Background. Demographic ageing is leading to a marked increase in the population aged 65 and older, which, in turn, is expected to result in a rise in chronic diseases and functional limitations. To avoid overburdening of the healthcare system, supporting the health of people of working age (20-66), who represent the future older adult population, through preventive measures is essential. Methods. Based on a selective literature search, a narrative review was conducted to synthesize current evidence on the anticipated effects of demographic change as well as on preventive measures relevant to the working-age population. Results. Key at-risk groups include, alongside older adults, people with a migration background, men with low levels of education, and women in unskilled occupations or facing a dual burden of paid work and caregiving responsibilities. The workplace can facilitate access to hard-to-reach at-risk populations. Occupational physicians therefore play a crucial role in informing employees about the range of available preventive options. This encompasses prevention at the primary, secondary (e.g., screenings), and tertiary (e.g., rehabilitation) levels. Prevention should not be viewed solely as a health-related intervention, but should ultimately enable participation in society, including in gainful employment. Digital platforms represent a promising complement to the broad spectrum of available options. Equitable access to all preventive measures must be ensured. Ultimately, a well-coordinated care pathway is essential to preventive success. Epidemiological research can help identify challenges, detect risk factors, and contribute to the evaluation of preventive interventions. Conclusion. Prevention during working age represents a key lever for improving population health in the future. Epidemiological research is essential for identifying at-risk groups and ensuring that preventive measures are evidence-based.

Abstract Background During the COVID-19 pandemic, non-COVID-19 related healthcare utilization declined in Germany, resulting in care delay, including delays and cancellations of routine, chronic, and even acute care. The aim of this study was to investigate factors (i.e. regional differences and participant characteristics) associated with care delay during the pandemic in Germany using a cross-sectional survey. Methods In October 2022, a total of 117,466 participants from the German National Cohort (NAKO) study completed an online questionnaire on pandemic-related topics, including care delay during the COVID-19 pandemic. Regional differences and participant characteristics associated with care delay were assessed using (multilevel) logistic regression. Results One third of participants reported having experienced care delay. Care delay did not differ across the 13 federal states or 32 districts in Germany for which sufficient data were available. In the medical practice setting, care delay was nearly equally provider- and patient-related and was reported mostly for routine check-ups. In the hospital setting, care delay was predominantly provider-related and reported for newly occurring conditions. The odds for care delay were higher in females vs. males (odds ratio (OR): 1.30; 95% confidence interval (CI): 1.27–1.34), and in participants with vs. without chronic conditions (e.g. mental disorders, OR: 1.41, 95%CI: 1.36–1.46 or cardiovascular diseases, OR: 1.20 95%CI: 1.16–1.24) and decreased with age (e.g. 70 + vs. 50–59 years, OR: 0.59, 95%CI: 0.57–0.62). Conclusion Care delay during the COVID-19 pandemic depended on participant characteristics including age, sex, and preexisting chronic conditions but not on regional (i.e. state and district-level) differences in Germany.

BACKGROUND:A large proportion of Europeans are exposed to high levels of transportation noise, which can cause physiological and psychological stress, leading to negative health impacts. Few studies have examined the association between transportation noise and self-rated health (SRH), a summary indicator of morbidity. OBJECTIVES:We aimed to assess the associations of SRH with both annual average road traffic noise exposure and nighttime transportation noise annoyance, examine geographic differences, evaluate potential effect modification and interaction by sex, and investigate whether annoyance mediates the relationship between road traffic noise and self-rated health. METHODS:Using NAKO baseline data (n = 174,956), we implemented a cross-sectional study using logistic regression to analyze associations of road traffic noise ≥55 dB(A) Lden and nighttime transportation noise annoyance with poor SRH, adjusting for relevant sociodemographic characteristics and environmental co-exposures, including air pollution and greenness. We examined geographic differences, tested for effect modification and interaction by sex, and used path analysis to assess mediation by annoyance. RESULTS:Road traffic noise ≥55 dB(A) (OR 1.06, 95 % CI 1.01; 1.10), and moderate (OR 1.28, 1.23; 1.32) and strong nighttime transportation noise annoyance (OR 1.73, 1.65; 1.81) were associated with higher odds of poor SRH. Associations were similar for males and females, but varied across study regions. The path analysis revealed that road traffic noise was associated with higher odds of poor SRH indirectly via nighttime transportation noise annoyance (indirect effect). CONCLUSIONS:In our study, nighttime transportation noise annoyance was more strongly and consistently associated with poor SRH than road traffic noise. Reducing both transportation noise and related annoyance could help protect population health.

BACKGROUND:The COVID-19 pandemic and its effects have aroused concern all over the world about its impact on mental health. The German National Cohort (NAKO) lends an opportunity to examine trends in altered mental health among adults in Germany during the pandemic. METHODS:We analyzed data from 79 239 participants in the NAKO study who were surveyed with respect to depressive and anxiety symptoms, stress, and self-perceived health at three points in time: at baseline (2014-2019) and in the early (2020) and late (2022) stages of the pandemic. Changes in mental health over time were analyzed with descriptive statistics, Sankey diagrams, and a post-hoc multinomial logistic regression. RESULTS:We observed an initial improvement in self-perceived health from baseline to 2020, but a deterioration from 2020 to 2022. The mental health of most participants remained the same over time. From baseline to 2022, the percentage of participants reporting depressive symptoms rose from 5.9% to 9.7%; rises were also seen in moderate to severe anxiety symptoms, from 3.9% to 6.2%, and in moderate to severe stress, from 4.1% to 10.2%. Both among young adults and among women, deterioration in self-perceived health was more common than improvement. CONCLUSION:Our findings indicate a rise in mental health symptoms among adults in Germany during the pandemic. These findings underscore the need for continuous monitoring and targeted strategies to improve public mental health.

Background: Human nutrition is tightly linked to health and disease and, as such, to longevity. Consequently, high adherence to a healthy diet, such as the Dietary Approaches to Stop Hypertension (DASH), has repeatedly been associated with a reduced mortality risk. However, the contribution of individual score components driving this association is incompletely understood. Objectives: We assessed the association of adherence to the DASH score as well as its individual components to all-cause mortality in the largest German population-based study, the German National Cohort (NAKO). Methods: We included n=131,486 individuals from the NAKO baseline examination (51.3% women, mean age 49.6 (±12.6) years). Dietary intake was assessed with a multiple source method combining up to four 24h dietary recalls with a self-administered, validated Food Frequency Questionnaire. DASH score was derived based on quintiles of consumption scoring fruits, vegetables, legumes/nuts, wholegrains, and low-fat dairy products positively, while scoring red/processed meat, soft drink, and sodium intake negatively. Cox proportional hazards regression models, adjusted for age, sex, body mass index, smoking, socioeconomic status, physical activity, alcohol, and total daily energy intake, were used to relate DASH adherence to all-cause mortality. Furthermore, we related individual components of DASH (per 1-portion increment) to all-cause mortality. Results: Over a mean follow-up time of 6 (±2) years, n=2,058 participants died. In multivariable-adjusted models, better adherence to DASH was associated with a reduced risk of all-cause mortality (HR: 0.88 [95% CI: 0.84; 0.91] per 5-point increment). When relating individual score components to all-cause mortality, we particularly observed a reduced mortality risk associated with the positively-scored food groups ‘vegetables’ (HR: 0.83 [95% CI: 0.74; 0.93] per 100g increment) and ‘legumes/nuts’ (HR: 0.85 [95% CI: 0.73; 0.92] per 25g increment), while the negatively-scored food groups ‘red/processed meat’ (HR: 1.57 [95% CI: 1.29; 1.92] per 100 g increment) and ‘sodium’ (HR: 1.57 [95% CI: 1.36; 1.83]) were associated with an increased mortality risk. Conclusion: Better adherence to DASH is associated with a reduced risk of all-cause mortality in a large sample from the German general population, with higher intake of vegetables, legumes, and nuts and lower intake of red/processed meat and sodium possibly having a particularly protective effect.

Background Health inequalities by sex/gender, migration, education and income persist across Europe, yet intersectionality-informed research on how these social positions jointly shape self-rated health (SRH) remains limited. Methods We conducted a cross-sectional analysis of the German National Cohort (NAKO; n=179 861). Sex/gender, education and income were combined with three migration characteristics (any migration, Turkish and ethnic German resettler backgrounds) into three 16-strata exposure variables. We used Poisson regression with robust SEs to estimate adjusted frequencies and relative risks of poor SRH, adjusting for age, household size and study site. Departures from additivity were assessed using two-, three-, four-way and total relative excess risk due to interaction (RERI). Results Poor SRH followed a social gradient. Adjusted frequency of poor SRH generally increased with each additional marginalised social position, from 6.3% (95% CI 5.5% to 7.2%) among high education and income migrant men to 22.6% (95% CI 21.3% to 23.8%) among low education and income migrant women. Adjusted frequencies were highest among participants with Turkish background. Joint exposure to female sex/gender, migration and low education and income was associated with risk of poor SRH beyond the sum of individual effects. Total RERIs for four-way intersections were 1.10 (95% CI 0.83 to 1.37) for any migration, 3.09 (95% CI 2.02 to 4.15) for Turkish and 1.62 (95% CI 0.84 to 2.41) for ethnic German resettler backgrounds. Conclusions SRH in Germany exhibits pronounced intersectional inequalities. Individuals occupying multiple marginalised social positions experienced a disproportionate burden of poor SRH, highlighting the importance of intersectionality in population health monitoring.

Abstract Background The COVID-19 pandemic and accompanying social distancing measures might have caused adverse health consequences. We aimed to describe changes in participants’ self-rated health and mental health (depression, anxiety, and stress), and investigate factors associated with them. Methods We collected data from the German National Cohort (NAKO). We first described changes in participants’ self-rated health and mental health from the baseline examination (1 to 6 years earlier) to the early phase of the COVID-19 pandemic. We then applied the multinomial logistic regression model (self-rated health) and the quantile regression model (mental health) to investigate the potential factors associated with the health status and changes. Results After a median of 3.1 [2.1, 4.1] years from baseline to the early pandemic phase (N = 91,809), 39.3% of participants with good health and 69.7% with less good health status at baseline reported better health. However, the percentage of participants with high depression, anxiety, and stress scores (≥ 10) increased from 6.2%, 4.1%, and 4.3% to 8.6%, 5.6%, and 10.1%, respectively. In the multivariable models, we found that being younger, being male, highly educated, being employed, having higher life satisfaction at baseline, being more physically active, drinking heavily, and experiencing improved anxiety symptoms were associated with improved self-rated health. In contrast, smoking and having mental health disorders were all associated with worse self-rated health. Our results showed that being younger, being female, smoking, drinking heavily, and drinking more since baseline were associated with higher depression scores. Having had a coronavirus test was associated with worse self-rated health and more severe anxiety and stress. Conclusions During the early COVID-19 pandemic, many participants experienced improvements in self-rated health but suffered deterioration in mental health and physical activity engagement. Female participants, those who were physically inactive, and those with pre-existing mental disorders were more likely to report poorer health.

Rib-cage morphology is a determinant of thoracic biomechanics, ventilation, and injury response, yet statistical shape models (SSMs) of the rib cage have relied on small cohorts (~100s of individuals) imaged by clinical computed tomography, which over-represents injury and disease. We constructed a surface-based SSM of the complete 24-rib cage from 26,275 standardised whole-body magnetic resonance imaging (MRI) scans of adults aged 19-74 years from the population-based German National Cohort (NAKO). Ribs were segmented with a deep-learning pipeline (a rib-extended SPINEPS model), reconstructed as per-rib surface meshes, and brought into dense vertex-wise correspondence by Gaussian-process morphable registration in Scalismo; the aligned ensemble was summarised by generalised Procrustes analysis and principal component analysis (PCA). Fourteen per-rib geometric descriptors provided a quantitative cross-walk between the abstract PCA modes and named shape features, and associations with sex, age, body size and composition (including body-fat percentage), and smoking exposure were estimated by multivariable regression with Benjamini-Hochberg false-discovery-rate control. Shape variation was strongly concentrated: 28 modes captured 95% of the total variance, and the first three alone accounted for 69.4% (PC1, 42.6%; PC2, 16.3%; PC3, 10.5%) and admitted consistent anatomical readings - a sexually dimorphic axis (PC1), a slender-versus-stout body-habitus contrast (PC2), and a free-rib-size axis at ribs 11-12 (PC3). The sexes were nearly fully separated along PC1 (Cohen's d = 2.52). Body mass and body-fat percentage were the dominant modifiable correlates of rib-cage shape, whereas the association with cumulative smoking exposure was comparatively small. The model is released as a population-representative geometric reference for benchmarking and morphing donor-derived finite-element human-body models and for further large-cohort shape analysis.

BACKGROUND:Chronic kidney disease (CKD) can be asymptomatic for many years and is often diagnosed late. Given the availability of new treatments, the early identification of relevant findings from screening of the kidney markers estimated glomerular filtration rate (eGFR) and albuminuria in the general population is becoming increasingly important. METHODS:In the NAKO study, self-reported medical diagnoses of kidney disease in 195 182 participants were compared with relevant findings from screening biomarkers (eGFR < 60 mL/min/1.73 m² and albuminuria). For the purpose of comparison, various equations for assessing kidney function were evaluated as well. RESULTS:2% of the participants reported having received a medical diagnosis of kidney disease, and 2% had an eGFR below 60 mL/min/1.73 m². There was, however, little overlap between these two groups: more than 80% of participants with an eGFR between 30 and 59 mL/min/1,73 m²) did not report any diagnosis of kidney disease. The additional inclusion of data on albuminuria did not materially affect this discrepancy: 6213 persons (17.5% of the cohort) with an abnormal eGFR or urinary albumin-to-creatinine ratio (UACR) did not report any diagnosis of kidney disease. Even among participants whose eGFR was in the range of 30-59 mL/min/1.73 m² and whose UACR was above 300 mg/g, less than half reported having a medically diagnosed kidney disease. CONCLUSION:These findings indicate a low level of awareness regarding the possible presence of CKD in the general population. Many people with abnormal screening findings needing further investigation due to their potential clinical relevance are unaware that they might be suffering from a kidney disease. As more effective treatments for kidney disease are now available, these findings indicate a need for structured screening and evaluation strategies to promote kidney health.

Abstract Objectives Low physical activity (PA) and poor cognitive function are associated with higher mortality risks. However, little is known about their interaction, including whether PA may moderate cognition-related mortality risks. This study examines the combined associations of PA and cognition with all-cause mortality, with attention to sex differences. Methods Using data from the German National Cohort and its mortality follow-up, we analyzed mortality risk based on: a) baseline low vs. sufficient PA (assessed via the global physical activity questionnaire using a threshold of < vs. ≥ 600 MET-minutes/week), b) baseline low vs. medium vs. high semantic memory (SM) and executive function/processing speed (EF/PS), assessed through factor analyses of a neurocognitive test battery, and c) their interaction on mortality in individuals aged 65 + up to 10 years of follow-up (N = 28,892). Cox models were estimated both in the total sample and stratified by sex, adjusting for relevant confounders and reporting both distinct and combined associations. Results During follow-up, 1,605 individuals (5.6%) died: 1,097 men (7.5%) and 508 women (3.6%). Compared to individuals with low cognitive function, those with high SM (Hazard Ratio (HR) = 0.83 [95%CI: 0.67–1.02]), as well as high EF/PS (HR = 0.66 [0.53–0.83]) and medium EF/PS (HR = 0.68 [0.60–0.78]) had lower mortality risks. PA was associated with a 29% decreased mortality risk (HR = 0.71 [0.62–0.82]) compared to low PA. PA moderated the elevated risk from low cognition, with regard to EF/PS (low EF/PS*PA: HR = 0.65 [0.50–0.84] vs. low EF/PS*low PA: HR = 1 (ref.)) and SM (low SM*PA: HR = 0.60 [0.46–0.77] vs. low SM*low PA: HR = 1 (ref.)). The associations did not differ between men and women. Conclusion Maintaining cognitive function and PA in older age is relevant for reducing mortality risk in both men and women. PA may offset risks linked to low cognition in both sexes, though mechanisms require further study. Trial registration Clinical trial number: not applicable.

BackgroundOncological exercise therapy (OET) can help improve various patient outcomes, including fatigue and quality of life, and in certain cancer types, progression-free and overall survival. Despite this, OET is not routinely implemented into clinical practice. A better understanding of cancer patients’ perceived barriers and facilitators to participating in OET may support its integration into routine care. This multi-center cross-sectional study investigating cancer patients’ views will help close this evidence-practice-gap.MethodsAs part of IMPLEMENT, a nationwide OET implementation research project in Germany, an exploratory study with a quasi-experimental design was conducted using a non-representative sample of consenting cancer patients. Participants completed a survey either online or in paper format. A comprehensive descriptive analysis was conducted using SPSS and RStudio.ResultsA total of 402 cancer patients provided a questionnaire (61% female; mean age 57 years, SD 15). The most common cancer types were breast cancer (34%), lymphoma or leukemia (12%), and colon cancer (5%). Most patients reported feeling physically (79% agreed or somewhat agreed) and mentally (85% agreed or somewhat agreed) capable of participating in OET. Motivation to engage in OET was perceived to be high (76% agreed or somewhat agreed), and patients reported having sufficient time to become physically active (83% agreed or somewhat agreed). However, only half of participants said they were offered OET by their healthcare providers (48% agreed or somewhat agreed).ConclusionOur findings indicate that most cancer patients are both willing and able to participate in OET. However, they are not routinely informed about OET. Therefore, tailored strategies for improving patient access to OET are needed.Trial registrationClin. Trials: NCT06496711. German Clinical Trial Register (Deutsches Register Klinischer Studien - DRKS): 00032292. Bavarian Cancer Research Center (Bayerisches Krebsforschungszentrum - BZKF resp. ZKS): DZ-2024-2165-9.

Background The nasal microbiome plays an important role in respiratory and systemic health, but data from large adult population cohorts remain scarce. We analyzed nasal microbiota from 2,070 adults aged 21–73 years in the population-based German National Cohort (NAKO) to characterize community composition and identify host factors associated with variation in the anterior nares’ microbiome. Microbial profiles were obtained using 16S rRNA gene sequencing, and associations with host characteristics—including sex, age, body composition, tobacco smoking, pulmonary function, household context, and self-reported physician diagnoses—were evaluated using a two-stage regression framework, beta diversity analyses, and complementary Latent Dirichlet Allocation (LDA) community modeling. Results Despite detecting 358 genera across the cohort, more than 90% of all sequencing reads were assigned to only 15 genera. These core genera showed distinct associations with host physiology and lifestyle. Sex and body mass index were the strongest correlates of alpha and beta diversity, while pulmonary function and tobacco smoking were associated with differences in the relative abundance of several commensal taxa, including Lawsonella , Cutibacterium , and Dolosigranulum . Age was not related to overall diversity but exhibited characteristic shifts in community composition. Antibiotic use within the previous 12 months was associated with lower levels of multiple commensal genera and higher relative abundance of Staphylococcus . LDA-derived sub-communities largely mirrored the genus-level associations and indicated that these patterns reflect transitions between recurrent nasal community types rather than isolated changes in single taxa. Conclusions This nationwide study provides a detailed characterization of nasal microbiome patterns in the general adult population (up to 73 years) of Germany and highlights that multiple host factors are associated with both taxon-specific and community-level variation. The findings offer a reference for future investigations into the role of the nasal microbiome in respiratory and systemic health.

Ultra short-chain perfluoroalkyl substances (USC PFAS) with C1-C3 chain lengths are increasingly important. Globally, trifluoroacetic acid (TFA) makes up the largest proportion of PFAS in the environment, however, knowledge about human internal exposure to these substances is scarce. We present a new, fast and robust human biomonitoring (HBM) method to quantify simultaneously 5 USC PFAS in urine. A simple dilute and shoot method based on liquid chromatography-tandem mass spectrometry using isotope dilution was developed, validated and applied in a HBM pilot study using samples from a population-based subsample of the general population. It showed linearity up to 75 µg/L, low limits of quantification (LOQ 0.05–1.5 μg/L), satisfactory matrix spiked mean relative recoveries (95–107 %) and overall precision (VC 2.9–12 %). In an initial set of two longitudinal samples from 150 participants, aged 21–69 years, of the German National Cohort Hamburg study center, TFA was detected in all samples, ranging from 2.96 to 1512 µg/L. Trifluoromethanesulfonic acid (TFMS) was detected in 73 % and quantified in 8 % of samples, providing first evidence of its occurrence in urine. All other analytes were below LOQ in all samples. Adjusted linear regression analyses showed that baseline TFA levels increased across five age groups and year of examination. From baseline (2015–2019) to follow-up (2020–2024) median of TFA increased on average by 1.6-fold, independent of aging. These are the first longitudinal data on TFA internal exposure among adults from a German metropolitan region, revealing the need for analyzing potential predictors of exposure over time.

BACKGROUND:The German National Cohort (NAKO Gesundheitsstudie) is a prospective cohort study with 205 053 participants. Its goal is to identify risk factors for chronic diseases, including cancer. METHODS:We describe the methods of ascertaining cancer cases in NAKO (i.e., linkage with cancer registries and self-reporting), the incidence and prevalence figures obtained so far, and the ratios of observed to expected (O/E) case numbers. RESULTS:Case ascertainment identified 2774 existing cancer cases diagnosed within the five years prior to study enrollment and 4295 new cancer cases diagnosed up to five years after enrollment. Cancers of the breast, prostate, lung, and colorectum made up 55% of the incident cases. Fewer incident cases were found than would have been expected on the basis of incidences in the general population (O/E ratio 0.80, 95% confidence interval [0.76;0.83] for the first two-years of prospective follow-up); the O/E ratio varied across tumor sites (breast 1.02, prostate 1.12, lung 0.38, colorectum 0.62). Possible explanations include healthy volunteer bias, delayed reporting, as well as incomplete data collection from registries and self-reporting. CONCLUSION:Rising case numbers for the most common types of cancer are expected in the next few years and will enable comprehensive epidemiological analysis of the risk factors of cancer.

Background For early detection of breast cancer, clinical palpation of the breast is offered yearly to all women aged 30 and older, and the German Mammography Screening Programme (MSP) offers biennial mammograms to all women aged 50 to 75 years. We investigated the utilization of both screening methods across various migrant groups in Germany, as well as the effect of German language proficiency. Methods Cross-sectional data on participation frequencies from the baseline examination (2014 to 2019) of more than 100,000 women of the German National Cohort study (NAKO) were analysed by migrant status. Adjusted logistic regression analyses were conducted for palpation and MSP to compare screening uptake among six migrant groups, and non-migrant population. Results Palpation of the breast was less frequently utilized in all migrant groups with odds ratios ranging from 0.5 (95% CI 0.4-0.6) for Turkish women to 0.9 for women from western countries (95% CI 0.7-1.1) compared to autochthone Germans. Lower German language proficiency further decreases its use. In contrast, odds ratios for MSP participation did not differ substantially compared to Germans ranging from 0.8 to 1.2. German language proficiency had little effect on MSP participation. Discussion In contrast to earlier studies, our findings suggest that MSP participation and motivation does not significantly differ by migration status or language skills. This may indicate that information on MSP is broadly accessible through established invitation procedures in Germany. However, lower uptake of breast palpation by a physician in some migrant populations highlights potential gaps in broader preventive care engagement.