National Health And Nutrition Evaluation Survey Research Articles

Age-specific prevalence, subtypes and risk factors of metabolic diseases in Chinese adults and the different patterns from other racial/ethnic populations

BackgroundAge has substantial influence on metabolic diseases patterns. Ethnic disparities of metabolic characteristics between Chinese and other populations also exist. Large-scale investigations of age-specific prevalence, subtypes and modifiable risk factors of metabolic disorders are essential to promote individualized strategies for the control and prevention of metabolic diseases in multi-ethnic populations. The study aims to address the age-specific prevalence, subtype characteristics and risk factor profiles of metabolic diseases among different races/ethnicities.MethodsWe analyzed data from the China Noncommunicable Disease Surveillance 2010 and the National Health and Nutrition Evaluation Survey (NHANES). We examined the prevalence and subtypes of hypertension, diabetes and hyperlipidemia across age groups in four ethnic populations. We also investigated the odds ratios (ORs) of metabolic diseases associated with 11 classical risk factors in the young and the elder Mainland Chinese.ResultsThe sex and BMI standardized prevalence of hypertension in Chinese aged 18–40 years was 18.5% and was the highest among the four populations. The main pathophysiologic subtype of diabetes was characterized by insulin resistance, instead of β-cell dysfunction in Mainland Chinese, and this pattern was more evident in obese subjects. The major subtype of hyperlipidemia in Mainland Chinese was hypertriglyceridemia, while Non-Hispanic Whites and Blacks were more prone to high low-density lipoprotein cholesterol. For risk of hypertension, diabetes and hyperlipidemia, young Chinese adults were more prone to general and central obesity than older ones. The other factors showed similar effects on the young and the old.ConclusionsThe age-specific prevalence, subtypes and risk factors of metabolic diseases were substantially different in Chinese and other ethnic/racial populations.

Associations between serum triglycerides and abdominal aortic calcification in a cross-sectional study from the United States of America

Abstract Background Abdominal aortic calcification (AAC) has recently been recognised as a risk factor for cardiovascular disease, as it shares pathophysiological mechanisms with coronary artery disease. Purpose We investigated relationships between AAC and traditional cardiovascular risk factors in a cross-sectional epidemiological cohort from the USA Methods We used data from the National Health and Nutrition Evaluation Survey (NHANES) from the years 2103–2014. Dual-energy X-ray absorptiometry (DXA scans) were performed for a subset of 3140 NHANES participants over the age of 40. The images were scored according to ACC-24, a 24-point scale. We performed binary logistic regression to investigate relationships between demographic variables (age, sex, poverty income ratio, & educational status) CV risk factors (triglycerides (fasting, and non-fasting) LDL-C, HDL-C systolic blood pressure, body mass index, smoking status & diabetes) medicine use (statins, antihypertensives and antiplatelets) and AAC status (patients with a score ≥2 on the 24-point scale were considered AAC positive). Non normally-distributed variables were categorised for the purposes of analysis. Results Participants with AAC were older (mean 65.5 years ± SD 11.7) than unaffected individuals (56.1±11.1) AAC was also associated with higher BMI (28.7±5.8 v. 27.6±4.8 kg/m2), and higher systolic blood pressure (131.3±19.5 v 125.8±18.4 mmHg). We found a strong relationship between plasma triglyceride concentrations and AAC. In univariate analysis, fasting triglycerides above the first quartile were associated with approximately double the risk of AAC, compared to those in the first quartile (see table). This relationship persisted when the analysis was adjusted for demographics, risk factors and medicine use. A similar pattern was seen with non-fasting triglycerides (see table). Conclusions We found a strong relationship between triglycerides and AAC. Further work is required to determine whether this observation can be validated in other cohorts, and whether interventions to reduce triglyceides can alter the progression of AAC. Funding Acknowledgement Type of funding sources: None. Odds ratios (95% CI) for AAC

Exposure to uranium and co-occurring metals among pregnant Navajo women

Navajo Nation residents are at risk for exposure to uranium and other co-occurring metals found in abandoned mine waste. The Navajo Birth Cohort Study (NBCS) was initiated in 2010 to address community concerns regarding the impact of chronic environmental exposure to metals on pregnancy and birth outcomes. The objectives of this paper were to 1) evaluate maternal urine concentrations of key metals at enrollment and delivery from a pregnancy cohort; and 2) compare the NBCS to the US general population by comparing representative summary statistical values. Pregnant Navajo women (N = 783, age range 14–45 years) were recruited from hospital facilities on the Navajo Nation during prenatal visits and urine samples were collected by trained staff in pre-screened containers. The U.S. Centers for Disease Control and Prevention (CDC), National Center for Environmental Health's (NCEH) Division of Laboratory Sciences (DLS) analyzed urine samples for metals. Creatinine-corrected urine concentrations of cadmium decreased between enrollment (1st or 2nd trimester) and delivery (3rd trimester) while urine uranium concentrations were not observed to change. Median and 95th percentile values of maternal NBCS urine concentrations of uranium, manganese, cadmium, and lead exceeded respective percentiles for National Health and Nutrition Evaluation Survey (NHANES) percentiles for women (ages 14–45 either pregnant or not pregnant.) Median NBCS maternal urine uranium concentrations were 2.67 (enrollment) and 2.8 (delivery) times greater than the NHANES median concentration, indicating that pregnant Navajo women are exposed to metal mixtures and have higher uranium exposure compared to NHANES data for women. This demonstrates support for community concerns about uranium exposure and suggests a need for additional analyses to evaluate the impact of maternal metal mixtures exposure on birth outcomes.

Long-term sleep disturbance and prescription sleep aid use among cancer survivors in the United States.

Insomnia and related sleep disorders are common complaints among cancer patients, and use of prescription sleep aids can be high in the treatment setting. The prevalence of sleep disturbance and prescription sleep aid use in the community-dwelling cancer survivorship population, however, remains relatively unexplored. We aim to ascertain the extent to which a cancer diagnosis is associated with sleep disturbances and prescription sleep aid use as measured in several cross sections of individuals across multiple disease sites and time since cancer diagnosis. We used data from five cross-sectional cycles of the National Health and Nutrition Evaluation Survey (NHANES) from 2005 to 2014. We identified a total of 2371 individuals who reported a diagnosis of cancer (averaging 61years old) and 25,788 individuals who did not report a cancer diagnosis (averaging 45years old). We considered several patient-reported sleep-related outcomes. Multivariate regression analyses, as well as propensity score matching, were used to clarify the relationship between sleep disturbances, prescription sleep aid use, and cancer diagnosis, stratified by time since diagnosis and primary disease site. Reported sleep disturbance was common in cancer survivors, with approximately 34% of patients with a history of cancer reporting having ever been told they had trouble sleeping, compared to 23% of non-cancer patients in the general population with no history of cancer (p < 0.001). Propensity score matching supported a significantly higher rate of trouble sleeping among cancer survivors compared to matched controls. Compared to the general adult population without cancer, cancer survivors 11 or more years past diagnosis were more likely to report being diagnosed with trouble sleeping or a sleep disorder. Further, patients with gynecological cancers were more likely to report prescription sleep aid use, sleep disorders, and trouble sleeping compared to adults without a history of cancer. Sleeping problems are common in the cancer survivorship population, especially in patients with a long survivorship history and a history of gynecological cancers. Consideration of symptoms of insomnia and sleep disturbance may be helpful in the follow-up care of these patients.

Prostate cancer and subsequent nutritional outcomes: the role of diagnosis and treatment.

To comprehensively explore the role of a prostate cancer diagnosis and its treatment to several outcomes including diet, Hemoglobin A1c, and weight status, in a large, nationally representative, cross-sectional study. This analysis used five cross sections from the publicly available National Health and Nutrition Evaluation Survey (NHANES) from 2001 to 2010. A sample of 289 men with a history of prostate cancer was matched to a comparison group of 655 men with elevated prostate-specific antigen (> 4ng/mL) but no reported diagnosis of prostate cancer. Analyses were stratified by diabetic or pre-diabetes status and treatment including surgery, radiotherapy, or both. Outcomes of interest included several broad macronutrient categories, HbA1c, body mass index, and obesity status. Multivariate regression analyses were conducted to clarify the associations of a prostate cancer diagnosis with these outcomes. Demographic and socioeconomic factors, including age, education, race, income, and marital status, were controlled for in all models. The clinical and demographic characteristics were relatively well balanced between the "at risk" comparison group and the group of men diagnosed with prostate cancer. Diabetic or pre-diabetic men diagnosed with prostate cancer were more likely to be obese (p < 0.05) and have a higher BMI (p < 0.10). On multivariate analysis, compared to controls, men with prostate cancer treated with surgery and radiation therapy were predicted to have a higher BMI (p < 0.01) and were more likely to be obese (p < 0.05). These findings were largely driven by the diabetic and pre-diabetic sample. Further diabetics and pre-diabetics with prostate cancer treated with both radiation and surgery were predicted to consume an average of 72 and 59 more daily grams of carbohydrates and sugar, respectively, compared to controls (p < 0.05). Men with prostate cancer report fewer behaviors and outcomes consistent with optimal glycemic management including a higher BMI, and in diabetics and pre-diabetics, increased carbohydrate sugar consumption. Men with more intense treatment including surgery and radiotherapy appeared to be more likely to be obese and make poorer dietary carbohydrate and sugar choices compared to men without prostate cancer. Men treated for prostate cancer have, on average, very long survivorship periods and are susceptible to diabetes and its complications. Interventions designed to improve diabetes awareness and self-management, especially weight and dietary sugar control, may be useful in this population.

Current epidemiology of hepatitis E virus infection in the United States: low seroprevalence in the National Health and Nutrition Evaluation Survey.

Analysis of the National Health and Nutrition Evaluation Survey (NHANES) 1988-1994 dataset found a relatively high seroprevalence (21%) of hepatitis E virus (HEV) infection in the U.S. general population. Using data obtained within the NHANES 2009-2010 survey, where a high performance assay for HEV was used, we estimated the weighted seroprevalence of HEV infection among U.S. individuals 6 years and older. We also evaluated factors associated with HEV seropositivity. A total of 8,814 individuals were included in the analysis. The median age of study participants was 37 years (interquartile range [IQR] 17-58 years), with 51.2% being female. The weighted national seroprevalence of HEV was 6% (95% confidence interval [CI] 5.1%-6.9%). About 0.5% of those with HEV had evidence of recent exposure (immunoglobulin M-positive). In the univariate analyses, factors associated with HEV seropositivity were increasing age (P-trend<0.001), birth outside of the U.S., Hispanic race, and "meat" consumption (>10 times/month). No significant association was observed with low socioeconomic status, water source, or level of education. In the multivariate analysis, only older age remained predictive of HEV seropositivity. The weighted national seroprevalence of HEV in the U.S. is much less than previously reported. Using data obtained with a high performance assay, the seroprevalence of HEV was estimated at 6.0% in the U.S. Based on these results, the seroprevalence of HEV is only one-third as high as previously reported.

An effective approach to high blood pressure control: a science advisory from the American Heart Association, the American College of Cardiology, and the Centers for Disease Control and Prevention.

Cardiovascular diseases, including heart disease, hypertension, and heart failure, along with stroke, continue to be leading causes of death in the United States.1,2 Hypertension currently affects nearly 78 million* adults in the United States and is also a major modifiable risk factor for other cardiovascular diseases and stroke.1 According to data from the National Health and Nutrition Evaluation Survey (NHANES) in 2007 to 2010, 81.5% of those with hypertension are aware they have it, and 74.9% are being treated, but only 52.5% are under control, with significant variation across different patient subgroups.1,4–7 Of those with uncontrolled hypertension, 89.4% reported having a usual source of health care, and 85.2% reported having health insurance.3 This is the current status, despite the fact that therapies to lower blood pressure and associated risks of cardiovascular events and death have been available for decades, and various education and quality improvement efforts have been targeted at patients and healthcare providers. The direct and indirect costs of hypertension are enormous, considering the number of patients and their families impacted, and the healthcare dollars spent on treatment and blood pressure–related complications.8 Currently, hypertension affects 46% of patients with known cardiovascular disease and 72% of those who have had a stroke, and it is listed as a primary or contributing cause in ≈15% of the 2.4 million deaths in 2009.1 In 2008, the total estimated direct and indirect cost of hypertension was estimated at $69.9 billion.8 Thus, it is imperative to identify, disseminate, and implement more effective approaches to achieve optimal control of this condition. High-quality blood pressure management is multifactorial and requires the engagement of patients, families, providers, and healthcare delivery systems and communities. This includes expanding patient and healthcare provider awareness, appropriate lifestyle …

Biomarkers of perchlorate exposure are correlated with circulating thyroid hormone levels in the 2007–2008 NHANES

Previous epidemiological studies provide conflicting evidence as to whether environmental perchlorate exposure can affect levels of circulating thyroid hormones in the general population. We investigated the statistical relationships between biomarkers of perchlorate exposure and serum thyroid hormone levels in 2007–2008 National Health and Nutrition Evaluation Survey (NHANES) subjects. Generalized additive mixed models (GAMMs) were developed to estimate the relationships between T3 and T4 levels and creatinine-adjusted urinary perchlorate excretion. The models included covariates related to gender, age, ethnicity, income, smoking status, prescription medications, and biomarkers of exposures to other goitrogenic ions and phthalate ester metabolites. Where necessary, relationships between hormone levels and covariates were represented as nonlinear smoothed terms. The effect of the hypothalamic–pituitary–thyroid (HPT) axis on serum hormone levels was taken into account by including a term for thyroid stimulating hormone (TSH) in the models. Regression coefficients for perchlorate were significant and negative in GAMMs predicting total T4 and free T3 levels in males, females, and for the entire cohort when phthalate ester biomarkers and other covariates were included. Coefficients for perchlorate were also significant and negative in regressions predicting free T4 levels in males and in the entire study population. The consistency of these results suggests that HPT axis controls do not completely compensate for small changes in thyroid hormone levels associated with perchlorate and phthalate ester exposures.

A critical evaluation of the creatinine correction approach: Can it underestimate intakes of phthalates? A case study with di-2-ethylhexyl phthalate

The creatinine correction approach has been used to estimate daily intake for contaminants whose primary route of elimination is through urine. This method is challenged using the phthalate di-2-ethylhexyl phthalate (DEHP) as an example. An alternate prediction approach based on human experimental metabolism and urinary excretion data on DEHP was developed. This alternate model was developed from urine measurements of four metabolites of DEHP from two individuals partaking in different experiments, for up to 44 h after known exposures. Particular attention was paid to the changing ratios of the metabolites over time: they took a certain form when exposure was in the "near" (the past few hours) versus the "distant" (24 h or more) past. The creatinine correction approach was applied to measurements of the same four metabolites from 18 individuals in the National Health And Nutrition Evaluation Survey (NHANES) 2003/2004. The alternate model was also applied to these individuals, and the results were compared. Predictions using the two methods were similar or the creatinine correction predicted higher concentrations when the ratio suggested that the DEHP exposure was "near" in time, but the alternate approach predicted intakes that were an order of magnitude higher when the ratios suggested that the intake was "distant". As much as 25% of all NHANES measurements contain metabolites whose key ratio suggest that exposure was "distant". Uncertainties notwithstanding, the analysis in this article suggests that the creatinine correction approach should be used cautiously for DEHP and possibly other contaminants with similar exposure characteristics: rapid metabolism with metabolite urine elimination half-lives on the order of hours, and exposure patterns that may not be continuous and ongoing.

Public health impact of antiviral therapy for hepatitis C in the United States

Despite dramatic improvements in antiviral therapy for hepatitis C, there is reason to believe that the uptake of antiviral therapy remains limited. The aims of this study were to determine the number of patients being treated with antiviral therapy in the U.S., to estimate the public health impact of these treatment patterns, and to identify barriers to treatment for patients with hepatitis C. Data on the number of new patient pegylated interferon prescriptions each year, from 2002-2007, was obtained from Wolters Kluwer Inc., which maintains an electronic audit of pharmacies nationwide. A Markov model was created of the population with chronic hepatitis C in the U.S. from 2002 to 2030, and was used to estimate the number of liver-related deaths caused by hepatitis C that will be prevented by current treatment patterns. The National Health and Nutrition Evaluation Survey (NHANES) Hepatitis C Follow-Up Questionnaire was used to investigate reasons for lack of treatment and to identify strategies for improving access. Approximately 663,000 patients received antiviral therapy between 2002 and 2007, and treatment rates appear to be declining. If this trend continues, only 14.5% of liver-related deaths caused by hepatitis C from 2002-2030 will be prevented by antiviral therapy. Results from the NHANES questionnaire suggest that the primary barrier to treatment is lack of diagnosis, with 69/133 (adjusted proportion 49%) of respondents previously unaware that they had hepatitis C. Efforts to improve rates of diagnosis and treatment will be required if the future public health burden of hepatitis C is to be ameliorated.

The metabolic syndrome and cardiovascular risk: implications for clinical practice

The clinical importance of the metabolic syndrome (MeS) is confused by the existence of at least three different definitions proposed by prominent organizations, and by a lack of information about the prognostic value of diagnosing a person as having the syndrome by any of the definitions. We used the US National Health and Nutrition Evaluation Survey (NHANES) to determine the prevalence in the United States of the variables used to define the MeS and cardiovascular disease (CVD), and to create a simulated population that matched the US population with respect to all the important characteristics, risk factors and treatments for CVD. We then used the Archimedes model to calculate the long-term CVD outcomes for each person in the simulated population. The definitions implied an increased risk of CVD of 1.5-1.6. The definitions varied considerably in their ability to identify people at risk of myocardial infarctions (MIs); the proportion of people destined to have a future MI captured by the different definitions varied from 57 to 77%. The definitions also varied widely in how well they ruled out future MIs; failure to have MeS by a definition still left a chance of a future MI ranging from 23 to 42%. The definitions differed importantly in which people they identified as having MeS; 34% of those who met the ATP definition did not meet the WHO definition, 30% of those who met the WHO definition did not meet the ATP definition and 28% of those who met the IDF definition did not meet the ATP definition. Of the components of the definitions, the most important single factor for identifying a person at risk of future CVD was high glucose, with hypertension, obesity, high triglycerides and low HDL following in that order. High glucose, by itself, was as good as any definition of the MeS in predicting risk of future MI. Whichever definition was used, individuals who met the definition varied widely in their risk of CVD. For assessing a particular person's risk of future CVD and for making treatment decisions a diagnosis of MeS by any of the definitions added little if anything to assessing each person's risk factors.

Metabolic syndrome in nondiabetic, obese, first-degree relatives of African American patients with type 2 diabetes: African American triglycerides-HDL-C and insulin resistance paradox.

Metabolic syndrome (MetS) defines cardiovascular disease (CVD) risks. Despite higher rates of obesity, type 2 diabetes, and hypertension, African Americans have lower rates of MetS when compared to Caucasians, which is paradoxical, since African Americans are more insulin resistant and have higher rates of cardiovascular morbidity and mortality when compared to White Americans. We hypothesized that genetic inheritance predisposes African Americans to the greater cardiovascular risk and the associated morbidity and mortality. Therefore, we investigated the prevalence of components of MetS in obese, glucose-tolerant, first degree relatives of African American patients with type 2 diabetes. We examined the clinical and metabolic characteristics of 201 first-degree relatives (159 females and 42 males, mean age 41 +/- 8 years, and mean body mass index (BMI) of 32 +/- 8 (kg/m2). The subjects were categorized with MetS according to the Adult Treatment Panel (ATP) III criteria. Insulin sensitivity (Bergman minimal model method) and insulin resistance (homeostasis model assessment [HOMA]) were determined. We compared the clinical and metabolic characteristics in the relatives with and without MetS. Where appropriate, we compared the prevalence of the components of MetS in our African American sample with those of African American data in the National Health and Nutrition Evaluation Survey (NHANES) III. Comparing the MetS group (n=65) vs control subjects (n=136), the mean age, BMI, and percent body fat were greater in the MetS group. Mean fasting serum glucose, insulin and C-peptide levels were also greater in the MetS group. Insulin resistance index (HOMA-IR) was higher in the MetS group (HOMA-IR: 3.7 +/- 2.7 vs 2.2 +/- 1.7, P=.0002). Mean insulin sensitivity tended to be lower in the MetS group (2.16 +/- 2.64 vs 2.82 +/- 2.31, P=.08). In addition, despite the moderately severe insulin resistance, the MetS group had very low serum triglyceride levels and was the parameter least likely to meet the ATP criteria. The metabolic cutoff points for ATP III criteria were much lower in African American first-degree relatives with MetS. Of the five components of the ATP III criteria, waist circumference was the single most common parameter to likely meet the MetS criteria. We found that the prevalence of MetS was 29% in women and 40% in men when compared with 20.9% in African American women and 13.9% for African American men in the NHANES III. We found that: 1) the prevalence of MetS is higher in a subgroup of African Americans who were first-degree relatives of patients with type 2 diabetes than that of African Americans in the NHANES III; and 2) waist circumference rather than metabolic parameters was the single most important parameter and was more likely to meet the MetS criteria in African American relatives.

The impact of hip subregion reference data on osteoporosis diagnosis

Manufacturers of bone densitometry devices have been moving from manufacturer-specific reference values to data derived from larger population-based cohorts such as the National Health and Nutrition Evaluation Survey (NHANES) III. One bone densitometer manufacturer has released software that provides hip subregion T-score calculations based upon four slightly different versions of hip reference data. Our aim was to determine how changes in hip reference data affect diagnostic classification based on minimum T-scores in older women. We extracted results for lumbar spine and hip bone density measurements from the Manitoba Bone Density database for women aged 50 years or older who had baseline scans on the manufacturer's equipment (n=17,053). T-scores were calculated using manufacturer-specific non-NHANES data and three software implementations of NHANES reference data. One software version gave results at subregions of the hip that were significantly lower than with the three other sets of reference data from the same manufacturer (mean femoral neck T-score absolute difference 0.23-0.48, P<0.00001; mean trochanter T-score absolute difference 0.49-0.70, P<0.00001). As a result the proportion of measurements with a T-score of -2.5 or lower almost doubled at the femoral neck (14.3 versus 27.7%, P<0.00001) and approximately tripled at the trochanter (8.1 versus 24.0%, P<0.00001). The final patient classification of osteoporosis based on a minimum T-score of -2.5 or lower from all four measured sites differed significantly between the four versions (absolute difference 7.9 to 10.4%, P<0.00001). Small changes in the reference data used in T-score calculations had large effects on patient categorization and the calculated prevalence of osteoporosis. The impact of changes in reference data need to be carefully evaluated by users and manufacturers before widespread clinical dissemination.

Projecting future complications of chronic hepatitis C in the United States

Chronic hepatitis C virus (HCV) infection is common and often results in slowly progressive liver disease. Although acute hepatitis C is now uncommon, most patients with acute infection have developed chronic hepatitis, and, therefore, the pool of infected patients is large. We used a modification of a previously described natural history model for HCV infection to project the number of cases of HCV infection, cirrhosis, and liver failure over the next 40 years. The model estimated the prevalence of HCV infection in the United States was 3.07 × 106 in 1993 (compared with an adjusted National Health and Nutrition Evaluation Survey (NHANES) III estimate of 2.8 to 3.5 × 106). A gradual decline in the prevalence of infection should occur by year 2040 because of aging and natural deaths among the infected pool. However, as the duration of infection increases in the surviving cohort, the proportion with cirrhosis will increase from 16% to 32% by 2020 in an untreated population. Complications of cirrhosis also will increase dramatically over the next 20 years: hepatic decompensation (up 106%), hepatocellular carcinoma (up 81%), and liver-related deaths (up 180%). Although current treatment regimens eradicate HCV in over 50% of cases, many more patients would need to be treated to significantly impact disease progression. Identification and treatment of every case of HCV infection (with or without cirrhosis) would reduce the number of cases of decompensated cirrhosis by almost half after 20 years. Despite the declining incidence of acute HCV infection, chronic hepatitis C is common. The prevalence of cirrhosis and the incidence of its complications will increase over the next 10 to 20 years, because the duration of infection increases among those with chronic hepatitis C. These data emphasize the need for greater access to transplantation by expansion of the donor pool, increasing use of split livers and living donors, and novel options such as xenotransplantation. (Liver Transpl 2003;9:331-338.)