National Health and Nutrition Examination Survey (NHANES)

Doctors and dentists accompany survey interviewers in a mobile medical center that travels the country. While survey researchers read the questionnaires, medical professionals administer laboratory tests and conduct a full medical examination. The blood work and in-person check-up allow epidemiologists to answer questions like, “how many people have diabetes but don’t know they have diabetes?”

• Many tables containing information from the various examinations, generally one row per respondent.

• A complex sample survey designed to generalize to the civilian non-institutionalized U.S. population.

• Released biennially since 1999-2000.

• Administered by the Centers for Disease Control and Prevention.

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Recommended Reading

Four Example Strengths & Limitations:

✔️ Biospecimen, dietary, and laboratory data

✔️ Basis for growth charts found on the walls of pediatricians’ offices and clinics worldwide

❌ Mobile Examination Centers require 150 minutes per interview

❌ Narrow set of demographic and family relationship questions

Three Example Findings:

1. Among US adults with diabetes across 2007-2010 and 2015-2018, the share achieving glycemic control (glycated hemoglobin level, <7%) declined from 57.4% to 50.5%.

2. Ten million Americans alive in 2015 had childhood blood lead levels 5x above the level of concern.

3. Among US children aged 2-5 years interviewed between 2017 and March of 2020 with at least one primary tooth, 11% had at least one untreated decayed primary tooth.

Two Methodology Documents:

About the National Health and Nutrition Examination Survey

NHANES Tutorials

One Haiku:

# doctor, dentist, labs
# mobile examination
#vanlife interviews

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Download, Import, Preparation

Download and import the demographics (demo) and total cholesterol laboratory (tchol) data:

library(haven)

nhanes_2015_2016_demo_url <- "https://wwwn.cdc.gov/Nchs/Nhanes/2015-2016/DEMO_I.XPT"

nhanes_2017_2018_demo_url <- "https://wwwn.cdc.gov/Nchs/Nhanes/2017-2018/DEMO_J.XPT"

nhanes_2015_2016_tchol_url <- "https://wwwn.cdc.gov/Nchs/Nhanes/2015-2016/TCHOL_I.XPT"
    
nhanes_2017_2018_tchol_url <- "https://wwwn.cdc.gov/Nchs/Nhanes/2017-2018/TCHOL_J.XPT"
    

nhanes_2015_2016_demo_tbl <- read_xpt( nhanes_2015_2016_demo_url )
nhanes_2017_2018_demo_tbl <- read_xpt( nhanes_2017_2018_demo_url )
nhanes_2015_2016_tchol_tbl <- read_xpt( nhanes_2015_2016_tchol_url )
nhanes_2017_2018_tchol_tbl <- read_xpt( nhanes_2017_2018_tchol_url )

nhanes_2015_2016_demo_df <- data.frame( nhanes_2015_2016_demo_tbl )
nhanes_2017_2018_demo_df <- data.frame( nhanes_2017_2018_demo_tbl )
nhanes_2015_2016_tchol_df <- data.frame( nhanes_2015_2016_tchol_tbl )
nhanes_2017_2018_tchol_df <- data.frame( nhanes_2017_2018_tchol_tbl )

Specify which variables to keep from both the demo and tchol data files, then stack the four years:

demo_vars <-
    c( 
         # unique person identifier (merge variable)
        "SEQN" ,

        # the two-year interviewed + MEC examined weight
        "WTMEC2YR" ,    
        # note that this is a special weight for only
        # individuals who took the mobile examination center (MEC) exam
        # there is one other weight available - WTINT2YR - 
        # that should be used when MEC variables are not part of the analysis
        
        # interviewed only or interviewed + MEC
        "RIDSTATR" ,
        
        # primary sampling unit varaible, used in complex design
        "SDMVPSU" ,
        
        # strata variable, used in complex design
        "SDMVSTRA" ,
        
        # race / ethnicity
        "RIDRETH3" ,

        # age
        "RIDAGEYR" ,
        
        # gender
        "RIAGENDR" ,
        
        # pregnant at interview
        "RIDEXPRG"
    )

nhanes_2015_2018_demo_df <-
    rbind(
        nhanes_2015_2016_demo_df[ , demo_vars ] ,
        nhanes_2017_2018_demo_df[ , demo_vars ]
    )
    

tchol_vars <-
    c( 
        # unique person identifier (merge variable)
        "SEQN" ,
        
        # laboratory total cholesterol variable
        # https://wwwn.cdc.gov/Nchs/Nhanes/2017-2018/TCHOL_J.htm
        "LBXTC"         

    )

nhanes_2015_2018_tchol_df <-
    rbind(
        nhanes_2015_2016_tchol_df[ , tchol_vars ] ,
        nhanes_2017_2018_tchol_df[ , tchol_vars ]
    )

Merge the two pooled datasets, limit the data.frame to mobile examination component respondents:

nhanes_full_df <-
    merge(
        nhanes_2015_2018_demo_df ,
        nhanes_2015_2018_tchol_df ,
        all = TRUE
    )

names( nhanes_full_df ) <- tolower( names( nhanes_full_df ) )
    
nhanes_df <- subset( nhanes_full_df , ridstatr %in% 2 )

Scale the mobile examination component two-year weight to generalize to the pooled, four year period:

nhanes_df[ , 'wtmec4yr' ] <- nhanes_df[ , 'wtmec2yr' ] / 2

Save Locally  

Save the object at any point:

# nhanes_fn <- file.path( path.expand( "~" ) , "NHANES" , "this_file.rds" )
# saveRDS( nhanes_df , file = nhanes_fn , compress = FALSE )

Load the same object:

# nhanes_df <- readRDS( nhanes_fn )

Survey Design Definition

Construct a complex sample survey design:

library(survey)

nhanes_design <- 
    svydesign(
        id = ~ sdmvpsu , 
        strata = ~ sdmvstra ,
        nest = TRUE ,
        weights = ~ wtmec4yr ,
        data = nhanes_df
    )

Variable Recoding

Add new columns to the data set:

nhanes_design <-

    update(

        nhanes_design ,

        one = 1 ,

        # define high total cholesterol as 1 if mg/dL is at or above 240 and zero otherwise.
        hi_tchol = ifelse( lbxtc >= 240 , 1 , 0 ) ,
        
        gender = factor( riagendr , levels = 1:2 , labels = c( 'male' , 'female' ) ) ,
        
        age_categories =
            factor( 
                1 + findInterval( ridageyr , c( 20 , 40 , 60 ) ) , 
                levels = 1:4 , 
                labels = c( "0-19" , "20-39" , "40-59" , "60+" )
            ) ,

        # recode the ridreth3 variable as:
        # mexican american and other hispanic -> 4
        # non-hispanic white -> 1
        # non-hispanic black -> 2
        # non-hispanic asian -> 3
        # other race including multi-racial -> 5
        race_ethnicity =
            factor( 
                c( 4 , 4 , 1 , 2 , NA , 3 , 5 )[ ridreth3 ] ,
                levels = 1:5 ,
                labels = c( 'nh white' , 'nh black' , 'nh asian' , 'hispanic' , 'other' )
            ) ,
            
        pregnant_at_interview = 
            ifelse( ridexprg %in% 1:2 , as.numeric( ridexprg == 1 ) , NA )
    )

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Analysis Examples with the survey library  

Unweighted Counts

Count the unweighted number of records in the survey sample, overall and by groups:

sum( weights( nhanes_design , "sampling" ) != 0 )

svyby( ~ one , ~ race_ethnicity , nhanes_design , unwtd.count )

Weighted Counts

Count the weighted size of the generalizable population, overall and by groups:

svytotal( ~ one , nhanes_design )

svyby( ~ one , ~ race_ethnicity , nhanes_design , svytotal )

Descriptive Statistics

Calculate the mean (average) of a linear variable, overall and by groups:

svymean( ~ lbxtc , nhanes_design , na.rm = TRUE )

svyby( ~ lbxtc , ~ race_ethnicity , nhanes_design , svymean , na.rm = TRUE )

Calculate the distribution of a categorical variable, overall and by groups:

svymean( ~ riagendr , nhanes_design )

svyby( ~ riagendr , ~ race_ethnicity , nhanes_design , svymean )

Calculate the sum of a linear variable, overall and by groups:

svytotal( ~ lbxtc , nhanes_design , na.rm = TRUE )

svyby( ~ lbxtc , ~ race_ethnicity , nhanes_design , svytotal , na.rm = TRUE )

Calculate the weighted sum of a categorical variable, overall and by groups:

svytotal( ~ riagendr , nhanes_design )

svyby( ~ riagendr , ~ race_ethnicity , nhanes_design , svytotal )

Calculate the median (50th percentile) of a linear variable, overall and by groups:

svyquantile( ~ lbxtc , nhanes_design , 0.5 , na.rm = TRUE )

svyby( 
    ~ lbxtc , 
    ~ race_ethnicity , 
    nhanes_design , 
    svyquantile , 
    0.5 ,
    ci = TRUE , na.rm = TRUE
)

Estimate a ratio:

svyratio( 
    numerator = ~ lbxtc , 
    denominator = ~ ridageyr , 
    nhanes_design ,
    na.rm = TRUE
)

Subsetting

Restrict the survey design to respondents aged 60 or older:

sub_nhanes_design <- subset( nhanes_design , age_categories == "60+" )

Calculate the mean (average) of this subset:

svymean( ~ lbxtc , sub_nhanes_design , na.rm = TRUE )

Measures of Uncertainty

Extract the coefficient, standard error, confidence interval, and coefficient of variation from any descriptive statistics function result, overall and by groups:

this_result <- svymean( ~ lbxtc , nhanes_design , na.rm = TRUE )

coef( this_result )
SE( this_result )
confint( this_result )
cv( this_result )

grouped_result <-
    svyby( 
        ~ lbxtc , 
        ~ race_ethnicity , 
        nhanes_design , 
        svymean ,
        na.rm = TRUE 
    )
    
coef( grouped_result )
SE( grouped_result )
confint( grouped_result )
cv( grouped_result )

Calculate the degrees of freedom of any survey design object:

degf( nhanes_design )

Calculate the complex sample survey-adjusted variance of any statistic:

svyvar( ~ lbxtc , nhanes_design , na.rm = TRUE )

Include the complex sample design effect in the result for a specific statistic:

# SRS without replacement
svymean( ~ lbxtc , nhanes_design , na.rm = TRUE , deff = TRUE )

# SRS with replacement
svymean( ~ lbxtc , nhanes_design , na.rm = TRUE , deff = "replace" )

Compute confidence intervals for proportions using methods that may be more accurate near 0 and 1. See ?svyciprop for alternatives:

svyciprop( ~ pregnant_at_interview , nhanes_design ,
    method = "likelihood" , na.rm = TRUE )

Regression Models and Tests of Association

Perform a design-based t-test:

svyttest( lbxtc ~ pregnant_at_interview , nhanes_design )

Perform a chi-squared test of association for survey data:

svychisq( 
    ~ pregnant_at_interview + riagendr , 
    nhanes_design 
)

Perform a survey-weighted generalized linear model:

glm_result <- 
    svyglm( 
        lbxtc ~ pregnant_at_interview + riagendr , 
        nhanes_design 
    )

summary( glm_result )

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Direct Method of Age-Adjustment Replication Example

This example matches the total cholesterol statistics and standard errors in Table 1 from Data Brief 363:

Match the crude estimates in the footnote and also in the unadjusted age categories:

crude_overall <-
    svymean( ~ hi_tchol , subset( nhanes_design , ridageyr >= 20 ) , na.rm = TRUE )

stopifnot( round( coef( crude_overall ) , 3 ) == 0.115 )

crude_by_gender <-
    svyby( 
        ~ hi_tchol , 
        ~ gender , 
        subset( nhanes_design , ridageyr >= 20 ) , 
        svymean , 
        na.rm = TRUE 
    )
    
stopifnot( round( coef( crude_by_gender )[ 1 ] , 3 ) == 0.103 )
stopifnot( round( coef( crude_by_gender )[ 2 ] , 3 ) == 0.126 )

crude_by_age <-
    svyby(
        ~ hi_tchol , 
        ~ age_categories , 
        subset( nhanes_design , ridageyr >= 20 ) , 
        svymean , 
        na.rm = TRUE 
    )
    
stopifnot( round( coef( crude_by_age )[ 1 ] , 3 ) == 0.075 )
stopifnot( round( coef( crude_by_age )[ 2 ] , 3 ) == 0.157 )
stopifnot( round( coef( crude_by_age )[ 3 ] , 3 ) == 0.114 )

stopifnot( round( SE( crude_by_age )[ 1 ] , 3 ) == 0.005 )
stopifnot( round( SE( crude_by_age )[ 2 ] , 3 ) == 0.011 )
stopifnot( round( SE( crude_by_age )[ 3 ] , 3 ) == 0.008 )

Sum up 2000 Census totals based on the age groupings specified in footnote:

pop_by_age <- 
    data.frame( 
        age_categories = c( "0-19" , "20-39" , "40-59" , "60+" ) ,
        Freq = c( 78782657 , 77670618 , 72816615 , 45363752 ) 
    )   

Create a design with the nationwide population stratified to the above census counts:

nhanes_age_adjusted <-
    postStratify( 
        subset( nhanes_design , !is.na( hi_tchol ) ) , 
        ~ age_categories , 
        pop_by_age 
    )

Match the overall adjusted estimates:

results_overall <-
    svymean( ~ hi_tchol , subset( nhanes_age_adjusted , ridageyr >= 20 ) , na.rm = TRUE )

stopifnot( round( coef( results_overall ) , 3 ) == 0.114 )

stopifnot( round( SE( results_overall ) , 3 ) == 0.006 )

Create a design stratified to census counts broken out by gender, then match those estimates:

nhanes_by_gender <-
    svystandardize(
        nhanes_design , 
        by = ~ age_categories ,         # stratification variable
        over = ~ gender ,               # break out variable
        population = pop_by_age ,       # data.frame containing census populations
        excluding.missing = ~ hi_tchol  # analysis variable of interest
    )

results_by_gender <-
    svyby( 
        ~ hi_tchol , 
        ~ gender , 
        subset( nhanes_by_gender , ridageyr >= 20 ) ,
        svymean , 
        na.rm=TRUE
    )

stopifnot( round( coef( results_by_gender )[ 1 ] , 3 ) == 0.105 )
stopifnot( round( coef( results_by_gender )[ 2 ] , 3 ) == 0.121 )

stopifnot( round( SE( results_by_gender )[ 1 ] , 3 ) == 0.007 )
stopifnot( round( SE( results_by_gender )[ 2 ] , 3 ) == 0.008 )

Create a design stratified to census counts broken out by race/ethnicity, then match those estimates:

nhanes_by_race <-
    svystandardize(
        nhanes_design , 
        by = ~ age_categories ,         # stratification variable
        over = ~ race_ethnicity ,       # break out variable
        population = pop_by_age ,       # data.frame containing census populations
        excluding.missing = ~ hi_tchol  # analysis variable of interest
    )

results_by_race_ethnicity <-
    svyby( 
        ~ hi_tchol , 
        ~ race_ethnicity , 
        design = subset( nhanes_by_race , ridageyr >= 20 ) ,
        svymean , 
        na.rm=TRUE
    )

stopifnot( round( coef( results_by_race_ethnicity )[ 1 ] , 3 ) == 0.117 )
stopifnot( round( coef( results_by_race_ethnicity )[ 2 ] , 3 ) == 0.100 )
stopifnot( round( coef( results_by_race_ethnicity )[ 3 ] , 3 ) == 0.116 )
stopifnot( round( coef( results_by_race_ethnicity )[ 4 ] , 3 ) == 0.109 )

stopifnot( round( SE( results_by_race_ethnicity )[ 1 ] , 3 ) == 0.007 )
stopifnot( round( SE( results_by_race_ethnicity )[ 2 ] , 3 ) == 0.009 )
stopifnot( round( SE( results_by_race_ethnicity )[ 3 ] , 3 ) == 0.011 ) 
stopifnot( round( SE( results_by_race_ethnicity )[ 4 ] , 3 ) == 0.009 ) 

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Analysis Examples with srvyr  

The R srvyr library calculates summary statistics from survey data, such as the mean, total or quantile using dplyr-like syntax. srvyr allows for the use of many verbs, such as summarize, group_by, and mutate, the convenience of pipe-able functions, the tidyverse style of non-standard evaluation and more consistent return types than the survey package. This vignette details the available features. As a starting point for NHANES users, this code replicates previously-presented examples:

library(srvyr)
nhanes_srvyr_design <- as_survey( nhanes_design )

Calculate the mean (average) of a linear variable, overall and by groups:

nhanes_srvyr_design %>%
    summarize( mean = survey_mean( lbxtc , na.rm = TRUE ) )

nhanes_srvyr_design %>%
    group_by( race_ethnicity ) %>%
    summarize( mean = survey_mean( lbxtc , na.rm = TRUE ) )