Article

Sample design: Third National Health and Nutrition Examination Survey

October 1992
Vital and health statistics. Series 2, Data evaluation and methods research 113(113):1-35

October 1992
113(113):1-35

Source
PubMed

Authors:

This report presents a detailed description of the sample design for the Third National Health and Nutrition Examination Survey, 1988-94, including a brief description of research that led to the choice of the final design. The National Health and Nutrition Examination Survey (NHANES) is one of the major surveys of the National Center for Health Statistics, Centers for Disease Control. Information on the health and nutritional status of the noninstitutionalized population of the United States is collected through the NHANES household interviews and standardized physical examinations.

Denture wearing status, cardiovascular health profiles, and mortality in edentulous patients: A prospective study with a 27-year follow-up

Article

Sep 2022
J DENT

Objectives Life's Simple 7 (LS7) metrics provide insight into improving cardiovascular health (CVH) and help reduce mortality risks. Edentulous older adults have a higher mortality risk than dentulous ones, probably due to worse oral function. It is reported that wearing dentures will decrease the mortality risk factor by improving oral function. This prospective study aimed to investigate if denture wearing could modify the association between CVH profile and mortality risk among edentulous elderly. Methods From the Third National Health and Nutrition Examination Survey (NHANES III), 1,735 edentulous older adults (mean age 69.4 years old) with CVH profiles and data on denture wearing status were selected for this study. CVH profiles according to LS7 metrics were classified into poor, intermediate, or ideal. Denture wearers were defined as those wearing complete dentures in both arches all the time or only when awake. Multivariable Cox proportional-hazards regression was conducted to estimate the association of CVH profiles with all-cause and cardiovascular mortality. Stratified analyses and the testing of interaction terms were used to evaluate the difference between the association in edentulous patients with and without dentures. Results A total of 1,420 (81.8%) older adults died during the 27-year follow-up, with 475 (27.6%) cases attributable to heart disease. After controlling for potential confounders, edentulous patients with an ideal CVH (LS7 = 10–14) had a lower mortality risk than those with poor CVH (LS7 = 0–4). Furthermore, we observed an effect modification by denture use (P interaction = 0.046), with the role of ideal CVH in mitigating mortality among the denture wearers (Hazard Ratio = 0.440 [0.329–0.588]), while no significant association among those without dentures. Similar results were achieved for cardiovascular mortality, but there was no effect modification of denture use (P interaction = 0.352). Conclusion In this study, a favorable cardiovascular health profile presents a protective effect on all-cause mortality only among edentulous patients wearing dentures instead of non-wearer.

Serum antibodies to periodontal pathogens are related to allergic symptoms

Article

Full-text available

Aug 2022
J PERIODONTOL

Background: The association between periodontitis and allergic symptoms has been investigated. However, the difference in immune signatures between them remains poorly understood. This cross-sectional study assessed the relationship between serum immunoglobulin G (IgG) antibodies to periodontal pathogens and allergic symptoms in a nationwide population cohort. Methods: Two phases of the Third National Health and Nutrition Examination Survey (NHANES III) were used as discovery dataset (n = 3700) and validation dataset (n = 4453), respectively. Based on the antibodies against 19 periodontal pathogens, we performed an unsupervised hierarchical clustering to categorize the population into three clusters. In the discovery dataset, cluster 1 (n = 2847) had the highest level of IgG antibodies, followed by clusters 2 (n = 588) and 3 (n = 265). Data on allergic symptoms (asthma, hay fever, and wheezing) were obtained using a self-reported questionnaire. Survey-weighted multivariable logistic regression evaluated the association between these clusters and allergic symptoms. Results: In the discovery dataset, the participants with lower levels of antibodies to periodontal pathogens exhibited a higher risk of asthma (odds ratio [OR] cluster 3 vs. cluster 1 = 1.820, 95% confidence interval [CI]: 1.153-2.873) and wheezing (OR cluster 3 vs. cluster 1 = 1.550, 95% CI: 1.095-2.194) compared to those with higher periodontal antibodies, but the non-significant association with hay fever. Consistent results were found in the validation dataset. Conclusion: Serum IgG titers to periodontal pathogens were inversely associated with the risk of asthma and wheezing, suggesting the potentially protective role against allergic conditions.

The impact of dental status on diet, nutrition and nutritional status in U.S.A. adults

Thesis

Jan 2000

Ruth Emilie Nowjack-Raymer

The hypothesis of this study was that dental status significantly affects diet, nutrition and nutritional status in U.S.A. adults. The objectives were to test whether significant relationships existed between numbers of teeth, of occluding pairs of teeth (OPs) and of posterior occluding pairs of teeth (POPs) amongst (1) those with a solely natural dentition and (2) those who had a dentition with a combination of replaced and natural teeth. In addition, to test whether complete denture wearers differed from fully dentate adults in relation to diet, nutrition and nutritional status. Data were for adults 25 years and older (n=12,243) from the third U.S.A. National Health and Nutrition Examination Survey (NHANES III) 1988-1994, which used a stratified, multi-staged probability sample of the United States non institutionalized civilian population. The population had a full dental examination and dietary analysis and an assessment of blood analytes and anthropometric measures. Findings of multivariate analyses indicated that complete denture wearers had lower (1) consumption of most foods (2) dietary fibre and (3) levels of blood analytes than did the fully dentate. Significant relationships existed between numbers of teeth (and OPs and POPs) and most of the nutrition related outcomes amongst people with only natural teeth. Among people who had both natural and replaced teeth there were some differences in diet, nutrition and nutritional status between those with low numbers of teeth, OPs or POPs (whether natural or replaced) compared to fully dentate adults. On the other hand, there were few associations between diet and dental status in the rehabilitated group with more than 20 teeth. An inverse relationship was found between dental status and Body Mass Index across all typologies.

Attributable Fractions of NAFLD for Mortality in the United States: Results From NHANES III With 27 Years of Follow‐up

Article

Full-text available

Nov 2019

Background and aims: Nonalcoholic fatty liver disease (NAFLD) encompasses a range of conditions, from simple steatosis to nonalcoholic steatohepatitis. Studies in the United States have reported an increased mortality risk among individuals with NAFLD; therefore, the population attributable fractions (PAFs) for mortality were examined. Approach and results: A total of 12,253 adult individuals with ultrasound assessment of NAFLD from the Third National Health and Nutrition Examination Survey and mortality follow-up through 2015 were included in the analysis. Cox proportional hazard regression was used to estimate multivariable-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for NAFLD in association with all-cause and cause-specific mortality. Overall, sex- and race/ethnicity-specific PAFs and 95% CIs were estimated. In the current study, presence of NAFLD was associated with a 20% increased risk of all-cause mortality (HR, 1.20; 95% CI, 1.08, 1.34). The overall PAF for all-cause mortality associated with NAFLD was 7.5% (95% CI, 3.0, 12.0). The PAF for diabetes-specific mortality was 38.0% (95% CI, 13.1, 63.0) overall, 40.8% (95% CI, 2.1, 79.6) in men, and 36.8% (95% CI, 6.6, 67.0) in women. The PAF for liver disease (LD)-specific mortality was notably higher in men (68.3%; 95% CI, 36.3, 100.0) than women (3.5%; 95% CI, -39.7, 46.8). In the race-specific analysis, the PAFs of NAFLD for all-cause mortality (9.3%; 95% CI, 4.0, 14.6) and diabetes-specific mortality (44.4%; 95% CI, 10.8, 78.0) were significantly greater than zero only for whites. Conclusions: In the United States, approximately 8% of all-cause mortality and more than one-third of LD- and diabetes-specific deaths are associated with NAFLD. With these high percentages, efforts are needed to reduce the burden of NAFLD in the United States.

Blood cell parameters and risk of nonalcoholic fatty liver disease: a comprehensive Mendelian randomization study

Article

Full-text available

Apr 2024
BMC MED GENOMICS

Background Nonalcoholic fatty liver disease (NAFLD) is on the rise globally, and past research suggests a significant association with various blood cell components. Our goal is to explore the potential correlation between whole blood cell indices and NAFLD risk using Mendelian randomization (MR). Methods We analyzed data from 4,198 participants in the 2017–2018 National Health and Nutrition Examination Survey to investigate the link between blood cell indicators and NAFLD. Using various methods like weighted quantile sum and multivariate logistic regression, we assessed the association. Additionally, two-sample Mendelian randomization were employed to infer causality for 36 blood cell indicators and NAFLD. Results Multivariate logistic regression identified 10 NAFLD risk factors. Weighted quantile sum revealed a positive correlation (p = 6.03e-07) between total blood cell indices and NAFLD, with hemoglobin and lymphocyte counts as key contributors. Restricted cubic spline analysis found five indicators with significant nonlinear correlations to NAFLD. Mendelian randomization showed a notable association between reticulocyte counts and NAFLD using the inverse-variance weighted method. Conclusions Hematological markers pose an independent NAFLD risk, with a positive causal link found for reticulocyte count. These results emphasize the importance of monitoring NAFLD and investigating specific underlying mechanisms further.

The bidirectional associations between sarcopenia-related traits and cognitive performance

Article

Full-text available

Mar 2024

While many studies have sought to explore the degree to which sarcopenia-related traits are associated with cognitive performance, these studies have yielded contradictory results without any clear indication of the causality of such relationships. In efforts to better understand associations between sarcopenia-related traits and cognitive ability, a series of multivariate linear regression assessments were carried out upon datasets derived through the National Health and Nutrition Examination Survey (NHANES). Of these, cognitive performance was assessed by the Digit Symbol Substitution Test (DDST), the Consortium to Establish a Registry for Alzheimer’s Disease Immediate Recall Test (CERAD-IR), Delayed Recall Test (CERAD-DR) and Animal Fluency Test (AFT). Causal relationships between the two were further inferred via a two-sample Mendelian randomization (MR) analysis approach. Sarcopenia-related traits considered in these assessments included walking speed, appendicular skeletal muscle mass (ASM), and hand grip strength (HGS). Walking speed, ASM, and HGS were all significantly independently related to cognitive scores following adjustment for covariates. MR assessments also identified that each 1-SD higher walking speed and appendicular lean mass were causally and respectively associated with a 0.34 [standard error (SE) = 0.09; p < 0.001)] standardized score higher and a 0.07 (SE = 0.01; p < 0.001) standardized score higher cognitive score, whereas a higher hand grip strength was positively associated with a better cognitive performance. Reverse MR assessments also yielded similar findings. These data suggest that lower walking speed, muscle strength, and muscle mass were all closely related to lower cognitive performance irrespective of gender, and that there may be a mutually reinforcing relationship among these variables.

Investigating the impact of elevated urinary trace elements on non-alcoholic fatty liver disease using vibration-controlled transient elastography

Article

Full-text available

Mar 2024

Introduction Non-alcoholic fatty liver disease (NAFLD) is a global public health concern. However, limited data are available on urinary trace elements and NAFLD caused by various exposure factors. This study aimed to investigate the relationship between the presence of 16 trace elements in urine and NAFLD using data from the National Health and Nutrition Examination Survey (NHANES). Methods By utilizing the NHANES data from 2017 to 2018, 1613 participants who fulfilled the research criteria were identified from the initial pool of 2979 participants with available urine trace element detection data. Among them, 706 individuals had been diagnosed with NAFLD based on a coefficient of attenuation parameter (CAP) value of at least 274 db/m, determined using vibration-controlled transient elastography (VCTE); whereas the remaining 907 participants were classified as non-NAFLD. The data obtained were used to construct univariate and multivariate logistic regression models and restricted cubic spline models (RCS) analyses. Results The presence of arsenic, iodine, barium, cesium, molybdenum, lead, tin, and tungsten in the urine of individuals with NAFLD showed a positive correlation with the likelihood of developing NAFLD. The risk of NAFLD had a non-linear dose-dependent relationship with urinary iodine, molybdenum, barium, and cesium. NAFLD was also associated with elevated levels of barium and cesium in urine, which were identified as significant risk factors. Conclusion These findings suggest a positive association between exposure to trace elements in the urine and the risk of NAFLD. Specifically, urinary barium and cesium appeared to have the greatest impact on the risk of NAFLD. These results provide novel insights into the diagnosis and treatment of NAFLD.

A Population-Based and Clinical Cohort Validation of the Novel Consensus Definition of Metabolic Hyperferritinemia

Article

Full-text available

Dec 2023

Background There is limited data on the clinical significance of metabolic hyperferritinemia (MHF) based on the most recent consensus. We aimed to validate the clinical outcomes of MHF in general population and biopsy-proven metabolic dysfunction-associated fatty liver disease (MAFLD) patients. Methods NHANES database and PERSONS cohort were included. MHF was defined as elevated serum ferritin with metabolic dysfunction (MD) and stratified into different grades according to ferritin (grade 1: 200 [females]/300 [males] - 550 ng/ml; grade 2: 550 - 1000 ng/ml; grade 3: > 1000 ng/ml). The clinical outcomes, including all-cause death, comorbidities and liver histology were compared between non-MHF and MHF in adjusted models. Results In NHANES, compared with non-MHF with MD, MHF was related to higher risks of advanced fibrosis (FIB-4, P = 0.036), elevated albumin-creatinine ratio (UACR, P = 0.001) and sarcopenia (P = 0.013). Although the association between all grades of MHF and mortality was insignificant (P = 0.122), grades 2/3 was associated with increased mortality (P = 0.029). While comparing with non-MHF without MD, the harmful effects of MHF were more significant in mortality (P < 0.001), elevated UACR (P < 0.001), cardiovascular disease (P = 0.028), and sarcopenia (P < 0.001). In PERSONS cohort, MHF was associated with more advanced grades of steatosis (P < 0.001), lobular inflammation (P < 0.001), advanced fibrosis (P = 0.017), and more severe hepatocellular iron deposition (P < 0.001). Conclusions Both in general population and at-risk individuals with MAFLD, MHF was related with poorer clinical outcomes.

Nutritional Status Indices and Monoclonal Gammopathy of Undetermined Significance Risk in the Elderly Population: Findings from the National Health and Nutrition Examination Survey

Article

Full-text available

Sep 2023

Objective: Although several studies have found dietary intake is related to multiple myeloma (MM) and its precursor status risks, the role of one's nutritional status has been ignored and its role in plasma cell neoplasm development is still unclear. This study aimed to explore the relationship between various clinical indices of nutritional status and the risk of monoclonal gammopathy of undetermined significance (MGUS) in the population. Methods: We selected 9520 participants from the NHANES III and NHANES 1999-2004 studies. Controlling nutritional status index (CONUT), prognostic nutritional index (PNI), geriatric nutritional risk index (GNRI) and body mass index (BMI) were calculated as indices of nutritional status of the participants. Associations between nutritional indices and MGUS were investigated using multiple logistic regression, subgroup analysis, and an RCS model. Results: In our study, 266 participants had MGUS, with a prevalence of 2.79%. This study found that CONUT and PNI identified populations with poor nutritional status and had a significant positive correlation with the risk of MGUS. In multivariate logistic regression, compared with the lower CONUT score (<3) group, the OR for the group with higher scores (≥3) was 1.805 (95%CI: 1.271, 2.564). Compared with the lowest quartile group, the highest quartile PNI score group had an OR of 0.509 (95%CI: 0.290, 0.896). GNRI had no significant correlation with the risk of MGUS, with an OR of 0.737 (95%CI: 0.443, 1.227). Conclusion: This study found that older adults with CONUT and PNI scores indicating poorer nutrition had a higher risk of MGUS.

Association of low-level lead exposure with all-cause and cardiovascular disease mortality in US adults with hypertension: evidence from the National Health and Nutrition Examination Survey 2003–2010

Article

Full-text available

Aug 2023

Background To explore the association of low-level lead exposure with all-cause mortality and cardiovascular disease (CVD) mortality among hypertensive patients. Methods This cohort study enrolled 6453 adults with hypertension from the National Health and Nutrition Examination Survey 2003–2010 and followed mortality information through December 31, 2019. The baseline population were divided into four groups based on quartiles of blood lead levels (Q1: < 1.2 μg/dL, Q2: 1.2–1.6 μg/dL, Q3: 1.7–2.4 μg/dL, Q4: 2.5–4.9 μg/dL). The correlation of blood lead levels to mortality was investigated by Kaplan–Meier survival curves, restricted cubic spline (RCS), proportional hazard regression model, and subgroup analysis. Results During a median follow-up period of 136 (interquartile range 113, 164) months, a total of 1943 (30.1%) deaths were documented, among which 553 (28.5%) were due to CVD. Blood lead showed a linear dose–response relationship with all-cause and CVD mortality. After adequate adjusting for confounders, the risk of all-cause death rose by 23% for each unit increase in continuous variable blood lead (hazard ratio (HR): 1.23; 95% confidence interval (CI):1.16–1.30). When blood lead was a quartile group variable, participants in the Q 4 group had a 73% higher risk of death than those in the Q 1 group (HR:1.73; 95% CI: 1.43–2.10; P for trend < 0.001). The association for CVD mortality was analogous. The concordant results were achieved in the subgroup analysis. Conclusion Elevated blood lead levels were strongly associated with an increased all-cause and CVD mortality in adults with hypertension, even at the reference range of blood lead.

Does Periodontitis Affect the Association of Biological Aging with Mortality?

Article

Full-text available

Jun 2023
J DENT RES

The prevalence of periodontitis is increasing with the aging of the global population. Periodontitis has been suggested to accelerate aging and increase mortality. The present nationwide prospective cohort study aimed to determine whether periodontitis could modify the impact of biological aging on all-cause and cause-specific mortality in middle-aged and older adults. Participants ≥40 years of age from the Third National Health and Nutrition Examination Survey (NHANES III) were included (n = 6,272). Phenotypic age acceleration (PhenoAgeAccel) was used to evaluate the biological aging process. Moderate/severe periodontitis was defined using a half-reduced CDC/AAP (Centers for Disease Control and Prevention and American Academy of Periodontology) case definition. Multivariable Cox proportional hazard regression was conducted to estimate the association between PhenoAgeAccel and mortality risk, followed by effect modification analysis to test whether periodontitis modified the association. During a median follow-up of 24.5 years, 3,600 (57.4%) deaths occurred. The positive relationships between PhenoAgeAccel and all-cause and cause-specific mortality were non-linear. After adjusting for potential confounders, the highest quartile of PhenoAgeAccel was associated with increased all-cause mortality in individuals with no/mild periodontitis (hazard ratio for Q4 vs. Q1 [HR Q4vsQ1] = 1.789, 95% confidence interval [CI]: 1.541–2.076). In contrast, the association was enhanced in patients with moderate/severe periodontitis (HR Q4vsQ1 = 2.446 [2.100–2.850]). Periodontal status significantly modified the association between PhenoAgeAccel and all-cause mortality (P for interaction = 0.012). In subgroup analyses, the modifying effect of periodontitis was observed in middle-aged adults (40–59 years), females, and non-Hispanic whites. Although cause-specific mortality showed a similar trend, the PhenoAgeAccel × periodontitis interaction did not reach statistical significance. In conclusion, periodontitis might enhance the association of biological aging with all-cause mortality in middle-aged and older adults. Hence, maintaining and enhancing periodontal health is expected to become an intervention to slow aging and extend lifespan.

Association between metabolic syndrome components and gingival bleeding is women-specific: a nested cross-sectional study

Article

Full-text available

Apr 2023
J TRANSL MED

Background Metabolic syndrome (MetS) is a cluster of atherosclerotic risk factors that increases cardiovascular risk. MetS has been associated with periodontitis, but the contribution of single MetS components and any possible sexual dimorphism in this relation remain undetermined. Methods Using the third National Health and Nutrition Examination Survey (NHANES III), we performed a nested cross-sectional study to test whether individuals aged > 30 years undergoing periodontal evaluation (population) exposed to ≥ 1 MetS component (exposure) were at increased risk of bleeding/non-bleeding periodontal diseases (outcome) compared to nonexposed individuals, propensity score matched for sex, age, race/ethnicity, and income (controls). The association between MetS components combinations and periodontal diseases was explored overall and across subgroups by sex and smoking. Periodontal health status prediction based on MetS components was assessed. Results In total, 2258 individuals (n. 1129/group) with nested clinical-demographic features were analyzed. Exposure was associated with gingival bleeding (+ 18% risk for every unitary increase in MetS components, and triple risk when all five were combined), but not with stable periodontitis; the association was specific for women, but not for men, irrespective of smoking. The only MetS feature with significant association in men was high BP with periodontitis. CRP levels significantly increased from health to disease only among exposed women. MetS components did not substantially improve the prediction of bleeding/non-bleeding periodontal disease. Conclusion The observed women-specific association of gingival bleeding with single and combined MetS components advances gender and precision periodontology. Further research is needed to validate and expand these findings.

Association between the quality of plant-based diets and periodontitis in the US general population

Article

Full-text available

Feb 2023
J CLIN PERIODONTOL

Aim: This study investigated the relationships of plant-based diet indices with periodontitis and serum IgG antibodies against periodontopathogens in the US population. Materials and methods: This study analyzed cross-sectional data on 5,651 participants ≥40 years of age from the Third National Health and Nutrition Examination Survey. Food frequency questionnaire data were used to calculate the overall plant-based diet index (PDI), healthful plant-based diet index (hPDI), and unhealthful plant-based diet index (uPDI). Periodontitis was defined using a half-reduced CDC/AAP (Centers for Disease Control and Prevention and American Academy of Periodontology) case definition. Serum antibodies against 19 periodontopathogens were used to classify the population into two subgroups using hierarchical clustering. Survey-weighted multivariable logistic regressions were applied to assess the associations of PDI/hPDI/uPDI z-scores with periodontitis and hierarchical clusters after adjusting for potential confounders. Results: A total of 2,841 (50.3) participants were defined as having moderate/severe periodontitis. Overall PDI z-score was not significantly associated with the clinical and bacterial markers of periodontitis. By considering the healthiness of plant foods, we observed an inverse association between hPDI z-score and periodontitis (odds ratio [OR] = 0.925, 95% confidence interval = 0.860 to 0.995). In contrast, higher uPDI z-score (adherence to unhealthful plant foods) might increase the risk of periodontitis (OR = 1.100, 1.043 to 1.161). Regarding antibodies against periodontopathogens, the participants in cluster 2 had higher periodontal antibodies than those in cluster 1. The hPDI z-score was positively associated with cluster 2 (OR = 1.192, 1.112 to 1.278). In contrast, an inverse association between uPDI z-score and cluster 2 was found (OR = 0.834, 0.775 to 0.896). Conclusion: Plant-based diets were associated with periodontitis, depending on their quality. A healthy plant-based diet was inversely related to an increased risk of periodontitis but positively related to elevated antibody levels against periodontopathogens. For an unhealthy plant-based diet, the opposite trends were observed.

Association between iron metabolism and non-alcoholic fatty liver disease: results from the National Health and Nutrition Examination Survey (NHANES 2017–2018) and a controlled animal study

Article

Full-text available

Dec 2022
NUTR METAB

Background Iron metabolism may be involved in the pathogenesis of the non-alcoholic fatty liver disease (NAFLD). The relationship between iron metabolism and NAFLD has not been clearly established. This study aimed to clarify the relationship between biomarkers of iron metabolism and NAFLD. Methods Based on the National Health and Nutrition Examination Survey (NHANES), restricted cubic spline models and multivariable logistic regression were used to examine the association between iron metabolism [serum iron (SI), serum ferritin (SF), transferrin saturation (TSAT), and soluble transferrin receptor (sTfR)] and the risk for NAFLD. In addition, stratified subgroup analysis was performed for the association between TSAT and NAFLD. Moreover, serum TSAT levels were determined in male mice with NAFLD. The expression of hepcidin and ferroportin, vital regulators of iron metabolism, were analyzed in the livers of mice by quantitative real-time PCR (qRT-PCR) and patients with NAFLD by microarray collected from the GEO data repository. Results Patients with NAFLD showed decreased SI, SF, and TSAT levels and increased STfR levels based on the NHANES. After adjusting for confounding factors, TSAT was significantly negatively correlated with NAFLD. Of note, the relationship between TSAT and NAFLD differed in the four subgroups of age, sex, race, and BMI ( P for interaction < 0.05). Consistently, mice with NAFLD exhibited decreased serum TSAT levels. Decreased hepcidin and increased ferroportin gene expression were observed in the livers of patients and mice with NAFLD. Conclusion Serum TSAT levels and hepatic hepcidin expression were decreased in both patients and mice with NAFLD. Among multiple biomarkers of iron metabolism, lower TSAT levels were significantly associated with a higher risk of NAFLD in the U.S. general population. These findings might provide new ideas for the prediction, diagnosis, and mechanistic exploration of NAFLD.

Serum Antioxidant Vitamins Mediate the Association between Periodontitis and Metabolically Unhealthy Overweight/Obesity

Article

Full-text available

Nov 2022

Background: Periodontal disease is associated with metabolic syndrome and obesity. This cross-sectional study aimed to investigate whether serum antioxidant vitamins could mediate the association between periodontitis and a metabolically unhealthy phenotype in the overweight and obese population; Methods: We included 6158 Americans (body mass index (BMI) ≥ 25 kg/m2) from the Third National Health and Nutrition Examination Survey (NHANES III). Periodontitis was defined using a half-reduced CDC/AAP (Centers for Disease Control and Prevention/American Academy of Periodontology) definition. Having two or more metabolic abnormalities was defined as a metabolically unhealthy overweight and obese (MUO) phenotype. Mediation analysis of four oxidative stress biomarkers (serum antioxidant vitamins A, C, D, and E) was conducted; Results: Of participants with overweight and obesity, 2052 (33.3%) Americans were categorized as having periodontitis. Periodontitis increased dyslipidemia risk and systemic inflammation in the overweight and obese population. In the multivariable logistic regression model, periodontitis was positively associated with MUO (adjusted odds ratio = 1.238; 95% confidence interval: 1.091 to 1.406). These findings were validated in an independent cohort. Serum vitamins C and D were estimated to mediate 19.3% and 8.4% of the periodontitis-MUO association. Conclusions: Periodontitis might decrease serum vitamins C and D and induce a metabolically unhealthy state among adults with overweight and obesity.

Periodontitis Is Associated With Heart Failure: A Population-Based Study (NHANES III)

Article

Full-text available

Apr 2022

Objectives: The aim of this study was to investigate the relationship between periodontitis and heart failure using the Third National Health and Nutrition Examination Survey (NHANES III). Methods: Participants who had received a periodontal examination were included and investigated for the occurrence of heart failure. The included participants were divided into no/mild periodontitis and moderate/severe periodontitis groups according to their periodontal status. Weighted prevalence of heart failure was calculated, and weighted logistic regressions models were used to explore the association between periodontitis and heart failure. Possible influencing factors were then explored through subgroup analysis. Results: Compared with that of the no/mild periodontitis group, the incidence of heart failure in participants with moderate/severe periodontitis was 5.72 times higher (95% CI: 3.76–8.72, p < 0.001). After adjusting for gender, age, race, body mass index, poverty income ratio, education, marital status, smoking status, drinking status, hypertension, diabetes, stroke, and asthma, the results showed that the incidence of heart failure in the moderate/severe group was 3.03 times higher (95% CI: 1.29–7.13, p = 0.012). Subgroup analysis showed that criteria, namely, male, 40–60 years old, non-Hispanic white, body mass index >30, poverty income ratio ≥1, not more than 12 years of education, currently drinking, stroke but no diabetes, or asthma supported moderate/severe periodontitis as a risk factor for heart failure ( p < 0.05). Conclusion: According to data from this nationally representative sample from the United States, periodontitis is associated with an increased risk of heart failure.

Sex differences in adipose development in a hunter‐gatherer population

Article

Oct 2021

Objective: Humans are unusually sexually dimorphic in body composition, with adult females having on average nearly twice the fat mass as males. The development of adipose sex differences has been well characterized for children growing up in food-abundant environments, with less known about cross-cultural variation, particularly in populations without exposure to market foods, mechanized technologies, schooling, vaccination, or other medical interventions. Methods: To add to the existing cross-cultural data, we fit multiple growth curves to body composition and anthropometric data to describe adipose development for the Savanna Pumé, South American hunter-gatherers. Results: (1) Little evidence is found for an adiposity 'rebound' at the end of early childhood among either Savanna Pumé girls or boys. (2) Rather, fat deposition fluctuates during childhood, from age ~4 to ~9 years, with no appreciable accumulation until the onset of puberty, a pattern also observed among Congo Baka hunter-gatherers. (3) Body fat fluctuations are more pronounced for girls than boys. (4) The age of peak skeletal, weight, and adipose gains are staggered to a much greater extent among the Savanna Pumé compared to the National Health and Nutrition Examination Survey (NHANES III) reference, suggesting this is an important developmental strategy in lean populations. Conclusion: Documenting growth patterns under diverse preindustrial energetic conditions provides an important baseline for understanding sex differences in body fat emerging today under food abundance.

Adjusted logistic propensity weighting methods for population inference using nonprobability volunteer‐based epidemiologic cohorts

Article

Full-text available

Jul 2021

Many epidemiologic studies forgo probability sampling and turn to nonprobability volunteer‐based samples because of cost, response burden, and invasiveness of biological samples. However, finite population (FP) inference is difficult to make from the nonprobability sample due to the lack of population representativeness. Aiming for making inferences at the population level using nonprobability samples, various inverse propensity score weighting methods have been studied with the propensity defined by the participation rate of population units in the nonprobability sample. In this article, we propose an adjusted logistic propensity weighting (ALP) method to estimate the participation rates for nonprobability sample units. The proposed ALP method is easy to implement by ready‐to‐use software while producing approximately unbiased estimators for population quantities regardless of the nonprobability sample rate. The efficiency of the ALP estimator can be further improved by scaling the survey sample weights in propensity estimation. Taylor linearization variance estimators are proposed for ALP estimators of FP means that account for all sources of variability. The proposed ALP methods are evaluated numerically via simulation studies and empirically using the naïve unweighted National Health and Nutrition Examination Survey III sample, while taking the 1997 National Health Interview Survey as the reference, to estimate the 15‐year mortality rates.

Environmental and Genetic Determinants of Major Chronic Disease in Beijing–Tianjin–Hebei Region: Protocol for a Community-Based Cohort Study

Article

Full-text available

Jun 2021

Introduction: Personal lifestyle and air pollution are potential risk factors for major non-communicable diseases (NCDs). However, these risk factors have experienced dramatic changes in the Beijing–Tianjin–Hebei (BTH) region in recent years, and few cohorts have focused on identifying risk factors for major NCDs in this specific region. The current study is a large, prospective, long-term, population-based cohort study that investigated environmental and genetic determinants of NCDs in BTH areas. The results of this study may provide scientific support for efforts to develop health recommendations for personalized prevention. Methods: About 36,000 participants 18 years or older would be obtained by multistage, stratified cluster sampling from five cities for the baseline assessment. Participants underwent seven examinations primarily targeting respiratory and circulatory system function and filled out questionnaires regarding lifestyle behavior, pollutant exposure, medical and family history, medication history, and psychological factors. Biochemistry indicators and inflammation markers were tested, and a biobank was established. Participants will be followed up every 2 years. Genetic determinants of NCDs will be demonstrated by using multiomics, and risk prediction models will be constructed using machine learning methods based on a multitude of environmental exposure, examination data, biomarkers, and psychosocial and behavioral assessments. Significant spatial and temporal differentiation is well-suited to demonstrating the health determinants of NCDs in the BTH region, which may facilitate public health strategies with respect to disease prevention and survivorship-related aspects.

Blood lead levels and lung cancer mortality: An updated analysis of NHANES II and III

Article

Full-text available

May 2021

Previous analyses within the National Health and Nutrition Examination Survey (NHANES) II and III cycles suggested an association between blood lead levels (BLLs) and lung cancer mortality, although the evidence was limited by small case numbers. To clarify this relationship, we conducted updated analyses of 4,182 and 15,629 participants in NHANES II and III, respectively, (extending follow‐up 20 and 8 years) aged ≥20 with BLL measurements and mortality follow‐up through 2014. We fit multivariable Cox models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) relating BLLs and lung cancer with adjustment for smoking and other factors. We did not observe an overall association between BLLs and lung cancer after adjustment for smoking (both surveys) and serum cotinine and environmental tobacco smoke exposure (NHANES III), although suggestive associations were observed among women (NHANES II: HR 2.7, 95% CI 0.7, 10.0 for ≥20.0 µg/dl vs. <10.0 µg/dl, Ptrend = 0.07; NHANES III: HR 11.2, 95% CI 2.1, 59.4 for ≥10.0 µg/dl vs. <2.5 µg/dl, Ptrend = 0.04). After stratifying on smoking status, an association with elevated BLLs was observed in NHANES II only among former smokers (HR 3.2, 95% CI 1.3, 8.0 for ≥15 vs. <15 µg/dl) and in NHANES III only among current smokers (HR 1.7, 95% CI 1.1, 2.8 for ≥5 vs. <5 µg/dl). In summary, we found elevated BLLs to be associated with lung cancer mortality among women in both NHANES II and III. Given the absence of an association among non‐smokers, we cannot rule out residual confounding as an explanation for our findings.

Efficient and Robust Propensity-Score-Based Methods for Population Inference using Epidemiologic Cohorts

Preprint

Nov 2020

Most epidemiologic cohorts are composed of volunteers who do not represent the general population. To enable population inference from cohorts, we and others have proposed utilizing probability survey samples as external references to develop a propensity score (PS) for membership in the cohort versus survey. Herein we develop a unified framework for PS-based weighting (such as inverse PS weighting (IPSW)) and matching methods (such as kernel-weighting (KW) method). We identify a fundamental Strong Exchangeability Assumption (SEA) underlying existing PS-based matching methods whose failure invalidates inference even if the PS-model is correctly specified. We relax the SEA to a Weak Exchangeability Assumption (WEA) for the matching method. Also, we propose IPSW.S and KW.S methods that reduce the variance of PS-based estimators by scaling the survey weights used in the PS estimation. We prove consistency of the IPSW.S and KW.S estimators of population means and prevalences under WEA, and provide asymptotic variances and consistent variance estimators. In simulations, the KW.S and IPSW.S estimators had smallest MSE. In our data example, the original KW estimates had large bias, whereas the KW.S estimates had the smallest MSE.

A three-part regression calibration to handle excess zeroes, skewness and heteroscedasticity in adjusting for measurement error in dietary intake data

Article

Nov 2020

Exposure measurement error (ME) biases exposure-outcome associations. Calibration dietary intake data used in the regression calibration (RC) response to adjust for ME are usually right-skewed, heteroscedastic and with excess zeroes. We proposed three-part RC models to handle these distributional complexities simultaneously , while correcting for ME in fish intake. We applied data from the National Health and Nutrition Examination Survey (NHANES), where long-term intake was measured with food frequency questionnaire (FFQ) in the main study and short-term intake with 24-hour recall (24HR) in the calibration study. In the three-part RC models, never consumers were modelled using two approaches: a zero distribution (Three-part RC-het-det), and logistic distribution (Three-part RC-het-prob); heteroscedasticity using an exponential distribution and right-skewness using generalized gamma distribution. The proposed models were compared with two-part RC model that ignores never consumers, and with methods that estimate intakes using FFQ and 24HR. The models were evaluated in a simulation study. With NHANES data, mean increase in the mercury level (in μg/L) was 1.20 using FFQ-method, 0.4 using 24HR-method, 1.87 using two-part RC and 2.02 using three-part RC-het-prob method. The three-part RC estimated the association with the least bias in the simulation study.

Adjusted Logistic Propensity Weighting Methods for Population Inference using Nonprobability Volunteer-Based Epidemiologic Cohorts

Preprint

Full-text available

Jul 2020

Many epidemiologic studies forgo probability sampling and turn to nonprobability volunteer-based samples because of cost, response burden, and invasiveness of biological samples. However, finite population inference is difficult to make from the nonprobability samples due to the lack of population representativeness. Aiming for making inferences at the population level using nonprobability samples, various inverse propensity score weighting (IPSW) methods have been studied with the propensity defined by the participation rate of population units in the nonprobability sample. In this paper, we propose an adjusted logistic propensity weighting (ALP) method to estimate the participation rates for nonprobability sample units. Compared to existing IPSW methods, the proposed ALP method is easy to implement by ready-to-use software while producing approximately unbiased estimators for population quantities regardless of the nonprobability sample rate. The efficiency of the ALP estimator can be further improved by scaling the survey sample weights in propensity estimation. Taylor linearization variance estimators are proposed for ALP estimators of finite population means that account for all sources of variability. The proposed ALP methods are evaluated numerically via simulation studies and empirically using the na\"ive unweighted National Health and Nutrition Examination Survey III sample, while taking the 1997 National Health Interview Survey as the reference, to estimate the 15-year mortality rates.

Active gingival inflammation is linked to hypertension

Article

Full-text available

Jun 2020
J Hypertens

Background: Cardiovascular diseases (CVD) including hypertension, are characterized by underlying systemic inflammation. Periodontitis, which can impact the systemic inflammatory burden has recently been linked to high blood pressure (BP). However, the relationship of gingival bleeding, as an easily accessible marker of periodontal disorder, with hypertension, remains unclear. Methods: Survey-based propensity score matching (PSM) incorporating major confounders shared between hypertension and periodontal diseases was applied to cross-sectional NHANES III data from 5396 adults at least 30 years old who underwent BP measurement and periodontal examination, identifying two matched groups with and without gingival bleeding. The association of bleeding gums with SBP (mmHg) and high/uncontrolled BP was then assessed with generalized additive models incorporating inflammatory markers. Stratification by periodontal status (healthy; gingivitis; stable periodontitis; unstable periodontitis) was performed. Variables importance was estimated using machine learning. Results: Gingival bleeding (gingivitis; unstable periodontitis) was independently associated with +2.6 mmHg (P < 0.001) SBP compared with no bleeding (healthy periodontium; stable periodontitis), and with greater odds (OR = 1.42; 95% CI = 1.19-1.68; P < 0.001) of high/uncontrolled BP. Participants with unstable periodontitis had higher SBP than those with stable periodontitis (+2.1 mmHg; P < 0.001) or gingivitis (+5.3 mmHg; P < 0.001). Unstable periodontitis and gingivitis were consistently associated with increased risk of high/uncontrolled BP (OR = 1.65, 95% CI = 2.14-1.82; OR = 1.49, 95% CI = 1.22-1.82, respectively). Inflammatory markers allowed a maximum of 12% gain in the models' predictive power. Conclusion: Gingival bleeding contributes to shaping the relationship between periodontal diseases and BP, but the burden represented by periodontitis is also crucial. Periodontal evaluation might be of importance in difficult to control hypertension.

The association of clinically determined periodontal disease and edentulism with total cancer mortality: The National Health and Nutrition Examination Survey III

Article

Full-text available

Mar 2020
INT J CANCER

Increasing evidence supports a positive association between periodontal disease and total cancer risk. We evaluated the association of clinically assessed periodontal disease and a consequence, edentulism with total cancer mortality in participants without a prior cancer diagnosis in a U.S. nationally representative population. Included were 6,034 participants aged ≥40 years without a prior cancer diagnosis who participated in the National Health and Nutrition Examination Survey III. Periodontal health was measured by trained dentists. Cancer deaths (n = 702) were ascertained during a median of 21.3 years of follow‐up. Cox proportional hazards regression was used to estimate the association of periodontal disease and edentulism with total cancer mortality using no periodontal disease/dentate as the reference and adjusting for potential demographic, lifestyle including smoking and social factor confounders. Fifteen percent had periodontitis and 17% were edentulous. Periodontitis was not statistically significantly associated with risk of total cancer death after multivariable adjustment. Edentulism was associated with an increased risk of cancer mortality (hazard ratio = 1.50, 95% confidence interval = 1.12–2.00) after multivariable adjustment, including in men and women and in each racial/ethnic group studied. The positive association was observed in overweight/obese participants but not participants with normal body mass index, more strongly in prediabetic/diabetic participants than in participants without diabetes and in ever cigarette smokers but not in never cigarette smokers. In this U.S. nationally representative population, those with edentulism, but not periodontal disease, had a higher risk of total cancer death, especially in those with shared risk factors for periodontal disease and cancer.

Development and validation of sensitive method for determination of serum cotinine in smokers and nonsmokers by liquid chromatography/atmospheric pressure ionization tandem mass spectrometry

Article

Dec 1997

We describe a sensitive and specific method for measuring cotinine in serum by HPLC coupled to an atmospheric pressure chemical ionization tandem mass spectrometer. This method can analyze 100 samples/day on a routine basis, and its limit of detection of 50 ng/L makes it applicable to the analysis of samples from nonsmokers potentially exposed to environmental tobacco smoke. Analytical accuracy has been demonstrated from the analysis of NIST cotinine standards and from comparative analyses by both the current method and gas chromatography/high-resolution mass spectrometry. Precision has been examined through the repetitive analysis of a series of bench and blind QC materials. This method has been applied to the analysis of cotinine in serum samples collected as part of the Third National Health and Nutrition Examination Survey (NHANES III).

Association between the Prognostic Nutritional Index and Dietary Intake in Community-Dwelling Older Adults with Heart Failure: Findings from NHANES III

Article

Full-text available

Oct 2019

The objective of this study was to examine the association between nutritional status and dietary intake in community-dwelling older adults with heart failure (HF). A cross-sectional analysis of NHANES III data was conducted. The analytic sample was comprised of n = 445 individuals aged 50+ years with congestive HF (54.4% male, 22.9% non-Hispanic Black, 43.8% low-income). Nutritional status was measured using the Prognostic Nutritional Index (PNI). Participants were classified by PNI quintiles with lower PNI scores indicating lower nutritional status. Participants in quintile 5 showed significantly greater intakes of energy, protein, vegetables, magnesium, zinc, copper, potassium, red meat, saturated fat, and sodium. In multivariate analyses, increased intake of red meat (β = 0.253, p = 0.040) and vegetables (β = 0.255, p = 0.038) was associated with significantly better nutritional status. In the absence of comprehensive nutritional guidance for HF patients, it appears that small increases in energy, protein (red meat), and vegetable consumption are associated with improved nutritional status.

Periodontal Antibodies and All-Cause and Cardiovascular Disease Mortality

Article

Full-text available

Oct 2019

Periodontitis is positively linked to cardiovascular disease (CVD), diabetes, cancer, and increased mortality. Empirically derived clusters of IgG antibodies against 19 selected periodontal microorganisms have been associated with hyperglycemia. We further investigated associations between these serum IgG antibody clusters and all-cause and CVD mortality in a representative US population. Participants free of CVD and cancer and aged ≥40 y at baseline ( N = 6,491) from the Third National Health and Nutrition Examination Survey (1988 to 1994) were followed up until December 31, 2011. Antibodies were categorized into 4 clusters: red-green, orange-red, yellow-orange, and orange-blue. Over a 23-y follow-up, 2,702 deaths occurred, including 810 CVD-related deaths. In fully adjusted Cox proportional hazard models, the red-green cluster was positively associated with all-cause mortality (tertile 3 vs. tertile 1: hazard ratio [HR] = 1.43, 95% CI = 1.08 to 1.90, P = 0.015). The yellow-orange cluster was inversely associated with all-cause mortality (tertile 3 vs. tertile 1: HR = 0.78, 95% CI = 0.63 to 0.97, P = 0.028) and CVD mortality (tertile 2 vs. tertile 1: HR = 0.57, 95% CI = 0.42 to 0.77, P = 0.005). The orange-blue cluster (composed of antibodies against Eubacterium nodatum and Actinomyces naeslundii) was inversely associated with all-cause mortality (tertile 3 vs. tertile 1: HR = 0.65, 95% CI = 0.55 to 0.78, P < 0.0001) and CVD mortality (tertile 3 vs. tertile 1: HR = 0.65, 95% CI = 0.47 to 0.88, P = 0.007). These antibodies could predict prognosis or be potential intervention targets to prevent systemic effects of periodontal disease if further studies establish a causal relationship.

Definition of hypertension‐associated oral pathogens in NHANES

Article

Full-text available

May 2019

Background: Increasing evidence links periodontal microbiota to several systemic conditions, including high blood pressure (BP). Antibodies to oral pathogens can be considered an indirect assessment of periodontal bacterial burden. We aimed at assessing the relationship between systemic exposure to periodontal microbiota, expressed in terms of relative antibodies, and BP, using data from NHANES III. Methods: We analyzed cross-sectional, nationally representative data from 7928 adults aged ≥40 years who underwent determination of BP and serum antibodies to 21 periodontal microorganisms. BP was examined as both continuous (mmHg) and binary (≷130/80 mmHg, ie. normal/controlled or high/uncontrolled BP) variable. Pearson's and Spearman's correlations, restricted maximum likelihood, crude and adjusted generalized additive models, and a machine learning approach based on gradient boosting modelling were combined to verify any association between antibodies to periodontal microbiota and BP. Results: Antibodies to C. rectus, V. parvula, and P. melaninogenica were consistently associated with high/uncontrolled BP by about +3 mmHg of systolic and +2 mmHg of diastolic BP and with 10-13% higher odds of high/uncontrolled BP, as well as with more active periodontal disease and greater changes in clinical parameters of periodontitis. Antibodies to C. rectus resulted in the strongest association with BP. Conclusions: There is an association between systemic exposure to periodontal microbiota and BP. Understanding the pathogenetic mechanisms that shape such relationship, and the relative potential impact on personalized medicine, is the challenge of future research. This article is protected by copyright. All rights reserved.

Influential factors on cognitive performance in middle-aged cohort: Third National Health and Nutrition Examination Survey-based study

Article

Full-text available

Sep 2018
MEDICINE

Aging-associated cognitive decline is closely linked to illness, dementia, increased mortality, and is a major health and social issue. The purpose of this study was to determine modifiable factors associated with cognitive performance. We analyzed data from a random sample of participants of the Third National Health and Nutrition Examination Survey, which is a cross-sectional survey, of the US population, aged 20 to 59 years, who underwent computer-based neurocognitive testing. There were 5 outcome measures in 3 neurocognitive tests: the mean of simple reaction time test, the mean total latency of the symbol digit substitution test (SDST), the average number of errors of the SDST, the average trials to criterion of the serial digit learning test (SDLT), and the average total score of the SDLT. Socioeconomic status, including older age, black ethnicity, lower income ratio, and lower education level, were associated with poorer neurocognitive function in all analyzed tests. In addition, participants with poor health, nonsmokers, and nondrinkers performed worse in all administered tests compared with individuals with good health, smokers, and participants consuming alcoholic beverages. Dietary and biochemical characteristics of the blood were not consistently associated with neurocognitive performance. Our results indicate that socioeconomic factors, health-related and dietary habits, biochemical parameters of the blood, and job category were associated with neurocognitive performance in visual attention, learning, and concentration in a large, nationally representative sample of healthy, ethnically diverse 20 to 59-year-olds. Future studies are needed to understand the mechanisms of cognitive aging and the factors that contribute to its individual differences.

Exhaled NO reference limits in a large population-based sample using the Lambda-Mu-Sigma method

Article

Aug 2018

Absolute values are used in the interpretation of the fraction of exhaled nitric oxide (FeNO), but it has been suggested that equations to calculate reference values may be a practical and clinically useful approach. We hypothesize that the application of the Lambda-Mu-Sigma (LMS) method may improve FeNO reference equations and their interpretation. Our aims were to develop FeNO reference equations with the LMS method and to describe the difference between this method and the absolute fixed cut-offs of the current recommendations. We utilized the United States National Health and Nutrition Examination Surveys 2007–2012 and included healthy individuals with no respiratory diseases and blood eosinophils <300/mm ³ ( n = 8,340). Natural log-transformed FeNO was modeled using the LMS method, imbedded in the generalized additive models for location, scale, and shape models. A set of FeNO reference equations was developed. The explanatory variables were sex, age, height, smoking habits, and race/ethnicity. A significant proportion of individuals with normal FeNO given by the equations were classified as having intermediate levels by the current recommendations. Further lower predicted FeNO compared with previous linear models was seen. In conclusion, we suggest a novel model for the prediction of reference FeNO values that can contribute to the interpretation of FeNO in clinical practice. This approach should be further validated in large samples with an objective measurement of atopy and a medical diagnosis of asthma and rhinitis. NEW & NOTEWORTHY Novel reference equations and fraction of exhaled nitric oxide (FeNO)-predicted values to improve interpretation of FeNO in clinical practice are presented. These may increase the accuracy of ruling out airway inflammation in patients with asthma or suspected asthma.

Association between Cluster of Antibodies against Periodontal Microorganisms and Alzheimer's Disease Mortality: Evidence from a Nationally Representative Survey in the US

Article

Jul 2023
J PERIODONTOL

Background: Alzheimer's Disease (AD) has been linked with periodontal microorganisms such as P. gingivalis in observational and mechanistic studies. IgG antibodies against periodontal microorganisms which are markers of past and current periodontal infection have been correlated with cognitive impairment. We examined associations between empirically derived groups of 19 IgG antibodies against periodontal microorganisms and AD mortality. Methods: Individuals participating in NHANES III with complete data on IgG titers and were followed up between 1988 and December 31st, 2019. The outcome was AD mortality and the main exposures were IgG antibodies against periodontal microorganisms classified into four mutually exclusive groups using cluster analysis. Survey-weighted Cox proportional hazard models were used to evaluate adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for the relationship between clusters and AD mortality. Results: With up to 21 years of follow-up, 160 AD-related death were documented. In the multivariable-adjusted model, AD mortality overall was not associated with the Red-Green (aHR 1.18; 95% CI 0.46-3.07), Yellow-Orange (aHR 1.36; 95% CI 0.58-3.19), Orange-Blue (aHR 0.63; 95% CI 0.33-1.21), and the Orange-Red (aHR 0.79; 95% CI 0.37-1.70) when the upper tertiles were compared to the bottom tertiles. However, the subgroup of middle-aged individuals in the highest tertile of the Red-Green cluster, but not older individuals, had a 13% higher risk of AD mortality (aHR 1.13; 95% CI 1.02-1.26) compared with those in the bottom tertile. Conclusion: Clusters of IgG antibodies against periodontal microorganisms did not predict AD mortality in this study. This article is protected by copyright. All rights reserved.

The association between iron metabolism with the change of blood pressure and risk of hypertension: A large cross-sectional study

Article

May 2023
J TRACE ELEM MED BIO

Background: The relationship between iron metabolism and variations in blood pressure and hypertension risk is still not clear. This study aimed to determine whether iron metabolism is associated with changes in blood pressure and hypertension prevalence in the general United States population. Methods: The National Health and Nutrition Examination Survey (NAHNES) database contains data on 116876 Americans from 1999 to 2020 years. Data from the NHANES database were used to examine the relationships between iron metabolism (serum iron [SI], serum ferritin [SF], and soluble transferrin receptor [sTfR]) and changes in blood pressure and hypertension prevalence. Generalized linear models and restricted cubic spline (RCS) plot curves were used to estimate the relationship between iron metabolism and hypertension. Further, generalized additive models with smooth functions were used to identify the relationship between iron metabolism and blood pressure. Finally, a stratified subgroup analysis was performed. Results: A total of 6710 participants were included in our analysis. The RCS plot showed a linear relationship between SI, as well as sTfR, and hypertension prevalence. SF and hypertension prevalence were associated in a J-shape. In addition, the relationship between SI and systolic blood pressure (SBP) and diastolic blood pressure (DBP) decreased initially and then increased. A correlation between SF, SBP, and DBP first decreased, then increased, and finally decreased. A positive linear correlation existed between sTfR and SBP, but it increased and then decreased with DBP. Conclusion: The correlation between SF and hypertension prevalence displayed a J-curve. In contrast, the correlation between SI, as well as sTfR, and hypertension risk was negative and positive, respectively.

Higher dietary intake of aromatic amino acids was associated with lower risk of cardiovascular disease mortality in adult participants in NHANES III

Article

Mar 2023
NUTR RES

Little is known about the associations between dietary aromatic amino acids (AAAs) intake and mortality from all causes and cardiovascular disease (CVD). Accordingly, we evaluated these associations in the adult population of the United States using data from the Third National Health and Nutrition Examination Survey. This was a cohort study. Dietary intake of AAAs (tyrosine, phenylalanine, and tryptophan) was determined from the total nutrient intake document. We hypothesized that higher dietary AAA intake would lower all-cause and CVD mortality in adults in the United States. First, we categorized participants into quintiles based on their dietary intakes of total AAAs, tyrosine, phenylalanine, and tryptophan. Then, we established 4 Cox proportional-hazards models (models 1-4) and calculated hazard ratios and 95% confidence intervals to estimate the associations between dietary intakes of total AAAs, tyrosine, phenylalanine, and tryptophan and all-cause and CVD mortality. Mortality status was primarily obtained from files linked to the National Death Index records up to December 31, 2015. After multivariate adjustment, the hazard ratios (95% confidence intervals) of CVD mortality in the highest quintiles of dietary total AAAs, tyrosine, phenylalanine, and tryptophan intake (reference: the lowest quintiles) were 0.66 (0.52-0.84), 0.65 (0.51-0.83), 0.66 (0.52-0.85) and 0.64 (0.50-0.82), respectively. In a nationally representative cohort, higher dietary intakes of total AAA and the 3 individual AAAs were independently associated with a lower risk of CVD mortality, and these associations were stronger in non-Hispanic White people than in other people.

Comparison of Current World Health Organization Guidelines with Physiologically Based Serum Ferritin Thresholds for Iron Deficiency in Healthy Young Children and Nonpregnant Women Using Data from the Third National Health and Nutrition Examination Survey

Article

Feb 2023
J NUTR

Background: Current WHO serum ferritin (SF) thresholds for iron deficiency (ID) in children (<12 μg/L) and women (<15 μg/L) are derived from expert opinion based on radiometric assays in use decades ago. Using a contemporary immunoturbidimetry assay, higher thresholds (children, <20 μg/L; women, <25 μg/L) were identified from physiologically based analyses. Objective: We examined relationships of SF measured using an immunoradiometric assay from the era of expert opinion with 2 independently measured indicators of ID, hemoglobin (Hb) and erythrocyte zinc protoporphyrin (eZnPP), using data from the Third National Health and Nutrition Examination Survey (NHANES III, 1988-1994). The SF at which circulating Hb begins to decrease and eZnPP begins to increase provides a physiological basis for identifying the onset of iron-deficient erythropoiesis. Methods: We analyzed NHANES III cross-sectional data from 2616 apparently healthy children, aged 12-59 mo, and 4639 apparently healthy nonpregnant women, aged 15-49 y. We used restricted cubic spline regression models to determine SF thresholds for ID. Results: SF thresholds identified by Hb and eZnPP did not differ significantly in children, 21.2 μg/L (95% confidence interval: 18.5, 26.5) and 18.7 μg/L (17.9, 19.7), and, in women, were similar although significantly different, 24.8 μg/L (23.4, 26.9) and 22.5 μg/L (21.7, 23.3). Conclusions: These NHANES results suggest that physiologically based SF thresholds are higher than the thresholds from expert opinion established during the same era. SF thresholds found using physiological indicators detect the onset of iron-deficient erythropoiesis, whereas the WHO thresholds identify a later, more severe stage of ID.

Impact of Thyroid Function on the Prevalence and Mortality of Metabolic Dysfunction-Associated Fatty Liver Disease

Article

Jan 2023
J CLIN ENDOCR METAB

Purpose: Thyroid function variation within thyroxine reference range has negative metabolic effects. Metabolic dysfunction-associated fatty liver disease (MAFLD) is a recently proposed definition. We aim to explore the effects of thyroid function status on prevalence and mortality of MAFLD. Methods: Data of 10,666 participants from the Third National Health and Nutrition Examination Survey (NHANES III) were used. MAFLD was diagnosed based on the new definition. Thyroid function variation within thyroxine reference range was defined based on thyroid stimulating hormone (TSH) levels as following: subclinical hyperthyroidism, < 0.39 mIU/L; strict-normal thyroid function, 0.39-2.5 mIU/L; and low thyroid function, > 2.5 mIU/L, which was the combination of low-normal thyroid function (2.5-4.5 mIU/L) and subclinical hypothyroidism (> 4.5 mIU/L). Logistic and cox regression were used in multivariate analysis. Results: Low thyroid function is independently associated with MAFLD (Odds ratio: 1.27). Compared with strict-normal thyroid function, subclinical hypothyroidism was significantly associated with increased risk for all-cause and cardiovascular mortality in total population (Hazard ratio [HR] for all-cause: 1.23; cardiovascular: 1.65) and MAFLD population (HR for all-cause: 1.32; cardiovascular: 1.99), meanwhile, with low-normal thyroid function group, increasing trend in mortality risk was observed. Furthermore, low thyroid function also showed significant negative impact on mortality in total and MAFLD population. Among thyroid function spectrum, mild subclinical hypothyroidism showed the highest HRs on mortality. Conclusions: Low thyroid function is independent risk factor of MAFLD and is associated with increased risk for all-cause and cardiovascular mortality in MAFLD population. Reevaluation of TSH reference range should be considered.

SVM-Based Blood Exam Classification for Predicting Defining Factors in Metabolic Syndrome Diagnosis

Article

Full-text available

Mar 2022

Biomarkers have already been proposed as powerful classification features for use in the training of neural network-based and other machine learning and artificial intelligence-based prognostic models in the scientific field of personalized nutrition. In this paper, we construct and study cascaded SVM-based classifiers for automated metabolic syndrome diagnosis. Specifically, using blood exams, we achieve an average accuracy of about 84% in correctly classifying body mass index. Similarly, cascaded SVM-based classifiers achieve a 74% accuracy in correctly classifying systolic blood pressure. Next, we propose and implement a system that achieves an 84% accuracy in metabolic syndrome prediction. The proposed system relies not only on prediction of the body mass index but also on prediction from blood exams of total cholesterol, triglycerides and glucose. For the aim of self-completeness of the paper, the key concepts with regard to metabolic syndrome are summarized, and a review of previous related work is included. Finally, conclusions are drawn and indications for related future research are outlined.

Discovery of Novel Trans-Ancestry and Ancestry-Specific Gene Loci for Total Testosterone in a Multi-Ancestral Analysis of Men in the Million Veteran Program

Preprint

Feb 2022

Utilizing data from the Million Veteran Program (MVP), we investigated the genetic determinants underlying total testosterone levels via a multi-ancestral analysis of 124,593 individuals of European (n=88,385), African (n=25,235) and Hispanic (n=10,973) ancestry. We identified 46 trans-ancestry variants and 17 ancestry-specific variants, of which 14 trans-ancestry variants and 15 ancestry-specific variants are novel associations with testosterone. Results implicate genes regulating testosterone shared across ancestral groups, which include SHBG, JMJD1C, FXR2, SENP3, TNFSF12-TNFSF13 while also implicating genes such as MSN, DMD, VSIG4, CHEK2, TKTL1 that may underlie ancestry-group differences in testosterone regulation. We also linked testosterone variants on the X chromosome with differential risk of chronic kidney disease and hereditary hemolytic anemias in African and Hispanic ancestry groups, respectively. Lastly, we constructed a polygenic score from our 46 trans-ancestry variants and associated it with testicular dysfunction, hyperlipidemia, gout and prostate cancer with stronger prostate cancer associations in Hispanic and African ancestry groups compared to the European ancestry group. These findings provide insight into ancestry-specific androgen regulation and identify novel variants for disease risk stratification in patients.

Antibodies against Periodontal Microorganisms and Cognition in Older Adults

Article

Feb 2022

Introduction Markers of poor oral health are associated with impaired cognition and higher risk of Alzheimer disease (AD) and thus may help predict AD. Objectives The aim of this study was to evaluate the cross-sectional association between empirically derived groups of 19 IgG antibodies against periodontal microorganisms and cognition in middle-aged and older adults. Methods The study population consisted of participants of the third National Health and Nutrition Examination Survey (NHANES III) (1988 to 1994), who were 60 y and older, among whom cognition and IgG antibodies against 19 periodontal microorganisms were measured (N = 5,162). Results In multivariable quantile regression analyses, the Orange-Red (Prevotella melaninogenica, Prevotella intermedia, Prevotella nigrescens, Porphyromonas gingivalis) and Yellow-Orange (Staphylococcus intermedius, Streptococcus oralis, Streptococcus mutans, Fusobacterium nucleatum, Peptostreptococcus micros, Capnocytophaga ochracea) cluster scores were negatively associated with cognition. A 1-unit higher cluster score for the Orange-Red cluster was associated on average with a lower cognitive score (β for 30th quantile = −0.2640; 95% confidence interval [CI], −0.3431 to −0.1848). Similarly, a 1-unit higher score for the Yellow-Orange cluster was associated with a lower cognitive score (β for 30th quantile = −0.2445; 95% CI, −0.3517 to −0.1372). Conclusion Groups of IgG antibodies against periodontal microorganisms were associated with lower cognition among free living adults 60 years and older, who were previously undiagnosed with cognitive impairment. Though poor oral health precedes the development of dementia and AD, oral health information is currently not used, to our knowledge, to predict dementia or AD risk. Combining our findings with current algorithms may improve risk prediction for dementia and AD. Knowledge Translation Statement IgG antibodies against periodontal microorganisms were associated with lower cognition among adults 60 years and older previously undiagnosed with cognitive impairment. Periodontal disease may predict cognition among older adults.

Association between groups of immunoglobulin G antibodies against periodontal microorganisms and diabetes related mortality

Article

Feb 2022

Background: Immunoglobulin G (IgG) antibodies against periodontal microorganisms can be markers of periodontal infection because their levels rise following infection and remain elevated several years later. Methods: We evaluated the relation between groups of IgG antibodies against 19 periodontal microorganisms and diabetes related mortality over 27 years among participants of the National Health and Nutrition Examination Survey III (1988 to 1992) 40 years and older at the time of examination (N = 8153). Results: Individuals in the highest versus lowest antibody tertiles were at 86% higher risk of dying due to diabetes related causes in the Red-Green antibody cluster (T. forsythia, T. denticola, A. actinomycetemcomitans, E. corrodens, S. noxia, V. parvula, C. rectus) (HR = 1.86, 95% CI 1.09 to 3.20) and 55% lower in the Orange-Blue antibody cluster (E. nodatum, A. naeslundii) (HR = 0.45, 95% CI 0.32 to 0.63) in multivariable models. In these models, individuals with diabetes at the time of examination had a 16-fold higher risk of dying due to diabetes related causes (HR = 16.4, 95% CI 11.0 to 24.7). Conclusion: As a subset of periodontal microorganisms are associated with adverse systemic outcomes, antibody profiles may help in prediction of diabetes related mortality and identify sub-groups of individuals among whom periodontal treatment may impact diabetes related outcomes. This article is protected by copyright. All rights reserved.

The Accelerated Aging Phenotype: The role of race and social determinants of health on aging

Article

Dec 2021
AGEING RES REV

The pursuit to discover the fundamental biology and mechanisms of aging within the context of the physical and social environment is critical to designing interventions to prevent and treat its complex phenotypes. Aging research is critically linked to understanding health disparities because these inequities shape minority aging, which may proceed on a different trajectory than the overall population. Health disparities are characteristically seen in commonly occurring age-associated diseases such as cardiovascular and cerebrovascular disease as well as diabetes mellitus and cancer. The early appearance and increased severity of age-associated disease among African American and low socioeconomic status (SES) individuals suggests that the factors contributing to the emergence of health disparities may also induce a phenotype of ‘premature aging’ or ‘accelerated aging’ or ‘weathering’. In marginalized and low SES populations with high rates of early onset age-associated disease the interaction of biologic, psychosocial, socioeconomic and environmental factors may result in a phenotype of accelerated aging biologically similar to premature aging syndromes with increased susceptibility to oxidative stress, premature accumulation of oxidative DNA damage, defects in DNA repair and higher levels of biomarkers of oxidative stress and inflammation. Health disparities, therefore, may be the end product of this complex interaction in populations at high risk. This review will examine the factors that drive both health disparities and the accelerated aging phenotype that ultimately contributes to premature mortality.

The trend and pattern of depression prevalence in the U.S.: Data from National Health and Nutrition Examination Survey (NHANES) 2005 to 2016

Article

Nov 2021
J AFFECT DISORDERS

Background: To assess the trend and pattern of depression prevalence among adult population by demographic characteristics and severity of disease from 2005 to 2016. Methods: We used six cycles of National Health and Nutrition Examination Survey. The Patient Health Questionnaire (PHQ-9) was used to measure of depression with the total score ranges 0-27. Socio-demographic variables including age, gender, marital status, race, education, and poverty income ratio (PIR) were used. The weighted prevalence was calculated for each cycle. Logistic regression was used for assessing time-trends in the prevalence of depression. Results: A total of 31191 participants aged>20 years were included. The intensity of prevalence trend was different among subgroups of demographic characteristics. Prevalence in females was 1.5-fold more than that in males and increased approximately 2-fold during the study period. The prevalence in “never married” and “other marital status” subgroups was almost 1.5-fold and 2-fold more than that in “married” subgroup, respectively. Prevalence in the never married subgroup increased 2-fold from the first cycle to the latest one. The prevalence of depression was more in the aged<60 years, race group other than white, low education and PIR≤1 subgroups. But, the intensity of the increasing trend was more in the subgroups of aged≥60 years, white race and PIR>1. Limitations: the possibility of age-period-cohort (APC) effect that we were unable to assess and control them. Conclusions: In sum, there was an overall increasing trend of depression which was different by demographic characteristics based on subtype of depression.

Multiple Imputation of Missing Data in Practice: Basic Theory and Analysis Strategies

Book

Sep 2021

Efficient and robust propensity‐score‐based methods for population inference using epidemiologic cohorts

Article

Sep 2021

Most epidemiologic cohorts are composed of volunteers who do not represent the general population. To improve population inference from cohorts, propensity-score (PS)-based matching methods, such as PS-based kernel weighting (KW) method, utilise probability survey samples as external references to develop PSs for membership in the cohort versus survey. We identify a strong exchangeability assumption (SEA) that underlies existing PS-based matching methods whose failure invalidates inferences, even if the propensity model is correctly specified. Herein, we develop a framework of propensity estimation and relax the SEA to a weak exchangeability assumption (WEA) for matching methods. To recover efficiency, we propose a scaled KW (KW.S) matching method by scaling survey weights in propensity estimation. We prove consistency of KW.S estimators of means/prevalences under WEA and provide consistent finite population variance estimators. In simulations, the KW.S estimators had smallest mean squared error (MSE). Our data example showed the KW estimates requiring the SEA had large bias, whereas the proposed KW.S estimates had the smallest MSE.

Prognostic implications of differences in forced vital capacity in black and white US adults: Findings from NHANES III with long-term mortality follow-up

Article

Full-text available

Sep 2021

Background Because Forced Vital Capacity (FVC) is reduced in Black relative to White Americans of the same age, sex, and height, standard lung function prediction equations assign a lower "normal" range for Black patients. The prognostic implications of this race correction are uncertain. Methods We analyzed 5,294 White and 3,743 Black participants age 20–80 in NHANES III, a nationally-representative US survey conducted 1988–94, which we linked to the National Death Index to assess mortality through December 31, 2015. We calculated the FVC-percent predicted among Black and White participants, first applying NHANES III White prediction equations to all persons, and then using standard race-specific prediction equations. We used Cox proportional hazard models to calculate the association between race and all-cause mortality without and with adjustment for FVC (using each FVC metric), smoking, socioeconomic factors, and comorbidities. Findings Black participants’ age- and sex-adjusted mortality was greater than White participants (HR 1.46; 95%CI:1.29, 1.65). With adjustment for FVC in liters (mean 3.7 L for Black participants, 4.3 L for White participants) or FVC percent-predicted using White equations for everyone, Black race was no longer independently predictive of higher mortality (HR∼1.0). When FVC-percent predicted was “corrected” for race, Black individuals again showed increased mortality hazard. Deaths attributed to chronic respiratory disease were infrequent for both Black and White individuals. Interpretation Lower FVC in Black people is associated with elevated risk of all-cause mortality, challenging the standard assumption about race-based normal limits. Black-White disparities in FVC may reflect deleterious social/environmental exposures, not innate differences. Funding No funding.

The Science of Environmental Pollution

Book

Apr 2021

Frank R. Spellman

Relationship Between Vitamin D Level and Mortality in Adults With Psoriasis: A Retrospective Cohort Study of NHANES Data

Article

Dec 2020
CLIN THER

Purpose Studies have shown an increased risk for mortality in patients with psoriasis. Furthermore, research has demonstrated an inverse relationship between 25-hydroxyvitamin D (25[OH]D) level and all-cause mortality. This study investigated the association between 25(OH)D level and all-cause mortality in US adults with psoriasis. Methods Data from NHANES (1999–2014 and mortality data through December 31, 2015) were analyzed. Quartiles of 25(OH)D level were created based on 25(OH)D levels among patients. Cox proportional hazards models were used for estimating hazard ratios (95% CI) for all-cause mortality. Findings A total of 82,091 participants were enrolled in the NHANES study from 1999 to 2014. Overall, 610 patients with psoriasis were identified in NHANES. The mean (SD) duration of follow-up was 5.61 (3.38) years (3427.92 person-years). The hazard ratio for mortality in the fully adjusted model was 0.12 (95% CI, 0.02–0.60; Ptrend = 0.01) in patients with a high 25(OH)D concentration compared to those with 25(OH)D deficiency. Implications The 25(OH)D concentration was significantly inversely associated with all-cause mortality among these patients with psoriasis. Studies have shown an increased risk for mortality in patients with psoriasis compared to the general population. Vitamin D is not regularly metabolized in patients with psoriasis due to their skin abnormality. Vitamin D supplementation has been associated with a reduced mortality in patients with psoriasis. In practice, attention to vitamin D level is crucial, as is the use of vitamin D supplementation, for improving the health of these patients.

The prevalence of clinically meaningful malocclusion among US adults

Article

Jun 2019

Objective the primary purpose of this study was to statistically evaluate age, ethnic and sex differences in the prevalence of clinically meaningful malocclusions among adults. Setting and Sample Population A random sample of 8804 untreated US adults between 17 and 46 years of age were selected from the Third National Health and Nutrition Examination Survey data. Materials & Methods Three ethnic (non‐Hispanic White, Non‐Hispanic Black and Mexican Americans) and three age (17‐26, 27‐36, 37‐46 years) groups were evaluated. Subjects with and without clinically meaningful malocclusions were categorized based on established cut‐off values. Chi‐square analyses were performed to determine differences in prevalence. Results The prevalence of clinically meaningful mandibular incisor irregularity, overjet and overbite increased significantly (p<.05) with age, while posterior crossbite decreased. There were statistically significant ethnic differences in the prevalence of incisor irregularity, overbite, overjet, open bite, and reverse overjet. Males had a significantly higher prevalence of clinically meaningful mandibular incisor irregularity, overbite, open bite and reverse overjet than females. One‐third of US adults exhibited no clinically meaningful malocclusions. Conclusions There are age, ethnic and sex differences in the prevalence of clinically meaningful malocclusions that characterize approximately two‐thirds of untreated US adults. This article is protected by copyright. All rights reserved.

The relationships between blood lead levels and serum thyroid stimulating hormone and total thyroxine in the third National Health and Nutrition Examination Survey

Article

Oct 2018
J TRACE ELEM MED BIO

Edward F Krieg

Regression analysis was used to estimate and test for relationships between the blood lead concentration and the concentrations of serum thyroid stimulating hormone and serum total thyroxine in adults, 20 years and older, participating in the third National Health and Nutrition Examination Survey. No relationship was found between the blood lead level and the concentration of serum thyroid stimulating hormone. The serum total thyroxine concentration decreased as the blood lead level increased in women, but not in men. The lowest concentration of blood lead at which a relationship could be detected was 2.1 μg/dL and 3.9 μg/dL for the non-pregnant and pregnant women, respectively. Hypothetical mechanisms of the action of lead are discussed.

Proportion of U.S. Trends in Breast Cancer Incidence Attributable to Long-term Changes in Risk Factor Distributions

Article

Aug 2018

Background: U.S. breast cancer incidence has been changing, as have distributions of risk factors, including body mass index (BMI), age-at-menarche, age-at-first-live-birth and number of live births. Methods: Using data for U.S. women from large nationally representative surveys, we estimated risk factor distributions from 1980-2008. To estimate ecologic associations with breast cancer incidence, we fitted Poisson models to age- and calendar-year-specific incidence data from the National Cancer Institute's Surveillance, Epidemiology and End Results registries from 1980-2011. We then assessed the proportion of incidence attributable to specific risk factors by comparing incidence from models that only included age and calendar period as predictors with models that additionally included age- and cohort-specific categorized mean risk factors. Analyses were stratified by age and race. Results: Ecologic associations usually agreed with previous findings from analytic epidemiology. From 1980-2011, compared to the risk factor reference level, increased BMI was associated with 7.6% decreased incidence in women aged 40-44 and 2.6% increased incidence for women aged 55-59. Fewer births were associated with 22.2% and 3.99% increased incidence in women aged 40-44 and 55-59 years, respectively. Changes in age at menarche and age-at-first-live-birth in parous women did not significantly impact population incidence from 1980-2011. Conclusions: Changes in BMI and number of births since 1980 significantly impacted U.S. breast cancer incidence. Impact: Understanding and quantifying long-term impact of risk factor trends on incidence is important to understand the future breast cancer burden and inform prevention efforts.

Variance Estimation for Complex Estimators in Sample Surveys

Article

Jan 1996
J Offic Stat

K.F. Rust

An Overview of Hot-Deck Procedures

Article

Jan 1983

B. L. Ford

Plan and operation of the HANES I augmentation survey of adults 25-74 years United States, 1974-1975

Article

Jul 1978
Vital Health Stat 1 Programs Collect Proced

Plan and initird program of the Health Exuruination Srrrvey

Jan 1965

N Center For Healtb
Statistics

N;tional Center for Healtb Statistics. Plan and initird program of the Health Exuruination Srrrvey. Nationaf Center for Heslth Statistics. Vitaf Health Stat 1(4). 1965.

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Jan 1968

National Center for Heslth Statistics. Plan, operation, and response results of a program of children's examinations. National Center for Herdth Statistics. Vital Health Stzt 1(5). 1968.

Plan and operation of the Health and Nutrition Examination Survey, United States, 1971-73. Nationsd Center for Health Statistics. Vhal Heattb Stst l(lOa)

Jan 1978

H W Miller

Miller HW. Plan and operation of the Health and Nutrition Examination Survey, United States, 1971-73. Nationsd Center for Health Statistics. Vhal Heattb Stst l(lOa). 1978.

Plan and operation of the second National Herdth and Nutrition Examination Snrvey, 1976-80

Jan 1981
1

Engela Mcdowella
Maarerk Masseyjt

McDowellA, EngelA, MasseyJT, MaarerK. Plan and operation of the second National Herdth and Nutrition Examination Snrvey, 1976-80. National Center forHeaIth Statistics. Vitat Herdrb stat 1(15). 1981.

P1sn rmd operution of the Hispanic Hesltb and Nutrition Examination Survey, 1982-S4. National Center for Herdth Statistics

Jan 1985

R R Marrrer

Marrrer RR. P1sn rmd operution of the Hispanic Hesltb and Nutrition Examination Survey, 1982-S4. National Center for Herdth Statistics. Vital Heafth Stat 1(19). 1985.

NHANES HI Ssmple Design-Final Report. Contract No. 282-86-0042

Jan 1988

A Chu
J Wakaberg

Chu A, Wakaberg J. NHANES HI Ssmple Design-Final Report. Contract No. 282-86-0042. Rockville, Md., Westat, Inc., 1988.

Durbin k Design of multistage surveys for estimation of surnpling errors

Jan 1967
16152-64

Durbin k Design of multistage surveys for estimation of surnpling errors. Applied Stat 16152-64.1967.

Sample Survey Methods and Theory

Jan 1953

M H Hnnsen
W N Hnrwitz
W G Madow

Hnnsen MH, Hnrwitz WN, Madow WG. Sample Survey Methods and Theory. New York. John Wiley and Sons, Inc. 1953.

A statistical methodology for analyzing data from a complex survey, the first National Heatth and Nutrition Examination Survey. Nationaf Center forHealth Statistics. Vital Health Stat 2(92). 1982, 15. ForthoferRN. Investigation of nonresponsebias in NHANES

Jan 1983
11-507

J R Lundis
J M Lepkowaki
S A Ekhrnd
S A Stehouwer

Lundis JR, Lepkowaki JM, Ekhrnd SA, Stehouwer SA. A statistical methodology for analyzing data from a complex survey, the first National Heatth and Nutrition Examination Survey. Nationaf Center forHealth Statistics. Vital Health Stat 2(92). 1982, 15. ForthoferRN. Investigation of nonresponsebias in NHANES IL Amer J of Epidemiology 11Z507-15. 1983.

Introduction to varirmce estimation

Jan 1985

K M Welter

Welter, KM. Introduction to varirmce estimation. New York Springer-Verlag. 1985.

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G Jones

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SESUDA~Standard Errors Program for Computing of Standardized Rates from Sample Survey Data

Jan 1981

B V Shah

Shah, BV. SESUDA~Standard Errors Program for Computing of Standardized Rates from Sample Survey Data. Research Triangle Institute, Reseurch Triangle Park, NC. 1981.

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Apr 1977

M M Holt
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Holt, MM. SURREGR. Standard Errors of Regression Coefficients from Srunple Survey Data. Research Triangle Institute, Research Trirmgle Park, NC. 1977. (Revised April 1982 by B.V. Shah.)

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Jan 1989
110-119

P Flyer
K Rust
D Morganstein

Flyer P, Rust K, and Morganstein D. Complex survey varharce estimation and contingency table analysis using replication. 1989 Proceedings of the Survey Research Methods Section of the American Statistical Association, 110-19.1990.

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Jan 1986
396-399

Johnson C Kovarmg

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Evaluation of design effects for the Mexican-Americunportion of theHkpanic Heuhh and Nutrition Examination Survey

Jan 1987
595-600

J Lago
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Sample design: Third National Health and Nutrition Examination Survey

Abstract

No full-text available

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