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Articles by G. Giani
Total Records ( 10 ) for G. Giani
  W. Rathmann , K. Strassburger , M. Heier , R. Holle , B. Thorand , G. Giani and C. Meisinger
  Aims:To determine the incidence of Type 2 diabetes in an elderly population in Germany and its association with clinical and lifestyle factors.
Methods:Oral glucose tolerance tests (OGTT, World Health Organization criteria) were carried out in a random sample of 1353 subjects (age group 55–74 years; 62% response) in Augsburg (Southern Germany) (1999–2001). The cohort was re-investigated in 2006–2008. Of those individuals without diabetes (baseline), 887 (74%) participated in the follow-up.
Results:Ninety-three (10.5%) developed diabetes during the 7-year follow-up period {standardized incidence rates [95% confidence interval (CI)] per 1000 person-years: total 15.5; 12.6, 19.1; men 20.2; 15.6, 26.1; women 11.3; 7.9, 16.1}. In both sexes, those who developed diabetes were slightly older, were more obese, had a more adverse metabolic profile (higher glucose values, HbA1c, fasting insulin, uric acid, and triglycerides) and were more likely to have hypertension at baseline than were participants remaining free of diabetes (P < 0.05). On stepwise logistic regression, age, parental diabetes, body mass index, uric acid, current smoking, HbA1c and fasting and 2-h glucose (OGTT) were strong predictors of diabetes incidence. The risk of diabetes was higher in subjects with isolated impaired glucose tolerance (odds ratio 8.8; 95% CI 5.0, 15.6) than in isolated impaired fasting glucose (4.7; 2.2, 10.0), although the difference did not reach statistical significance.
Conclusions:For the first time, we have estimated the incidence of Type 2 diabetes in an elderly German cohort and demonstrated that it is among the highest in Europe. The OGTT appears to be useful in identifying individuals with high Type 2 diabetes risk. Our results support a role of smoking in the progression to diabetes.
  A. Icks , J. Kruse , N. Dragano , M. Broecker-Preuss , U. Slomiany , K. Mann , K. H. Jockel , R. Erbel , G. Giani and S. Moebus
  Aims  To estimate the association between depressive symptoms and Type 2 diabetes, as well as previously undetected diabetes, in a large population-based sample in Germany and to determine associated variables.

Methods  We used baseline data on 4595 participants (age 45-75 years, 50.2% women) from the German Heinz Nixdorf Recall study, a population-based, prospective cohort study which started in 2000. Diabetes mellitus was assessed by self report (physician diagnosis or medication), undiagnosed diabetes based on blood glucose levels. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale short form (cut-off ≥ 15 points). We fitted multiple logistic regression models.

Results  The prevalence of diagnosed and previously undetected diabetes was 9.3% (95% confidence interval 8.2-11.6) and 7.6% (6.6-8.8) in men and 6.0% (5.1-7.1) and 3.2% (2.5-4.0) in women, respectively. Compared with non-diabetic women, the prevalence of depressive symptoms was not significantly different in diabetic women (age-adjusted odds ratio, 95% confidence interval 1.48; 0.98-2.24) and women with undiagnosed diabetes (0.67; 0.33-1.36). In men, the prevalence of depressive symptoms tended to be lower in diabetic than in non-diabetic subjects (0.62; 0.35-1.09), but the depressive symptoms were significantly less frequent in men with undiagnosed diabetes (0.30; 0.13-0.70). The pattern remained after further adjustment. Significant associations with depressive symptoms were found for co-morbidities and living without a partner in both women and in men, and for body mass index and activity level in women only.

Conclusions  After adjustment for relevant covariates, the association between depressive symptoms and Type 2 diabetes was heterogenous in our population-based study. In subjects with undiagnosed diabetes, however, depressive symptoms were less frequent in men. Co-morbidities and psychosocial conditions are strongly associated with depressive symptoms.

  C. Meisinger , K. Strassburger , M. Heier , B. Thorand , S. E. Baumeister , G. Giani and W. Rathmann
  Aims  Limited data are available for European populations regarding the prevalence of diabetes and disturbed glucose metabolism in younger individuals. Our aim was to estimate the prevalence of diagnosed and undiagnosed diabetes, isolated impaired fasting glucose (i-IFG), isolated impaired glucose tolerance (i-IGT) and combined IFG/IGT in a population-based sample (n = 1653) from Southern Germany aged 35-59 years.

Methods  Oral glucose tolerance tests were carried out in all non-diabetic participants of the KORA F4 Study (2006-2008). Diabetes, IGT and IFG were defined according to the 1999 World Health Organization diagnostic criteria. The original IFG criteria (6.1-6.9 mmol/l) were used as recommended by the European Diabetes Epidemiology Group.

Results  The age-standardized prevalence was 2.2% for known diabetes, 2.0% for newly detected diabetes, 2.9% for i-IFG, 6.3% for i-IGT and 1.1% for combined IFG/IGT. About half of the cases with overt diabetes were undiagnosed in all age groups. The prevalence of i-IGT was approximately twice as high as that of i-IFG. The proportion of i-IGT varied between 3.2% (age group 35-44 years) and 11.8% (age group 55-59 years); the corresponding numbers for i-IFG were 1.1% and 5.9%. IFG/IGT was present in 1.2% of the total sample, and was most frequently found in the age group 55-59 years (2.4%). Overall, 16% of the study population had either diabetes or abnormalities of glucose metabolism.

Conclusions  The study reveals for the first time a high prevalence of impaired glucose regulation in the younger and middle-aged German population. The detection of disturbed glucose metabolism or diabetes needs to be improved.

  J. Genz , M. Scheer , C. Trautner , I. Zollner , G. Giani and A. Icks
  Aims  We estimated the incidence of blindness in the diabetic and non-diabetic population in 2008 and compared it with results from 1990-1998 in a neighbouring region.

Methods  All newly registered blindness allowance recipients in 2008 were drawn up in a German region (population 4.5 million). We estimated sex-specific, age-specific and standardized incidence rates of blindness in the diabetic and the non-diabetic population and relative and attributable risks as a result of diabetes. A comparison to the data from 1990-1998 was performed using log-linear Poisson regression.

Results  Four-hundred and sixty-eight cases were drawn up (63% female). One-hundred and twenty-two (26.1%) had diabetes. Blindness incidence rates (per 100 000 person-years) standardized to the 2008 German population were: men 9.1 (95% confidence interval 7.8-10.5), women 9.9 (8.8-11.1); diabetic population: men 21.8 (11.6-31.9), women 19.7 (9.2-30.1); non-diabetic population: men 8.0 (6.6-9.5), women 9.1 (7.9-10.3). Relative risk of blindness, diabetic vs. non-diabetic population: men 2.7 (1.6-4.5), women 2.2 (1.3-3.8). Attributable risk among exposed: 63% in men, 54% in women. Population attributable risk: 12% in men, 8% in women. Incidences of blindness were significantly lower than in all years of the period 1990-1998 in both the diabetic and the non-diabetic population.

Conclusions  We found the incidence of blindness to be approximately 2.5-fold higher in the diabetic compared with the non-diabetic population. Fifty-eight per cent of the risk to become blind in diabetic individuals and 9% of the risk to become blind in the entire population were attributable to diabetes. The decrease of the blindness incidence observed during the 1990s may have continued.

  A. Beyerlein , R. Von Kries , M. Hummel , N. Lack , B. Schiessl , G. Giani and A. Icks
  Aims  Reducing the risk of adverse outcomes in diabetic pregnancies to the level of risk in non-diabetic pregnancies is a major goal in diabetes care. So far there have not been any data to show whether progress is being made towards this goal.

Methods  We used population-based data on 2 292 053 deliveries between 1987 and 2007 in Bavaria, Germany, to assess temporal trends for stillbirths, early neonatal mortality, preterm delivery, macrosomia and malformations in consecutive 7 year intervals. We estimated prevalences and prevalence odds ratios for these outcomes. For stillbirth, as the most severe adverse outcome, we assessed the contributions of several predictors using multiple regression models.

Results  With the exception of early neonatal deaths, the risks for all outcomes were significantly increased in the offspring of mothers with pregestational diabetes in all three time periods (e.g. odds ratio for stillbirths in diabetic compared with non-diabetic mothers in 2001-2007, 1.89; 95% confidence interval 1.24, 2.87). However, the prevalence of stillbirths, premature delivery and macrosomia decreased over time in diabetic mothers (e.g. 1.71% for stillbirths in 1987-1993 and 0.66% in 2001-2007), as did the respective odds ratios. Maternal smoking, hypertension and substandard utilization of antenatal care were significantly associated with stillbirths in diabetic women.

Conclusions  Although the risk of adverse pregnancy outcomes is still increased in diabetic mothers, considerable improvement has been achieved. We hypothesize that this improvement is possibly due to improved diabetes care.

  W. Rathmann , B. Kowall , M. Heier , C. Herder , R. Holle , B. Thorand , K. Strassburger , A. Peters , H.-E. Wichmann , G. Giani and C. Meisinger
  Background  The aim was to derive Type 2 diabetes prediction models for the older population and to check to what degree addition of 2-h glucose measurements (oral glucose tolerance test) and biomarkers improves the predictive power of risk scores which are based on non-biochemical as well as conventional clinical parameters.

Methods  Oral glucose tolerance tests were carried out in a population-based sample of 1353 subjects, aged 55-74 years (62% response) in Augsburg (Southern Germany) from 1999 to 2001. The cohort was reinvestigated in 2006-2008. Of those individuals without diabetes at baseline, 887 (74%) participated in the follow-up. Ninety-three (10.5%) validated diabetes cases occurred during the follow-up. In logistic regression analyses for model 1, variables were selected from personal characteristics and additional variables were selected from routinely measurable blood parameters (model 2) and from 2-h glucose, adiponectin, insulin and homeostasis model assessment of insulin resistance (HOMA-IR) (model 3).

Results  Age, sex, BMI, parental diabetes, smoking and hypertension were selected for model 1. Model 2 additionally included fasting glucose, HbA1c and uric acid. The same variables plus 2-h glucose were selected for model 3. The area under the receiver operating characteristic curve significantly increased from 0.763 (model 1) to 0.844 (model 2) and 0.886 (model 3) (P < 0.01). Biomarkers such as adiponectin and insulin did not improve the predictive abilities of models 2 and 3. Cross-validation and bootstrap-corrected model performance indicated high internal validity.

Conclusions  This longitudinal study in an older population provides models to predict the future risk of Type 2 diabetes. The OGTT, but not biomarkers, improved discrimination of incident diabetes.

  J. Genz , B. Haastert , H. Muller , F. Verheyen , D. Cole , W. Rathmann , B. Nowotny , M. Roden , G. Giani , A. Mielck , C. Ohmann and A. Icks
  Aims  To compare the effect of our newly developed online evidence-based patient information vs. standard patient information about sub-threshold elevated blood glucose levels and primary prevention of diabetes on informed patient decision making.

Methods  We invited visitors to the cooperating health insurance company, Techniker Krankenkasse, and the German Diabetes Center websites to take part in a web-based randomized controlled trial. The population after randomization comprised 1120 individuals aged between 40 and 70 years without known diabetes, of whom 558 individuals were randomly assigned to the intervention group receiving evidence-based patient information, and 562 individuals were randomly assigned to the control group receiving standard information from the Internet. The primary endpoint was acquired knowledge of elevated blood glucose level issues and the secondary outcomes were attitude to metabolic testing, intention to undergo metabolic testing, decisional conflict and satisfaction with the information.

Results  Overall, knowledge of elevated glucose level issues and the intention to undergo metabolic testing were high in both groups. Participants who had received evidence-based patient information, however, had significantly higher knowledge scores. The secondary outcomes in the evidence-based patient information subgroup that completed the 2-week follow-up period yielded significantly lower intention to undergo metabolic testing, significantly more critical attitude towards metabolic testing and significantly higher decisional conflict than the control subgroup (n = 466). Satisfaction with the information was not significantly different between both groups.

Conclusions  Evidence-based patient information significantly increased knowledge about elevated glucose levels, but also increased decisional conflict and critical attitude to screening and treatment options. The intention to undergo metabolic screening decreased. Future studies are warranted to assess uptake of metabolic testing and satisfaction with this decision in a broader population of patients with unknown diabetes.

  A. Icks , B. Albers , B. Haastert , S. Pechlivanis , B. Bokhof , U. Slomiany , R. Erbel , K.-H. Jockel , J. Kruse , B. Nowotny , C. Herder , G. Giani and S. Moebus
  Aims  Cross-sectional studies have consistently reported evidence for an association between diabetes and depressive disorders. However, only limited prospective studies have examined this association, reporting conflicting results. In a population-based cohort study, we compared cumulative incidences of diabetes between participants with and without high depressive symptoms.

Method  We analysed the 5-year follow-up data from the German Heinz Nixdorf Recall study of 3547 participants without diabetes at baseline [mean age 58.8 (sd 7.6) years, 47.5% male]. Depressive symptoms were defined using the Centre for Epidemiologic Studies Depression scale (cut point ≥ 17). Diabetes (diagnosed or previously undetected) was identified by self-reported physician-diagnosed diabetes, medication and high blood glucose levels. We estimated 5-year cumulative incidences with 95% confidence intervals and fitted multiple logistic regression models to calculate the odds ratios, adjusted for age, sex, physical activity, smoking, living with or without partner, and educational level.

Results  The cumulative incidence of diabetes was 9.2% (95% CI 6.3-12.8) in participants with high depressive symptoms at baseline and 9.0% (95% CI 8.0-10.0) in participants without these symptoms. The age- and sex-adjusted odds ratio of diabetes in participants with depressive symptoms compared with those without was 1.13 [95% CI 0.77-1.68; fully adjusted 1.11 (95% CI 0.74-1.65)]. These results did not substantially change in several additional sensitivity analyses.

Conclusion  Our study did not show a significantly increased risk of developing diabetes in individuals with high depressive symptoms compared with those without high depressive symptoms during a 5-year follow-up period.

  R. Waldeyer , R. Brinks , W. Rathmann , G. Giani and A. Icks


To model the future costs of Type 2 diabetes in Germany, taking into account demographic changes, disease dynamics and undiagnosed cases.


Using a time-discrete Markov model, the prevalence of diabetes (diagnosed/undiagnosed) between 2010 and 2040 was estimated and linked with cost weights. Demographic, epidemiological and economic scenarios were modelled. Inputs to the model included the official population forecasts, prevalence, incidence and mortality rates, proportions of undiagnosed cases, health expenditure and cost ratios of an individual with (diagnosed/undiagnosed) diabetes to an individual without diabetes. The outcomes were the case numbers and associated annual direct medical excess costs of Type 2 diabetes from a societal perspective in 2010€.


In the base case, the case numbers of diabetes will grow from 5 million (2.8 million diagnosed) in 2010 to a maximum of 7.9 million (4.6 million diagnosed) in 2037. From 2010 to 2040, the prevalence rate amonf individuals ≥40 years old will increase from 10.5 to 16.3%. The annual costs of diabetes will increase by 79% from €11.8 billion in 2010 to €21.1 billion in 2040 (€9.5 billion to €17.6 billion for diagnosed cases).


The projected increase in costs will be attributable to demographic changes and disease dynamics, and will be enhanced by higher per capita costs with advancing age. Better epidemiological and economic data regarding diabetes care in Germany would improve the forecasting accuracy. The method used in the present study can anticipate the effects of alternative policy scenarios and can easily be adapted to other chronic diseases.

  A. Icks , H. Claessen , K. Strassburger , R. Waldeyer , N. Chernyak , F. Julich , W. Rathmann , B. Thorand , C. Meisinger , C. Huth , I.-M. Rückert , M. Schunk , G. Giani and R. Holle


Patient time costs have been described to be substantial; however, data are highly limited. We estimated patient time costs attributable to outpatient and inpatient care in study participants with diagnosed diabetes, previously undetected diabetes, impaired glucose regulation and normal glucose tolerance.


Using data of the population-based KORA S4 study (55-74 years, random sample of n = 350), we identified participants' stage of glucose tolerance by oral glucose tolerance test. To estimate mean patient time costs per year (crude and standardized with respect to age and sex), we used data regarding time spent with ambulatory visits including travel and waiting time and with hospital stays (time valued at a 2011 net wage rate of €20.63/h). The observation period was 24 weeks and data were extrapolated to 1 year.


Eighty-nine to 97% of participants in the four groups (diagnosed diabetes, undetected diabetes, impaired glucose regulation and normal glucose tolerance.) had at least one physician contact and 4-14% at least one hospital admission during the observation period. Patient time [h/year (95% CI)] was 102.0 (33.7-254.8), 53.8 (15.0-236.7), 59.3 (25.1-146.8) and 28.6 (21.1-43.7), respectively. Age-sex standardized patient time costs per year (95% CI) were €2447.1 (804.5-6143.6), €880.4 (259.1-3606.7), €1151.6 (454.6-2957.6) and €589.2 (435.8-904.8).


Patient time costs were substantial-even higher than medication costs in the same study population. They are higher in participants with diagnosed diabetes, but also in those with undetected diabetes and impaired glucose regulation compared with those with normal glucose tolerance. Research is needed in larger populations to receive more precise and certain estimates that can be used in health economic evaluation.

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