Data Sources and Data Analysis
Blood, serum, and urine samples from NHANES
Biomonitoring measurements for CDC’s National Report on Human Exposure to Environmental Chemicals (Report) are made using samples from participants in the National Health and Nutrition Examination Survey (NHANES), conducted by CDC’s National Center for Health Statistics (NCHS). NHANES is designed to collect data on the health and nutritional status of the U.S. population. NHANES collects information about a wide range of health-related behaviors, performs physical examinations, and collects clinical samples for laboratory tests. Beginning in 1999, NHANES became a continuous survey, sampling the U.S. population annually and releasing the data in 2-year cycles. The sampling plan follows a complex, stratified, multistage, probability-cluster design to select a representative sample of the civilian, noninstitutionalized population in the United States based on age, gender, and race/ethnicity.
The NHANES protocol includes a home interview, followed by a standardized physical examination in a mobile examination center. As part of the examination, blood is obtained by venipuncture from participants aged 1 year and older, and urine specimens are collected from participants aged 6 years and older. Starting with the 2015–2016 survey, urine specimens were collected from children ages 3–5 years. Additional detailed information on the design and conduct of the NHANES survey is available at https://www.cdc.gov/nchs/nhanes/.
NHANES measures environmental chemicals in blood, serum, or urine collected from participants. Most of the environmental chemicals are measured in randomly selected subsamples within specific age groups. Randomization of subsample selection is built into the NHANES design before sample collection begins. Different random subsamples include different participants. Subsampling is needed to ensure an adequate quantity of sample for analysis and the mass spectrometry analytical methods.
- Data tables in the Report specify age groups and sample sizes for each exposure measurement.
- Blood measurements in children younger than 12 years are limited by the amount of blood that can be collected.
- Blood metals are measured in participants aged 1 year and older.
- Beginning in 2011, the blood mercury species methyl mercury and ethyl mercury were added.
- Most measurements of chemicals in serum are made in samples from participants ages 12 years and older.
- Urine was collected from participants ages 6 years and older until 2015, when it became possible to collect urine from children as young as 3 years.
- Most urine chemicals are measured in a representative one-third subsample, but a full sample is used for participants ages 3–5 years.
If a particular chemical or an entire chemical group has no detectable results for three survey periods, it is usually not measured in subsequent survey periods. Some examples include:
- The sulfonyl urea herbicide group was measured in NHANES 2003–2004, 2005–2006, and 2007–2008 with no detections, even at the 95th percentile, so this group is no longer measured in the ongoing survey.
- Mono-n-octyl phthalate (MOP), a phthalate urinary metabolite, was not detected above the 95th percentile for more than three survey cycles, so it was no longer reported after 2010.
- Several banned organophosphate and organochlorine pesticides have become largely undetectable and are no longer measured.
- Some chemicals are widely detected but have had unchanging levels in the population (e.g., phytoestrogens) and are no longer measured.
By discontinuing measurements of chemicals that are rarely or not detected, and well-characterized chemicals for which the source of exposure is consistent, CDC’s Division of Laboratory Sciences can better focus its resources on assessing exposure to chemicals of highest priority. In addition to performing measurements on NHANES samples, these efforts include developing new and improving existing biomonitoring methods for chemicals of concern.
Beginning with NHANES 2005–2006, CDC used a weighted pooled-sample design to measure serum concentrations of dioxins, furans, polychlorinated biphenyls (PCBs), organochlorine pesticides and metabolites, and brominated flame retardants (polybrominated diphenyl ethers and polybrominated biphenyl [PBB] 153). Pooled samples are used when larger sample volumes are needed to improve the sensitivity of the measurements and to reduce the number of samples being analyzed, balancing the cost of the analysis against a low frequency of detectable results.
The following considerations guided the selection of chemicals in the Report:
- Scientific data suggested exposure in the U.S. population.
- Health effects known or suspected to result from some levels of exposure were serious enough to cause concern.
- Data were needed to assess the effectiveness of public health actions to reduce exposure to a chemical.
- Biomonitoring analytical methods could provide results with adequate accuracy, precision, sensitivity, specificity, and throughput.
- Adequate blood or urine samples were available.
- Incremental analytical costs to perform the biomonitoring analysis for the chemical were reasonable.
The availability of biomonitoring methods with adequate performance and acceptable cost was a major consideration. Details on the prioritization process for scoring nominated chemicals and the resulting scores are available at: https://www.cdc.gov/exposurereport/chemical_selection.html.
CDC’s Division of Laboratory Sciences made the blood, serum, and urine exposure measurements in the Report. The following analytical techniques were used for measuring the environmental chemicals or their metabolites in blood, serum, and urine:
- Isotope dilution mass spectrometry
- Inductively coupled plasma mass spectrometry
- Graphite furnace atomic absorption spectrometry
Laboratory measurements underwent extensive quality control and quality assurance review:
- Tolerance limits for operational parameters were maintained.
- Quality control samples were measured in each analytical run to detect unacceptable performance in accuracy or precision.
- Traceable calibration materials were verified.
References for the analytical methods used to measure the different chemicals are available at: https://www.cdc.gov/exposurereport/.
NHANES is a complex, stratified, multistage, probability-cluster design survey. This survey design requires sample weights to be used to adjust for the unequal probability of selection into the survey. Sample weights are also used to adjust for possible bias resulting from nonresponse and are post-stratified to U.S. Census Bureau estimates of the U.S. population. Data were analyzed using Statistical Analysis System (SAS) (SAS Institute Inc.) and the SUDAAN (RTI International, NC) statistical software packages. SUDAAN uses sample weights and calculates variance estimates that account for the complex survey design. The design does not permit straightforward analysis of exposure levels by non-targeted strata such as locality, state, or region; seasons of the year; proximity to sources of exposure; or by use of particular products. NCHS guidelines for analysis of NHANES data are available at https://wwwn.cdc.gov/nchs/nhanes/analyticguidelines.aspx.
The Report presents descriptive statistics on the blood, serum, or urine levels for each environmental chemical reported. Statistics include unadjusted geometric means and percentiles with confidence intervals. In each table, results are given for the total population and by age group, gender, and race/ethnicity, as defined in NHANES. For these analyses, based on the sample design, race/ethnicity is categorized as Mexican American, non-Hispanic Black, and non-Hispanic White. Beginning in 2011–2012, two additional categories were added: all Hispanic and non-Hispanic Asian (referred to as Asian in the tables). Other racial/ethnic groups are sampled, but the proportion of the total U.S. population represented by other racial/ethnic groups is not large enough to produce valid estimates. Other racial/ethnic groups are included in estimates that are based on the entire population sample. Age groups are as described for each chemical in each data table. Gender is coded as male or female.
For chemicals measured in urine, levels are presented per volume of urine and per gram of creatinine. Urinary levels are expressed both ways in the literature and used for different purposes. Levels per gram of creatinine (i.e., creatinine corrected) adjust for urine dilution. For example, a person who drinks more fluids than another person will likely have a higher, but more dilute, urine output. Interpretation of creatinine-corrected results should also recognize that creatinine correction can partially adjust for differences in lean body mass or renal function among persons. Children and young adolescents typically have less muscle mass than adults. Because muscle is an important source of creatinine in urine, children have lower urinary creatinine concentrations than do adults. The lower urine creatinine concentration can result in higher creatinine-corrected results in children in comparison with adults.
For dioxins, furans, PCBs, and organochlorine pesticides, serum levels are presented per gram of total lipid and per whole weight of serum. These compounds are lipophilic and concentrate in the body’s lipid stores, including the lipid in serum. Serum levels reported per gram of total lipid reflect the amount of these compounds stored in body fat. Serum levels per whole weight of serum are also included for easier comparison with studies investigating exposure to these chemicals that reported levels in these units. Other, mostly non-lipophilic chemicals, measured in serum are expressed per liter of serum (e.g., micrograms per liter). Hemoglobin adducts are expressed in nanomoles or picomoles per gram of blood hemoglobin.
Results are reported in standard units, generally conforming to those most commonly used in biomonitoring measurements. The table below shows some useful unit conversions.
Table 2. Units of Measurements and Abbreviations
A geometric mean gives a better estimate of central tendency for data that are distributed with a long tail at the upper end of the distribution. This type of distribution is common when measuring environmental chemicals in blood or urine. The geometric mean is influenced less by high values than is the arithmetic mean. In the Report, geometric means are calculated by taking the log of each concentration and then using SUDAAN software to compute the weighted mean of those log-transformed values. Ninety-five percent confidence intervals around the weighted mean are calculated by adding and subtracting an amount equal to the product of a Student’s t-statistic and the standard error of the weighted mean estimate. The degrees of freedom of the t-statistic was determined by subtracting the number of strata from the number of primary sampling units, according to the data available from the complex survey design. The standard error was computed with SUDAAN’s PROC DESCRIPT procedure and “with replacement” design option (design = WR), with Taylor series linearization used for variance estimation. The weighted geometric mean and its confidence limits were obtained by taking the antilog of this weighted mean and its upper and lower confidence limits.
The measured value for a pooled sample is comparable to an arithmetic average of measurements in individuals. Consequently, the pooled sample result is expected to be higher than the geometric mean of multiple individual results. In addition, direct calculation of the design effects required for accurate standard error and confidence interval estimation is not possible because samples are pooled across the design cells of the original survey. For these reasons, data tables showing the pooled sample results present only weighted arithmetic means and unadjusted standard errors for each category. The standard errors are unadjusted and therefore, do not reflect the design effects of the survey. In many cases, the standard errors are based on very few pooled sample measurements and cannot be expected to accurately reflect the true imprecision of the weighted arithmetic mean estimates. Therefore, when the unadjusted standard error was more than 30% of the weighted arithmetic mean, this is noted with a double asterisk (**) and footnoted.
Limit of detection
The limit of detection (LOD) is the level at which the measurement has a 95% probability of being greater than zero (Taylor, 1987). In the Report, the LODs for each chemical and survey period are provided in a footnote to each data table. Concentrations less than the LOD are assigned a value equal to the LOD divided by the square root of two for calculation of geometric means (Hornung and Reed, 1990). Assigning concentrations less than the LOD a value equal to the LOD divided by the square root of two made little difference in geometric mean estimates. If the proportion of results below the LOD was greater than 40%, geometric means were not calculated. For the same chemical, LOD values sometimes change over time as a result of improvements to analytical methods. One possible consequence is that results reported as “< LOD” in the 1999–2000 data might be reported as a concentration value above the LOD in 2001–2002 or 2003–2004 because the analytical method had improved. Thus, for proper interpretation of LODs in the data tables, care must be taken to use the LOD that applies to the survey period. Percentile estimates (see below) that are less than the LOD for the chemical analysis were reported as “< LOD.”
For most chemicals, the LOD is constant for each specimen analyzed. Dioxins, furans, PCBs, organochlorine pesticides, and a few other pesticides are different: these have an individual LOD for each sample, mostly because the sample volume used for each analysis was different. A higher volume of the specimen results in a lower LOD (i.e., a better ability to detect low levels). The maximum LOD values are given in each data table. The maximum LOD was the highest LOD among all samples analyzed. Typically, the mean LOD is about 40%–50% of the maximum LOD. The same procedure for imputing values below the LOD in calculations of geometric means was used for chemicals with individual LODs for each sample. Concentrations less than the individual LOD were assigned a value equal to the individual LOD divided by the square root of two. When reporting percentiles for chemicals with individual sample LODs, if any sample LOD in the demographic group was above the percentile estimate, then the percentile estimate was not reported.
For chemicals measured in urine, separate tables are presented for the chemical concentration expressed per volume of urine (uncorrected table) and the chemical concentration expressed per gram of creatinine (creatinine corrected table). Geometric mean and percentile calculations were performed separately for each of these concentrations. LOD calculations were performed using the chemical concentration expressed per volume of urine, because this concentration determines the analytical sensitivity. For this reason, LOD results for urine measurements in each data table are in units of weight per volume of urine. In the creatinine corrected tables, a result for a geometric mean or percentile was reported as < LOD if the corresponding geometric mean or percentile was < LOD in the table using weight per volume of urine. For example, if the 50th percentile for males was < LOD in the table using weight per volume of urine, it would also be < LOD in the creatinine corrected table.
For chemicals measured in serum lipid, separate tables are presented for the chemical concentration expressed per volume of serum (lipid unadjusted or whole weight table) and the chemical concentration expressed per amount of lipid (lipid adjusted table). Geometric mean and percentile calculations were performed separately for each of these concentrations. LOD calculations were performed using the chemical concentration expressed per amount of lipid, because this concentration determines the analytical sensitivity. For this reason, LOD results for chemicals measured in each data table are expressed in units of weight per amount of lipid. In the lipid unadjusted tables, a result for a geometric mean or percentile was reported as < LOD if the corresponding geometric mean or percentile was < LOD in the lipid adjusted table.
Percentiles (50th, 75th, 90th, and 95th) provide additional information about the shape of the distribution. Percentile estimates and 95% confidence interval estimates less than the limit of detection in the data tables are indicated as <LOD. An explanation of the procedure for estimating percentiles and an example using SAS-callable SUDAAN is provided on the website (see “SAS Code Example” at: https://www.cdc.gov/exposurereport/).
Taylor JK. 1987. Quality assurance of chemical measurements. Boca Raton, FL: Lewis Publishers.
Hornung RW, Reed LD. 1990. Estimation of average concentration in the presence of nondetectable values. Appl Occup Environ Hyg 5(1):46-51.