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«Slide 2 Data Used for Public Health Policies and Programs Slide 3 Pediatric Growth Charts  Developed by NCHS/CDC in 1977 and 2000  Clinical ...»

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NHANES Contributions to Public Health

Slide 1

50 Significant NHANES Contributions to Public Health

Slide 2

Data Used for Public Health Policies and Programs

Slide 3

Pediatric Growth Charts

 Developed by NCHS/CDC in 1977 and 2000

 Clinical tools to track children’s growth

 Addition of BMI charts to track overweight

 Growth charts are one of the most widely used NCHS products

 2007 WHO growth charts use NHANES data

Alternative text for image: picture of three babies and the growth charts Slide 4 Monitoring Obesity in the US Over the Last Generation In adults

• Increase in obesity between 1976-80 and 1988-94, with a continued upward trend through 2005-06 In children

• A similar increase documented between 1988-94 and 2005-06 NHANES weight and height data used for Federal nutrition recommendations, dietary

programs and policy:

• USDA School Lunch and Breakfast programs

• WIC program eligibility

• Dietary Guidelines for Americans

• Obesity Education Initiative

• Shape Up America

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Newspaper article with the headline “Study Finds that in U.S., 1 in 3 are Obese.” Line graph showing increase in obesity for females, males and both genders Slide 5 Evaluating Folic Acid Fortification

• FDA regulation to fortify grain products with folic acid (1998)

• NHANES data pre- and post- fortification showed increased blood folate levels in young women

• Vital Statistics data showed ultimate impact with declines in Spina Bifida rates

• Continuing data collection allows evaluation of fortification policy safety

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Picture of mother with baby reaching to touch a pregnant women’s belly Line graph showing increase in median RBC folate levels in women 15-45 years of age and children 4 years of age and older, and corresponding decrease in Spina bifida rates Slide 6 Tracking Iron Deficiency Anemia

• Grain and cereal product iron fortification based on low iron levels from NHANES I (1970-73)

• WIC used NHANES cut-off values for participant eligibility

• NHANES II & III iron status used to set RDAs by Food and Nutrition Board (1989 & 2001) and to track progress on Healthy People objectives to reduce iron deficiency (1990-now) Alternative text for image: cartoon drawing of a box and bowl of cereal Slide 7 Monitoring Iodine Levels after Fortification Policy Changes

• Iodine deficiency disorders such as goiter, cretinism and stillbirth virtually eliminated through the iodization of salt

• NHANES I, III and 2000 data showed the dietary sufficiency of changes in iodine fortification decisions Alternative text for image: cartoon drawing of salt and pepper shaker Slide 8 First National Survey with Expanded Dietary Supplement Data • Continuous NHANES uses label-based nutrient data for over 7,000 products • In 1988-94 more detail was collected on dose, frequency, and manufacturer allowing quantification of nutrient intake from supplements Alternative text for image: Line graph showing percentage of dietary supplement use among women, men, and both genders aged 20 years and older increasing from 1971to 2003-2006 Slide 9 Total Nutrient Intake - Nutrient Intake from Diet and Dietary Supplements • Increasing prevalence of supplement use in the US • Supplement use is an integral component of nutrient intake • NHANES supplement data drove development of methods for estimating total intake • First national estimates of total nutrient intake from NHANES III • Data used for setting Dietary Reference Intakes (DRI) by National Academy of Sciences Alternative text for image: Area graph showing the distribution of vitamin C intake for the total population from 1988-1994 and the proportion from diet alone and diet plus supplements.

Slide 10 First Measured Physical Activity Data in the US

• Measured PA significantly lower than self-reported PA

• Less than 5% of adults achieve recommended 30 minutes/day PA

• NHANES PA data used in Healthy People 2010 and to evaluate compliance with PA Guidelines

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Picture of accelerometer Collage of pictures of people playing basketball, jogging, and walking Line graph showing the step count for one person throughout the day Slide 11 Monitoring Declines in High Cholesterol NHANES measures National Cholesterol Education Program (NCEP) success

• Total cholesterol declined from 1960-2008: Healthy People 2010 goals met

• LDL cholesterol decline between 1976-2002 paralleled decreased dietary fat intake recommended in NCEP

• Total and LDL cholesterol declines since 1999 parallel introduction of statins

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Cartoon drawing of stoplight with cholesterol levels Line graph showing Healthy People 2010 Target of 200 mg/dL cholesterol goal and average total cholesterol for men and women decreasing over time Slide 12 Tracking Hypertension

• Used to track hypertension prevalence by Joint National Committee on Detection Evaluation and Treatment of High Blood Pressure since 1980 o Decline between 1976-80 and 1988-1994 o Increase between 1988-94 and 1999-2000

• Since 1988-94 interview plus measured blood pressure data allow estimation of awareness, treatment, and control of hypertension

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Picture of interviewer interviewing participant in her home Picture of participant having his blood pressure measured by a doctor in the Mobile Examination Center Bar chart showing awareness of hypertension among hypertensive adults in the United States from 2005-2006 Line graph showing measured blood pressure from 1960-1962 to 1999-2002 Slide 13 Monitoring Increase in Diabetes, Measuring Disease Management & Undiagnosed Disease Monitor Diagnosed and Undiagnosed Disease

• Diagnosed diabetes doubled from 3.4% to 7.7 % between 1976-80 and 2005 12.9% of adults age 20 years have diagnosed or undiagnosed diabetes (2005 42% of adults age 20 years have diabetes or pre-diabetes (2005-2006) Monitor Improvements in Diabetes Management

• Hemoglobin A1C declined from 7.8% to 7.2% between 1999-2004 (good control = 7.0%) Alternative text for images: Bar chart showing percentage of population with diabetes and pre-diabetes in 2005-2006. 7.7% are diagnosed; 5.1% were undiagnosed; 29.5 % had impaired fasting glucose or impaired glucose tolerance.

Slide 14 Chronic Kidney Disease (CKD) – Less Than 5% Aware

• Risk factors include diabetes, hypertension & obesity

• CKD can lead to end-stage renal disease (stage 5)

• CKD increased from 10% to 13.1% (1988-94 to 1999-04)

• Awareness ranged from 3.7% (stage 1) to 41.8% (stage 4)

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Ultrasound cross-section of kidneys Slide 15 First National Estimates of Lower Extremity Disease (LED) Peripheral Neuropathy (PN) • 14.8% of adults 40 years • 19.4% of diabetics Peripheral Arterial Disease (PAD) • 4.5% of adults 40 years • 7.5% of diabetics

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Screenshot of software used to record lower extremity disease results Picture of equipment used to gather data on peripheral arterial disease Slide 16 First Exam-based Study of Gallbladder Disease

• NHANES III was the 1st US population-based study to use ultrasonography to detect gallbladder disease.

• Analyses revealed Mexican-American ethnicity a significant risk factor for gallbladder disease in women

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Illustration of abdomen highlighting gall bladder Slide 17 Principal Data Source of Measured Arthritis Rheumatoid Arthritis (RA)

• First national estimates from NHES

• Updated prevalence using revised criteria (NHANES III) Osteoarthritis (OA)

• Estimates based on X-ray results • 37% older adults had knee OA (NHANES III) Back Pain

• Seminal low back pain estimates from NHANES II

• First national survey of Spondyloarthritis (NHANES 2009-10)

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Picture of arthritic hands X-ray of knees Illustration of regions of the spinal column Picture of person having their back measured Slide 18 Characterized Osteoporosis in the US and Established International Reference Database

• First national survey to include Dual Energy X-ray Absorptiometry in mobile exam setting

• NHANES III femur bone mineral density data adopted as reference standard by International Committee for Standards in Bone Measurement

• Reference database used by WHO for calculation of absolute fracture risk scores (FRAX™)

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Whole body X-ray Inset of whole body X-ray showing hip bone Slide 19 Documented Emerging Infectious Diseases HIV 1st prevalence estimates of HIV infection in US household population (NHANES • III)

• Findings assisted in prevention campaigns and treatment program development H. Pylori • 1st estimates of H. Pylori prevalence in U.S. adults (NHANES III)

• Indicated almost one third of adults infected with H. Pylori MRSA • 1st national estimates of staphylococcus & MRSA carriage (NHANES 2001 Characterization of predominant subtypes and changes in these patterns helped shape prevention policies

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Cartoon drawing of germ Slide 20 Infectious Disease Data Used to Shape Vaccine Policy Hepatitis B (HBV) • 1st estimates of HBV in U.S. household population (NHANES II)

• Findings instrumental in implementation of HBV universal vaccination of children Human Papilloma Virus (HPV)

• NHANES 2003-2004 showed 1 in 4 females 14 - 59 years old infected with HPV

• Findings informed ACIP as they developed recommendations for HPV vaccination

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Picture of mother holding baby while doctor gives the baby a vaccination shot Picture of a girl getting a vaccination shot from a doctor Slide 21 NHANES used to Monitor Vaccination Policy

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Carton drawing of virus with bottle labeled vaccine and hypodermic needle Slide 22 Documented Declines of Blood Lead Levels after Removal of Lead from Gasoline, Paint and Other Household Agents

• Provided key information in the policy decision to eliminate leaded gasoline in the US

• Continuous monitoring of additional lead exposure and helped to target screening of children in inner-city areas

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Line graph showing predicted blood lead, gasoline lead, and observed lead levels Barchart showing percent of U.S. children 1-5 years of age with blood levels greater than or equal to 10 micrograms per deciliter – 88% in 1976-1980; 4% in 1991-1994 and 2% in 1999-2000.

Slide 23 First US Population-based Assessment of Mercury Exposures in Women and Children

• Comprehensive assessment with biological specimens of blood, urine, hair, and related behaviors such as fish and shellfish consumption

• Essential information to help formulate dietary recommendations on fish consumption for pregnant women

• Important baseline data to track long term policies to reduce methyl mercury exposure

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Line graph showing blood mercury levels Bar chart showing frequency of fish consumption in past 30 days Barchart showing percentage of women 16-49 years of age having blood mercury concentrations greater than those associated with exposures considered higher than U.S. EPA’s RfD for MeHg.

Cartoon drawing of a fish listing species lower in Mercury concentration.

Slide 24 Elucidating Exposure to Second Hand Smoke (SHS) & Monitoring Reduction Policies • 1st measured biological assessment of SHS in US (NHANES III)

• Documented widespread SHS exposure – 84% of non-smokers

• Trend analysis showed decline of 45% among nonsmokers between 1988-94 and 1999-2004

• Inverse relationship between smoke-free law coverage and SHS exposure

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Picture of children with cartoon cigarette with no smoking symbol superimposed Barchart showing decrease in smokers as a percentage of the U.S. population from 84% in 1988-1994 to 46% in 1999-2004.

Slide 25 Lung Disease Prevalence Estimates and Spirometry Reference Data

• First national estimates of asthma and COPD (exam-based)

• NHANES III spirometry data used to establish U.S. reference ranges

• Allergy components expand asthma epidemiology

• Interdisciplinary research including environmental and occupational lung disease and mortality

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Collage of woman having her lung capacity tested in the Mobile Examination Center, an interviewer taking an allergen sample from a participant’s home, screenshots of the software used to record data.

Slide 26 Tracking Oral Health and Monitoring Prevention Initiatives • 1st standardized dental exam to collect national oral health data (HES) • 1st estimates of US dental conditions (HES)

• NHANES data used in 1st Surgeon General’s Report on Oral Health in the US in 2000

• NHANES used as baseline data for oral health for Healthy People Alternative text for image: cartoon drawing of a mouth showing teeth Slide 27 Monitoring Visual Health in the U.S.

Vision assessed in HES, NHANES I & Continuous NHANES Currently….

• 11million have visual impairment that can be corrected with glasses/contact lenses • 3 million have visual impairment that cannot be corrected with glasses/contact lenses Alternative text for image: Piechart with eye as background showing 83% of visual impairments can be corrected with glasses or contact lenses; 17% cannot be corrected with glasses or contact lenses Slide 28 Setting National Audiometric Standards & Tracking Trends and Disparities in Hearing Loss • 1st national prevalence estimates of hearing loss based on audiometric data (HES)

• Used to define normal audiograms

• Mainstay of public health tracking and risk assessment for hearing loss (NHANES I, II, III, 1999-2009) • 16% of adults age 20-69 years have speech-frequency hearing loss (NHANES 1999-2004)

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