1. Kirsten Herrick, MSc, PhD
NHANES: History, Data Collection, and Future Directions
Kirsten Herrick, MSc, PhD
Senior Service Fellow
NHANES/NCHS/CDC
Disclaimer: The findings and conclusions in this presentation are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Health Statistics

2. NHANES 1999-present All Ages
Evolution of NHANES
Survey
Dates
Ages
NHES I years
NHES II years
NHES III years
NHANES I years
NHANES II mo.-74 years
HHANES mo.-74 years
NHANES III mo. +
Continuous
NHANES 1999-present All Ages

3. National Health and Nutrition Examination Survey
OBJECTIVE: To assess the health and nutritional status of adults and children in the United States
Produce population-based estimates of:
Health conditions and environmental exposures
Awareness, treatment, and control of selected diseases
Prescription medication and dietary supplement use
Nutrition status and diet behaviors

4. The NHANES Sampling Procedure
Stage 1
Counties
Stage 2
Segments
Stage 3
Households
Stage 4
SPs

5. The NHANES Sample US civilian, non-institutionalized population
All ages
About 5,000 people sampled each year
Oversampling of subgroups
increase the reliability and precision of estimates of health status indicators

6. Oversampling in NHANES
Non-Hispanic Black X
Mexican American
Hispanic
Low income white
Age 70 +
80+
Age 12-19
Non-Hispanic Asian
a supplemental sample of pregnant women

7. NHANES Components Summary
In-person home interview
Health examinations conducted in a mobile examination center (MEC)
Includes blood and urine collection
Dietary interview
Questionnaires
Post exam components
Second dietary interview

8. NHANES Mobile Exam Center (MEC)

9. Inside the MEC ( )

10. Continuous NHANES Operation Timeline NHANES 2013-14 Survey Cycle
2011
2012
2013
2014
2015
2016
Planning x
Piloting x
Data
collection
Data release Process Release Process Release
Analyses … 10 10

11. What about the DIET DATA?
survey finishes data collection
2015 coders finish 2nd diet interview
Dietary weights created
NCHS
USDA
Diet data released
USDA updates nutrient data base and identifies reliable and complete recalls

12. WIC Sample in NHANES

13. CHILDREN WIC Analytic Sample, NHANES 2005-08
All children
WIC participants
Income-eligible nonparticipants
Higher-income participants
1,956
791
496
606
1 year old
566
305 96
153
2 years old
587
223
162
183
3 years old
389
132
104
134
4 years old
414
131
136
Source: NHANES Demographics data. Sample includes NHANES respondents with complete dietary recall, 1-4 years
Notes: ‘All children’’ includes respondents with missing WIC participation or income.
Citation: Condon et al. (2015) Diet Quality of American Children by WIC Participation Status: Data from the National Health and Nutrition Examination Sruvey, Prepared by Walter R. McDonald & Associates Inc. and Mathematica Policy Research for Food and Nutrition Service.

14. Breastfeeding status WIC Analytic Sample, NHANES 2005-08
All infants
WIC participants
Income-eligible nonparticipants
Higher-income participants
880
555
102
209
0-5 months
407
257 56 86
Any BF
169 81 36 48 FF
238
176 20 38
6-11 months
473
298 46
123
368 45 12
105
253 34 78
Source: NHANES Demographics data. Sample includes NHANES respondents with demographic and dietary data.
Notes: ‘All children’’ includes respondents with missing WIC participation or income; 8 infants 0-5 months, 6 infants 6-11 months
To analyze breastfed infants – impute volume of breastmilk consumed using Feeding Infants and Toddlers Study (FITS) methodology

15. WOMEN WIC Analytic Sample, NHANES 2005-08
All women
WIC participants
Income-eligible nonparticipants
Higher-income participants
604
244 83
211
Pregnant
373
144 54
136
Breastfeeding 71 31 12 24
Postpartum
226
114 25 63
Source: NHANES demographics data. Sample includes NHANES respondents with complete dietary recall data, Sample includes pregnant, breastfeeding, and postpartum women, years old. Postpartum women are non-breastfeeding women up to 12 months postpartum and include an unknown number of non-breastfeeding women who are more than 6-months postpartum.
Notes: ‘All women’ includes pregnant, breastfeeding and postpartum women.

16. Short term solutions Children Infants Women. . . . WAIT!!!!
Dietary data from NHANES should be available in late summer or early fall
Boost sample sizes for children
Infants
Consider imputing breastmilk volumes
Women

17. Future Directions NHANES is committed to the Asian oversample
Consider funding a separate study to boost number of pregnant and postpartum women and infants and children

18. Financial Considerations
Internal funding
Collaborators

19. Around 25 partners with various degrees of collaboration
Our Collaborators
Around 25 partners with various degrees of collaboration

20. Examples of Collaborations
Red blood cell folate and serum folate
National Center on Birth Defects and Developmental Disabilities (NCBDDD) funds collection and analysis
Females ages 15-44
Approximate cost: $200,00 per year
NHANES National Youth Fitness Survey
Affordable Care Act
1500 youth aged 3-15
5th NHANES trailer
Approximate cost: $6 million over three years

21. NNYFS Objective
Assess exercise and the nutrition habits of youth in the U.S. through interviews and fitness tests

22. NNYFS Study Methods Screening on age and gender only
Data collection in 2012 only
Males and females
Ages 3-15 years
Separate sample from NHANES
No overlapping households
Screening on age and gender only
Same 15 stands (locations) as NHANES
Planning for new components in NHANES normally begins 1-2 years before implementation. We were able to implement a new survey in just 8 months.

23. Fitness Measures in the 2012: NHANES and NNYFS
Component
NHANES
NNYFS
Body measures
All ages
3-15 y
Physical activity monitor
3+ y
24-hour dietary recall
Physical activity questionnaire
Handgrip
(upper body muscle strength)
6+ y
6-15 y

24. Fitness Measures in the 2012: NHANES and NYFS
Component
NHANES
NNYFS
Cardiovascular fitness:
(Treadmill) 6-11 y: endurance
12-15 y: aerobic capacity --
6-15 y
Gross Motor Development, 2nd Edition (TGMD-2)
3-5 y
Plank
(core strength, endurance)
3-15 y
Upper body muscle strength
(modified pull up)
5-15 y
Lower body muscle strength
(knee flexion)

25. Exam Room 1

26. Exam Room 2

27. Dietary Recall and Interview Room

28. NHANES Mother and Child Study?
Goal: boost numbers of select subgroups to produce reliable and precise estimates.
Infants 0-11 months
Pregnant women
Postpartum women
Modeled on NHANES
Anthropometry
Dietary interviews
Questionnaires
Laboratory

29. Opportunities of an NHANES Mother and Child study
Utilize the field operations infrastructure
Opportunity to have novel data
Mother-child pairs: diet, anthropometry, others?
Additional biomarkers?
Breastmilk samples?

30. Realities of a focused study
NEED a 5th trailer
All respondents in the ‘boost’ sample would go through the 5th trailer ONLY.
NHANES MEC Laboratory might be able to handle additional samples or use MEC mobile lab
Cost – NNYFS additional 1500 kids -- $6M over 3 yrs
Time – NHANES start now!

31. Current planning 2019-2020 NHANES
Letter of intent 24
Proposal 18
Pilot test 12
Months
Translations
Manuals/Training
Outreach materials 6 3 9
Start
January 2019 31

32. Proposal guidelines: Additional data collection in NHANES

33. Proposal Review and Evaluation
All sections can be modified through proposal request
Pending financial support and justification
Committee evaluation
Public health significance
Scientific merit
Appropriateness
Feasibility and ethical issues 33

34. Kirsten Herrick: kherrick1@cdc.gov
Thank You!
For more information:
Kirsten Herrick:
Centers for Disease Control and Prevention
National Center for Health Statistics