National Health and National Health and Nutrition Examination Nutrition Examination

Survey: OverviewSurvey: Overview

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionNational Center for Health Statistics

Clifford Johnson, Director

ObjectivesObjectives

•Some NHANES history

•Survey operations and data collection

•Content

•Uses and findings

•Summary thoughts

NHANES

Objective

To assess the health and

nutritional status of adults

and children in the United

States

SampleSample

• Civilian, non-institutionalized household population

• Residents of all states and the District of Columbia

• All ages

• 5,000 individuals each year

NHANESNHANES

•Unique in combining a home interview with health examinations conducted in a mobile examination center

•Almost 50 years experience conducting survey using direct physical measures

National Health and NutritionNational Health and NutritionExamination SurveysExamination Surveys

NHES I 1960-62 18-79 yearsNHES II 1963-65 6-11 yearsNHES III 1966-70 12-17 yearsNHANES I 1971-75 1-74 yearsNHANES II 1976-80 6 mo.-74 yearsHHANES 1982-84 6 mo.-74 yearsNHANES III 1988-94 2 mo. +

Survey Dates Ages

OP96S025

National Health and NutritionNational Health and NutritionExamination SurveysExamination Surveys

NHANES 1999-2000 All agesNHANES 2001-2002 All agesNHANES 2003-2004 All agesNHANES 2005-2006 All agesNHANES 2007-2008 All agesNHANES 2009-2010 All agesNHANES 2011-2012 All ages

Survey Dates Ages

OP96S025

NHANES response ratesNHANES response rates

1999-2006

Interviewed 81.4%

MEC examined 77.9%

Benefits of ParticipationBenefits of Participation

• Opportunity for community service

• Free health measurements and lab studies with report of findings

• Numerous lab studies not usually provided during a routine physical examination

• Toll free number to discuss abnormal results with the NHANES Medical Officer

BBenefits of Participationenefits of Participation

• Cash remuneration

• Reimbursement for travel or free transportation

Data Collection

Task

Advanced Arrangements/Outreach Identify county demographicsCreate county videoMeet w/ local Health Department officials

Identify key community offficials Mail 1st outreach letter to officials Mail 2nd outreach letter to officials

Identify county health clinicsIdentify interpreter services

Request Endorsement Letters Health DepartmentArea Agency on AgingOthers as needed

MediaCreate media list Contact media sources Send media list to Field OfficeFirst press release Second press release

Open HouseSend invitations to key officialsContact media

Household interviewingMEC examinations

SEP

Advance Arrangements/Outreach Timeline for Interviews Beginning in June

MAY JUN JUL AUGJAN FEB MAR APR

Participant health interviewParticipant health interview

• Length of interview varies depending on age

• Self report -16 years and older and emancipated minors

• Proxy report - children under 16

• Demographic and risk factor data

• Standardized physical exam

• Conducted at mobile exam center• Medical & dental exams

• Physiological measurements

• Laboratory test

• Administered by trained medical personnel

NHANES ExaminationNHANES Examination

NHANES Mobile Exam Center NHANES Mobile Exam Center (MEC)(MEC)

NHANES topicsNHANES topics

• Cardiovascular disease

• Diabetes

• Bone status, osteoporosis

• Oral health

• Vision and eye diseases

• Hearing and balance

• Fitness and strength

• Allergies

OP96S035

NHANES topicsNHANES topics

• Nutrition

• Anthropometry

• Mental health

• Risk behaviors

• Reproductive health

• Environmental exposures

• Infectious diseases

• Spirometry

OP96S036

Examples of NHANES Examples of NHANES FindingsFindings

and Uses and Uses

Landmark findings and Landmark findings and public health resultspublic health results

•High blood lead levelsLead out of gasoline

•Low folate levelsMandatory food fortification

•Rising levels of obesityPublic health action plan

•Racial and ethnic disparities in Hepatitis BUniversal vaccination of all infants &

children

OP96065

2000 CDC Growth Charts: 2000 CDC Growth Charts: United StatesUnited States

0

5

10

15

20

1963-5 1966-70 1971-4 1976-80 1988-94 1999-00 2001-2 2003-4

6-11 y

12-19 y

Percent

Trends in Child and Adolescent Trends in Child and Adolescent OverweightOverweight

Note: Overweight is defined as BMI >= gender- and weight-specific 95th percentile from the 2000 CDC Growth Charts.Source: National Health Examination Surveys II (ages 6-11) and III (ages 12-17), National Health and Nutrition Examination Surveys I, II, III and 1999-2004, NCHS, CDC.

0

10

20

30

40

1960-62 1971-74 1976-80 1988-94 1999-00 2001-2 2003-4

Male

Female

Percent

Trends in Adult Obesity, 20-74 yearsTrends in Adult Obesity, 20-74 years

Note: NHES and NHANES data; Age-adjusted by the direct method to the year 2000 US Bureau of the Census estimates using the age groups 20-39, 40-59 and 60-74 years. Obesity defined as BMI>=30.

Prevalence of Obesity Among Adults Prevalence of Obesity Among Adults ≥ ≥ 18 years, United States18 years, United States

0

5

10

15

20

25

30

35

Total Male Female

Per

cen

t

MeasuredNHANES 99-02

Self-reportedNHANES 99-02

Self-reportedNHIS 2000

Self-reported BRFSS2000

SOURCE: Hedley, unpublished analyses

0

5

10

15

20

25

3-5 6-11 12-19 20-39 40-59 60+

ng/mL

Mean Serum Folate Concentrations Mean Serum Folate Concentrations Females: United StatesFemales: United States

Years

NHANES III 1988-1994NHANES 1999-2000

Trends in Median Serum Folate

Levels of Males and Females; United States: 1988-2006

0

5

10

15

20

25

30

Males Females

1999-2000

2001-2002

2003-2004

1988-1994

85

90

95

100

1949-56 1957-66 1967-76 1977-86 1987-96 1997-98

NH-white NH- black Mex. Americans

Threshold for herd immunity

Seroprevalence of measlesAntibody by birth cohort

Seroprevalence of measlesAntibody by birth cohort

SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey (NHANES) 1999-2004.

% measles seropositive IgG

Birth Cohort

OH9900OH9900

Additional Chemicals in Additional Chemicals in 33rdrd Report Report148 chemicals148 chemicals

38 new chemicals One new class

– Pyrethroid pesticides

Additions w/in class – PAHs– Aldrin, dieldrin, endrin– Phthalate metabolites– Dioxins, furans and PCBs– Pesticides and herbicides

www.cdc.gov/exposurereport

Lead used in gasoline production and

average blood lead levels

40

50

60

70

80

90

100

110

8

9

10

11

12

13

14

15

16

17

Tota

l le

ad

use

d p

er

6

mon

th p

eri

od

(1

00

0

ton

s)

1977 1979

Average blood lead

levels

Lead usedIn gasoline

0

SOURCE: CDC/NCHS, Second National Health and Nutrition Examination Survey, 1976-80.

1978

Avera

ge b

lood

lead

le

vels

(m

icro

gra

ms/

deci

liter)

19760

1980

1976 1978 1980 1982 1984 1986 1988 1990 1992

2

4

6

8

10

12

14

16

Blo

od

lead

lev

els

(g

/dL

)

0

1994 1996 1998 2000

Blood lead levels in the U.S. ChildrenBlood lead levels in the U.S. ChildrenAges 1-5 yrs, 1976 - 2002Ages 1-5 yrs, 1976 - 2002

Year2002

Exposure to Second Hand Smoke: Nonsmokers with Detectable Cotinine*

Levels,

88.1

53.9

83.4

93.9

72.0

52.0

44.1

87.8

0

10

20

30

40

50

60

70

80

90

100

2010 Target

1988-94 Baseline Percent with detectable serum cotinine 1999-2000

Mexican American Total White, not Hispanic Black, not Hispanic

Source: National Health and Nutrition Examination Survey (NHANES), NCHS, CDC.

Ages 4 years and older

0

2

4

6

8

10

12

0 25 50 75 100

Percentile

Blo

od

Hg

(u

g/L

)No fish orshellfishOnly shellfish

Only fish

Both fish andshellfish

Selected Percentiles of Total Blood Mercury

Women 16-49 years

NOTE: NHANES 1999-2000 SOURCE: CDC/NCHS

0

20

40

60

80

100

Prevalence of reduced hip bone Prevalence of reduced hip bone density among persons 65 years density among persons 65 years

of age and overof age and overPercent

65-74years

Osteoporosis

Osteopenia

75-84years

85 yearsand over

Women

65-74years

75-84years

85 yearsand over

MenSOURCE: CDC/NCHS, NHANES III 1988-94 OP96S071

3.8

15.5

33.9

0

10

20

30

40Percent

20-39 40-59 60

6.1

2.5

6.2

0

4

8

12

16

Diagnosed

Undiagnosed

Impairedfastingglucose

Percent

SOURCE: CDC/NCHS, National Nutrition and Health Examination Survey, 1999-2000; National Health Interview Survey, 1999, 2000.

Diabetes and Impaired Diabetes and Impaired Fasting Glucose, 1999-2000Fasting Glucose, 1999-2000

OH9900

Prevalence of lower extremity disease (LED) in the United States among adults aged > 40 years by type of LED*, symptomatic and

diabetes status. NHANES, 1999–2000

0

5

10

15

20

25

30

35

PAD PN AnyLED

PAD PN AnyLED

PAD PN AnyLED

Assymptomatic Symptomatic

REF: Gregg, Sorlie, Paulose-Ram, Gu, Eberhardt, Wolz, Burt, Curtin, Engelgau, Geiss. Diabetes Care. 2004 Jul;27(7):1591-7

Not all estimates meet standard of statistical reliability and precision (relative SE >30%).

* PAD: peripheral arterial disease; PN: peripheral neuropathy

Total DiabeticNon-Diabetic

Percent

OH9900

NHANES Data Central to NHANES Data Central to Health Policy and Practice Health Policy and Practice

• Unique national source of actual measurement data

• Ability to integrate findings from each interview and exam component

• High quality of data collection, processing and analysis

• Responsive and relevant to current and future data needs

NHANES Provides Data for NHANES Provides Data for Many Essential Public Health Many Essential Public Health

FunctionsFunctions• Prevention initiatives

• Monitoring exposure levels—pollutants, chemicals

• Food safety and fortification

• Disease control

• Tracking health behaviors

Other ActivitiesOther Activities

• Future of Health and Nutrition Examination Surveys

•Community HANES

•Longitudinal Follow-ups

•Linked files

•Efficiencies

•Web tools

Final ThoughtsFinal Thoughts

• Many lessons learned over fifty years

• We know better when we measure

• Focus should be on content, logistical issues and operational methods – everything matters and is important

• Survey design important but quality data collection and timely release of results is essential to success

http://www.cdc.gov/nchs/nhanes.htm