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

NHANES 1999-present All Ages Evolution of NHANES Survey Dates Ages NHES I 1960-62 18-79 years NHES II 1963-65 6-11 years NHES III 1966-70 12-17 years NHANES I 1971-75 1-74 years NHANES II 1976-80 6 mo.-74 years HHANES 1982-84 6 mo.-74 years NHANES III 1988-94 2 mo. + Continuous NHANES 1999-present All Ages

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

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

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

Oversampling in NHANES 1999-2006 2007-2010 2011-2014 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

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

NHANES Mobile Exam Center (MEC)

Inside the MEC (2011-2012)

Continuous NHANES Operation Timeline NHANES 2013-14 Survey Cycle 2011 2012 2013 2014 2015 2016 Planning 2015-16 2017-18 2017-18 2019-20 x Piloting x 2015-16 2017-18 Data 2013 2014 2015 2016 collection Data release Process Release Process Release 2011-12 2011-12 2013-14 2013-14 Analyses 2009-10 2011-12 2011-12 2013-14 … 10 10

What about the DIET DATA? 2013-2014 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

WIC Sample in NHANES

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 2005-2008 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, 2005-2008. Prepared by Walter R. McDonald & Associates Inc. and Mathematica Policy Research for Food and Nutrition Service.

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 2005-2008 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

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 2005-2008 demographics data. Sample includes NHANES respondents with complete dietary recall data, Sample includes pregnant, breastfeeding, and postpartum women, 20-44 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.

Short term solutions Children Infants Women. . . . WAIT!!!! Dietary data from 2013-2014 NHANES should be available in late summer or early fall Boost sample sizes for children Infants Consider imputing breastmilk volumes Women. . . .

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

Financial Considerations Internal funding Collaborators

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

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

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

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.

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 http://www.cdc.gov/nchs/nyfs.htm

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) http://www.cdc.gov/nchs/nyfs.htm

Exam Room 1

Exam Room 2

Dietary Recall and Interview Room

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

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?

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 2019-2020 start now!

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

Proposal guidelines: Additional data collection in NHANES http://www.cdc.gov/nchs/nhanes/proposal_guidelines.htm

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

Kirsten Herrick: kherrick1@cdc.gov Thank You! For more information: Kirsten Herrick: kherrick1@cdc.gov http://www.cdc.gov/nchs/nhanes.htm Centers for Disease Control and Prevention National Center for Health Statistics