National Health and Nutrition Examination Survey: Overview U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Disease Control and Prevention National Center for Health Statistics Clifford Johnson, Director

Objectives 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

Sample Civilian, non-institutionalized household population Residents of all states and the District of Columbia All ages 5,000 individuals each year

NHANES 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 Nutrition Examination Surveys NHES I years NHES II years NHES III years NHANES I years NHANES II mo.-74 years HHANES mo.-74 years NHANES III mo. + SurveyDatesAges OP96S025

National Health and Nutrition Examination Surveys NHANES All ages NHANES All ages NHANES All ages NHANES All ages NHANES All ages NHANES All ages NHANES All ages Survey Dates Ages OP96S025

NHANES response rates Interviewed 81.4% MEC examined 77.9%

Benefits of Participation Benefits 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

B enefits of Participation Cash remuneration Reimbursement for travel or free transportation

Data Collection

Participant 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 Examination

NHANES Mobile Exam Center (MEC)

NHANES topics Cardiovascular disease Diabetes Bone status, osteoporosis Oral health Vision and eye diseases Hearing and balance Fitness and strength Allergies OP96S035

NHANES topics Nutrition Anthropometry Mental health Risk behaviors Reproductive health Environmental exposures Infectious diseases Spirometry OP96S036

Examples of NHANES Findings and Uses Examples of NHANES Findings and Uses

Landmark findings and public health results High blood lead levels  Lead out of gasoline Low folate levels  Mandatory food fortification Rising levels of obesity  Public health action plan Racial and ethnic disparities in Hepatitis B  Universal vaccination of all infants & children

OP CDC Growth Charts: United States

Percent Trends in Child and Adolescent Overweight 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 , NCHS, CDC.

Percent Trends in Adult Obesity, 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, and years. Obesity defined as BMI>=30.

Prevalence of Obesity Among Adults ≥ 18 years, United States SOURCE: Hedley, unpublished analyses

ng/mL Mean Serum Folate Concentrations Females: United States Years NHANES III NHANES

Trends in Median Serum Folate Levels of Males and Females; United States:

Threshold for herd immunity Seroprevalence of measles Antibody by birth cohort SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey (NHANES) % measles seropositive IgG Birth Cohort

OH9900 Additional Chemicals in 3 rd Report 148 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

Lead used in gasoline production and average blood lead levels Total lead used per 6 month period (1000 tons) Average blood lead levels Lead used In gasoline 0 SOURCE: CDC/NCHS, Second National Health and Nutrition Examination Survey, Average blood lead levels (micrograms/deciliter)

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

Exposure to Second Hand Smoke: Nonsmokers with Detectable Cotinine* Levels, 2010 Target Baseline Percent with detectable serum cotinine Mexican American Total White, not Hispanic Black, not Hispanic Source: National Health and Nutrition Examination Survey (NHANES), NCHS, CDC. Ages 4 years and older

Selected Percentiles of Total Blood Mercury Women years NOTE: NHANES SOURCE: CDC/NCHS

Prevalence of reduced hip bone density among persons 65 years of age and over Percent years Osteoporosis Osteopenia years 85 years and over Women years years 85 years and over Men SOURCE: CDC/NCHS, NHANES III OP96S071

Percent  60 Diagnosed Undiagnosed Impaired fasting glucose Percent SOURCE: CDC/NCHS, National Nutrition and Health Examination Survey, ; National Health Interview Survey, 1999, Diabetes and Impaired Fasting Glucose,

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 REF: Gregg, Sorlie, Paulose-Ram, Gu, Eberhardt, Wolz, Burt, Curtin, Engelgau, Geiss. Diabetes Care Jul;27(7): Not all estimates meet standard of statistical reliability and precision (relative SE >30%). * PAD: peripheral arterial disease; PN: peripheral neuropathy TotalDiabeticNon-Diabetic Percent

OH9900

NHANES Data Central to 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 Many Essential Public Health Functions Prevention initiatives Monitoring exposure levels— pollutants, chemicals Food safety and fortification Disease control Tracking health behaviors

Other Activities Future of Health and Nutrition Examination Surveys Community HANES Longitudinal Follow-ups Linked files Efficiencies Web tools

Final 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