Statistics Canada • Statistique Canada Canadian Health Measures Survey (CHMS): an introduction and overview -today I would like to provide you with an introduction and overview of the CHMS, including: -information on data that we have produced so far and -information on the data to come -opportunities to access the data -an idea of the documentation available to help you use the data Brent Day Health Statistics Division Statistics Canada Statistics Canada • Statistique Canada

Statistics Canada • Statistique Canada CHMS OBJECTIVES Explore emerging public health issues and new measurement technologies Establish national baseline data on major health concerns Determine relationships among risk factors, protection practices and health status Assess the validity of self- and proxy-reported information Assemble a nationally representative sample for storage in a biobank -rotate content every second cycle so that if new technology or measures come up we can adapt; we allow for buy-in measures and new content -objective measures on a wide variety of health-related topics -self-report vs. actual examples; we ask height, weight and chronic conditions and also measure height and weight and blood/urine measures can help indicate chronic condition may not have been aware of -not only take blood and urine at clinic but store indefinitely for future research Statistics Canada • Statistique Canada

HEALTH SURVEYS PROGRAM CCHS Annual CCHS Rapid Response CCHS Focus Content CHMS Content General health surveillance Sample buy-ins Emerging need - determined by client Single content in-depth HH information related to physical measures Physical measures in MEC Laboratory tests Buy-ins Sample size 65,000 respondents 11,000 respondents by 2 months collection period 27,000 respondents 5,700 respondents per cycle Frequency Annual Up to 6 periods by year Every three years 2 year cycle Geography Canada, provinces, territories & health regions Canada & provinces Canada only Age groups 12+ Varies depending on survey 3 - 79 This table is helpful to help users know when to use CCHS vs CHMS data A few highlights: -emphasis on physical measures with the household information providing contextual information only; use CCHS when only self-reported household info is required as sample size is much larger -Canada only; national estimates only, not designed for regional or provincial – very few exceptions (C1&C2 combined) -3 to 11 year olds in CHMS

CHMS: ONE PROJECT, FOUR COMPONENTS Household component – about 1¼ hours Mobile Examination Centre (MEC) component – about 2 ¼ to 3 hours Laboratory component – several external reference labs, one lab in the MEC Biobank component - storage for future health research of : whole blood, plasma, serum, urine and DNA. -time will vary according to eligibility for questionnaire modules/tests and whether or not 1 or 2 persons from the same household participated (about 40% of respondents in the survey have a family member also participating). -with an additional trailer for cycle 4, we have more flexibility to do tests concurrently within the same family which will cut down on some of the length at the MEC -as the survey goes on, the number of labs we have been working with has been growing as each one specializes in different measures and we are now close to 10 if we include the biobank projects -there is an extensive consent process for the survey, including a consent form that respondents sign Statistics Canada • Statistique Canada

OVERALL RESPONSE RATES: CYCLE 3 All sites (%) Households who provided a list of household members (as a percentage of households within the scope of the survey) 74 Respondents who completed questionnaire (as a percentage of total respondents selected) 88 Respondents who attended mobile clinic (as a percentage of respondents who completed questionnaire) 79 Overall combined response rate (combination of the three response rates above) 52 -response rates are quite high for the survey, especially considering the up to 4 hour time commitment for some 2-person households; respondents definitely seem to see value in the survey -overall roughly represents the percentage of people who participated in all parts of the survey from who was eligible (.74*.88*.79) -for more detailed information on how response rates are calculated, see Data User Guide Statistics Canada • Statistique Canada

SURVEY PARAMETERS: CYCLES 3 & 4 National estimates: n = 5,700 each cycle Survey population aged 3 to 79 Direct physical measurements completed in mobile clinic over 2 years Collection: cycle 3 from Jan 2012 to Dec 2013 cycle 4 from Jan 2014 to Dec 2015 -currently in collection for cycle 4, with cycle 3 collection just completed -collection for the survey has been pretty well continuous since its beginning in Mar 2007 -numbers are similar for cycles 1 and 2 except that 3 to 5 year olds only added to the survey in cycle 2 -most StatCan analytical products have been released for cycles 1 and 2 and dissemination for cycle 3 will start in the fall -in some cases data from cycles 1 and 2 can be combined so that there is more sample to work with (up to 11,387 - 6 to 79 yr olds in both cycles combined) – an instructions document is available to help researchers and combined weight files need to be used Statistics Canada • Statistique Canada

SAMPLING STRATEGY: CYCLES 3 & 4 National sampling frame (360 eligible collection sites) Collection sites stratified in 5 regions Covers about 96% of population 11 age/sex groups from age 3 to 79 Sample size (n = 5,700) to yield national estimates by sex/age group at 10% prevalence with coefficient of variation of 16.5% Collection sites selected Very similar sampling strategy for cycles 1 and 2; estimates for 3-5 yr olds cannot be broken down by sex; important to keep the limitation of sample size in mind when considering research projects using CHMS data Sample allows for reliable national estimates for 11 groups at 10% frequency 3 to 5 both sexes 6 to 11 M & 6 to 11 F 12 to 19 M&F 20 to 39 M&F 40 to 59 M&F 60 to 79 M&F Households selected Respondents selected Statistics Canada • Statistique Canada

COLLECTION SITES: CYCLE 4 Terrace Kitimat Edmonton Saguenay -there are 16 sites in each of cycle 3 and cycle 4, well distributed across the regions; here is cycle 4 as an example -collection will end in December of this year and then cycle 5 collection will start in January next year Fredericton St Hyacinthe Shelburne Thunder Bay Laval Kelowna Montreal Regina Brockville Kitchener-Waterloo Toronto (2) Statistics Canada • Statistique Canada Hamilton

QUESTIONNAIRE CONTENT: CYCLE 3 The questionnaire content is to be used only in context with physical measures data and covers the following topics: Health status Nutrition and food Medication use Health behaviours Environmental factors Socio-economic information -the household questionnaire content has remained relatively stable over the different cycles; a Content summary document is available that shows the changes that have happened for household, clinic and lab from cycles 1 to 8 Statistics Canada • Statistique Canada

Statistics Canada • Statistique Canada THE MOBILE CLINIC -respondent does a typical household interview and then goes to a trailer up to 100 km away for physical measures -of the respondents who do the household interview, about 79% agree to go to the clinic -once at the clinic, there is a very high participation rate for specific tests and measures – well over 90% for all the tests Statistics Canada • Statistique Canada

Statistics Canada • Statistique Canada THE MOBILE CLINIC Trained health measure specialists and lab professionals – stations/rooms for different measures Statistics Canada • Statistique Canada

PHYSICAL MEASURES: CYCLE 3 Anthropometry Standing height, sitting height, weight Waist and hip circumference Cardiorespiratory fitness Resting blood pressure and heart rate Spirometry Fractional exhaled nitric oxide (FENO) Muscular strength Hand grip strength Hearing assessment Skin pigmentation Physical activity Accelerometer Indoor air sampler Tap water samples (taken from some randomly selected households) Statistics Canada • Statistique Canada

BLOOD AND URINE TESTS: CYCLE 3 General: Complete blood count (CBC), blood chemistry panel Allergies Cardiovascular health: C-reactive protein (high sensitivity), HDL, LDL, total cholesterol and triglycerides and fatty acids Diabetes: Fasting, non-fasting and random glucose, fasting insulin and HbA1c Environmental exposure: Metals (cadmium, lead and mercury (total and methyl)), acrylamide and volatile organic compounds (VOCs) Infectious diseases: Hepatitis B and C Nutritional status: Ferritin, red blood cell folate, vitamin B12, vitamin C and vitamin D Reproductive hormones Thyroid status Urine Environmental exposure: Metals (arsenic (speciated), fluoride and inorganic mercury), benzene metabolites, bisphenol A, organophosphate insecticides, polyaromatic hydrocarbons (PAHs), parabens, tobacco and triclosan Kidney function: Creatinine and microalbumin Nutritional status: Iodine -we measure for a very wide range of substances in the blood and urine that are related to a wide variety of health conditions – over 200 tests -only a few changes between cycles 3 and 4 Statistics Canada • Statistique Canada

MICRODATA FILES (CYCLE 1) Full sample file Subsample files Medication file Content # obs. Age covered Household questionnaire, clinic and laboratory measures done on all respondents 5604 obs. Ages 6 to 79 Medication File 5604 obs. Ages 6 to 79 Fasting measures 2,634 6 to 79 Inorganic mercury 1,123 6 to 79 PBDE / PCB 1,696 20 to 79 PFCs 2,880 20 to 79 -quite a few files are available using cycle 1 data (2007 to 2009) -be aware that several files have fewer observations to work with (subsample files) -some tests are done on fewer respondents usually due to the cost of the tests Activity monitor 4,441 6 to 79 Phthalates 3,237 6 to 49 Nicotine 2,483 12 to 79 Statistics Canada • Statistique Canada

MICRODATA FILES (CYCLE 2) Full sample file Subsample files Medication file Content # obs. Age covered Household questionnaire, clinic and laboratory measures done on all respondents 6,395 obs. Ages 3 to 79 Medication File 6,395 obs. Ages 3 to 79 Fasting measures 2,793 6 to 79 Indoor air - hhld 3,857 N/A Indoor air - person 5,191 3 to 79 Activity monitor 4,948 3 to 79 -again there are full sample and subsample files with the content quite similar to cycle 1 except that indoor air was introduced to the survey -2010 to 2011 Environmental blood 1,524 12 to 79 Environmental urine 2,563 3 to 79 Statistics Canada • Statistique Canada

MICRODATA FILES (CYCLE 3) - Released Full sample file Subsample files Medication file Content # obs. Age covered Household questionnaire, clinic and laboratory measures done on all respondents 5,785 obs. Ages 3 to 79 Medication File 5,785 obs. Ages 3 to 79 Fasting measures 2,571 6 to 79 Activity monitor 4,271 3 to 79 RBC fatty acids 1,984 20 to 79 Fluoride - hhld 2,188 12 to 79 -the data files are separated out a bit from previous cycles and if a researcher needs more than one file, the files will have to be merged using CLINICID -2012 to 2013 Fluoride - person 2,671 12 to 79 VOCs - hhld 2,650 12 to 79 VOCs - person 2,527 12 to 79 Statistics Canada • Statistique Canada

PLANS FOR MICRODATA FILES (CYCLE 3) To be released Release date Topic July 15, 2015 Environmental lab blood and urine full sample data Acrylamide subsample (environmental blood) Methyl mercury subsample (environmental blood) NNAL and glucuronides (environmental urine) Environmental urine full sample data Sept 16, 2015 Indoor air subsample - hhld Indoor air subsample - person Fall 2015 Medication full sample data (derived variables added) Fall 2016 Pooled serum data file (50 environmental variables) -a dissemination plan is available that provides more specific information on these files Statistics Canada • Statistique Canada

Statistics Canada • Statistique Canada CHMS DOCUMENTATION User guide Survey content, procedures Data quality, weighting Data dictionaries Information for all variables on the full sample and subsample files Name, length, data type (character / numeric) Location on the file, applicable values Coverage statements Univariate counts (weighted and unweighted; at RDC only) Derived variables documentation Sampling documentation -virtually all StatCan products using cycles 1 and 2 data have already been released -sampling document provides a bit more info that what is in the user guide Statistics Canada • Statistique Canada

CHMS DOCUMENTATION (CONT’D) Instructions for combining multiple cycles of CHMS data CHMS Bibliography Electronic record of CHMS data releases and analytical products Includes links to external articles and publications Content summary document Content topics in the survey by age for cycles 1 to 8 Information on how to access CHMS documentation on-line -bibliography updated once a year – a new electronic version will be available on-line within the next couple of months Statistics Canada • Statistique Canada

RESEARCH DATA CENTRES (RDCs) Access route for most researchers Allows microdata access in universities across Canada, under research agreement, in a secure setting CHMS microdata and supporting documentation, all Statistics Canada health survey microdata Similar files at Health Canada & PHAC http://www.statcan.gc.ca/rdc-cdr -how to access CHMS data itself -more information on the RDCs available at the link Statistics Canada • Statistique Canada

STATISTICS CANADA ANALYTICAL PRODUCTS Health Reports journal articles Peer reviewed, academic, fairly lengthy Cycle 3 releases to come: Prevalence of hearing loss - 20-79 year olds Activity monitor results - 3-5 year olds RBC fatty acids - 3-79 year olds Health at a Glance articles Moderate length Cycle 3 release to come: Volatile organic compounds - 3-79 year olds Data tables -though researchers have the potential to do their own research at the RDCs, StatCan also does a fair bit on their own -all data releases must be released through StatCan’s Daily – hyperlinks included to access each product; many of the products are released at later dates than the corresponding data file(s); basic analytical text is also included in the Daily -hearing – July 2015; activity monitor and RBC expected this fall -VOCs in air, water and blood – May/June 2016 Statistics Canada • Statistique Canada

STATCAN ANALYTICAL PRODUCTS (CONT’D) Fact sheets Plain language, basic descriptive analysis Cycle 3 already released: Blood pressure: 1. adults, 2. children and youth Body composition/BMI: 1. adults, 2. children and youth Chronic obstructive pulmonary disease Metabolic syndrome Cholesterol levels Vitamins: 1. C, 2. D Physical activity: 1. adults, 2. children and youth Hearing loss Cycle 3 releases to come: 1. Bisphenol A, 2. Tobacco use, 3. Lead, mercury and cadmium, 4. RBC fatty acids -12 cycle 3 fact sheets have been released so far and 4 are to come -2 pages on average, often with a couple of charts -Bisphenol A, tobacco use and lead, mercury and cadmium fact sheets are to be released on July 15th and the RBC fatty acids fact sheet will be released in the fall Statistics Canada • Statistique Canada

DATA HIGHLIGHTS FROM CYCLE 3 11% of adults aged 35 to 79 measured airflow obstruction consistent with chronic obstructive pulmonary disease; however, 90% of these individuals were unaware of their condition 22% of Canadian adults aged 20 and older and 2% of children and youth aged 19 and younger suffer from high blood pressure 65% of Canadians aged 3 to 79 had vitamin D levels that are likely sufficient to fulfill the body’s requirement for optimal bone health while 25% were at risk for inadequate vitamin D and 10% were at risk for having a vitamin D deficiency 21% of Canadian adults aged 18 to 79 suffer from metabolic syndrome 38% of Canadian adults aged 18 to 79 suffer from dyslipidemia; however, half of those individuals were unaware of their condition Statistics Canada • Statistique Canada

Statistics Canada • Statistique Canada Adults -Almost 2 out of every 3 (62%) Canadian adults aged 18 to 79 were overweight or obese while 2% were underweight and 36% had a normal BMI   -The prevalence of obesity in the Canadian adult population has changed since the 1978/1979 Canada Health Survey.5 The prevalence of overweight Canadians did not change, but the proportion considered to be obese doubled (from 13% to 26%). Children and youth -31% of children and youth 5 to 17 years were overweight and obese while 68% had a normal BMI -Boys (15%) were more likely to be obese than girls (11%); however boys and girls were equally likely to be overweight (19%) Statistics Canada • Statistique Canada

Statistics Canada • Statistique Canada Adults -Approximately one in five adults achieved the recommended 150 minutes of moderate-to-vigorous physical activity (in 10 minute bouts) set out by the Canadian Physical Activity Guidelines for adults and older adults. The percentage of adults meeting the guideline was lower in older age groups. Children and youth The majority of school-aged children and youth are not getting enough physical activity to meet the current Canadian Physical Activity Guidelines, only 13% of boys and 6% of girls were getting an average of at least 60 minutes of moderate-to-vigorous physical activity daily as recommended in the guidelines Statistics Canada • Statistique Canada 25

Physical Activity Guidelines -20% of adults aged 19 to 79 years had at least mild hearing loss in at least one ear (Chart 1). Hearing loss was more prevalent in older age groups. Hearing loss was roughly 50-50 being unilateral (one ear) or bilateral (both ears) -5% of children had at least mild hearing loss in at least one ear (data not shown) the vast majority being unilateral hearing loss Physical Activity Guidelines 26 Source: Canadian Health Measures Survey, 2007-2009. Statistics Canada 26

FUTURE CONTENT CYCLES 5-8 Neighbourhood environment Sleep apnea Hair (metals) Saliva (DNA) Vision pQCT and mechanography Cycles 7 & 8 Dual-energy x-ray absorptiometry (DXA) Here is some of the main new content planned for the future – as we get closer to cycles 7 and 8, content will likely be added Vision = visual acuity, visual field, retinal photography Statistics Canada • Statistique Canada

ADDITIONAL INFORMATION For more information on the CHMS: toll-free number: 1-888-253-1087 e-mail: infostats@statcan.gc.ca Web site: www.statcan.gc.ca/chms -we also do custom tabulations at a cost Statistics Canada • Statistique Canada

Statistics Canada • Statistique Canada QUESTIONS? Statistics Canada • Statistique Canada