Validation of diagnosis codes to identify hospitalized COVID-19 patients in health care claims data.

PURPOSE: Health plan claims may provide complete longitudinal data for timely, real-world population-level COVID-19 assessment. However, these data often lack laboratory results, the standard for COVID-19 diagnosis. METHODS: We assessed the validity of ICD-10-CM diagnosis codes for identifying patients hospitalized with COVID-19 in U.S. claims databases, compared to linked laboratory results, among six Food and Drug Administration Sentinel System data partners (two large national insurers, four integrated delivery systems) from February 20-October 17, 2020. We identified patients hospitalized with COVID-19 according to five ICD-10-CM diagnosis code-based algorithms, which included combinations of codes U07.1, B97.29, general coronavirus codes, and diagnosis codes for severe symptoms. We calculated the positive predictive value (PPV) and sensitivity of each algorithm relative to laboratory test results. We stratified results by data source type and across three time periods: February 20-March 31 (Time A), April 1-30 (Time B), May 1-October 17 (Time C). RESULTS: The five algorithms identified between 34 806 and 47 293 patients across the study periods; 23% with known laboratory results contributed to PPV calculations. PPVs were high and similar across algorithms. PPV of U07.1 alone was stable around 93% for integrated delivery systems, but declined over time from 93% to 70% among national insurers. Overall PPV of U07.1 across all data partners was 94.1% (95% CI, 92.3%-95.5%) in Time A and 81.2% (95% CI, 80.1%-82.2%) in Time C. Sensitivity was consistent across algorithms and over time, at 94.9% (95% CI, 94.2%-95.5%). CONCLUSION: Our results support the use of code U07.1 to identify hospitalized COVID-19 patients in U.S. claims data.

Implementing the National Heart, Lung, and Blood Institute's Strategic Vision in the Division of Cardiovascular Sciences.

As we commemorate the 70th Anniversary of the National Heart, Lung, and Blood Institute (NHLBI) and celebrate important milestones that have been achieved by the Division of Cardiovascular Sciences (DCVS), it is imperative that DCVS and the Extramural Research community at-large continue to address critical public health challenges that persist within the area of Cardiovascular Diseases (CVD). The NHLBI's Strategic Vision, developed with extensive input from the extramural research community and published in 2016, included overarching goals and strategic objectives that serve to provide a general blueprint for sustaining the legacy of the Institute by leveraging opportunities in emerging scientific areas (e.g., regenerative medicine, omics technology, data science, precision medicine, and mobile health), finding new ways to address enduring challenges (e.g., social determinants of health, health inequities, prevention, and health promotion), and training the next generation of heart, lung, blood, and sleep researchers. DCVS has developed a strategic vision implementation plan to provide a cardiovascular framing for the pursuit of the Institute's overarching goals and strategic objectives garnered from the input of the broader NHLBI community. This plan highlights six scientific focus areas that demonstrate a cross-cutting and multifaceted approach to addressing cardiovascular sciences, including 1) addressing social determinants of cardiovascular health (CVH) and health inequities, 2) enhancing resilience, 3) promoting CVH and preventing CVD Across the lifespan, 4) eliminating hypertension-related CVD, 5) reducing the burden of heart failure, and 6) preventing vascular dementia. These priorities will guide our efforts in Institute-driven activities in the coming years but will not exclude development of other novel ideas or the support of investigator-initiated grant awards. The DCVS Strategic Vision implementation plan is a living document that will evolve with iterative dialogue with the NHLBI community and adapt as the dynamic scientific landscape changes to seize emerging opportunities.

Trends in Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

Importance: Favorable trends occurred in the lipid levels of US youths through 2010, but these trends may be altered by ongoing changes in the food supply, obesity prevalence, and other factors. Objective: To analyze trends in levels of lipids and apolipoprotein B in US youths during 18 years from 1999 through 2016. Design, Setting, and Participants: Serial cross-sectional analysis of US population-weighted data for youths aged 6 to 19 years from the National Health and Nutrition Examination Surveys for 1999 through 2016. Linear temporal trends were analyzed using multivariable regression models with regression coefficients (ß) reported as change per 1 year. Exposures: Survey year; examined periods spanned 10 to 18 years based on data availability. Main Outcomes and Measures: Age- and race/ethnicity-adjusted mean levels of high-density lipoprotein (HDL), non-HDL, and total cholesterol. Among fasting adolescents (aged 12-19 years), mean levels of low-density lipoprotein cholesterol, geometric mean levels of triglycerides, and mean levels of apolipoprotein B. Prevalence of ideal and adverse (vs borderline) levels of lipids and apolipoprotein B per pediatric lipid guidelines. Results: In total, 26 047 youths were included (weighted mean age, 12.4 years; female, 51%). Among all youths, the adjusted mean total cholesterol level declined from 164 mg/dL (95% CI, 161 to 167 mg/dL) in 1999-2000 to 155 mg/dL (95% CI, 154 to 157 mg/dL) in 2015-2016 (ß for linear trend, -0.6 mg/dL [95% CI, -0.7 to -0.4 mg/dL] per year). Adjusted mean HDL cholesterol level increased from 52.5 mg/dL (95% CI, 51.7 to 53.3 mg/dL) in 2007-2008 to 55.0 mg/dL (95% CI, 53.8 to 56.3 mg/dL) in 2015-2016 (ß, 0.2 mg/dL [95% CI, 0.1 to 0.4 mg/dL] per year) and non-HDL cholesterol decreased from 108 mg/dL (95% CI, 106 to 110 mg/dL) to 100 mg/dL (95% CI, 99 to 102 mg/dL) during the same years (ß, -0.9 mg/dL [95% CI, -1.2 to -0.6 mg/dL] per year). Among fasting adolescents, geometric mean levels of triglycerides declined from 78 mg/dL (95% CI, 74 to 82 mg/dL) in 1999-2000 to 63 mg/dL (95% CI, 58 to 68 mg/dL) in 2013-2014 (log-transformed ß, -0.015 [95% CI, -0.020 to -0.010] per year), mean levels of low-density lipoprotein cholesterol declined from 92 mg/dL (95% CI, 89 to 95 mg/dL) to 86 mg/dL (95% CI, 83 to 90 mg/dL) during the same years (ß, -0.4 mg/dL [95% CI, -0.7 to -0.2 mg/dL] per year), and mean levels of apolipoprotein B declined from 70 mg/dL (95% CI, 68 to 72 mg/dL) in 2005-2006 to 67 mg/dL (95% CI, 65 to 70 mg/dL) in 2013-2014 (ß, -0.4 mg/dL [95% CI, -0.7 to -0.04 mg/dL] per year). Favorable trends were generally also observed in the prevalence of ideal and adverse levels. By the end of the study period, 51.4% (95% CI, 48.5% to 54.2%) of all youths had ideal levels for HDL, non-HDL, and total cholesterol; among adolescents, 46.8% (95% CI, 40.9% to 52.6%) had ideal levels for all lipids and apolipoprotein B, whereas 15.2% (95% CI, 13.1% to 17.3%) of children aged 6 to 11 years and 25.2% (95% CI, 22.2% to 28.2%) of adolescents aged 12 to 19 years had at least 1 adverse level. Conclusions and Relevance: Between 1999 and 2016, favorable trends were observed in levels of lipids and apolipoprotein B in US youths aged 6 to 19 years.

Bias in Hazard Ratios Arising From Misclassification According to Self-Reported Weight and Height in Observational Studies of Body Mass Index and Mortality.

Misclassification of body mass index (BMI) categories arising from self-reported weight and height can bias hazard ratios in studies of BMI and mortality. We examined the effects on hazard ratios of such misclassification using national US survey data for 1976 through 2010 that had both measured and self-reported weight and height along with mortality follow-up for 48,763 adults and a subset of 17,405 healthy never-smokers. BMI was categorized as <22.5 (low), 22.5-24.9 (referent), 25.0-29.9 (overweight), 30.0-34.9 (class I obesity), and ≥35.0 (class II-III obesity). Misreporting at higher BMI categories tended to bias hazard ratios upwards for those categories, but that effect was augmented, counterbalanced, or even reversed by misreporting in other BMI categories, in particular those that affected the reference category. For example, among healthy male never-smokers, misclassifications affecting the overweight and the reference categories changed the hazard ratio for overweight from 0.85 with measured data to 1.24 with self-reported data. Both the magnitude and direction of bias varied according to the underlying hazard ratios in measured data, showing that findings on bias from one study should not be extrapolated to a study with different underlying hazard ratios. Because of misclassification effects, self-reported weight and height cannot reliably indicate the lowest-risk BMI category.

Trends in Prescription Medication Use Among Children and Adolescents-United States, 1999-2014.

Importance: Access to appropriate prescription medications, use of inappropriate or ineffective treatments, and adverse drug events are public health concerns among US children and adolescents. Objective: To evaluate trends in use of prescription medications among US children and adolescents. Design, Setting, and Participants: US children and adolescents aged 0 to 19 years in the 1999-2014 National Health and Nutrition Examination Survey (NHANES)-serial cross-sectional, nationally representative surveys of the civilian noninstitutionalized population. Exposures: Sex, age, race and Hispanic origin, household income and education, insurance status, current health status. Main Outcomes and Measures: Use of any prescription medications or 2 or more prescription medications taken in the past 30 days; use of medications by therapeutic class; trends in medication use across 4-year periods from 1999-2002 to 2011-2014. Data were collected though in-home interview and direct observation of the prescription container. Results: Data on prescription medication use were available for 38 277 children and adolescents (mean age, 10 years; 49% girls). Overall, use of any prescription medication in the past 30 days decreased from 24.6% (95% CI, 22.6% to 26.6%) in 1999-2002 to 21.9% (95% CI, 20.3% to 23.6%) in 2011-2014 (ß = -0.41 percentage points every 2 years [95% CI, -0.79 to -0.03]; P = .04), but there was no linear trend in the use of 2 or more prescription medications (8.5% [95% CI, 7.6% to 9.4%] in 2011-2014). In 2011-2014, the most commonly used medication classes were asthma medications (6.1% [95% CI, 5.4% to 6.8%]), antibiotics (4.5% [95% CI, 3.7% to 5.5%]), attention-deficit/hyperactivity disorder (ADHD) medications (3.5% [95% CI, 2.9% to 4.2%]), topical agents (eg, dermatologic agents, nasal steroids) (3.5% [95% CI, 3.0% to 4.1%]), and antihistamines (2.0% [95% CI, 1.7% to 2.5%]). There were significant linear trends in 14 of 39 therapeutic classes or subclasses, or in individual medications, with 8 showing increases, including asthma and ADHD medications and contraceptives, and 6 showing decreases, including antibiotics, antihistamines, and upper respiratory combination medications. Conclusions and Relevance: In this study of US children and adolescents based on a nationally representative survey, estimates of prescription medication use showed an overall decrease in use of any medication from 1999-2014. The prevalence of asthma medication, ADHD medication, and contraceptive use increased among certain age groups, whereas use of antibiotics, antihistamines, and upper respiratory combination medications decreased.

Gross Motor Development in Children Aged 3-5 Years, United States 2012.

Objective Gross motor development in early childhood is important in fostering greater interaction with the environment. The purpose of this study is to describe gross motor skills among US children aged 3-5 years using the Test of Gross Motor Development (TGMD-2). Methods We used 2012 NHANES National Youth Fitness Survey (NNYFS) data, which included TGMD-2 scores obtained according to an established protocol. Outcome measures included locomotor and object control raw and age-standardized scores. Means and standard errors were calculated for demographic and weight status with SUDAAN using sample weights to calculate nationally representative estimates, and survey design variables to account for the complex sampling methods. Results The sample included 339 children aged 3-5 years. As expected, locomotor and object control raw scores increased with age. Overall mean standardized scores for locomotor and object control were similar to the mean value previously determined using a normative sample. Girls had a higher mean locomotor, but not mean object control, standardized score than boys (p < 0.05). However, the mean locomotor standardized scores for both boys and girls fell into the range categorized as "average." There were no other differences by age, race/Hispanic origin, weight status, or income in either of the subtest standardized scores (p > 0.05). Conclusions In a nationally representative sample of US children aged 3-5 years, TGMD-2 mean locomotor and object control standardized scores were similar to the established mean. These results suggest that standardized gross motor development among young children generally did not differ by demographic or weight status.

Normative Values for Cardiorespiratory Fitness Testing Among US Children Aged 6-11 years.

BACKGROUND: Nationally representative normative values for cardiorespiratory fitness (CRF) have not been described for US children since the mid 1980s. OBJECTIVE: To provide sex- and age-specific normative values for CRF of US children aged 6-11 years. METHODS: Data from 624 children aged 6-11 years who participated in the CRF testing as part of the 2012 National Health and Nutrition Examination Survey National Youth Fitness Survey, a cross-sectional survey, were analyzed. Participants were assigned to one of three age-specific protocols and asked to exercise to volitional fatigue. The difficulty of the protocols increased with successive age groups. CRF was assessed as maximal endurance time (min:sec). Data analysis was conducted in 2016. RESULTS: For 6-7, 8-9, 10-11 year olds, corresponding with the age-specific protocols, mean endurance time was 12:10 min:sec (95% CI: 11:49-12:31), 11:16 min:sec (95% CI: 11:00-11:31), and 10:01 min:sec (95% CI: 9:37-10:25), respectively. Youth in the lowest 20th percentile for endurance time were more likely to be obese, to report less favorable health, and to report greater than two hours of screen time per day. CONCLUSIONS: These data may serve as baseline estimates to monitor trends over time in CRF among US children aged 6-11 years.

Trends in the use of prescription antibiotics: NHANES 1999-2012.

OBJECTIVES: The objectives of this study were: to examine trends in the use of prescription antibiotics overall and by population subgroups between 1999 and 2012; and to examine trends in the use of categories of antibiotics and individual antibiotics. METHODS: Use of antibiotics was examined among 71 444 participants in the nationally representative National Health and Nutrition Examination Survey (NHANES; 1999-2012). Use of an antibiotic in the past 30 days was the main outcome variable. Analyses of trends were conducted overall and separately by population subgroups (i.e. age, sex, race/Hispanic origin, health insurance status and respiratory conditions) across four time periods (1999-2002, 2003-06, 2007-10 and 2011-12). RESULTS: The percentage of the US population that used a prescription antibiotic in the past 30 days significantly declined from 6.1% in 1999-2002 to 4.1% in 2011-12 (P < 0.001). Declines were also identified for five age groups (0-1 year, 6-11 years, 12-17 years, 18-39 years and 40-59 years), both sexes, non-Hispanic white and non-Hispanic black persons, persons with and without insurance and among those who currently had asthma. Significant declines were also observed for three categories of antibiotics (penicillins, cephalosporins and macrolide derivatives). Of the most common antibiotics prescribed, only amoxicillin use decreased significantly. CONCLUSIONS: Overall, there was a significant decline in the use of antibiotics between 1999-2002 and 2011-12. Due to concerns about antimicrobial resistance, it is important to continue monitoring the use of antibiotics.

Trends in Obesity Prevalence Among Children and Adolescents in the United States, 1988-1994 Through 2013-2014.

IMPORTANCE: Previous analyses of obesity trends among children and adolescents showed an increase between 1988-1994 and 1999-2000, but no change between 2003-2004 and 2011-2012, except for a significant decline among children aged 2 to 5 years. OBJECTIVES: To provide estimates of obesity and extreme obesity prevalence for children and adolescents for 2011-2014 and investigate trends by age between 1988-1994 and 2013-2014. DESIGN, SETTING, AND PARTICIPANTS: Children and adolescents aged 2 to 19 years with measured weight and height in the 1988-1994 through 2013-2014 National Health and Nutrition Examination Surveys. EXPOSURES: Survey period. MAIN OUTCOMES AND MEASURES: Obesity was defined as a body mass index (BMI) at or above the sex-specific 95th percentile on the US Centers for Disease Control and Prevention (CDC) BMI-for-age growth charts. Extreme obesity was defined as a BMI at or above 120% of the sex-specific 95th percentile on the CDC BMI-for-age growth charts. Detailed estimates are presented for 2011-2014. The analyses of linear and quadratic trends in prevalence were conducted using 9 survey periods. Trend analyses between 2005-2006 and 2013-2014 also were conducted. RESULTS: Measurements from 40,780 children and adolescents (mean age, 11.0 years; 48.8% female) between 1988-1994 and 2013-2014 were analyzed. Among children and adolescents aged 2 to 19 years, the prevalence of obesity in 2011-2014 was 17.0% (95% CI, 15.5%-18.6%) and extreme obesity was 5.8% (95% CI, 4.9%-6.8%). Among children aged 2 to 5 years, obesity increased from 7.2% (95% CI, 5.8%-8.8%) in 1988-1994 to 13.9% (95% CI, 10.7%-17.7%) (P < .001) in 2003-2004 and then decreased to 9.4% (95% CI, 6.8%-12.6%) (P = .03) in 2013-2014. Among children aged 6 to 11 years, obesity increased from 11.3% (95% CI, 9.4%-13.4%) in 1988-1994 to 19.6% (95% CI, 17.1%-22.4%) (P < .001) in 2007-2008, and then did not change (2013-2014: 17.4% [95% CI, 13.8%-21.4%]; P = .44). Obesity increased among adolescents aged 12 to 19 years between 1988-1994 (10.5% [95% CI, 8.8%-12.5%]) and 2013-2014 (20.6% [95% CI, 16.2%-25.6%]; P < .001) as did extreme obesity among children aged 6 to 11 years (3.6% [95% CI, 2.5%-5.0%] in 1988-1994 to 4.3% [95% CI, 3.0%-6.1%] in 2013-2014; P = .02) and adolescents aged 12 to 19 years (2.6% [95% CI, 1.7%-3.9%] in 1988-1994 to 9.1% [95% CI, 7.0%-11.5%] in 2013-2014; P < .001). No significant trends were observed between 2005-2006 and 2013-2014 (P value range, .09-.87). CONCLUSIONS AND RELEVANCE: In this nationally representative study of US children and adolescents aged 2 to 19 years, the prevalence of obesity in 2011-2014 was 17.0% and extreme obesity was 5.8%. Between 1988-1994 and 2013-2014, the prevalence of obesity increased until 2003-2004 and then decreased in children aged 2 to 5 years, increased until 2007-2008 and then leveled off in children aged 6 to 11 years, and increased among adolescents aged 12 to 19 years.

More than half of US youth consume seafood and most have blood mercury concentrations below the EPA reference level, 2009-2012.

BACKGROUND: Consuming seafood has health benefits, but seafood can also contain methylmercury, a neurotoxicant. Exposure to methylmercury affects children at different stages of brain development, including during adolescence. OBJECTIVE: The objective was to examine seafood consumption and blood mercury concentrations in US youth. METHODS: In the 2009-2012 NHANES, a cross-sectional nationally representative sample of the US population, seafood consumption in the past 30 d and blood mercury concentrations on the day of examination were collected from 5656 youth aged 1-19 y. Log-linear regression was used to examine the association between frequency of specific seafood consumption and blood mercury concentration, adjusting for race/Hispanic origin, sex, and age. RESULTS: In 2009-2012, 62.4% ± 1.4% (percent ± SE) of youth consumed any seafood in the preceding month; 38.4% ± 1.4% and 48.5% ± 1.5% reported consuming shellfish and fish, respectively. In 2009-2012, the geometric mean blood mercury concentration was 0.50 ± 0.02 µg/L among seafood consumers and 0.27 ± 0.01 µg/L among those who did not consume seafood. Less than 0.5% of youth had blood mercury concentrations ≥5.8 µg/L. In adjusted log-linear regression analysis, no significant associations were observed between frequency of breaded fish or catfish consumption and blood mercury concentrations, but frequency of consuming certain seafood types had significant positive association with blood mercury concentrations: high-mercury fish (swordfish and shark) [exponentiated ß coefficient (expß): 2.40; 95% CI: 1.23, 4.68]; salmon (expß: 1.41; 95% CI: 1.26, 1.55); tuna (expß: 1.38; 95% CI: 1.29, 1.45); crabs (expß: 1.35; 95% CI: 1.17, 1.55); shrimp (expß: 1.12; 95% CI: 1.05, 1.20), and all other seafood (expß: 1.23; 95% CI: 1.17, 1.32). Age-stratified log-linear regression analyses produced similar results. CONCLUSION: Few US youth have blood mercury concentrations ≥5.8 µg/L, although more than half of US youth consumed seafood in the past month.

Interrelationships between BMI, skinfold thicknesses, percent body fat, and cardiovascular disease risk factors among U.S. children and adolescents.

BACKGROUND: Although the estimation of body fatness by Slaughter skinfold thickness equations (PBF(Slaughter)) has been widely used, the accuracy of this method is uncertain. We have previously examined the interrelationships among the body mass index (BMI), PBF(Slaughter), percent body fat from dual energy X-ray absorptiometry (PBF(DXA)) and CVD risk factor levels among children who were examined in the Bogalusa Heart Study and in the Pediatric Rosetta Body Composition Project. The current analyses examine these associations among 7599 8- to 19-year-olds who participated in the (U.S.) National Health and Nutrition Examination Survey from 1999 to 2004. METHODS: We analyzed (1) the agreement between (1) estimates of percent body fat calculated from the Slaughter skinfold thickness equations and from DXA, and (2) the relation of lipid, lipoprotein, and blood pressure levels to BMI, PBF(Slaughter) and PBF(DXA). RESULTS: PBF(Slaughter) was highly correlated (r ~ 0.85) with PBF(DXA). However, among children with a relatively low skinfold thicknesses sum (triceps + subscapular), PBF(Slaughter) underestimated PBF(DXA) by 8 to 9 percentage points. In contrast, PBF(Slaughter) overestimated PBF(DXA) by 10 points among boys with a skinfold thickness sum ≥ 50 mm. After adjustment for sex and age, lipid levels were related similarly to the body mass index, PBF(DXA) and PBF(Slaughter). There were, however, small differences in associations with blood pressure levels: systolic blood pressure was more strongly associated with body mass index, but diastolic blood pressure was more strongly associated with percent body fat. CONCLUSIONS: The Slaughter equations yield biased estimates of body fatness. In general, lipid and blood pressure levels are related similarly to levels of BMI (following adjustment for sex and age), PBF(Slaughter,) and PBF(DXA).

Body mass index categories in observational studies of weight and risk of death.

The World Health Organization (Geneva, Switzerland) and the National Heart, Lung, and Blood Institute (Bethesda, Maryland) have developed standard categories of body mass index (BMI) (calculated as weight (kg)/height (m)(2)) of less than 18.5 (underweight), 18.5-24.9 (normal weight), 25.0-29.9 (overweight), and 30.0 or more (obesity). Nevertheless, studies of BMI and the risk of death sometimes use nonstandard BMI categories that vary across studies. In a meta-analysis of 8 large studies that used nonstandard BMI categories and were published between 1999 and 2014 and included 5.8 million participants, hazard ratios tended to be small throughout the range of overweight and normal weight. Risks were similar between subjects of high-normal weight (BMI of approximately 23.0-24.9) and those of low overweight (BMI of approximately 25.0-27.4). In an example using national survey data, minor variations in the reference category affected hazard ratios. For example, choosing high-normal weight (BMI of 23.0-24.9) instead of standard normal weight (BMI of 18.5-24.9) as the reference category produced higher nonsignificant hazard ratios (1.05 vs. 0.97 for men and 1.06 vs. 1.02 for women) for the standard overweight category (BMI of 25.0-29.9). Use of the standard BMI groupings avoids problems of ad hoc and post hoc category selection and facilitates between-study comparisons. The ways in which BMI data are categorized and reported may shape inferences about the degree of risk for various BMI categories.

Prevalence of childhood and adult obesity in the United States, 2011-2012.

IMPORTANCE: More than one-third of adults and 17% of youth in the United States are obese, although the prevalence remained stable between 2003-2004 and 2009-2010. OBJECTIVE: To provide the most recent national estimates of childhood obesity, analyze trends in childhood obesity between 2003 and 2012, and provide detailed obesity trend analyses among adults. DESIGN, SETTING, AND PARTICIPANTS: Weight and height or recumbent length were measured in 9120 participants in the 2011-2012 nationally representative National Health and Nutrition Examination Survey. MAIN OUTCOMES AND MEASURES: In infants and toddlers from birth to 2 years, high weight for recumbent length was defined as weight for length at or above the 95th percentile of the sex-specific Centers for Disease Control and Prevention (CDC) growth charts. In children and adolescents aged 2 to 19 years, obesity was defined as a body mass index (BMI) at or above the 95th percentile of the sex-specific CDC BMI-for-age growth charts. In adults, obesity was defined as a BMI greater than or equal to 30. Analyses of trends in high weight for recumbent length or obesity prevalence were conducted overall and separately by age across 5 periods (2003-2004, 2005-2006, 2007-2008, 2009-2010, and 2011-2012). RESULTS: In 2011-2012, 8.1% (95% CI, 5.8%-11.1%) of infants and toddlers had high weight for recumbent length, and 16.9% (95% CI, 14.9%-19.2%) of 2- to 19-year-olds and 34.9% (95% CI, 32.0%-37.9%) of adults (age-adjusted) aged 20 years or older were obese. Overall, there was no significant change from 2003-2004 through 2011-2012 in high weight for recumbent length among infants and toddlers, obesity in 2- to 19-year-olds, or obesity in adults. Tests for an interaction between survey period and age found an interaction in children (P = .03) and women (P = .02). There was a significant decrease in obesity among 2- to 5-year-old children (from 13.9% to 8.4%; P = .03) and a significant increase in obesity among women aged 60 years and older (from 31.5% to 38.1%; P = .006). CONCLUSIONS AND RELEVANCE: Overall, there have been no significant changes in obesity prevalence in youth or adults between 2003-2004 and 2011-2012. Obesity prevalence remains high and thus it is important to continue surveillance.

Association of all-cause mortality with overweight and obesity using standard body mass index categories: a systematic review and meta-analysis.

IMPORTANCE: Estimates of the relative mortality risks associated with normal weight, overweight, and obesity may help to inform decision making in the clinical setting. OBJECTIVE: To perform a systematic review of reported hazard ratios (HRs) of all-cause mortality for overweight and obesity relative to normal weight in the general population. DATA SOURCES: PubMed and EMBASE electronic databases were searched through September 30, 2012, without language restrictions. STUDY SELECTION: Articles that reported HRs for all-cause mortality using standard body mass index (BMI) categories from prospective studies of general populations of adults were selected by consensus among multiple reviewers. Studies were excluded that used nonstandard categories or that were limited to adolescents or to those with specific medical conditions or to those undergoing specific procedures. PubMed searches yielded 7034 articles, of which 141 (2.0%) were eligible. An EMBASE search yielded 2 additional articles. After eliminating overlap, 97 studies were retained for analysis, providing a combined sample size of more than 2.88 million individuals and more than 270,000 deaths. DATA EXTRACTION: Data were extracted by 1 reviewer and then reviewed by 3 independent reviewers. We selected the most complex model available for the full sample and used a variety of sensitivity analyses to address issues of possible overadjustment (adjusted for factors in causal pathway) or underadjustment (not adjusted for at least age, sex, and smoking). RESULTS: Random-effects summary all-cause mortality HRs for overweight (BMI of 25-<30), obesity (BMI of ≥30), grade 1 obesity (BMI of 30-<35), and grades 2 and 3 obesity (BMI of ≥35) were calculated relative to normal weight (BMI of 18.5-<25). The summary HRs were 0.94 (95% CI, 0.91-0.96) for overweight, 1.18 (95% CI, 1.12-1.25) for obesity (all grades combined), 0.95 (95% CI, 0.88-1.01) for grade 1 obesity, and 1.29 (95% CI, 1.18-1.41) for grades 2 and 3 obesity. These findings persisted when limited to studies with measured weight and height that were considered to be adequately adjusted. The HRs tended to be higher when weight and height were self-reported rather than measured. CONCLUSIONS AND RELEVANCE: Relative to normal weight, both obesity (all grades) and grades 2 and 3 obesity were associated with significantly higher all-cause mortality. Grade 1 obesity overall was not associated with higher mortality, and overweight was associated with significantly lower all-cause mortality. The use of predefined standard BMI groupings can facilitate between-study comparisons.

Trends in lipids and lipoproteins in US adults, 1988-2010.

CONTEXT: Serum total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) contribute to atherosclerosis and its clinical consequences. Between the periods 1988-1994 and 1999-2002, mean TC and mean LDL-C declined in adults. During this time, there was an increase in the percentage of adults receiving lipid-lowering medications. Geometric mean triglyceride levels increased but mean high-density lipoprotein cholesterol (HDL-C) remained unchanged. OBJECTIVE To examine trends in serum lipids in adults between 1988 and 2010. DESIGN, SETTING, AND PARTICIPANTS Three distinct US cross-sectional National Health and Nutrition Examination Surveys, 1988-1994 (n = 16,573), 1999-2002 (n = 9471), and 2007-2010 (n = 11,766). MAIN OUTCOME MEASURES: Mean TC, LDL-C, HDL-C, non-HDL-C, and geometric mean triglyceride levels and the prevalence of lipid-lowering medication use. RESULTS: Mean TC declined from 206 (95% CI, 205-207) mg/dL in 1988-1994 to 196 (95% CI, 195-198) mg/dL in 2007-2010 (P <.001 for linear trend); mean LDL-C declined from 129 (95% CI, 127-130) mg/dL to 116 (95% CI, 114-117) mg/dL (P <.001 for linear trend). Mean non-HDL-C declined from 155 (95% CI, 153-157) mg/dL in 1988-1994 to 144 (95% CI, 143-145) mg/dL in 2007-2010 (P <.001 for linear trend). Mean HDL-C increased from 50.7 (95% CI, 50.0-51.0) mg/dL during 1988-1994 to 52.5 (95% CI, 51.8-53.2) mg/dL in 2007-2010 (P =.001 for linear trend). Geometric mean serum triglyceride levels increased from 118 (95% CI, 114-121) mg/dL in 1988-1994 to 123 (95% CI, 119-127) mg/dL in 1999-2002 and decreased to 110 (95% CI, 107-113) mg/dL in 2007-2010 (P <.001 for quadratic trend). The prevalence of lipid-lowering medication use increased from 3.4% (95% CI, 2.9%-3.9%) in 1988-1994 to 15.5% (95% CI, 14.7%-16.3%) in 2007-2010 (P <.001 for linear trend). Among adults not receiving lipid-lowering medications, trends in lipids were similar to those reported for adults overall. Among obese adults, mean TC, non-HDL-C, LDL-C, and geometric mean triglycerides declined between 1988 and 2010. CONCLUSION: Between 1988 and 2010, favorable trends in lipid levels have occurred among adults in the United States.

Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010.

CONTEXT: Between 1980 and 1999, the prevalence of adult obesity (body mass index [BMI] ≥30) increased in the United States and the distribution of BMI changed. More recent data suggested a slowing or leveling off of these trends. OBJECTIVE: To estimate the prevalence of adult obesity from the 2009-2010 National Health and Nutrition Examination Survey (NHANES) and compare adult obesity and the distribution of BMI with data from 1999-2008. DESIGN, SETTING, AND PARTICIPANTS: NHANES includes measured heights and weights for 5926 adult men and women from a nationally representative sample of the civilian noninstitutionalized US population in 2009-2010 and for 22,847 men and women in 1999-2008. MAIN OUTCOME MEASURES: The prevalence of obesity and mean BMI. RESULTS: In 2009-2010 the age-adjusted mean BMI was 28.7 (95% CI, 28.3-29.1) for men and also 28.7 (95% CI, 28.4-29.0) for women. Median BMI was 27.8 (interquartile range [IQR], 24.7-31.7) for men and 27.3 (IQR, 23.3-32.7) for women. The age-adjusted prevalence of obesity was 35.5% (95% CI, 31.9%-39.2%) among adult men and 35.8% (95% CI, 34.0%-37.7%) among adult women. Over the 12-year period from 1999 through 2010, obesity showed no significant increase among women overall (age- and race-adjusted annual change in odds ratio [AOR], 1.01; 95% CI, 1.00-1.03; P = .07), but increases were statistically significant for non-Hispanic black women (P = .04) and Mexican American women (P = .046). For men, there was a significant linear trend (AOR, 1.04; 95% CI, 1.02-1.06; P < .001) over the 12-year period. For both men and women, the most recent 2 years (2009-2010) did not differ significantly (P = .08 for men and P = .24 for women) from the previous 6 years (2003-2008). Trends in BMI were similar to obesity trends. CONCLUSION: In 2009-2010, the prevalence of obesity was 35.5% among adult men and 35.8% among adult women, with no significant change compared with 2003-2008.

Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010.

CONTEXT: The prevalence of childhood obesity increased in the 1980s and 1990s but there were no significant changes in prevalence between 1999-2000 and 2007-2008 in the United States. OBJECTIVES: To present the most recent estimates of obesity prevalence in US children and adolescents for 2009-2010 and to investigate trends in obesity prevalence and body mass index (BMI) among children and adolescents between 1999-2000 and 2009-2010. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analyses of a representative sample (N = 4111) of the US child and adolescent population (birth through 19 years of age) with measured heights and weights from the National Health and Nutrition Examination Survey 2009-2010. MAIN OUTCOME MEASURES: Prevalence of high weight-for-recumbent length (≥95th percentile on the growth charts) among infants and toddlers from birth to 2 years of age and obesity (BMI ≥95th percentile of the BMI-for-age growth charts) among children and adolescents aged 2 through 19 years. Analyses of trends in obesity by sex and race/ethnicity, and analyses of trends in BMI within sex-specific age groups for 6 survey periods (1999-2000, 2001-2002, 2003-2004, 2005-2006, 2007-2008, and 2009-2010) over 12 years. RESULTS: In 2009-2010, 9.7% (95% CI, 7.6%-12.3%) of infants and toddlers had a high weight-for-recumbent length and 16.9% (95% CI, 15.4%-18.4%) of children and adolescents from 2 through 19 years of age were obese. There was no difference in obesity prevalence among males (P = .62) or females (P = .65) between 2007-2008 and 2009-2010. However, trend analyses over a 12-year period indicated a significant increase in obesity prevalence between 1999-2000 and 2009-2010 in males aged 2 through 19 years (odds ratio, 1.05; 95% CI, 1.01-1.10) but not in females (odds ratio, 1.02; 95% CI, 0.98-1.07) per 2-year survey cycle. There was a significant increase in BMI among adolescent males aged 12 through 19 years (P = .04) but not among any other age group or among females. CONCLUSION: In 2009-2010, the prevalence of obesity in children and adolescents was 16.9%; this was not changed compared with 2007-2008.

Trends in serum lipids among US youths aged 6 to 19 years, 1988-2010.

CONTEXT: For more than 20 years, primary prevention of coronary heart disease has included strategies intended to improve overall serum lipid concentrations among youths. OBJECTIVE: To examine trends in lipid concentrations among youths from 1988-1994 through 2007-2010. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of serum lipid concentrations among 16,116 youths aged 6 to 19 years who participated in the nationally representative National Health and Nutrition Examination Survey during 3 time periods: 1988-1994, 1999-2002, and 2007-2010. MAIN OUTCOME MEASURES: Among all youths, mean serum total cholesterol (TC), non-high-density lipoprotein cholesterol (non-HDL-C), high-density lipoprotein cholesterol (HDL-C); and among adolescents only, low-density lipoprotein cholesterol (LDL-C) and geometric mean triglyceride levels. Trends in adverse lipid concentrations are reported for TC levels of 200 mg/dL and greater, non-HDL-C levels of 145 mg/dL and greater, HDL-C levels of less than 40 mg/dL, LDL-C levels of 130 mg/dL and greater, and triglyceride levels of 130 mg/dL and greater. RESULTS: Among youths aged 6 to 19 years between 1988-1994 and 2007-2010, there was a decrease in mean TC (from 165 mg/dL [95% CI, 164-167] to 160 mg/dL [95% CI, 158-161]; P < .001) and a decrease in the prevalence of elevated TC (from 11.3% [95% CI, 9.8%-12.7%] to 8.1% [95% CI, 6.7%-9.5%]; P = .002). Mean HDL-C significantly increased between 1988-1994 and 2007-2010, but the prevalence of low HDL-C did not change. Mean non-HDL-C and prevalence of elevated non-HDL-C both significantly decreased over the study period. In 2007-2010, 22% (95% CI, 20.3%-23.6%) of youths had either a low HDL-C level or high non-HDL-C, which was lower than the 27.2% (95% CI, 24.6%-29.7%) in 1988-1994 (P = .001). Among adolescents (aged 12-19 years) between 1988-1994 and 2007-2010, there was a decrease in mean LDL-C (from 95 mg/dL [95% CI, 92-98] to 90 mg/dL [95% CI, 88-91]; P = .003) and a decrease in geometric mean triglycerides (from 82 mg/dL [95% CI, 78-86] to 73 mg/dL [95% CI, 70-76]; P < .001). Prevalence of elevated LDL-C and triglycerides between 1988-1994 and 2007-2010 also significantly decreased. CONCLUSIONS: Between 1988-1994 and 2007-2010, a favorable trend in serum lipid concentrations was observed among youths in the United States but almost 1 in 10 had elevated TC in 2007-2010.

Differences in Hypertension and Stage II Hypertension by Demographic and Risk Factors, Obtained by Two Different Protocols in US Adults: National Health and Nutrition Examination Survey, 2017-2018.

BACKGROUND: To compare prevalence of hypertension and stage II hypertension assessed by 2 blood pressure (BP) observation protocols. METHODS: Participants aged 18 years and older (n = 4,689) in the National Health and Nutrition Examination Survey (NHANES 2017-2018) had their BP measured following 2 protocols: the legacy auscultation protocol (AP) and oscillometric protocol (OP). The order of protocols was randomly assigned. Prevalence estimates for hypertension (BP ≥130/80 mm Hg or use of medication for hypertension) and stage II hypertension (BP ≥140/90 mm Hg) were determined overall, by demographics, and by risk factors for each protocol. Ratios (OP% ÷ AP%) and kappa statistics were calculated. RESULTS: Age-adjusted hypertension prevalence was 44.5% (95% confidence interval [CI]: 41.1%-48.0%) using OP and 45.1% (95% CI: 41.5%-48.7%) using AP, prevalence ratio = 0.99 (95% CI = 0.94-1.04). Age-adjusted stage II hypertension prevalence was 15.8% (95% CI: 13.6%-18.2%) using AP and 17.1% (95% CI: 14.7%-19.7%) using OP, prevalence ratio = 0.92 (95% CI = 0.81-1.04). For both hypertension and stage II hypertension, the prevalence ratios by demographics and by risk factors all included unity in their 95% CI, except for stage II hypertension in adults 60+ years (ratio: 0.88 [95% CI: 0.78-0.98]). Kappa for agreement between protocols for hypertension and stage II hypertension was 0.75 (95% CI = 0.71-0.79) and 0.67 (95% CI = 0.61-0.72), respectively. CONCLUSIONS: In adults and for nearly all subcategories there were no significant differences in prevalence of hypertension and stage II hypertension between protocols, indicating that protocol change may not affect the national prevalence estimates of hypertension and stage II hypertension.