National Health and Nutrition Examination Survey: sample design, 2007-2010.

BACKGROUND: Data collection for the National Health and Nutrition Examination Survey (NHANES) comprises three levels: a household screener, an interview, and a physical examination. The primary objective of the screener is to determine whether any household members are eligible for the interview an dexamination. Eligibility is determined by preset selection probabilities for the desired demographic subdomains. After an eligible sample person is selected, the interview collects person-level demographic, health, and nutrition information, as well as information about the household. The examination includes physical measurements, tests such as hearing and dental examinations, and the collection of blood and urine specimens for laboratory testing. OBJECTIVES: This report provides some background on the NHANES program, beginning with the first survey cycle in the 1970s and highlighting significant changes since its inception. The report then describes the broad design specifications for the 2007-2010 survey cycle, including survey objectives, domain and precision specifications, and operational requirements unique to NHANES. In addition, the report describes the details of the survey design, including the calculation of sampling rates and sample selection methods. Documentation of survey content, data collection procedures, estimation methods, and methods to assess nonsampling errors are reported elsewhere.

The prevalence of HLA-B27 in the US: data from the US National Health and Nutrition Examination Survey, 2009.

OBJECTIVE: To carry out the first large-scale population study of the prevalence of HLA-B27 in the US, which is needed for public health planning purposes because of recent improvements in medical therapy and diagnostic testing for ankylosing spondylitis (AS). METHODS: The national prevalence of HLA-B27 was determined as part of the 2009 US National Health and Nutrition Examination Survey (NHANES), a cross-sectional survey monitoring the health and nutritional status of the US civilian, noninstitutionalized population. DNA polymerase chain reaction analysis was conducted in samples from 2,320 adults ages 20-69 years from this nationally representative sample. RESULTS: The age-adjusted US prevalence of B27 was 6.1% (95% confidence interval [95% CI] 4.6-8.2). By race/ethnicity, the prevalence of B27 was 7.5% (95% CI 5.3-10.4) among non-Hispanic whites and 3.5% (95% CI 2.5-4.8) among all other US races/ethnicities combined. In Mexican Americans, the prevalence was 4.6% (95% CI 3.4-6.1). The prevalence of B27 could not be reliably estimated for other US racial/ethnic groups because of the low number of B27-positive individuals in those groups. For adults 50-69 years of age, the prevalence of B27 was 3.6% (95% CI 2.2-5.8), which suggested a decrease in B27 with age. These prevalence estimates took into account the NHANES survey design and are reviewed with respect to data from the medical literature. CONCLUSION: Our findings provide the first US national prevalence estimates for HLA-B27. A decline in the prevalence of HLA-B27 with age is suggested by these data but must be confirmed by additional studies.

The National Health and Nutrition Examination Survey: Sample Design, 1999-2006.

BACKGROUND: Data collection for the National Health and Nutrition Examination Survey (NHANES) comprises three levels: a household screener, an interview, and a physical examination. The primary objective of the screener is to determine whether any household members are eligible for the interview and examination. Eligibility is determined by the preset selection probabilities for the desired demographic subdomains. After selection as an eligible sample person, the interview collects person-level demographic, health, and nutrition information as well as information about the household. The examination includes physical measurements, tests such as eye and dental examinations, and the collection of blood and urine specimens for laboratory testing. OBJECTIVES: This report will first describe the broad design specifications for the 1999-2006 survey including survey objectives, domain and precision specifications, operational requirements, sample design, and estimations procedures. Details of the sample design are divided into two sections. The first section (NHANES 1999-2001 Sample Design) broadly describes the sample design and various design changes during the first three years of the continuous NHANES (1999-2001). The second section (NHANES 2002-2006 Sample Design) describes the final sample design developed and applied for 2002-2006. Weighting and variance estimation procedures are presented in the same manner; however, to correspond to the public data release cycles, the weighting and variance sections are separated into those used for 1999-2002, and those used for 2003-2006. Much of this report is based on survey operations documents and sample design reports prepared by Westat. Documentation of the survey content, procedures, and methods to assess nonsampling errors are reported elsewhere.

The impact of knee and hip chondrocalcinosis on disability in older people: the ProVA Study from northeastern Italy.

OBJECTIVES: Chondrocalcinosis is frequently associated with osteoarthritis. The role of osteoarthritis in the onset and progression of disability is well known. The impact of chondrocalcinosis on disability has never been investigated in epidemiological studies. METHODS: Progetto Veneto Anziani is a survey of 3099 older Italians, focusing on chronic diseases and disability. Assessment was by questionnaires, physical performance tests and clinical evaluations. Chondrocalcinosis was determined by x-ray readings of 1629 consecutive subjects. Knee and hip osteoarthritis severity was evaluated by summing the radiographic features score (RFS) assigned during x-ray reading. SUBJECTS: with chondrocalcinosis were older and more frequently women (age-adjusted p<0.0001). The gender association disappeared following adjustment for osteoarthritis severity. However, at the knee, the prevalence of osteoarthritis was higher in chondrocalcinosis patients independently of age and sex (age-adjusted p<0.0001). No difference was found between chondrocalcinosis and controls in sociodemographic variables and comorbidity. Knee chondrocalcinosis was strongly associated with clinical features of knee osteoarthritis and with disability assessment parameters in the bivariate analysis. Most associations remained after adjusting for age. After further adjustment for RFS, a significant association remained for knee deformity and pain, the need for a cane, difficulty walking 500 m, using a toilet, shopping and repeatedly rising from a chair. CONCLUSIONS: Pain and physical function are the outcome measures of choice for assessing disability in osteoarthritis patients. The presence of chondrocalcinosis contributes to both, independently of age and osteoarthritis severity, thus compromising the quality of life and worsening comorbidity.

Drug use and sexual behaviors reported by adults: United States, 1999-2002.

This report presents prevalence estimates for self-reported adult drug use and sexual behaviors in the United States. Data are from the National Health and Nutrition Examination Survey (NHANES) collected from 1999 to 2002. NHANES surveys a stratified multistage probability sample of the civilian noninstitutionalized population of the United States. Tables included in this report present estimates for use of cocaine, including crack or freebase, or other street drugs, and sexual behavior by selected sociodemographic characteristics among adults 20-59 years of age.

Anthropometric reference data for children and adults: U.S. population, 1999-2002.

This report presents national anthropometric reference data based on health examination survey results from the National Health and Nutrition Examination Survey (NHANES), 1999-2002, for all ages of the U.S. population. Weighted population means, standard errors of the means, and selected percentiles are presented for the total U.S. population by sex, race or ethnic group, and age in years or age group. Findings for some population groups are reported in a way that is comparable with results reported from National Health Examination Surveys (NHES) and NHANES conducted between 1960 and 1994. These data add to the knowledge about trends in child growth and development and are used to monitor prevalent conditions in the U.S. population such as overweight and obesity.

Increasing the Number of Outpatients Receiving Spiritual Assessment: A Pain and Palliative Care Service Quality Improvement Project.

BACKGROUND: Spirituality is a patient need that requires special attention from the Pain and Palliative Care Service team. This quality improvement project aimed to provide spiritual assessment for all new outpatients with serious life-altering illnesses. MEASURES: Percentage of new outpatients receiving spiritual assessment (Faith, Importance/Influence, Community, Address/Action in care, psychosocial evaluation, chaplain consults) at baseline and postinterventions. INTERVENTION: Interventions included encouraging clinicians to incorporate adequate spiritual assessment into patient care and implementing chaplain covisits for all initial outpatient visits. OUTCOMES: The quality improvement interventions increased spiritual assessment (baseline vs. postinterventions): chaplain covisits (25.5% vs. 50%), Faith, Importance/Influence, Community, Address/Action in care completion (49% vs. 72%), and psychosocial evaluation (89% vs. 94%). CONCLUSIONS/LESSONS LEARNED: Improved spiritual assessment in an outpatient palliative care clinic setting can occur with a multidisciplinary approach. This project also identifies data collection and documentation processes that can be targeted for improvement.

The relationship between blood lead levels and periodontal bone loss in the United States, 1988-1994.

An association between bone disease and bone lead has been reported. Studies have suggested that lead stored in bone may adversely affect bone mineral metabolism and blood lead (PbB) levels. However, the relationship between PbB levels and bone loss attributed to periodontal disease has never been reported. In this study we examined the relationship between clinical parameters that characterize bone loss due to periodontal disease and PbB levels in the U.S. population. We used data from the Third National Health and Nutritional Examination Survey (NHANES III), 1988-1994, for the analyses. A total of 10,033 participants 20-69 years of age who completed a periodontal examination and had whole blood tested for lead were examined. Four types of periodontal disease measures were used to indicate oral bone loss: periodontal pocket depth, attachment loss extent, attachment loss severity, and the presence of dental furcations. We found that dental furcations were the best periodontal bone loss indicator for PbB levels (p = 0.005) in a multivariate linear regression model adjusting for sex, age, race/ethnicity, educational attainment, poverty status, smoking, and age of home. Furthermore, after additional modeling, we found a smoking and dental furcation interaction (p = 0.034). Subsequent stratified analyses indicated that current and past smoking is an effect modifier for dental furcations on PbB levels. These findings indicate that increased PbB levels may be associated with advanced periodontal bone loss, particularly among people with a history of smoking.

Trends in high LDL cholesterol, cholesterol-lowering medication use, and dietary saturated-fat intake: United States, 1976-2010.

From 1976­1980 through 2007­2010, for U.S. adults aged 40­74, a decrease was observed in the prevalence of high LDL­C, as well as an increase in adults using lipid-lowering medications and consuming a diet low in saturated fat. A substantial decline in the prevalence of high LDL­C from 59% to 28% was seen over this same time period. There also were significant increases in the percentage of adults meeting federal dietary guidelines (6) for low dietary saturated-fat intake, from 25% to 42%, between 1976­1980 and 2007­2010; however, no significant changes were observed from 1988­1994 to 2007­2010. Although declines in the proportion of calories from saturated fat have occurred since the 1970s, the average dietary energy intake has increased (7). Use of cholesterol-lowering medication continued to grow steadily, from 5% to 23%, from 1988­1994 to 2007­2010. Despite recent advances in medical treatment, high cholesterol remains a significant public health problem in the United States, with more than one-quarter of adults aged 40­74 having high LDL­C. These findings may provide useful information for evaluation of programs and policy initiatives aimed at reducing the prevalence of high cholesterol in the adult population.

Infectious disease prevalence in Los Angeles county--a comparison to national estimates, 1999-2004 birth rates for U.S. teenagers reach historic lows for all age and ethnic groups.

This is the first time seroprevalence of antibody to these nine infectious diseases have been available for LAC. Differences in the race and ethnicity distribution of the United States and LAC were observed. Because disease prevalence varies by race and ethnicity, in some instances these demographic differences affected the population differences seen between the United States and LAC in the seroprevalence of the infectious diseases reported in this study. Seroprevalence for HAV was higher in LAC as compared with the United States among the total population and among the Mexican-American population. California is 1 of 11 states in which routine vaccination of children was recommended in 1999 by the Advisory Committee on Immunization Practices (ACIP) because mean incidence rates in these states were at least twice the national mean from 1987­1997 (9). Seroprevalence to CMV and T. gondii have been shown to be higher among Mexican-American persons then other race and ethnicity groups (1,3). The higher seropositivity for CMV and T. gondii among persons from LAC is due to the higher proportion of Mexican-American persons in the LAC population. No differences in seropositivity were observed when comparing Mexican-American persons in the United States and LAC for these two outcomes. No significant differences in seroprevalence between the United States and LAC were seen for measles, mumps, rubella, varicella, HSV-1, and HSV-2. Estimates of seropositivity from immunization or disease for LAC may assist in policy development, program planning, and measuring health disparities.

The United States National Health and Nutrition Examination Survey and the epidemiology of ankylosing spondylitis.

Currently available U.S. population-based data for ankylosing spondylitis (AS), spondyloarthritis and inflammatory back pain (IBP) from the nationally representative U.S. National Health and Nutrition Examination Survey (NHANES) include both NHANES I (1971-1975) and NHANES II (1976-1980) surveys. The pelvic radiographs obtained in NHANES I provided U.S. prevalence estimates for radiographic sacroiliitis, an important component of the AS case definition. AS and spondyloarthritis prevalences cannot readily be calculated from NHANES I survey data; however, IBP prevalence (Rudwaleit et al Criteria 7b) can be estimated from NHANES II. The NHANES II estimate for IBP is 0.8% of the adult population ages 25 to 49 years. The prevalence of IBP in the subset of persons with a history of a back pain episode lasting 2 or more weeks was 6.7%. The 2009-2010 NHANES U.S. Inflammatory Back Pain/Spondyloarthritis survey is currently fielded.

Viral hepatitis.

KEY FINDINGS: The prevalence of hepatitis A antibody, which is indicative of immunity to hepatitis A virus, increased among U.S. born persons aged 6-19, but decreased among persons aged 40 years and over. Hepatitis B virus (HBV) infection among persons aged 6-19 has decreased in recent years. By 2003-2006, over 90% of children had received at least one dose of the recommended three-dose series of hepatitis B vaccine. Prevalence of infection with hepatitis C virus (HCV) decreased among those at highest risk of infection including males and Mexican- American and non-Hispanic black populations. Despite this decrease, the prevalence of infection remains higher in the non-Hispanic black population. The peak prevalence of HCV infection has shifted over time from persons aged 30-39 years (3.9%) to those aged 40-49 years (4.3%).

Hypertension, high serum total cholesterol, and diabetes: racial and ethnic prevalence differences in U.S. adults, 1999-2006.

KEY FINDINGS: Forty-five percent of adults had at least one of three diagnosed or undiagnosed chronic conditions­hypertension, hypercholesterolemia, or diabetes; one in eight adults (13%) had two of these conditions; and 3% of adults had all three chronic conditions. Nearly one in seven U.S. adults (15%) had one or more of these conditions undiagnosed. Non-Hispanic black persons were more likely than non-Hispanic white and Mexican-American persons to have at least one of the three conditions (diagnosed or undiagnosed). Non-Hispanic black and non-Hispanic white persons were more likely than Mexican-American persons to have both diagnosed or undiagnosed hypertension and hyper-cholesterolemia. Non-Hispanic black and Mexican-American persons were more likely than non-Hispanic white persons to have both diagnosed or undiagnosed hypertension and diabetes.

One-third of U.S adults embraced most heart healthy behaviors in 1999-2002.

A number of U.S. Department of Health and Human Services programs recommend behaviors to reduce risk of cardiovascular disease (CVD), including the National High Blood Pressure Education Program (NHBPEP) and the National Cholesterol Education Program (NCEP) (1-6). The objective of this report is to estimate the prevalence of persons engaging in multiple behaviors recommended to reduce risk of CVD. Behaviors identified by NHBPEP and NCEP as primary lifestyle modifications to reduce CVD risk include physical activity, four dietary recommendations, smoking abstention, moderate alcohol consumption, and screening for high blood pressure and high blood cholesterol (5,6).

Smoking, alcohol use, and illicit drug use reported by adolescents aged 12-17 years: United States, 1999-2004.

OBJECTIVE: This report presents national prevalence estimates for self-reported health risk behaviors of smoking, alcohol use, and illicit drug use by U.S. adolescents aged 12-17 years in the National Health and Nutrition Examination Surveys (NHANES). METHODS: Data in this report are from 6 years (1999-2004) of NHANES, which is conducted on a complex, stratified, multistage probability sample of the civilian, noninstitutionalized U.S. population. RESULTS: The tables included in this report present weighted percentages and standard errors for smoking, alcohol, and illicit drug use behaviors in U.S. adolescents, by sex, race/ethnicity, education, and poverty level (when sufficient data are available). Selected highlights are presented from information included in the tables.

Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I.

OBJECTIVE: To provide a single source for the best available estimates of the US prevalence of and number of individuals affected by arthritis overall, rheumatoid arthritis, juvenile arthritis, the spondylarthritides, systemic lupus erythematosus, systemic sclerosis, and Sjögren's syndrome. A companion article (part II) addresses additional conditions. METHODS: The National Arthritis Data Workgroup reviewed published analyses from available national surveys, such as the National Health and Nutrition Examination Survey and the National Health Interview Survey (NHIS). For analysis of overall arthritis, we used the NHIS. Because data based on national population samples are unavailable for most specific rheumatic conditions, we derived estimates from published studies of smaller, defined populations. For specific conditions, the best available prevalence estimates were applied to the corresponding 2005 US population estimates from the Census Bureau, to estimate the number affected with each condition. RESULTS: More than 21% of US adults (46.4 million persons) were found to have self-reported doctor-diagnosed arthritis. We estimated that rheumatoid arthritis affects 1.3 million adults (down from the estimate of 2.1 million for 1995), juvenile arthritis affects 294,000 children, spondylarthritides affect from 0.6 million to 2.4 million adults, systemic lupus erythematosus affects from 161,000 to 322,000 adults, systemic sclerosis affects 49,000 adults, and primary Sjögren's syndrome affects from 0.4 million to 3.1 million adults. CONCLUSION: Arthritis and other rheumatic conditions continue to be a large and growing public health problem. Estimates for many specific rheumatic conditions rely on a few, small studies of uncertain generalizability to the US population. This report provides the best available prevalence estimates for the US, but for most specific conditions, more studies generalizable to the US or addressing understudied populations are needed.

Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II.

OBJECTIVE: To provide a single source for the best available estimates of the US prevalence of and number of individuals affected by osteoarthritis, polymyalgia rheumatica and giant cell arteritis, gout, fibromyalgia, and carpal tunnel syndrome, as well as the symptoms of neck and back pain. A companion article (part I) addresses additional conditions. METHODS: The National Arthritis Data Workgroup reviewed published analyses from available national surveys, such as the National Health and Nutrition Examination Survey and the National Health Interview Survey. Because data based on national population samples are unavailable for most specific rheumatic conditions, we derived estimates from published studies of smaller, defined populations. For specific conditions, the best available prevalence estimates were applied to the corresponding 2005 US population estimates from the Census Bureau, to estimate the number affected with each condition. RESULTS: We estimated that among US adults, nearly 27 million have clinical osteoarthritis (up from the estimate of 21 million for 1995), 711,000 have polymyalgia rheumatica, 228,000 have giant cell arteritis, up to 3.0 million have had self-reported gout in the past year (up from the estimate of 2.1 million for 1995), 5.0 million have fibromyalgia, 4-10 million have carpal tunnel syndrome, 59 million have had low back pain in the past 3 months, and 30.1 million have had neck pain in the past 3 months. CONCLUSION: Estimates for many specific rheumatic conditions rely on a few, small studies of uncertain generalizability to the US population. This report provides the best available prevalence estimates for the US, but for most specific conditions more studies generalizable to the US or addressing understudied populations are needed.

Symptomatic hand osteoarthritis in the United States: prevalence and functional impairment estimates from the third U.S. National Health and Nutrition Examination Survey, 1991-1994.

OBJECTIVE: To estimate the United States prevalence of symptomatic hand osteoarthritis using American College of Rheumatology (ACR) physical examination criteria. DESIGN: The Third National Health and Nutrition Examination Survey (NHANES III), a nationally representative cross-sectional health examination survey, performed upper-extremity physical examinations on a sample of United States adults age 60+ yrs. Data for demographics, pain history, analgesic use, and activity limitations were obtained by interview. RESULTS: Among United States adults, 58% had Heberden's nodes, 29.9% had Bouchard's nodes, and 18.2% had first carpal-metacarpal deformities. Women had significantly more first carpal-metacarpal deformities (24.3%) than men (10.3%). Symptomatic osteoarthritis prevalence at these sites was 5.4, 4.7, and 1.9%, respectively. Overall, symptomatic hand osteoarthritis prevalence by ACR criteria was 8% (95% CI 6.5-9.5%), or 2.9 million persons. Symptomatic hand osteoarthritis significantly increased with age and was decreased among non-Hispanic blacks, but there were no gender differences. Symptomatic hand osteoarthritis was associated with self-reported difficulty lifting 10 lbs (OR 2.31; 95% CI 1.23-4.33), dressing (OR 3.77; 95% CI 1.99-7.13), and eating (OR 3.44; 95% CI 1.76-6.73). Frequent monthly use was significantly increased for analgesics, especially acetaminophen, but not nonsteroidal antiinflammatory drugs. CONCLUSION: Symptomatic hand osteoarthritis affects 1 in 12 older United States adults. NHANES III data provide a population-based assessment of the impact and associated functional impairments of symptomatic hand osteoarthritis.