood pressure than non-obese women. Obese new knowledge [19–21], but in our survey a BMI above 30
men had a threefold higher risk of elevated blood pressure leads to a four times higher risk of elevated blood pressure
than non-obese men (OR 3.41, 95 %-CI 3.03–3.83, p < 0.001). and a three times higher risk of elevated glucose levels, thus
Both male and female probands with elevated glucose summing up cardiovascular risks. In addition to that, for-
levels had a twofold higher risk of having elevated blood mer smokers had a 1.4 times higher risk of being obese than
pressure (OR 2.34, 95 %-CI 1.89–2.90, p < 0.001). Moreover, active or non-smokers. This reconfirms former studies [22,
the risk for elevated blood pressure was increased by hyper- 23]. Furthermore, the rate of obese probands rose with age
cholesterolemia (OR 1.28, 95 %-CI 1.21–1.36, p < 0.001). reaching almost 20 % in the group of 60 to 70 year-olds.

Obesity
Table II. Proportion of obesity (%) among active, former, and never
Former smokers had a significant higher prevalence of
smokers.
obesity than active smokers and non-smokers (Table II).
This applied for both sexes (p  < 0.001). In the regression Prevalence of obesity by smoking status (n=26,593)
analysis with sex, age, smoking status, elevated blood sug-
Active smoker Former smoker Never-smoker
ar, hypercholesterolemia, and elevated blood pressure as
covariates, former smokers showed a 1.4 times higher risk Total 12.5 % 18.2 % 12.3 %

of obesity (OR 1.41, 95 %-CI 1.28–1.54, p  < 0.001), men: Men 14.5 % 20.5 % 13.1 %
(OR 1.46, 95 %-CI 1.30–1.64, p < 0.001), women: (OR 1.37,
Women 10.2 % 14.9 % 11.5 %
95 %-CI 1.18–1.59, p < 0.001).

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208 M. Scheerbaum et al., Cardiovascular risk factors in Germany
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Figure 2. Upper left (A): history of arterial hypertension by gender and age groups (nn = 27,130). Upper right (B): use of antihypertensive medication
among probands with history of hypertension by gender and age groups (n=4,333). Bottom left (C): prevalence of unknown hypertension defined as
significantly elevated blood pressure among probands without history of hypertension or antihypertensive medication by gender and age groups
(nn = 22,514). Bottom right (D): occurrence of severe hypertension among different proband groups (without history of hypertension, with or with-
out antihypertensive medication).

Our analysis further demonstrated a rise of various car- However, elevated cholesterol levels seemed to be associ-
diovascular risk factors with age. The prevalence of known ated to elevated blood pressure, which already has been
diabetes, elevated glucose levels, and known hypertension published [33], and former smoking men.
as well as elevated blood pressure and hypercholester- Limitations in our sample with over 27,000 datasets can
olemia constantly rose with age, confirming former findings be found in the non-randomized sampling of companies as
[2, 24, 25]. Only the prevalence of active smokers decreased well as the voluntary participation in the offered screen-
with age. Interestingly, the rate of hypercholesterolemia, el- ing. Furthermore, only companies who already have a
evated glucose levels, and elevated blood pressure was health sensitive management conducted screening oppor-
higher in those probands who already had a pre-existing tunities in their companies. In addition, there is a risk of
condition of the examined disease. Surprisingly, probands selection and channelling bias, since health-conscious
in treatment for these conditions still showed severely ele- probands were more likely to take part in such screenings.
vated results; thus, raising the questions of compliance and On the other hand, our dataset included many big compa-
awareness of those diseases and the effectiveness of their nies with a wide spectrum of working people, different de-
treatment, a problem which has already been addressed in partments of diverse branches, and different employees
former studies [26–29]. with variances concerning the educational level, social sta-
Moreover, our regression analysis is showing that ele- tus, etc. We further tried to reduce our data limitation by
vated glucose levels are more than doubling the risk for distinguishing age and gender using the official micro cen-
hypertension – thus confirming the associations of diabe- sus data of the Federal Statistical Office of Germany.
tes and hypertension in former studies [30, 31]. Surpris- Our main result, which should be discussed, is the heavy
ingly, in our regression analysis obesity did not lead to ele- triggering of other cardiovascular risk factors by obesity.
vated levels of cholesterol. Cholesterol seems to be the This question has also been raised by Zalesin et al. [8] and
sole risk factor with no affection towards obesity among Mandviwala et al. [20]. In our opinion, it is difficult to de-
employees. This seems contrary to former findings [32]. termine whether obesity can be regarded as a single cardi-

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M. Scheerbaum et al., Cardiovascular risk factors in Germany 209
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Figure 3. History of active (panel A) and former (panel B) smoking by gender and age groups (n=26,593).

ovascular risk factor for the development of arterioscle- unknown. Nonetheless, we regard obesity as the number
rosis or wheter it should be regarded as a sole trigger for one target that can be assessed by various medical, legis-
other established cardiovascular risk factors. This also ap- lative, and socio-economic actions to reduce the cardio-
plies for other pathophysiologically established cardiovas- vascular risk profile of the population and to limit mortal-
cular risk factors, if we regard obesity itself as sole trigger. ity and health care costs in Germany in the future. For
Especially, since we were able show that elevated glucose one, the efforts made by the US CDC should also be incor-
levels as well as elevated blood pressure could three to four porated into a German prevention plan. Furthermore, the
times more often be found in obese probands than in non- general practicing colleagues in the field, who deal with
obese ones. In contrast to former studies, our investigation the entire variety of the German population should raise
could not significantly link obesity to hypercholester- their awareness of treating and guiding younger patients
olemia [32]. In addition to that, the factor of former smok- with severe overweight for cardiovascular diseases on a
ing men as a risk enhancer for higher cholesterol levels has daily basis.
not been proven so far. This seems troubling since smok-
ing cessation has been the number one prevention aim
over the last decades [34, 35]. Due to these differing re-
sults, further investigations seem necessary. Electronic supplementary material
Furthermore, obesity is one of the few cardiovascular
risk factors that can be influenced by the patients them- The electronic supplementary material is available with
selves. Especially, with the knowledge, that the rate of obe- the online version of the article at http://dx.doi.org/10.
sity tripled in the group of the adolescents from 11–17 years 1024/0301-1526/a000611.
within the last decade in Germany [7], a rise of health costs
in the coming decades seems inevitable. A lower life expec- ESM 1. Table. Regression analysis of risk factors. The table
tancy within the next century as described for the US [25] reads as follows: In bold letters we present the tested val-
appears also highly likely. Prevention seems to be the most ue. Underneath each sub header a precondition which in-
suitable and cost effective way to keep this problem under fluences the bold written condition is indicated. The influ-
control for future generations. Programs for young adoles- ence is indicated by total numbers as well as by sex for
cents have been reported to show promising results [36]. each sub header.
Also, the effort of the US Centers for Disease Control and
Prevention to fight obesity via a multi-sectional approach
seems promising [9] and should also be adapted to a Ger-
man setting. There is also a certain urgency to these meas- References
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