1. National Health and Nutrition Examination Survey Monitoring the Nation’s Health Kathryn S. Porter, M.D., M.S. Director Division of Health and Nutrition Examination Surveys National Center for Health Statistics Division of Health and Nutrition Examination Surveys

2. Objective To assess the health and nutritional status of adults and children in the United States

4. NHANES in the News

5. Goals

6. U.S. population-based estimates of: Health conditions Awareness, treatment and control of selected diseases Environmental exposures Nutrition status and diet behaviors Goals of NHANES

7. History

8. National Health and Nutrition Examination Surveys NHES I1960-6218-79 years NHES II1963-656-11 years NHES III1966-7012-17 years NHANES I1971-751-74 years NHANES II1976-806 mo.-74 years HHANES1982-84 6 mo.-74 years NHANES III1988-942 mo. + SurveyDatesAges

9. National Health and Nutrition Examination Surveys NHANES 1999-2000All ages NHANES 2001-2002All ages NHANES 2003-2004All ages NHANES 2005-2006All ages NHANES 2007-2008All ages NHANES2009-2010 All ages NHANES 2011-2012All ages NHANES2013-2014All ages NHANES2015-2016All ages Survey Dates Ages

10. Data Collection

11. NHANES Sample Civilian, non-institutionalized household population in the United States Target: 5,000 individuals examined annually Oversample: African Americans Asian Americans Hispanics Older persons aged 60+ Low income whites

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

13. NHANES information flow Advance letter Screening In-home interview Exam Biologic Specimens LaboratoriesCDC/NCHSParticipant Informed consent Banking facilities

14. NHANES Home Interview

15. NHANES Mobile exam center

17. Mobile exam center entrance

18. Reception

19. Cardiovascular health

20. Hearing and vision

21. Anthropometry and body composition

22. Whole body scan – percentage body fat

23. Sagittal abdominal diameter Participants 8 years and older

24. Taste and smell

25. Private interviews

26. Oral health

27. Laboratory

28. Mobile exam center laboratory Complete blood count Pregnancy test Specimen processing Blood, urine, water, swabs 500 assays 24 laboratories

29. NHANES labs/graders 10 3 1

30. NCHS 10 3 1 NHANES labs/graders

31. Laboratory tests Nutritional biomarkers Hormone tests Diabetes Lipid profile Biochemistry profile Celiac disease Infectious diseases Hepatitis viruses Sexually transmitted infections Environmental Chemicals Water fluoride levels

32. Participant remuneration Remuneration $125 Transportation (bus, taxi, mileage) reimbursed Additional remuneration for other components

33. Post exam assessments Day 2 Dietary Recall Home urine collection Physical Activity Monitor

34. 24-hour Urine Collection

35. NHANES Response Rates 2013 Interviewed 72% Interviewed and examined 70%

36. Information technology architecture h i Household interviews Westat home office T1 NCHS Labs & graders T1 MEC 64kb Field office National Frame Relay Network OP96S049

37. Data release process QA/QC Editing/cleanup Weighting Data preparation Documentation Confidentiality review

39. Do we give participants their results? Initial findings Abnormal values Call for STD results w/ pre-set passwords Final report Kathryn S. Porter, MD Yes

40. Benefits to Participants

41. Early notification of abnormal results

42. Interesting story – high mercury Spanish-speaking family examined. Mom and three kids, the youngest was 3 years old. All had high levels of mercury

43. Interesting story, cont.

47. Monitoring the nation’s health

48. NHANES data findings

49. Environmental health

50. 197619781980198219841986198819901992 2 4 6 8 10 12 14 16 Blood lead levels (  g/dL) 0 199419961998 2000 Blood lead levels in U.S. children Ages 1-5 yrs, 1976 - 2002 Year 2002

51. Second hand smoke

52. Percent of non-smoking U.S. population exposed to second hand smoke Source: Pirkle JL et al. Trends in Exposure of Nonsmokers in the U.S. Population to SHS: 1988–2002. Env Hlth Persp. 2006; 114(6): 853–8. CDC. Vital Signs: Nonsmokers’ Exposure to Secondhand Smoke — United States, 1999-2008. MMWR. September 7, 2010. 59; 7-12

53. Pediatric growth charts

55. Obesity

56. Americans heavier in 2007-2010 than in the 1960s Sources: CDC/NCHS: National Health and Nutrition Examination Survey; www.cdc.gov/nchs/data/ad/ad347.pdfSources: CDC/NCHS: National Health and Nutrition Examination Survey; www.cdc.gov/nchs/data/ad/ad347.pdf; http://www.cdc.gov/nchs/data/databriefs/db82.htm http://www.cdc.gov/nchs/data/series/sr_11/sr11_252.pdf (NHESI, NHESII, 2007-2010) http://www.cdc.gov/nchs/data/series/sr_11/sr11_252.pdf

57. Prevalence of obesity in the US, 2011-2012 17% of children & teens 2-19 y 35% of adults ≥20 y Source: CDC/NCHS, National Health and Nutrition Examination Survey, 2011-2012; Ogden et al. NCHS Data Brief 2013 and Ogden et al. JAMA 2014

58. Percent 1960-21988-94 Percent Trends 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. 99-00 01-2 03-4 Male Female 1971-41976-80 05-6

60. Federal Aviation Administration TABLE 2-1. STANDARD AVERAGE PASSENGER WEIGHTS Standard Average Passenger Weight Per Passenger Summer Weights Average adult passenger weight 190 lb Average adult male passenger weight 200 lb Average adult female passenger weight 179 lb Child weight (2 years to less than 13 years of age) 82 lb Winter Weights Average adult passenger weight 195 lb Average adult male passenger weight 205 lb Average adult female passenger weight 184 lb Child weight (2 years to less than 13 years of age) 87 lb

61. Diet

62. The 2010 Dietary Guidelines for Americans recommend a sodium intake of less than 2300 mg per day

63. Sugary drink consumption 70% of boys aged 2-19 years consume sugar drinks on any given day; 60% of girls

64. Measuring Progress: trans-Fatty Acids Reduction Policies

65. Birth Defect Prevention

66. Birth Defect Prevention – Spina Bifida 20-50% of cases can be prevented Requires adequate intake of folic acid (400 mcg daily)

67. Median serum and red blood cell folate concentrations: US females ages 15-45 SOURCE: CDC/NCHS, National Health and Nutrition Examination Surveys, 1988-94 1988-94 ng/mL Serum folateRed blood cell folate 1988-94 5 10 15 20 4.8 0 50 100 150 200 250 300 160

68. Median serum and red blood cell folate concentrations: US females ages 15-45 SOURCE: CDC/NCHS, National Health and Nutrition Examination Surveys, 1988-94 and 2003-04 1988-941999-2000 ng/mL Serum folateRed blood cell folate 1988-941999-2000 5 10 15 20 4.8 13.0 0 50 100 150 200 250 300 160 264

69. Spina bifida rates United States 1991-2005 NOTE: Excludes data for Maryland, New Mexico, and New York which did not require reporting for spina bifida for some years. CI is 95% confidence interval. SOURCE: National Vital Statistics System, NCHS, CDC

70. Infectious disease

71. Measuring Progress: HPV Vaccine Effectiveness

72. Prescription medication use

73. Prescription antidepressant use NOTE: The 1988–1994 estimates for men are considered unreliable because the estimates have relative standard errors of 20%–30%. SOURCE: CDC/NCHS, Health, United States, 2013, Figure 25. Data from the National Health and Nutrition Examination Survey.

74. Chronic disease

75. Source: 2005–2008 National Health and Nutrition Examination Survey.

76. Challenges

77. Translated Materials

81. Financial considerations Internal funding Collaborators

82. Who are our collaborators? Around 25 partners with various degrees of collaboration

83. Thank you