Van S. Hubbard, M.D., Ph.D. National Institutes of Health and Clifford L. Johnson, M.S.P.H.

1. Surveillance Methodologies Utilized within NHANES with Emphasis on Identification of Non-communicable Chronic Disease 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

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

3. 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

4. What are the goals of NHANES? 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

5. Measuring is better than asking

6. Prevalence of adult obesityMeasured vs Self-reported data SOURCE: CDC/NCHS

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

8. Who is eligible to participate? • 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 2011-14

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

10. Multiple stages in NHANES • Screener interview • Participant interview (in-person) • Participant examination • Additional interview or exam components

11. What is the home interview? • Doorstep screening • Traditional CAPI interviewing with portable keyboard.

12. What do we ask about in the interview? • Broad range of health conditions • Health-related behaviors and exposures • Health care utilization • Health insurance • Prescription medications • Dietary supplements

13. NHANES Mobile Exam Center (MEC)

14. Mobile Examination CenterProvides Standardized Data Collection • 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

15. How long is the exam? • 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

16. NHANES response rates1999-2008

17. How do we decide what gets in? • Public health significance • Scientific merit • Appropriateness • Feasibility and ethical issues • Financial considerations

18. NHANES 2011-12 examination • 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

19. NHANES Provides Data for Many Essential Public Health Functions • Reference data Growth Charts • Nutrition monitoring Obesity, Cholesterol • Disease control Diabetes • Prevention initiatives Infectious Diseases,Folate • Monitor chemical/ Lead pollutant exposure • Track health behaviors Second-hand Smoke

20. Monitoring Increase in Diabetes, Measuring Disease Management & Undiagnosed Disease Monitor Diagnosed and Undiagnosed Disease Diabetes and Pre-diabetes (%) 2005-2006 Diagnosed diabetes doubled from 3.4% to 7.7 % between 1976-80 and 2005-2006 Impaired Fasting Glucose or Impaired Glucose Tolerance 12.9% of adults age > 20 years have diagnosed or undiagnosed diabetes; no gender-specific differences (2005-2006) 42% of adults age > 20 years have diabetes or pre-diabetes (2005-2006) Monitor Improvements in Diabetes Management Undiagnosed Hemoglobin A1C declined from 7.8% to 7.2% between 1999-2004 (good control = 7.0%) Diagnosed

21. Cornerstone of the CDC’s National Biomonitoring Program and the US Environmental Exposure Report Card • 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

22. Blood lead levels in the U.S. Children Ages 1-5 yrs, 1976 - 2002 16 14 12 10 Blood lead levels (mg/dL) 8 6 4 2 0 2000 2002 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 Year

23. NHANES Data Directly download from our website http://www.cdc.gov/nchs/nhanes.htm Join our LISTSERV

24. Food frequency questionnaire by mail Hair sample for mercury measurement Physical activity monitor worn for 7 days Additional urine sample collected at home 2nd Dietary recall and FCBS follow-up interview by phone Dust sample collected by vacuum Hepatitis C and PSA follow-up interview by phone 6 months later Self-administered vaginal swab Oral HPV rinse Tap water sample from home Adapting to Complex Data Needs • 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

25. NHANES Core Characteristics • Sound science • Produce high quality data • Responsive to emerging public health issues • Timely • Innovative • Proven model

26. A Pot of Gold and a Gold Standard

27. Our ultimate goal is to prevent disease and disability Surveillance and Research Are Keys to SuccessThank you