Series 1

No. 38

Plan and Operation

of the NHANES II Mortality

Study, 1992

June 1999

Vital and

Health Statistics

From the CENTERS FOR DISEASE CONTROL AND PREVENTION / National Center for Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics
Copyright information

All material appearing in this report is in the public domain and may be

reproduced or copied without permission; citation as to source, however, is

appreciated.

Suggested Citation

Loria CM, Sempos CT, Vuong C. Plan and operation of the NHANES II Mortality

Study, 1992. National Center for Health Statistics. Vital Health

Stat 1(38). 1999.

Library of Congress Cataloging-in-Publication Data

Plan and operation of the NHANES II Mortality Study, 1992.

p. cm. — (Vital and health statistics. Series 1, Programs and collection

procedures ; no. 38) (DHHS publication ; no. (PHS) 99-1314).

ISBN 0-8406-0556-0

1. Health surveys—United States. 2. Mortality—United States Statistics.

3. Vital statistics—United States. I. National Center for Health Statistics (U.S.)

II. Series. III. Series: DHHS publication ; no. (PHS) 99-1314.

[DNLM: 1. National Health and Nutrition Examination Survey (U.S.)

2. Mortality—United States. 3. Data Collection—methods—United States.

4. Health Surveys—United States. W2 A N148va no. 38 1999]

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Printed on acid-free paper.
Plan and Operation of the

NHANES II Mortality Study,

1992

Series 1:

Programs and Collection

Procedures

No. 38

Hyattsville, Maryland

June 1999

DHHS Publication No. (PHS) 99-1314

Vital and

Health Statistics

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Disease Control and Prevention

National Center for Health Statistics
National Center for Health Statistics

Edward J. Sondik, Ph.D., Director

Jack R. Anderson, Deputy Director

Jack R. Anderson, Acting Associate Director for

International Statistics

Lester R. Curtin, Ph.D., Acting Associate Director for

Research and Methodology

Jennifer H. Madans, Ph.D., Acting Associate Director for

Analysis, Epidemiology, and Health Promotion

P. Douglas Williams, Acting Associate Director for Data

Standards, Program Development, and Extramural Programs

Edward L. Hunter, Associate Director for Planning, Budget,

and Legislation

Jennifer H. Madans, Ph.D., Acting Associate Director for

Vital and Health Statistics Systems

Douglas L. Zinn, Acting Associate Director for

Management

Charles J. Rothwell, Associate Director for Data

Processing and Services

Office of Analysis, Epidemiology, and Health Promotion

Jennifer H. Madans, Ph.D., Acting Associate Director

Division of Epidemiology

Elsie Pamuk, Ph.D., Acting Director

Elsie Pamuk, Ph.D., Acting Chief, Population Epidemiology

Branch

Sandra T. Rothwell, Chief, Longitudinal Studies Branch
Preface

This first wave of the NHANES II

Mortality Study was jointly

funded by the National Center for

Health Statistics and the Food and Drug

Administration. The authors would like

to acknowledge the assistance of

Dorothy Blodgett, Sandy (Chia-Ying)

Chien, Mary Dudley, and Shirley Gray,

Division of Health Examination

Statistics, in carrying out this study. Dr.

Jennifer Madans, Sandra Rothwell, and

Christine Cox deserve thanks for

providing advice throughout the study.

The contribution of Westat, Inc., the

contractor who assisted with data

collection, is also gratefully

acknowledged.

iii
Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Background .............................................................................................. 1

The Second National Health and Nutrition Examination Survey (1976–80) ......................................... 2

NHANES II Mortality Study, 1992 Study Design............................................................... 2

Mortality Ascertainment .................................................................................. 2

National Death Index Search ............................................................................ 3

Social Security Administration Death Master File Search ..................................................... 3

Combination of the National Death Index and Death Master File Searches for 1979–88 ............................ 3

Death Certificate Ordering and Review .................................................................... 4

Final Mortality Status on the Public-Release File ............................................................ 5

Causes of Death......................................................................................... 5

Assessment of the NHANES II Mortality Study, 1992 ............................................................ 5

Methods Used .......................................................................................... 6

Results ................................................................................................ 6

Discussion ............................................................................................. 6

NHANES II Mortality Study, 1992 Analytic Cohort.............................................................. 7

References ............................................................................................... 8

Detailed Tables

1. Number of deaths according to years of follow-up and sources of mortality status information in the the NHANES II

Mortality Study, 1992 ................................................................................. 9

2. Comparison of cumulative survival probabilities after 5 and 10 years for the U.S. population compared with

those for the NHANES II Mortality Study cohort according to race, sex, and age group ........................... 9

3. Expected number of survivors and decedents based on U.S. vital statistics data compared with observed number of

decedents from 1976–78 in the NHANES II Mortality Study according to sex and age for all races combined . . . . . . . . . 10

4. Expected number of survivors and decedents based on U.S. vital statistics data compared with observed number of

decedents from 1976–78 in the NHANES II Mortality Study according to race, sex, and age for selected race

groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

5. Number of participants in the NHANES II Mortality Study by mortality status at end of follow-up in 1992 according

to sex and age at baseline for all races combined . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

6. Number of participants in the NHANES II Mortality Study by mortality status at end of follow-up in 1992 according

to race, sex, and age at baseline for selected race groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figures

1. Tracing status of participants in the NHANES II Mortality Study, 1992 cohort ................................... 3

2. An overview of the process used to assign mortality status to the NHANES II Mortality Study, 1992 participants ...... 4

Appendixes

I. NHANES II baseline examination components for participants 30–75 years of age (1976–80). . . . . . . . . . . . . . . . . . . . . . . 14

II. NHANES II baseline blood and urine assessments by specimen types for participants 30–75 years

of age (1976–80) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

III. NHANES II baseline pesticide residue and metabolite determinations for participants 30–75 years

of age (1976–80) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

v
Objectives

The NHANES II Mortality Study is a

prospective study of adult participants

examined in the second National Health

and Nutrition Examination Survey

(NHANES II) conducted between 1976

and 1980. It was designed to investigate

the association between factors

measured at baseline and mortality. The

methods used in the study are described

and assessed in this report.

Methods

The vital status of NHANES II

participants who were 30–75 years of

age at their examination was ascertained

after 12–16 years. Vital status was

assessed by searching the National

Death Index and the Social Security

Administration Death Master File for

deaths occurring in the United States.

Causes of death were obtained from the

National Center for Health Statistics

Multiple Cause of Death file or death

certificates. To assess how well mortality

was ascertained, the survival of the

cohort after 5 and 10 years was

compared to that of the U.S. population

during the same period.

Results

As of December 31, 1992,

23.2 percent of the 9,250 cohort

members were found to be deceased.

The remaining 76.8 percent that were not

found to be deceased may be assumed

to be alive for analytic purposes.

Cumulative survival probabilities for the

cohort were generally higher than

probabilities calculated from U.S. life

table data. Although some differences

were expected, these data suggest that

after 10 years of follow-up using passive

methods, mortality may have been under

ascertained for the cohort. Discrepancies

between the survival patterns for

NHANES II cohort and U.S. vital statistics

were larger for black than for white

participants, indicating that ascertainment

of mortality was poorer among black

participants. Researchers using the

NHANES II Mortality Study, 1992 data

should be aware of these study limitations.

Keywords: Epidemiologic methods c

data collection c health surveys c

cohort studies c longitudinal study c

follow-up studies

Plan and Operation of the

NHANES II Mortality Study,

1992

by Catherine M. Loria, Ph.D., Offıce of Analysis, Epidemiology, and

Health Promotion, National Center for Health Statistics, Centers for

Disease Control and Prevention; Christopher T. Sempos, Ph.D., Offıce

of Research on Minority Health, National Institutes of Health; and

Cuong Vuong, Division of Health Examination Statistics, National

Center for Health Statistics, Centers for Disease Control and

Prevention

Background

The NHANES II Mortality Study is

a prospective cohort study, which

passively followed a subset

of participants in the Second National

Health and Nutrition Examination Survey

(NHANES II). NHANES II, conducted

between 1976–80, collected data from a

national probability sample of the U.S.

civilian, noninstitutionalized population

6 months–74 years of age (1). The

survey included a standardized physical

examination, laboratory tests, and

questionnaires that covered various

health-related topics. NHANES II

provided a wealth of information on the

prevalence of health conditions and risk

factors. Nevertheless, the cross-sectional

nature of the original survey limits its

usefulness for studying the effects of

clinical, environmental, and behavioral

factors on the development of specific

health conditions.

The NHANES II Mortality Study

was designed to investigate the

association between factors measured at

baseline and overall mortality or death

from specific causes. NHANES II

obtained information gathered from

physical examinations, laboratory tests,

and interviews, whereas the NHANES II

Mortality Study involved searching

national data bases containing

information about mortality and causes

of death. Mortality data from the

NHANES II Mortality Study can be

linked with the earlier baseline

NHANES II data to examine the

relationships between various factors

and specific causes of death.

Note that the design of the

NHANES II Mortality Study differs

substantially from that of the

NHANES I Epidemiologic Followup

Study (NHEFS), a longitudinal

follow-up of an earlier NHANES

cohort (2–5). NHEFS was an active

follow-up study in which participants

were recontacted and medical records

and death certificates were obtained. In

contrast, the NHANES II Mortality

Study is entirely passive, that is,

participants were not recontacted.

Instead, mortality status was ascertained

solely by computerized matching to

national data bases and evaluation of the

resulting matches. Furthermore, no

recontact is planned in the future.

Instead, matching to the National Death

Index (NDI) and other national data

bases will continue periodically. Future

waves will be released for public use as

they become available. One important

consequence of the NHANES II Mortality

Study design is that persons not found to

be deceased are assumed alive for analytic

purposes. As a result the potential for

misclassification of vital status exists.

Researchers using data from the

NHANES II Mortality Study should be

aware of this study limitation.

Page 1
The Second National

Health and Nutrition

Examination Survey

(1976–80)

An understanding of the

NHANES II study design and

procedures is needed to use the

NHANES II Mortality Study, 1992

data effectively. A brief overview of

the baseline study design and methods

is provided as follows and reported in

more detail elsewhere (1).

NHANES II was designed to collect

extensive demographic, medical history,

nutritional, clinical, and laboratory data

on a probability sample of the civilian,

noninstitutionalized population between

the ages of 6 months and 74 years (1).

The survey, conducted between

1976–80, had a complex sample design

consisting of a multistage, stratified,

probability-based cluster sample of

households throughout the United

States (1). The primary sampling units,

which consisted of a county or group of

contiguous counties, were stratified

according to demographic characteristics

and geographic region and grouped into

64 superstrata. One primary sampling

unit was selected from each

superstratum using a control selection

procedure to produce a balanced sample

with respect to variables such as region,

State group, race-ethnicity, and poverty

level (1). Within each primary sampling

unit, census enumeration districts,

stratified by poverty level, were selected

with probability proportional to their

size. Households within selected

enumeration districts were clustered into

segments. One segment was

systematically selected within each

enumeration district. Approximately one

person was sampled from each

household with oversampling of persons

6 months–5 years of age and 60–74

years of age.

A standardized set of questions and

examination procedures was

administered by centrally trained staff

and blood was drawn for various

laboratory tests (1). At the initial visit to

the household, interviewers introduced

the survey, administered questionnaires,

and made appointments for the

examination. Interviewers also obtained

consent to retrieve additional

information from records including

those from physicians, hospitals,

schools, and State registry offices (1).

Interviews and examinations were

conducted from Tuesdays through

Saturdays in mobile examination

centers (MEC’s). Each MEC consisted

of three trailers connected by enclosed

passageways and was divided into

separate rooms for examination

components, including a laboratory for

processing blood and other biological

samples. The examination and

interview lasted, on average, 2–3

hours. Quality control procedures

included centralized training and

periodic retraining of field staff,

routine calibration of instruments,

replicate measures for a subset of

participants, and duplicate specimen

processing for biochemical

measures (1).

NHANES II Mortality

Study, 1992 Study

Design

The NHANES II Mortality Study

cohort consists of adults who

were 30–75 years of age at

the time of their NHANES II

examination. This cohort is a subset of

the approximately 28,000 persons

selected to participate in NHANES II.

Some participants were interviewed but

not examined and only those examined

were followed for mortality status. The

baseline included persons between the

ages of 6 months and 74 years but only

adults were included in the follow-up

cohort. Age at examination was used to

identify participants 30 years of age and

over for selection into the NHANES II

Mortality Study, 1992 cohort. Because

several weeks could have elapsed

between the interview and examination,

some participants who were 74 years of

age during their interview turned 75

years of age between their interview and

examination. Therefore, the upper age

limit for the NHANES II Mortality

Study, 1992 cohort is 75 years. At

baseline, 12,102 adults 30–74 years of

age agreed to be interviewed and 9,252

(76 percent) completed a physical

examination.

During this first wave of the

study, mortality status was ascertained

for the years 1976–92. Two

participants were unable to be

followed because of incomplete

personal identifying data and are

considered lost to follow-up. The

remaining 9,250 cohort members were

traced in the NHANES II Mortality

Study, 1992 by searching national data

bases containing mortality and cause

of death information. Length of

follow-up ranges from 12 through 16

years. Approximately 23 percent

(n = 2,145) of the NHANES II

Mortality Study, 1992 cohort were

found to be deceased as of December

31, 1992 (figure 1).

Mortality Ascertainment

Mortality status was ascertained by

searching two computerized data bases

containing information on deaths

occurring in the United States. The NDI,

compiled by the National Center for

Health Statistics (NCHS), contains a

standard set of identifying data for each

decedent provided by State vital

statistics offices (6,7). Beginning with

deaths occurring in 1979, the NDI

contains deaths for all 50 States, the

District of Columbia, Puerto Rico, and

the Virgin Islands (6). The Social

Security Administration’s (SSA) Death

Master File (DMF) contains information

on all U.S. decedents whose

beneficiaries received death benefits

from the SSA (8). The DMF pools data

from a variety of SSA files, including

the SSA Master Beneficiary Record that

contains a record for each person

entitled to receive retirement or

survivor’s benefits and disability

insurance.

The results of each search were

evaluated separately and later combined

using the following process (also,

outlined in figure 2) to create the

NHANES II Mortality Study, 1992

public-release file.

Page 2 [ Series 1, No. 38
National Death Index Search

The NDI was searched for deaths

occurring between 1979–92. At the time

the NHANES II Mortality Study, 1992

data were collected, 1992 was the latest

year for which cause of death data were

available. Social Security numbers were

not collected during NHANES II;

therefore, potential matches with the

NDI were initially identified using

name, date of birth, and sex, according

to the standard NDI matching

process (6). These NDI matching criteria

are liberal enough to ensure that true

matches will not be missed, but also

they generally yield many false matches,

especially for participants with common

names.

In an attempt to eliminate false

positive matches, all matches returned

by the NDI were manually reviewed

using the previously mentioned

information and, additionally, observed

race, State of birth, State of residence,

and marital status. Each potential NDI

match was tentatively classified by

NHANES II Mortality Study, 1992 staff

as ‘‘true,’’ ‘‘possible,’’ or ‘‘false.’’ The

only exceptions to this manual review

process were those matches that

matched all fields exactly (i.e., name,

date of birth, sex, observed race, State

of birth, State of residence, and marital

status); these matches were classified as

true without further review (54 percent

of 1,973 true matches). For all other

NDI matches, a ‘‘true’’ classification

was assigned if enough evidence existed

to assume that the death pertained to the

NHANES II participant. A ‘‘possible’’

was assigned if NHANES II Mortality

Study, 1992 staff were uncertain whether

the death pertained to the NHANES II

participant based on the available

evidence from the NDI. This code was

used to identify cases for whom the

death certificate identified by the

potential match should be ordered to

allow for further evaluation. A ‘‘false’’

was assigned if the available evidence

from the NDI suggested that the death

did not pertain to the NHANES II

participant. Overall, NHANES II

Mortality Study, 1992 staff erred on the

side of being conservative and assigned

a possible if they were uncertain in

either direction.

Social Security Administration

Death Master File Search

Because the NDI does not include

deaths occurring before 1979, the SSA

DMF was searched for deaths occurring

in 1976–78. Additionally, the DMF was

also searched from 1979 through March

31, 1988, to confirm the NDI match

results for this period. Data extracted

from the DMF after March 1988 were

not available at the time this study was

conducted.

As with the NDI, the initial criteria

to identify potential matches to the

DMF were based on name and date of

birth and were liberal enough to ensure

that ‘‘true’’ matches would not be

missed. The quality of potential matches

was further evaluated using a numerical

scoring algorithm based on first and last

name, date of birth, and State of

residence. Matches with scores high

enough to indicate at least partial

matching on name and date of birth

were then manually examined in an

attempt to eliminate ‘‘false’’ matches.

Besides name and date of birth, these

evaluations used the last known State of

residence compared with the Zip code

where the lump sum payment was sent.

Each DMF match was tentatively

classified by NHANES II Mortality

Study, 1992 staff as true, possible, or

false. A ‘‘true’’ classification was

assigned if enough evidence existed to

assume that the death pertained to the

NHANES II participant. A ‘‘possible’’

was assigned if NHANES II Mortality

Study, 1992 staff were uncertain whether

the death pertained to the NHANES II

participant based on the available

evidence from DMF. The ‘‘possible’’

code was used to identify cases for

whom the death certificate identified by

the potential match should be ordered to

allow for further evaluation. A ‘‘false’’

was assigned if the available evidence

from DMF suggested that the death did

not pertain to the NHANES II

participant. Overall, NHANES II

Mortality Study, 1992 staff erred on the

side of being conservative and assigned

a ‘‘possible’’ if they were uncertain in

either direction.

Combination of the National

Death Index and Death Master

File Searches for 1979–88

When the NDI and DMF results

were combined, differing outcomes

existed for some NHANES II

participants. For example, NCHS staff

may have assigned a ‘‘true’’ match

based on NDI and a ‘‘possible’’ match

based on DMF for the same participant.

In some cases, NDI and DMF could

have been referring to the same death

certificate, but NHANES II Mortality

Study, 1992 staff could not be certain

because DMF did not provide the death

certificate number. The dates of death

were used to identify cases where NDI

and DMF were most likely referring to

the same death certificate.

Because very few cases existed

where the NDI and DMF dates of death

differed, NHANES II Mortality Study,

1992 staff were able to order the death

certificates for both matches from State

vital statistics offices. If the certificates

were received, they were evaluated to

resolve the discrepancy. Data on the

Figure 1. Tracing status of participants in the NHANES II Mortality Study, 1992 cohort

Series 1, No. 38 [ Page 3
death certificate, including address,

spouse, State of birth, next of kin, race,

marital status, and usual occupation,

were checked against these data

collected during NHANES II. Based on

this review, NHANES II Mortality

Study, 1992 staff decided which of the

two matches, if any, pertained to the

NHANES II participant.

More cases existed where the death

dates from NDI and DMF matched

exactly or were fairly close (e.g., the

year was the same but the month

differed, and it looked like a

transposition error). In such cases, it

was assumed that NDI and DMF were

referring to the same death certificate.

Before ordering death certificates,

NHANES II Mortality Study, 1992 staff

assigned an outcome that gave more

weight to the NDI results because more

information was used in the matching

process for NDI (i.e., name, gender, date

of birth, race, State of birth, State of

residence, and marital status) as

compared with DMF (i.e., name,

gender, date of birth, and State of

residence). However, the NDI-based

outcome may have been changed in

these discrepant cases if the

DMF-identified death certificate was

reviewed and it was determined that

the DMF match pertained to the

NHANES II participant.

Death Certificate Ordering and

Review

Because of limited resources for

this study, NHANES II Mortality Study,

1992 staff were unable to order death

certificates from States and evaluate all

of the true and possible matches

identified from the NDI and DMF. The

matches were ranked and as many of

the death certificates as resources

allowed were ordered. Priority was

given to the following:

+ Matches for which NHANES II

Mortality Study, 1992 staff could not

obtain the cause of death from

internal NCHS files.

+ Cases with discrepant matches from

NDI and DMF in which the dates of

death differed.

+ ‘‘True’’ and ‘‘possible’’ matches

identified solely through DMF

(because NCHS had received so

little information from DMF to

determine whether the match

pertained to the NHANES II

participant). NHANES II Mortality

Study, 1992 staff ordered as many

NDI ‘‘true’’ and ‘‘possible’’

matches as resources permitted,

mainly from States that NCHS was

already requesting death

certificates identified by DMF,

because this was the most

cost-effective approach. As a

result, death certificates were

ordered for relatively few NDI

‘‘true’’ and ‘‘possible’’ matches,

because NHANES II Mortality

Study, 1992 staff felt more

Figure 2. An overview of the process used to assign mortality status to the NHANES II

Mortality Study, 1992 participants

Page 4 [ Series 1, No. 38
confident given that the NDI

matches used more information in

the matching process.

Death certificates were ordered and

received for approximately 27 percent of

the 2,145 decedents. A small percentage

of the death certificates ordered were

not received for one of the following

reasons:

+ DMF did not provide the State of

death and death certificate number,

and the State vital statistics office

could not find the death certificate

based on name, gender, date of

death, and date of birth.

+ NDI provided the State of death and

death certificate number; but in a

small number of cases, the death

certificate received did not appear to

be the death certificate referenced on

the NDI, possibly because of

typographic errors in the death

certificate number.

NCHS was unable to evaluate all

of the death certificates received

because of staffing limitations. For

deaths occurring during the period

covered by DMF only (1976–78),

death certificates were evaluated for a

sample of the DMF ‘‘true’’ matches to

ensure that criteria for classifying

DMF ‘‘true’’ matches were sensitive.

For the same period, all death

certificates were evaluated for DMF

‘‘possible’’ matches because of the

uncertainty about these matches that

were based on so little information.

Certificates for deaths occurring

between 1979–88 for all ‘‘true’’ and

‘‘possible’’ matches identified solely

through DMF were evaluated in case

the death on the NDI was missed. A

sample of death certificates for all

NDI ‘‘true’’ and ‘‘possible’’ matches

were evaluated to ensure that criteria

for classifying them were sensitive. In

all evaluations data on the death

certificate were checked against these

data collected during NHANES II,

including address, spouse, State of

birth, next of kin, race, marital status,

and usual occupation. About one-third

of the 712 death certificates ordered

and received were reviewed by

NHANES II Mortality Study, 1992

staff.

Final Mortality Status on the

Public-Release File

Decedents on the public-release file

consist only of participants with a final

‘‘true’’ match after combining the results

of the NDI and DMF evaluations and

reviewing selected death certificates. For

participants with a final ‘‘possible’’

match, NHANES II Mortality Study,

1992 staff concluded that the available

evidence was not convincing enough to

determine that the match pertained to

the NHANES II participant. Thus,

NHANES II Mortality Study, 1992 staff

assumed that the participants were still

alive. Matches with a ‘‘possible’’ code

will be stored on internal NCHS files

for later investigation if the participant

does not match to a national data base

after a reasonable amount of time.

Participants with a final ‘‘false’’ match

were also assumed alive.

In all, 2,145 deaths were identified

using the process described earlier. The

numbers of deaths by year of follow-up

and sources of mortality data are

presented in table 1. Between 1976 and

1978, 84 deaths were identified through

DMF, the only source of mortality

information available for this period.

Between 1979 and 1988, 863 deaths

were identified through NDI and DMF,

363 deaths by NDI alone, and 88 deaths

by DMF alone. During the final period

1989–92, 747 deaths were identified

through the NDI, the only source

available. A small percentage of the

deaths that occurred between 1979–88

were identified through DMF

(4.1 percent) and were not found

through NDI. In these cases,

NHANES II Mortality Study, 1992 staff

reviewed the death certificates and

confirmed the deaths.

Causes of Death

For most deaths identified through

the NDI, causes of death were obtained

from the NCHS Multiple Cause of

Death (MCD) file (9,10) by matching on

the death certificate number. These

deaths were coded by nosologists in the

individual State vital statistics offices or

at NCHS according to the International

Classification of Diseases, Ninth

Revision (ICD–9). Death certificates

were ordered for all deaths identified

only through the DMF. The causes of

death for these participants were coded

by nosologists at NCHS using the same

criteria as those used for the MCD file.

Additionally, death certificates were

ordered and causes of death coded for a

small percentage of NDI-identified

deaths from States that did not have

100 percent coverage on the MCD file.

Multiple causes of death are

available for 98 percent (n = 2,104) of

decedents, and, thus, are missing for 41

decedents. Causes of death were missing

if the death certificate could not be

found in State vital statistics offices.

Additionally, causes of death were not

obtained for a few deaths that were later

determined to be missing from the MCD

file.

The date of death was abstracted

from either the file returned by NDI or

the death certificate.

Assessment of the

NHANES II Mortality

Study, 1992

The main advantage of using

passive follow-up methods is the

low cost of tracing large,

dispersed cohorts. Nevertheless, reliance

solely on these methods to ascertain

mortality introduces some uncertainty

and potential biases (11). Previous

studies have estimated the sensitivity of

matching to the NDI at 87 to 97 percent.

As in the NHANES II Mortality Study,

1992, these studies used name and date

of birth as initial matching criteria with

additional information, such as gender,

race, and marital status, to eliminate

false matches (12–15). Estimates of the

sensitivity of searching the SSA DMF

are unavailable from previous studies

when the Social Security number is not

used in the matching process. In this

study the sensitivity of matching to

DMF with the NHANES II Mortality

Study, 1992 study protocol was

70 percent, using overlapping data for

the period 1979–88 from the DMF and

NDI and using NDI as the ‘‘gold

standard.’’

Series 1, No. 38 [ Page 5
Given the limitations of passive

methods, the survival of the NHANES II

Mortality Study, 1992 cohort was

compared to that of the U.S. population

during the same period to assess how

well mortality was ascertained in the

NHANES II Mortality Study, 1992. The

overall performance of the combined

results from the NDI and DMF searches

were evaluated by examining cumulative

survival rates after 5 and 10 years.

Additionally, the number of expected

deaths were compared with observed

deaths for the period covered solely by

DMF because matching to DMF

appeared to be less sensitive than

matching to NDI.

Methods Used

To assess how well mortality was

ascertained in the NHANES II Mortality

Study, 1992, the survival of the cohort

was compared to that of the U.S.

population during the same period.

Cumulative survival probabilities after 5

and 10 years were calculated for 24

race-sex-age groups in the NHANES II

Mortality Study, 1992 cohort using the

Kaplan-Meier product limit method (16).

Sample weights were used to calculate

estimates for the cohort but the complex

sample design of NHANES II was not

taken into account. Cumulative survival

probabilities (nP0) for the U.S.

population after 5 and 10 years were

calculated using mortality rates extracted

from U.S. life tables according to

formula (1):

nP0 =∏i = 0

n − 1

[1 − 1qa + i, 1978 + i]

(1)

where

n = number of years of follow-up

1qx,y = probability that persons in a

given race-sex group alive at

age x will die within 1 year

according to the U.S. life table

for year y

a = midpoint of the age interval at

baseline (1978)

The year 1978 was used as the

beginning of follow-up because it was

the approximate midpoint of

NHANES II. Mortality rates for

successive years from life tables were

used to account for the decrease in U.S.

death rates that occurred over the

follow-up period. Participants of race

groups other than white and black were

omitted from this analysis because of

their small numbers in the NHANES II

Mortality Study, 1992 cohort.

To evaluate mortality ascertainment

for the years covered solely by the

DMF, the number of deaths expected to

occur between 1976 and 1978 were

estimated and compared with the

observed number of deaths for this

period. Mortality rates for each race,

sex, and age group from U.S. life tables

were used to calculate the expected

number of survivors at the beginning of

1979 (n1979) as:

n1979 = [O1976 (1 − qa, 19761/2)

(1 − qa + 1, 1977) (1 − qa + 2, 1978)]

+[O1977 (1 − qa, 1977

1/2)

(1 − qa + 1, 1978)]

+[O1978 (1 − qa, 19781/2)] (2)

where

Oy = number examined during year y

1qx, y = probability that persons in a

given race-sex group alive at

age x will die within 1 year

according to the U.S. life table

for year y

a = midpoint of the age interval at

baseline

The expected number of deaths in each

race-age-sex group was then calculated

as the difference between the total

number examined from 1976–79

(N1976–78) and the expected number of

survivors during this period (n1979).

Results

The cumulative survival

probabilities for the U.S. population and

the NHANES II Mortality Study, 1992

cohort are presented in table 2 by race,

sex, and age group. The survival

probabilities for the cohort were larger

than for the U.S. population in each of

the four race-sex groups. Differences

between probabilities for the cohort and

the U.S. population were most similar

among white males and females. In both

groups the largest differences after five

years were observed in the oldest age

group but after 10 years, groups with

the largest differences expanded to

include 65–69-year-olds and

60–64-year-old females. The largest

discrepancies between the cohort and

U.S. survival patterns were found

among black men and women.

Compared with white men and women,

differences between survival

probabilities after 5 years of follow-up

were consistently larger in all age

groups and much larger among black

males 70–75 years of age. Differences

between survival probabilities by race

were generally larger after 10 years

compared to 5 years of follow-up.

The expected and observed number

of deaths during 1976–78 are presented

in table 3 by sex and age group for all

race groups combined and in table 4 for

24 selected race-sex-age groups.

Overall, 84 deaths were observed, just

over one-half of the expected deaths

during this period. Ratios of observed to

expected deaths were lowest among

participants 50–59 and 70–75 years of

age and highest among those 60–64 and

65–69 years of age. Observed to

expected ratios were approximately the

same for males and females, although

some variation existed by age group

between the sexes, primarily in the

younger age groups. Ratios were

approximately the same for white males

and white females but lower for black

participants. While the observed to

expected ratio for all age groups

combined was lowest among black

females, there were more age groups

among black males in which none of the

expected deaths were found during the

first 3 years of follow-up.

Discussion

Cumulative survival probabilities

for the NHANES II Mortality Study,

1992 cohort were generally higher than

expected probabilities calculated from

U.S. life table data. Based on the

magnitude of differences between them,

mortality ascertainment was better for

the white participants and worse for the

black participants. Ascertainment after 5

years was poorer among the white

Page 6 [ Series 1, No. 38
participants 70–75 years of age

compared with other age groups,

although it did not change substantially

after 10 years for the oldest age group.

On the other hand, ascertainment among

white females 60 years of age and over

was poorer after 10 years compared

with 5 years. Among black participants

poor ascertainment was not limited to

specific age groups. Although

differences between 5- and 10-year

survival varied by age group among the

black participants, the differences

suggest that ascertainment was generally

poorer after 10 years.

Some differences in mortality

ascertainment were expected given the

NHANES II sample design. NHANES II

was a sample of noninstitutionalized

persons, whereas expected probabilities

were based on data for the entire U.S.

population that included institutionalized

persons with lower survival rates. Given

this design the largest differences were

expected among the oldest age group

and should have decreased over time.

This expectation was consistent with the

results. Mortality ascertainment was

poorest among participants in the oldest

age group during the first 3 years of

follow-up. Larger discrepancies in

5-year survival existed in this age group,

and such differences did not increase

over time except among black females.

However, it is unlikely that the sample

design could explain all of the

differences found between the cohort

and U.S. survival patterns, even among

white men and women.

Incomplete national mortality data

for the first 3 years of follow-up could

have contributed to under ascertainment

of mortality in the NHANES II

Mortality Study, 1992. Because the first

wave of the study included years not

covered by NDI, NHANES II Mortality

Study, 1992 staff relied on the DMF for

finding deaths occurring for 1976–79. In

another study comparing the total

number of deaths on the DMF to U.S.

vital statistics data, the DMF contained

89 percent of all deaths occurring in the

United States between 1975–84 (8).

Thus, at best, only 89 percent of

deaths could be detected in the

NHANES II Mortality Study during

the first 3 years of follow-up. The

percent of deaths actually detected

during the first 3 years of the study

was much less than this, especially

among black participants 70–75 years

of age at baseline.

Limitations in personal identifying

data for NHANES II participants

probably also contributed to under

ascertainment. NHANES II was not

designed as a longitudinal study, and

because of this, important personal

identifiers, such as Social Security

number and father’s surname, were not

collected. Furthermore, personal

identifiers were not recorded with as

much care as they would have been if

NHANES II staff had known that

identifiers would be used to link to

national mortality data bases. For

example, some participants only gave

their first and middle initials instead of

complete names and this was accepted

without further probing. Thus, the

quality of personal identifiers was not as

high as it could have been if a

longitudinal component had been

included in the NHANES II design.

Problems with personal identifiers in the

NHANES II Mortality Study would

have affected passive follow-up

throughout the entire follow-up period,

and possibly contributed to larger

differences in survival probabilities

between 5 and 10 years among the

black participants and older women.

Under ascertainment of deaths

during the years covered solely by the

DMF was greater among the black than

among the white participants. Poorer

mortality ascertainment among the black

participants was consistent with larger

discrepancies in 5-year survival for this

group and with previous studies (17,18)

using the DMF. Furthermore,

discrepancies in 10-year survival were

larger among black than white

participants, suggesting that

ascertainment was problematic for the

former group throughout the entire

follow-up period. Previous studies

evaluating the effectiveness of NDI have

suggested that ascertainment may not be

as good for black decedents as it is for

white decedents (12,19,20). In a study

of the survival of the NHEFS cohort,

differences between observed and

expected survival after 5 and 8 years of

follow-up were larger for black than for

white participants (21). Because

mortality was ascertained through active

tracing methods in NHEFS (22), some

of the differential ascertainment by race

in the NHANES II Mortality Study,

1992 may have been independent of the

passive methods used. Other factors

besides under ascertainment may have

contributed to the larger differences in

survival among black participants. In the

NHANES II Mortality Study, 1992,

survival estimates for black participants

may have been less stable than for white

participants, given the smaller number

of black participants compared with

white participants in the NHANES II

sample. Differences by race in the

quality of denominator data used to

calculate the U.S. estimates may also

have affected the comparisons.

In conclusion, the analysis

presented here suggests that after 10

years of follow-up using passive

methods, mortality may have been under

ascertained for the NHANES II

Mortality Study, 1992 cohort. Because

this analysis used expected data based

on the U.S. population, it probably

overestimated the degree of under

ascertainment, but it is unclear by how

much. Nonetheless, the analysis shows

that compared with white participants,

ascertainment of mortality was poorer

among black participants.

NHANES II Mortality

Study, 1992 Analytic

Cohort

Approximately 23 percent

(n = 2,145) of the NHANES II

Mortality Study, 1992 cohort

(n = 9,250) was found to be deceased

(table 5). The percentage of male

decedents (28.9 percent) was higher than

the percentage of female decedents

(18.1 percent) among all races

combined, a trend that was also

observed within each age group

(table 5). This same pattern, higher

percentages of male decedents compared

with female decedents, was also

observed among the white and black

participants (table 6).

Series 1, No. 38 [ Page 7
The remaining 77 percent

(n = 7,105) that were not found to be

deceased as of December 31, 1992,

(table 5) may be assumed to be alive for

analytic purposes. This assumption may

potentially result in the misclassification

of vital status for some cohort members

because of the passive methods used in

this study. That is, some true matches

may have been inadvertently eliminated

and some false matches retained. It is

more likely that true matches were

eliminated rather than false matches

retained because NHANES II Mortality

Study, 1992 staff erred on the side of

being conservative in determining

matches. True matches that were

eliminated would continue to

accumulate person-years of follow-up. If

the rate of eliminating true matches is

unrelated to the exposure of interest,

eliminating true matches should not

attenuate risk ratios but may reduce the

statistical power of studies using the

NHANES II Mortality Study, 1992 data

(11). More important, caution should be

exercised when using the NHANES II

Mortality Study, 1992 data to make

comparisons based on race because of

the apparent differential ascertainment of

mortality by race. Researchers using the

NHANES II Mortality Study, 1992 data

should be aware of these study

limitations and consider them when

drawing conclusions based on these

data.

Finally, subjects 60–74 years of age

were oversampled in NHANES II and,

thus, are overrepresented in the

NHANES II Mortality Study, 1992

cohort. Therefore, NCHS recommends

that analysts use the baseline sample

weights and sample design variables to

account for the complex sample design

in analyses of the NHANES II Mortality

Study, 1992 data.

References

1. McDowell A, Engle A, Massey JT,

Maurer K. Plan and operation of the

Second National Health and Nutrition

Examination Survey 1976–1980.

National Center for Health Statistics.

Vital and Health Stat 1(15). 1981.

2. Cohen BB, Barbano HE, Cox CS, et al.

Plan and operation of the NHANES I

Epidemiologic Followup Study

1982–84. National Center for Health

Statistics. Vital and Health Stat 1(22).

1987.

3. Finucane FF, Freid VM, Madans JH, et

al. Plan and operation of the NHANES

I Epidemiologic Followup Study, 1986.

National Center for Health Statistics.

Vital and Health Stat 1(25). 1990.

4. Cox CS, Rothwell ST, Madans JH, et

al. Plan and operation of the NHANES

I Epidemiologic Followup Study, 1987.

National Center for Health Statistics,

Vital and Health Stat 1(27). 1992.

5. Cox CS, Mussolino ME, Rothwell ST,

et al. Plan and operation of the

NHANES I Epidemiologic Followup

Study, 1992. National Center for Health

Statistics, Vital and Health Stat 1(35).

1997.

6. National Center for Health Statistics.

National Death Index user’s manual.

DHHS Pub. No. (PHS) 90–1148.

Washington: Public Health Service.

1991.

7. Patterson BH, Bilgrad R. Use of the

National Death Index in cancer studies.

J Natl Cancer Inst 77(4):877–81. 1986.

8. Schnorr TM, Steenland K. Identifying

deaths before 1979 using the Social

Security Administration Death Master

File. Epidemiology 8(3):321–3. 1997.

9. Israel RA, Rosenberg HM, Curtin LR.

Analytical potential for multiple

cause-of-death data. Am J Epidemiol

124(2):161–79. 1986.

10. National Center for Health Statistics.

Multiple Causes of Death in the

United States. Volume 32, number 10,

supplement (2). (PHS) 84–1120. 1984.

11. Howe GR. Use of computerized record

linkage in cohort studies. Epidemiol

Rev 20(1):112–21. 1998.

12. Boyle CA, Decoufle P. National sources

of vital status information: Extent of

coverage and possible selectivity in

reporting. Am J Epidemiol 131:160–8.

1990.

13. Stampfer MJ, Willett WC, Speizer FE,

et al. Test of the National Death Index.

Am J Epidemiol 119:837–9. 1984.

14. Wentworth DN, Neaton JD, Rasmussen

WL. An evaluation of the Social

Security Administration Master

Beneficiary Record File and the

National Death Index in the

ascertainment of vital status. Am J

Public Health 73:1270–4. 1983.

15. Williams BC, Demitrack LB, Fries BE.

The accuracy of the National Death

Index when personal identifiers other

than Social Security number are used.

Am J Public Health 82(8):1145–7.

1992.

16. SAS Institute Inc. SAS Language and

Procedures: Usage, Version 6. 1st ed.

Cary, NC: SAS Institute, Inc., 1989.

17. Alvey W, Aziz F. Quality of mortality

reporting in SSA linked data: Some

preliminary descriptive results.

Statistical Uses of Administrative

Records with Emphasis on Mortality

and Disability Research. Washington,

D.C.: Social Security Administration.

1979.

18. Reyes M, Stebbings JH, Voelz GL.

Evaluation of social security follow-up

of some southwestern populations. J

Occup Med 24:198–202. 1982.

19. Curb JD, Ford CE, Pressel S, et al.

Ascertainment of vital status through

the National Death Index and the

Social Security Administration. Am J

Epidemiol 121(5):754–66. 1985.

20. Acquavella JF, Donaleski D, Hanis

NM. An analysis of mortality follow-up

through the National Death Index for a

cohort of refinery and petrochemical

workers. Am J Ind Med 9(2):181–7.

1986.

21. Madans JH, Cox CS, Kleinman JC, et

al. 10 years after NHANES I: Mortality

experience at initial followup, 1982–84.

Public Health Rep 101(5):474–81.

1986.

22. Madans JH, Kleinman JC, Cox CS, et

al. 10 years after NHANES I: Report

of initial followup, 1982–84. Public

Health Rep 101(5):465–73. 1986.

Page 8 [ Series 1, No. 38
Table 1. Number of deaths according to years of follow-up and sources of mortality status information in the the NHANES II Mortality Study,

1992

Year

Source of morality status

DMF1 NDI2 and DMF NDI Total

Number

of deaths Percent

Number

of deaths Percent

Number

of deaths Percent

Number

of deaths Percent

1976–78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 3.9 . . . . . . . . . 84 3.9

1979–883 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 4.1 863 40.2 363 16.9 1,314 61.3

1989–92 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 747 34.8 747 34.8

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 8.0 863 40.2 1,110 51.7 2,145 100.0

. . . Category not applicable.

1DMF is the Social Security Administration’s Death Master File.

2NDI is National Death Index.

3DMF was available through March 31, 1988. The remainder of 1988 was covered solely by the NDI.

NOTE: NHANES II is the Second National Health and Nutrition Examination Survey.

Table 2. Comparison of cumulative survival probabilities after 5 and 10 years for the U.S. population compared with those for the

NHANES II Mortality Study cohort according to race, sex, and age group

Race, sex, and age group

5 years 10 years

United States

NHANES II

Mortality Study

cohort1 United States

NHANES II

Mortality Study

cohort1

White male

30–39 years ........................... 0.990 0.996 0.977 0.980

40–49 years ........................... 0.977 0.987 0.944 0.954

50–59 years ........................... 0.940 0.957 0.858 0.891

60–64 years ........................... 0.874 0.880 0.735 0.763

65–69 years ........................... 0.824 0.835 0.624 0.669

70–75 years ........................... 0.744 0.811 0.485 0.550

White female

30–39 years ........................... 0.995 0.994 0.988 0.989

40–49 years ........................... 0.987 0.981 0.968 0.968

50–59 years ........................... 0.969 0.989 0.923 0.937

60–64 years ........................... 0.938 0.952 0.852 0.902

65–69 years ........................... 0.908 0.935 0.780 0.847

70–75 years ........................... 0.857 0.904 0.668 0.720

Black male

30–39 years ........................... 0.974 0.995 0.940 0.977

40–49 years ........................... 0.948 1.000 0.883 0.980

50–59 years ........................... 0.892 0.943 0.770 0.836

60–64 years ........................... 0.827 0.887 0.654 0.834

65–69 years ........................... 0.782 0.846 0.556 0.711

70–75 years ........................... 0.715 0.872 0.451 0.595

Black female

30–39 years ........................... 0.989 1.000 0.973 0.989

40–49 years ........................... 0.973 0.952 0.938 0.924

50–59 years ........................... 0.942 1.000 0.865 0.964

60–64 years ........................... 0.901 0.929 0.784 0.866

65–69 years ........................... 0.869 0.942 0.706 0.859

70–75 years ........................... 0.812 0.892 0.600 0.723

1Sample weights from the Second National Health and Nutrition Examination Survey were used.

NOTE: NHANES II is the Second National Health and Nutrition Examination Survey.

Series 1, No. 38 [ Page 9
Table 3. Expected number of survivors and decedents based on U.S. vital statistics data compared with observed number of decedents

from 1976–78 in the NHANES II Mortality Study according to sex and age for all races combined

Sex and age group

Number

examined

Expected

number of

survivors

Expected

number of

decedents

Observed

number of

decedents

Ratio of

observed to

expected

Male1

30–39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 629 626 3 – –

40–49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 497 493 4 3 0.75

50–59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 511 501 10 2 0.20

60–64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 631 607 24 18 0.75

65–69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 495 468 27 19 0.70

70–75 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 373 345 28 12 0.43

Total ................................ 3,136 3,040 96 54 0.56

Female1

30–39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 697 696 1 2 2.00

40–49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 541 538 3 1 0.33

50–59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 591 585 6 3 0.50

60–64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 660 648 12 6 0.50

65–69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 585 570 15 11 0.73

70–75 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 452 433 19 7 0.37

Total ................................ 3,526 3,470 56 30 0.54

Total1

30–39 years ........................... 1,326 1,322 4 2 0.50

40–49 years ........................... 1,038 1,031 7 4 0.57

50–59 years ........................... 1,102 1,086 16 5 0.31

60–64 years ........................... 1,291 1,255 36 24 0.67

65–69 years ........................... 1,080 1,038 42 30 0.71

70–75 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 825 778 47 19 0.40

Total ................................ 6,662 6,510 152 84 0.55

– Quantity zero.

1Includes races other than white and black.

NOTE: NHANES II is the Second National Health and Nutrition Examination Survey.

Page 10 [ Series 1, No. 38
Table 4. Expected number of survivors and decedents based on U.S. vital statistics data compared with observed number of decedents

from 1976–78 in the NHANES II Mortality Study according to race, sex, and age for selected race groups

Race, sex, and age group

Number

examined

Expected

number of

survivors

Expected

number of

decedents

Observed

number of

decedents

Ratio of

observed to

expected

White male

30–39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 549 547 2 – –

40–49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 442 439 3 3 1.00

50–59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 455 447 8 2 0.25

60–64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 572 551 21 14 0.67

65–69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 428 406 22 15 0.68

70–75 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 305 24 12 0.50

Total ................................ 2,775 2,695 80 46 0.58

White female

30–39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 602 601 1 2 2.00

40–49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 457 455 2 – –

50–59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 503 499 4 3 0.75

60–64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 588 578 10 5 0.50

65–69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 517 504 13 10 0.77

70–75 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 410 394 16 6 0.38

Total ................................ 3,077 3,031 46 26 0.57

Black male

30–39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 61 1 – –

40–49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 38 1 – –

50–59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 45 2 – –

60–64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 49 3 4 1.33

65–69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 44 4 3 0.75

70–75 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 33 4 – –

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 270 15 7 0.47

Black female

30–39 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 82 – – . . .

40–49 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 71 1 1 1.00

50–59 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 72 2 – –

60–64 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 58 2 1 0.50

65–69 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 53 2 1 0.50

70–75 years . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 35 3 1 0.33

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381 371 10 4 0.40

– Quantity zero.

. . . Category not applicable.

NOTE: NHANES II is the Second National Health and Nutrition Examination Survey.

Series 1, No. 38 [ Page 11
Table 5. Number of participants in the NHANES II Mortality Study by mortality status at end of follow-up in 1992 according to sex and age at

baseline for all races combined

Sex and age group Total

Status at follow-up

Assumed alive1 Decedents

Number Percent Number Percent

Male2

30–39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 871 832 95.5 39 4.5

40–49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 691 629 91.0 62 9.0

50–59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 700 565 80.7 135 19.3

60–64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 877 548 62.5 329 37.5

65–69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 697 339 48.6 358 51.4

70–75 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 513 178 34.7 335 65.3

Total ................................ 4,349 3,091 71.1 1,258 28.9

Female2

30–39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 988 968 98.0 20 2.0

40–49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 766 719 93.9 47 6.1

50–59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 795 701 88.2 94 11.8

60–64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 926 727 78.5 199 21.5

65–69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 799 565 70.7 234 29.3

70–75 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 627 334 53.3 293 46.7

Total ................................ 4,901 4,014 81.9 887 18.1

Total2

30–39 ............................... 1,859 1,800 96.8 59 3.2

40–49 ............................... 1,457 1,348 92.5 109 7.5

50–59 ............................... 1,495 1,266 84.7 229 15.3

60–64 ............................... 1,803 1,275 70.7 528 29.3

65–69 ............................... 1,496 904 60.4 592 39.6

70–75 ............................... 1,140 512 44.9 628 55.1

Total ................................ 9,250 7,105 76.8 2,145 23.2

1Not found to be deceased, therefore, assumed alive.

2Includes races other than white and black.

NOTE: NHANES II is the Second National Health and Nutrition Examination Survey.

Page 12 [ Series 1, No. 38
Table 6. Number of participants in the NHANES II Mortality Study by mortality status at end of follow-up in 1992 according to race, sex, and

age at baseline for selected race groups

Race, sex, and age group Total

Status at follow-up

Assumed alive1 Decedents

Number Percent Number Percent

White male

30–39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 750 719 95.9 31 4.1

40–49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 610 560 91.8 50 8.2

50–59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611 500 81.8 111 18.2

60–64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 791 490 62.0 301 38.0

65–69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 605 285 47.1 320 52.9

70–75 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448 152 33.9 296 66.1

Total ................................ 3,815 2,706 70.9 1,109 29.1

White female

30–39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 860 843 98.0 17 2.0

40–49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 654 618 94.5 36 5.5

50–59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 677 595 87.9 82 12.1

60–64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 828 653 78.9 175 21.1

65–69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 696 491 70.6 205 29.4

70–75 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 559 296 53.0 263 47.0

Total ................................ 4,274 3,496 81.8 778 18.2

Black male

30–39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 91 92.9 7 7.1

40–49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 52 82.5 11 17.5

50–59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 56 70.9 23 29.1

60–64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 52 66.7 26 33.3

65–69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 41 56.2 32 43.8

70–75 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 23 39.7 35 60.3

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449 315 70.2 134 29.8

Black female

30–39 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 108 97.3 3 2.7

40–49 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 88 89.8 10 10.2

50–59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 92 89.3 11 10.7

60–64 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 66 77.6 19 22.4

65–69 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 61 69.3 27 30.7

70–75 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 36 56.2 28 43.8

Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 549 451 82.1 98 17.8

1Not found to be deceased, therefore, assumed alive.

NOTE: NHANES II is the Second National Health and Nutrition Examination Survey.

Series 1, No. 38 [ Page 13
Appendix I

NHANES II baseline examination components for participants 30–75 years of age

(1976–80)

Examination components

Test group

Bile acids Glucose tolerance

Urine ...................................................... X X

Body measurements ............................................ X X

Physician examination ........................................... X X

Venipuncture ................................................. X X

Dietary interview ............................................... X X

Allergy test .................................................. X X

Electrocardiogram .............................................. X X

Chest and neck x rays ........................................... X X

Back x ray

30–75 years for men ........................................... X X

50–75 years for women ......................................... X X

Glucose tolerance test ........................................... X

Bile acids test: 35–75 years only ..................................... X

NOTE: NHANES II is the Second National Health and Nutrition Examination Survey.

Page 14 [ Series 1, No. 38
Appendix II

NHANES II baseline blood and urine assessments by specimen types for participants

30–75 years of age (1976–80)

Test group

Bile acids1 Glucose tolerance

Whole blood

Lead: Odd-numbered examinees .................................... X X

Carboxyhemoglobin: Even-numbered examinees ........................... X X

Protoporphyrin ....................... ....................... X X

Red blood cell folate2 ............................................ X X

Serum

Ferritin2 .................................................... X X

Bile acids: 35–75 years only ....................................... X

Cholesterol .................................................. X X

Triglyceride .................................................. X

High density lipoprotein .......................................... X

Pesticides: All examinees ......................................... X

Creatinine ................................................... X X

Syphilis .................................................... X X

Iron ....................................................... X X

Total iron binding capacity ......................................... X X

Folate2 ..................................................... X X

Vitamin B122 ................................................. X X

Copper .................................................... X X

Zinc ...................................................... X X

Albumin .................................................... X X

Glucose tolerance 75 gram load at 0-, 1-, and 2-hour intervals .................. X

Vitamin C ................................................... X X

Urine

N-Multistix ................................................... X X

Gonorrhea:

30–40 years for both sexes ...................................... X X

30–40 years for men ........................................... X

Microscopy .................................................. X

Specific gravity ................................................ X

Pesticides ................................................... X

1Bilirubin, SGOT, and alkaline phosphatase performed only on those samples with elevated bile acids.

2Performed only on those samples with abnormal complete blood count, hemoglobin, hematocrit, or mean corpuscular volume.

NOTE: NHANES II is the Second National Health and Nutrition Examination Survey.

Series 1, No. 38 [ Page 15
Appendix III

NHANES II baseline pesticide residue and metabolite determinations for participants

30–75 years of age (1976–80)

Serum Urine

Hexachlorobenzene alpha Monocarboxylic acid

trans Nonachlor Dicarboxylic acid

DDT and Associated Analogs 3,5,6-Trichloro-2-pyridinol

alpha-BHC Isopropoxyphenol

gamma-BHC Carbofuranphenol

beta-BHC 3-Ketocarbofuran

delta-BHC Dicamba

Aldrin 2,4-D

Dieldrin Pentachlorophenol

Endrin para-Nitrophenol

Heptachlor alpha-Naphthol

Heptachlor Epoxide DMTP

Oxychlordane DETP

Mirex DMDTP

DEDTP

DMP

DEP

2,4,5-T

Silvex

2,4,5-Trichlorophenol

NOTE: NHANES II is the Second National Health and Nutrition Examination Survey.

Page 16 [ Series 1, No. 38
Vital and Health Statistics

series descriptions

SERIES 1. Programs and Collection Procedures—These reports describe

the data collection programs of the National Center for Health

Statistics. They include descriptions of the methods used to

collect and process the data, definitions, and other material

necessary for understanding the data.

SERIES 2. Data Evaluation and Methods Research—These reports are

studies of new statistical methods and include analytical

techniques, objective evaluations of reliability of collected data,

and contributions to statistical theory. These studies also include

experimental tests of new survey methods and comparisons of

U.S. methodology with those of other countries.

SERIES 3. Analytical and Epidemiological Studies—These reports present

analytical or interpretive studies based on vital and health

statistics. These reports carry the analyses further than the

expository types of reports in the other series.

SERIES 4. Documents and Committee Reports—These are final reports of

major committees concerned with vital and health statistics and

documents such as recommended model vital registration laws

and revised birth and death certificates.

SERIES 5. International Vital and Health Statistics Reports—These

reports are analytical or descriptive reports that compare U.S.

vital and health statistics with those of other countries or present

other international data of relevance to the health statistics

system of the United States.

SERIES 6. Cognition and Survey Measurement—These reports are from

the National Laboratory for Collaborative Research in Cognition

and Survey Measurement. They use methods of cognitive science

to design, evaluate, and test survey instruments.

SERIES 10. Data From the National Health Interview Survey—These

reports contain statistics on illness; unintentional injuries;

disability; use of hospital, medical, and other health services; and

a wide range of special current health topics covering many

aspects of health behaviors, health status, and health care

utilization. They are based on data collected in a continuing

national household interview survey.

SERIES 11. Data From the National Health Examination Survey, the

National Health and Nutrition Examination Surveys, and the

Hispanic Health and Nutrition Examination Survey—Data

from direct examination, testing, and measurement on

representative samples of the civilian noninstitutionalized

population provide the basis for (1) medically defined total

prevalence of specific diseases or conditions in the United States

and the distributions of the population with respect to physical,

physiological, and psychological characteristics, and (2) analyses

of trends and relationships among various measurements and

between survey periods.

SERIES 12. Data From the Institutionalized Population Surveys—

Discontinued in 1975. Reports from these surveys are included in

Series 13.

SERIES 13. Data From the National Health Care Survey—These reports

contain statistics on health resources and the public’s use of

health care resources including ambulatory, hospital, and

long-term care services based on data collected directly from

health care providers and provider records.

SERIES 14. Data on Health Resources: Manpower and Facilities—

Discontinued in 1990. Reports on the numbers, geographic

distribution, and characteristics of health resources are now

included in Series 13.

SERIES 15. Data From Special Surveys—These reports contain statistics on

health and health-related topics collected in special surveys that

are not part of the continuing data systems of the National

Center for Health Statistics.

SERIES 16. Compilations of Advance Data From Vital and Health

Statistics—Advance Data Reports provide early release of

information from the National Center for Health Statistics’ health

and demographic surveys. They are compiled in the order in

which they are published. Some of these releases may be

followed by detailed reports in Series 10–13.

SERIES 20. Data on Mortality—These reports contain statistics on mortality

that are not included in regular, annual, or monthly reports.

Special analyses by cause of death, age, other demographic

variables, and geographic and trend analyses are included.

SERIES 21. Data on Natality, Marriage, and Divorce—These reports

contain statistics on natality, marriage, and divorce that are not

included in regular, annual, or monthly reports. Special analyses

by health and demographic variables and geographic and trend

analyses are included.

SERIES 22. Data From the National Mortality and Natality

Surveys—Discontinued in 1975. Reports from these sample

surveys, based on vital records, are now published in Series 20

or 21.

SERIES 23. Data From the National Survey of Family Growth—These

reports contain statistics on factors that affect birth rates,

including contraception, infertility, cohabitation, marriage,

divorce, and remarriage; adoption; use of medical care for family

planning and infertility; and related maternal and infant health

topics. These statistics are based on national surveys of women

of childbearing age.

SERIES 24. Compilations of Data on Natality, Mortality, Marriage,

Divorce, and Induced Terminations of Pregnancy—These

include advance reports of births, deaths, marriages, and divorces

based on final data from the National Vital Statistics System that

were published as supplements to the Monthly Vital Statistics

Report (MVSR). These reports provide highlights and summaries

of detailed data subsequently published in Vital Statistics of the

United States. Other supplements to the MVSR published here

provide selected findings based on final data from the National

Vital Statistics System and may be followed by detailed reports

in Series 20 or 21.

For answers to questions about this report or for a list of reports published in

these series, contact:

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National Center for Health Statistics

Centers for Disease Control and Prevention

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Hyattsville, MD 20782-2003

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