Van S. Hubbard, M.D., Ph.D. National Institutes of Health and Clifford L. Johnson, M.S.P.H. Centers for Disease Control and Prevention Department of Health and Human Services

National Health and Nutrition Examination Survey To assess the health and nutritional status of adults and children in the United States Objective

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

To produce U.S. population-based estimates of: Health conditions and environmental exposures Awareness, treatment and control of selected diseases Prescription drug and supplement use Nutrition status and diet behaviors

SOURCE: CDC/NCHS

% meeting guidelines Direct Measure vs. Self-report Physical Activity BRFSS NHANES

Civilian, non-institutionalized household population in the US All ages 5,000 individuals each year Oversample: African Americans Hispanics Older persons aged 60+ Low income whites Asians – new for

Stage 4 Participants Stage 1 Counties Stage 2 Segments Stage 3 Households

Screener interview Participant interview (in- person) Participant examination Additional interview or exam components

Doorstep screening Traditional CAPI interviewing with portable keyboard.

Broad range of health conditions Health-related behaviors and exposures Health care utilization Health insurance Prescription medications Dietary supplements

 Systematic operation with travelling staff and standardized environment  MEC design provides standardized specimen collection and exam protocols with regularly calibrated equipment  Facilitates automated data collection  Minimizes site-specific error

Adults and teens: 3.5 hours Children: 1-2 hours Two sessions per day; up to 12 participants per session Morning, afternoon Afternoon, evening Morning, evening

NHANES response rates

Public health significance Scientific merit Appropriateness Feasibility and ethical issues Financial considerations

Hearing, Taste and Smell Blood pressure Muscles strength/Physical activity monitor Dietary recall Private and AudioCASI interview Spirometry w/bronchodilator, ENO Oral health Anthropometry/Body Composition Cognitive function Blood, urine collection, PPD Specimen bank

Reference dataGrowth Charts Nutrition monitoringObesity, Cholesterol Disease controlDiabetes Prevention initiativesInfectious Diseases, Folate Monitor chemical/ Lead pollutant exposure Track health behaviorsSecond-hand Smoke

Undiagnosed Diabetes and Pre-diabetes (%) Diagnosed Impaired Fasting Glucose or Impaired Glucose Tolerance Monitoring Increase in Diabetes, Measuring Disease Management & Undiagnosed Disease Diagnosed diabetes doubled from 3.4% to 7.7 % between and % of adults age > 20 years have diagnosed or undiagnosed diabetes; no gender-specific differences ( ) 42% of adults age > 20 years have diabetes or pre-diabetes ( ) Monitor Improvements in Diabetes Management Hemoglobin A1C declined from 7.8% to 7.2% between (good control = 7.0%) Monitor Diagnosed and Undiagnosed Disease

 Monitoring environmental exposures through direct measures of over 200 chemicals in blood, urine, or hair  Passive exposure monitors for volatile chemicals, household dust, allergen and water samples  Data reported in CDC’s National Report on Human Exposure to Environmental Chemicals

Blood lead levels (  g/dL) Blood lead levels in the U.S. Children Ages 1-5 yrs, Year 2002

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Each new generation of surveys - Added unique specimens, post-exam components, and follow-back surveys Required innovative survey design, operations, and methods Provided ability to integrate a breadth of interdisciplinary health data Enhanced utility of baseline survey data Hair sample for mercury measurement 2 nd Dietary recall and FCBS follow-up interview by phone Food frequency questionnaire by mail Hepatitis C and PSA follow-up interview by phone 6 months later Physical activity monitor worn for 7 days Dust sample collected by vacuum Tap water sample from home Oral HPV rinse Additional urine sample collected at home Self-administered vaginal swab

Sound science Produce high quality data Responsive to emerging public health issues Timely Innovative Proven model

A Pot of Gold and a Gold Standard