Challenges and Lessons Learned in Generating and Interpreting NHANES Nutritional Biomarker Data

Abstract

For the past 45 y, the National Center for Health Statistics at the CDC has carried out nutrition surveillance of the US population by collecting anthropometric, dietary intake, and nutritional biomarker data, the latter being the focus of this publication. The earliest biomarker testing assessed iron and vitamin A status. With time, a broad spectrum of water- and fat-soluble vitamins was added and biomarkers for other types of nutrients (e.g., fatty acids) and bioactive dietary compounds (e.g., phytoestrogens) were included in NHANES. The cross-sectional survey is flexible in design, and biomarkers may be measured for a short period of time or rotated in and out of surveys depending on scientific needs. Maintaining high-quality laboratory measurements over extended periods of time such that trends in status can be reliably assessed is a major goal of the testing laboratories. Physicians, health scientists, and policy makers rely on the NHANES reference data to compare the nutritional status of population groups, to assess the impact of various interventions, and to explore associations between nutritional status and health promotion or disease prevention. Focusing on the continuous NHANES, which started in 1999, this review uses a "lessons learned" approach to present a series of challenges that are relevant to researchers measuring biomarkers in NHANES and beyond. Some of those challenges are the use of multiple related biomarkers instead of a single biomarker for a specific nutrient (e.g., folate, vitamin B-12, iron), adhering to special needs for specimen collection and handling to ensure optimum specimen quality (e.g., vitamin C, folate, homocysteine, iodine, polyunsaturated fatty acids), the retrospective use of long-term quality-control data to correct for assay shifts (e.g., vitamin D, vitamin B-12), and the proper planning for and interpretation of crossover studies to adjust for systematic method changes (e.g., folate, vitamin D, ferritin).

Keywords: biochemical indicator; biological specimen; cutoff; fat-soluble vitamin; iron-status indicator; national nutrition survey; water-soluble vitamin.

FIGURE 1

Tools used to ensure the quality of laboratory data with an example from the CDC Division of Laboratory Sciences Policies and Procedures Manual. pH, potential of hydrogen; PT, proficiency testing; QC, quality control; SOP, standard operating procedures; UV/vis, UV/visible detection.

FIGURE 2

Approaches to derive reference intervals and clinical decision points (A) and the utility of these tools (B).