Prevalence of risk factors of coronary heart disease in Turks living in Germany: The Giessen Study
Introduction
Coronary heart disease (CHD) is the most important cause of death in the industrialized countries. Epidemiological studies brought evidence for a tight linkage between the appearance of CHD and distinct concurrently occurring factors [1]. The major risk factors of CHD, i.e. diabetes mellitus, hypertension, smoking, and dyslipoproteinemia (DLP), are influenced both by environmental and genetic factors.
Evidence for genetically determined susceptibility for CHD is derived in particular from migration studies. Indians, for instance, are susceptible for the manifestation of glucose intolerance, DLP and, subsequently, for CHD. A marked increase in CHD was observed after migration of Indians to more industrialized regions such as Great Britain or Singapore [2], [3], [4].
Interest was focused on the Turkish population, which showed both a remarkable migration within Turkey from rural towards urban regions and a high migration rate to more industrialized countries like Germany during the past three decades.
Since the early 1960s a continuous migration of Turkish people to Germany occurred. These Turks, in the beginning predominantly males, underwent a physical examination by German physicians in Turkey before emigration. Thus, Turks migrating to Germany were a healthy, young population between the ages 20 and 30 at the time of immigration. In 1994 about 1 900 000 Turks [5] lived in Germany, including wives having followed their husbands, and their offspring.
In the 1980s there was increasing evidence that the prevalence and incidence of CHD increased dysproportionally in this population as compared to those Turks remaining in Turkey [6]. Angiographical findings also brought evidence for an earlier onset of CHD and a more severe disease in Turks living in Germany as compared to Germans (unpublished observations of the authors). A few years ago the first valid data concerning CHD morbidity rates of the Turkish population in Turkey were published [7]. Yet, there are no data available concerning the incidence of CHD and its risk factors in the general population of Turks living in Germany.
Investigators in Turkey and Germany found low high density lipoprotein-cholesterol (HDL-C) levels in Turks independent of their geographic origin or socio-economic status as a possible predisposing factor for CHD [8], [9]. In addition, a positive correlation between socio-economic status and total cholesterol (TC) levels was observed in Turkey [10]. In keeping with this observation, it was reported that meat consumption is significantly higher in urban regions in Turkey. A survey of alimentary habits of Turks living in Berlin, which is known for having a high percentage of Turkish people, found a 4-fold higher intake of meat compared to those living in Turkey [11].
A cross sectional study was conducted to obtain data about the risk factor status of Turks living in Germany. For this purpose a sample of 480 Turks older than 34 years were investigated, who voluntarily participated in a health check-up program provided by the German health authorities (so-called Check-up ’35) [12]. The survey was performed within a period of 2 years. All examinations were mainly considered as a primary prevention emphasizing the detection of CHD, diabetes mellitus, renal disease and DLP. The Check-up ’35 program was initiated in 1989 by German health authorities providing examinations in 2-year intervals. Within the first 2 years only 20% of all entitled Germans underwent this examination indicating the poor interest of the general population in primary prevention. All data concerning the Check-up ’35 are collected by the ‘Zentralinstitut für die kassenärztliche Versorgung in der BRD’ (ZI), Köln and published every 2 years [13].
Section snippets
Survey design
A cross sectional study was designed in order to investigate the prevalence of CHD and concomitant risk factors. During a period of 2 years 25 Turkish and German general practitioners with a high percentage of Turkish patients from different parts of Germany participated in the survey. Within this time frame complete data of 480 Turkish people, undergoing the health check-up were collected. Examinations and questionnaires were identical with the Check-up ’35 protocol provided by German health
Demographic data
More than 50% of the Turkish population studied originated from the western (Marmara and Egean region) and the middle parts of Anatolia with a high portion of people coming from urban regions. Turks from other parts of Anatolia, which are known to be more conservative, represented a minority (Table 1).
A total of 97.5% of the male and 85.8% of the female Turks had lived in Germany for more than 10 years. The average residence time since immigration was 21 years in males and 17 years in females,
Discussion
Several epidemiological studies in different ethnic groups showed an increase of morbidity and mortality rates in individuals migrating from developing countries with a lower prevalence of CHD to more industrialized regions [2], [3], [4], [24], [25]. For instance, in Indians migrating to the UK, the USA and other countries with advanced economic status a genetically caused low glucose tolerance seemed to lead to a more frequent manifestation of diabetes, which was consecutively associated with
Acknowledgements
We would like to thank all the practitioners (The Giessen Study Group) who enabled this survey: Dr Alpagut A, Siegen; Dr Aydin B, Bielefeld; Dr Biber G, Niddatal; Dr Burhanoglu M, Frankfurt; Dr Dottke, Driedorf; Dr Hakim F, Köln; Drs Höfinghof B/Kriechel A, Köln; Dr Honsy E, Ludwigshafen; Dr Igli M, Heilbronn; Drs Kadir F/Uyar F, Nürtingen; Dr Kielhorn R, Berlin; Dr Kücükoglu R, Berlin; Dr Müller A, Hanau; Dr Oygun Ü, Berlin; Dr Özgen-Basar Ü, Lollar; Dr Sauerbeck KH, Schifferstadt; Dr Saval C,
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