1. 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

2. Objectives Some NHANES history Survey operations and data collection Content Uses and findings Summary thoughts

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

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

5. 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

6. 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 OP96S025

7. 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 Survey Dates Ages OP96S025

8. NHANES response rates 1999-2006 Interviewed 81.4% MEC examined 77.9%

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

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

11. Data Collection

13. 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

14. Standardized physical exam Conducted at mobile exam center Medical & dental exams Physiological measurements Laboratory test Administered by trained medical personnel NHANES Examination

15. NHANES Mobile Exam Center (MEC)

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

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

18. Examples of NHANES Findings and Uses Examples of NHANES Findings and Uses

19. 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

20. OP96065 2000 CDC Growth Charts: United States

21. 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 1999-2004, NCHS, CDC.

22. 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.

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 Prevalence of Obesity Among Adults ≥ 18 years, United States SOURCE: Hedley, unpublished analyses

24. ng/mL Mean Serum Folate Concentrations Females: United States Years NHANES III 1988-1994 NHANES 1999-2000

25. Trends in Median Serum Folate Levels of Males and Females; United States: 1988-2006 1999-2000 2001-2002 2003-2004 1988-1994

26. Threshold for herd immunity Seroprevalence of measles Antibody by birth cohort SOURCE: CDC/NCHS, National Health and Nutrition Examination Survey (NHANES) 1999-2004. % measles seropositive IgG Birth Cohort

27. 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 www.cdc.gov/exposurereport

28. Lead used in gasoline production and average blood lead levels Total lead used per 6 month period (1000 tons) 19771979 Average blood lead levels Lead used In gasoline 0 SOURCE: CDC/NCHS, Second National Health and Nutrition Examination Survey, 1976-80. 1978 Average blood lead levels (micrograms/deciliter) 1976 0 1980

29. 197619781980198219841986198819901992 2 4 6 8 10 12 14 16 Blood lead levels (  g/dL) 0 199419961998 2000 Blood lead levels in the U.S. Children Ages 1-5 yrs, 1976 - 2002 Year 2002

30. Exposure to Second Hand Smoke: Nonsmokers with Detectable Cotinine* Levels, 2010 Target 1988-94 Baseline Percent with detectable serum cotinine1999-2000 Mexican American Total White, not Hispanic Black, not Hispanic Source: National Health and Nutrition Examination Survey (NHANES), NCHS, CDC. Ages 4 years and older

31. Selected Percentiles of Total Blood Mercury Women 16-49 years NOTE: NHANES 1999-2000 SOURCE: CDC/NCHS

32. Prevalence of reduced hip bone density among persons 65 years of age and over Percent 65-74 years Osteoporosis Osteopenia 75-84 years 85 years and over Women 65-74 years 75-84 years 85 years and over Men SOURCE: CDC/NCHS, NHANES III 1988-94 OP96S071

33. Percent 20-3940-59  60 Diagnosed Undiagnosed Impaired fasting glucose Percent SOURCE: CDC/NCHS, National Nutrition and Health Examination Survey, 1999-2000; National Health Interview Survey, 1999, 2000. Diabetes and Impaired Fasting Glucose, 1999-2000

34. 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. 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 TotalDiabeticNon-Diabetic Percent

35. OH9900

37. 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

38. 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

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

40. 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

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