Table of Contents

Component Description

Users of the 2013-2014 dual-energy X-ray absorptiometry android/gynoid data (DXXAG_H) are encouraged to read the documentation before accessing the data file. NOTE: missing and invalid android and gynoid data were not multiply imputed.

Dual-energy x-ray absorptiometry (DXA) is the most widely accepted method of measuring body composition, due in part to its speed, ease of use, and low radiation exposure (Baran, 1997; Genant, 1996; Heymsfield, 1989; and Njeh, 1999). In 2013-2014, whole body DXA scans were administered in the NHANES mobile examination center (MEC).

Android and gynoid (A/G) regions were defined by the Hologic APEX software used in the scan analysis. The android area was defined as the lower trunk area bounded by two lines: the pelvic horizontal cut line on its lower side, and a line automatically placed above the pelvic line. The upper gynoid line was placed 1.5 times of the height of android region below the pelvic line and the lower gynoid line was placed such that the distance between the two gynoid lines was twice the height of the android region. All these lines were automatically placed by Hologic software (Shepherd, 2012).

Android obesity is often referred to as the “apple” shape since the increased fat is in the trunk. Gynoid obesity is referred to as the “pear” shape with increased fat in the hip and thigh areas. Fat deposition in the android region is associated with increased risk of cardiovascular disease, hypertension, hyperlipidemia, insulin resistance, and type 2 diabetes (Kissebah, 1994; Folsom, 2000), while gynoid fat deposition is associated with decreased risk of metabolic and cardiovascular diseases (Folsom, 2000; Ashwell, 1994).

Visceral Adipose Tissue (VAT) and subcutaneous Adipose Tissue (SAT) were defined by the Hologic APEX software used in the scan analysis. Visceral adipose tissue area, mass and volume of fat inside abdominal cavity were measured at the approximate interspace location of L4 and L5 vertebra. Subcutaneous adipose tissue area, mass and volume of fat outside abdominal cavity were measured at the approximate interspace location of L4 and L5 vertebra.

The NHANES whole body scans provide nationally representative data on abdominal soft tissue composition and fat distribution overall and for age, gender, and racial/ethnic groups; and data to study the association between abdominal fat distribution and other health conditions and risk factors, such as cardiovascular disease, diabetes, hypertension, and activity and dietary patterns.

Analysis of the whole body scans provides abdominal soft tissue measurements for the android and gynoid areas of the trunk, VAT and SAT. These measurements include:

Eligible Sample

DXA whole body scans were administered to eligible survey participants aged 8-59. Pregnant females were ineligible for the DXA examination. Participants who were excluded from the DXA examination for reasons other than pregnancy were considered to be eligible nonrespondents. Reasons for exclusion from the DXA examination were as follows:

The variable DXXAGST indicates the examination status for the android/gynoid region. The codes for DXXAGST are as follows:
1= Whole body scan completed, android/gynoid region is valid
2= Whole body scan completed, but android or gynoid region is invalid
3= Whole body not scanned, pregnancy
4= Whole body not scanned, weight > 450 lbs
5= Whole body not scanned, height > 6'5”
6= Whole body not scanned, other reason

The main reasons for completed but invalid whole body scans were implants, excessive X-ray “noise” due to obesity, and jewelry not removed. The “Not scanned, other reason” code includes no time to complete the examination, pregnancy test not completed, and participant refusal.

Protocol and Procedure

The whole body scans were acquired on the Hologic Discovery model A densitometers (Hologic, Inc., Bedford, Massachusetts), using software version Apex 3.2. The radiation exposure from DXA whole body scans is extremely low at less than 20 uSv. All scans in the DXXAG_H file were analyzed with Hologic APEX version 4.0 software with NHANES BCA option.

The DXA examinations were administered by trained and certified radiology technologists. Further details of the DXA examination protocol are documented in the Body Composition Procedures Manual located on the NHANES website.

Quality Assurance & Quality Control

A high level of quality control was maintained throughout the DXA data collection and scan analysis, including a rigorous phantom scanning schedule.

Monitoring of Field Staff and Densitometers
Staff from the National Center for Health Statistics (NCHS) and the NHANES data collection contractor monitored technologist acquisition performance through in-person observations in the field. Retraining sessions were conducted with the technologists annually and as needed to reinforce correct techniques and appropriate protocol. In addition, technologist performance codes were recorded by the NHANES quality control center at the University of California, San Francisco (UCSF), Department of Radiology as part of the participants’ scan review. The codes documented when the technologist had deviated from acquisition procedures and scan quality could have been improved. The performance codes were tracked for each technologist individually and a summary was reported to NCHS on a quarterly basis. Constant communication was maintained throughout the year among the UCSF, the NCHS, and the data collection contractor regarding any issues that arose.

Hologic service engineers performed all routine densitometer maintenance and repairs. Copies of all reports completed by the manufacturer’s service engineers were sent to the UCSF when the scanners were serviced or repaired so any changes in measurement, as a result of the work, could be assessed.

Scan Analysis
Each participant scan and phantom scan was reviewed and analyzed by the UCSF using standard radiologic techniques and study-specific protocols developed for NHANES. The Hologic software, APEX v4.0 (Hologic) was used to analyze whole body scans acquired in 2013-14. Expert review was conducted by the UCSF on 100% of analyzed participant scans to verify the accuracy and consistency of the results.

Invalidity Codes
Invalidity codes were applied by the UCSF to indicate the reasons regions of the body could not be analyzed accurately. The invalidity codes for the trunk region are provided in the data file (see Analytic Notes for a description of the invalidity codes).

Quality Control Scans
The quality control phantoms were scanned according to a predetermined schedule. The Hologic Anthropomorphic Spine Phantom associated with each MEC was scanned daily as required by the manufacturer to ensure accurate calibration of the densitometer. Other MEC-specific phantoms, such as the Hologic Whole Body Slim-line Phantom and Hologic Tissue Step Phantom, were scanned 1 to 3 times weekly. Another set of phantoms, the Hologic Spine (HSP-Q96), Hologic Block, and Hologic Whole Body Phantoms, circulated among the MECs and was scanned at the start of operations at each survey site.

Air scans, which are phantom-less scans using the whole body scan mode, were used to describe and monitor the systems’ radiographic uniformity across the entire scan field. Poor uniformity could be caused by poor aperture alignment, incorrect gantry rotation, non-uniform gain in detectors, etc., that result in localized inaccuracies in the attenuation values.

The complete phantom scanning schedule is described in the Body Composition Procedures Manual located on the NHANES website.

In 2013-2014, longitudinal monitoring was conducted through the daily spine phantom scans as required by the manufacturer, 3 times weekly whole body slim-line phantom scans, and weekly air scans in order to correct any scanner-related changes in participant data. The circulating HSP-Q96, block, and whole body phantoms, which were scanned at the start of operations at each site, provided additional data for use in longitudinal monitoring and cross calibration. The cross-comparability of the data from each MEC was critical so the data could be pooled for analysis.

The UCSF used the Cumulative Statistics method (CUSUM) and the MEC-specific phantom data to determine breaks in the calibration of the densitometers over the course of the survey (Lu, 1996). Multiplicative correction factors were used to correct the phantom data back to the baseline calibration. The type, frequency, and magnitude of calibration problems detected in the NHANES data were similar to those in other studies using stationary densitometers that were being monitored by UCSF.

After applying the correction factors developed by UCSF from the cross-calibration and longitudinal phantom data to the NHANES participant data, the adjusted participant data were compared to unadjusted data. The magnitude of the changes and reduction in standard errors between the adjusted and unadjusted data were found to be small and correction of the participant data was not required.

A number of data quality issues were addressed through the quality control program. Direct feedback given to the technologists regarding acquisition problems affecting the quality of the scans and yearly refresher training resulted in improved technologist performance. The rigorous schedule of quality control scans provided continuous monitoring of machine performance. The expert review procedures helped to ensure that scan analysis was accurate and consistent.

Data Processing and Editing

During the editing process, data were reviewed for completeness, consistency, and outliers. Back-end edits of the data were performed when errors were identified. The NHANES BCA option was enabled for whole body scan analysis, this option adds 5% of lean mass to the fat mass. The correction is based on the results of an analysis of QDR-4500A DXA data from seven research laboratories indicating that the QDR-4500A algorithm underestimated fat mass and overestimated lean mass (Schoeller, 2005).

Invalidity Codes
Invalidity codes were included in the data file to indicate the reasons regions could not be analyzed accurately. Invalidity codes were applicable to completed scans only (DXXAGST=1 or 2). If a participant was not scanned, all invalidity codes are missing. Objects found in the upper portion of the trunk such as pacemakers or breast implants did not invalidate the scan validity for the android gynoid data.

Values for DXXVATV(VAT and SAT), DXXANTV (Android region) and DXXGYTV (Gynoid region) invalidity codes
0 = Valid 
1 = Invalid

The percentage of eligible survey participants in 2013-2014 with valid DXA data in android/gynoid region is shown by age group in Table 1. The percentage of participants with valid data decreases with increasing age. The decrease in valid data with age was due primarily to an increase in the number of participants with implants, such as stents and hip replacements and higher rates of obesity resulting in invalid truncal data from “obesity noise.” The percentage of participants with valid DXA data in android/gynoid region also decreases with increasing BMI due to weight over 450 pounds and “obesity noise” (Table 2).

Table 1. Percentages of interviewed and examined participants aged 8-59 years with valid DXA data in android/gynoid region by age group, NHANES 2013-2014

Age group (years) Interviewed and examined * Eligible for DXA %100 valid DXA data
N N % N %
8-11 839 839 100 770 92
12-15 713  713  100 638  90 
16-19 678  678 100 608  90 
20-29 919  876  95 792 90 
30-39 961  942 98 851  90 
40-49 1,007  1,004  99 932  93
50-59 916  916  100 826  90 
Total 6,033 5,968 99  4,417 91 

* The number interviewed and examined is the total number of participants in the data file with a SEQN variable. This number includes pregnant females.
† The total number eligible for DXA does not include pregnant women.
‡ Of those eligible for DXA who successfully completed a scan.

Table 2. Percentages of participants aged 20-59 years with valid DXA data in android/gynoid region by body mass index (BMI) * category, NHANES 2013-14

BMI group Interviewed and Examined (N) Eligible for DXA (N) Eligible for DXA (%) 100% valid DXA data (N) 100% valid DXA data (%)
<18 41 41  100  36 88 
18-24.9 1,155 1,131 98 1,038  92 
25-29.9 1,138 1,120 98 1,049  94 
30-34.9 760 746  98 689  92 
35-39.9 359 356 99 328  92 
≥ 40 318  312  98 249  80 
Total 3,771 3,706 98 3,401 92 

*Measured weight in kilograms divided by measured height in meters squared.
†The total number eligible for DXA does not include pregnant women.
‡ Of those eligible for DXA who successfully completed a scan.

Analytic Notes

The NHANES examination sample weight should be used for any analyses using the DXXAG_H data. Please refer to the NHANES Analytic Guidelines and the online NHANES Tutorial for further details on the use of sample weights and other analytic issues.

References

Codebook and Frequencies

SEQN - Respondent sequence number

Variable Name:
SEQN
SAS Label:
Respondent sequence number
English Text:
Respondent sequence number.
Target:
Both males and females 8 YEARS - 59 YEARS

DXXAGST - Android/gynoid region status

Variable Name:
DXXAGST
SAS Label:
Android/gynoid region status
English Text:
Android/gynoid region status
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
1 Whole body scan completed; android/gynoid region is valid 5417 5417
2 Whole body scan completed, but android or gynoid region is invalid 31 5448
3 Whole body not scanned, pregnancy 65 5513
4 Whole body not scanned, weight > 450 lbs 2 5515
5 Whole body not scanned, height > 6'5” 7 5522
6 Whole body not scanned, other reason 511 6033
. Missing 0 6033

DXXVATV - VAT and SAT invalidity code

Variable Name:
DXXVATV
SAS Label:
VAT and SAT invalidity code
English Text:
VAT and SAT invalidity code
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
0 Valid 5427 5427
1 Invalid 21 5448
. Missing 585 6033

DXXANTV - Android region invalidity code

Variable Name:
DXXANTV
SAS Label:
Android region invalidity code
English Text:
Android region invalidity code
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
0 Valid 5425 5425
1 Invalid 23 5448
. Missing 585 6033

DXXGYTV - Gynoid region invalidity code

Variable Name:
DXXGYTV
SAS Label:
Gynoid region invalidity code
English Text:
Gynoid region invalidity code
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
0 Valid 5426 5426
1 Invalid 22 5448
. Missing 585 6033

DXXANFM - Android fat mass

Variable Name:
DXXANFM
SAS Label:
Android fat mass
English Text:
Android fat mass
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
158.8 to 10155.1 Range of Values 5425 5425
. Missing 608 6033

DXXANLM - Android lean mass

Variable Name:
DXXANLM
SAS Label:
Android lean mass
English Text:
Android lean mass
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
664.3 to 10793.8 Range of Values 5425 5425
. Missing 608 6033

DXXANTOM - Android total mass

Variable Name:
DXXANTOM
SAS Label:
Android total mass
English Text:
Android total mass
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
835.8 to 19994.4 Range of Values 5425 5425
. Missing 608 6033

DXXGYFM - Gynoid fat mass

Variable Name:
DXXGYFM
SAS Label:
Gynoid fat mass
English Text:
Gynoid fat mass
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
443.1 to 14227.3 Range of Values 5426 5426
. Missing 607 6033

DXXGYLM - Gynoid lean mass

Variable Name:
DXXGYLM
SAS Label:
Gynoid lean mass
English Text:
Gynoid lean mass
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
1409.3 to 18187.1 Range of Values 5426 5426
. Missing 607 6033

DXXGYTOM - Gynoid total mass

Variable Name:
DXXGYTOM
SAS Label:
Gynoid total mass
English Text:
Gynoid total mass
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
1852.5 to 30962.4 Range of Values 5426 5426
. Missing 607 6033

DXXAGRAT - Android to Gynoid ratio

Variable Name:
DXXAGRAT
SAS Label:
Android to Gynoid ratio
English Text:
Android to gynoid ratio
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
0.4 to 1.8 Range of Values 5417 5417
. Missing 616 6033

DXXAPFAT - Android percent fat

Variable Name:
DXXAPFAT
SAS Label:
Android percent fat
English Text:
Android percent fat
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
11.4 to 58.5 Range of Values 5425 5425
. Missing 608 6033

DXXGPFAT - Gynoid percent fat

Variable Name:
DXXGPFAT
SAS Label:
Gynoid percent fat
English Text:
Gynoid percent fat
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
12.8 to 58.6 Range of Values 5426 5426
. Missing 607 6033

DXXSATA - Subcutaneous fat area

Variable Name:
DXXSATA
SAS Label:
Subcutaneous fat area
English Text:
Subcutaneous fat area
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
17.84 to 1058.15 Range of Values 5427 5427
. Missing 606 6033

DXXSATM - Subcutaneous fat mass

Variable Name:
DXXSATM
SAS Label:
Subcutaneous fat mass
English Text:
Subcutaneous fat mass
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
85.99 to 5101.63 Range of Values 5427 5427
. Missing 606 6033

DXXSATV - Subcutaneous fat volume

Variable Name:
DXXSATV
SAS Label:
Subcutaneous fat volume
English Text:
Subcutaneous fat volume
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
92.96 to 5515.27 Range of Values 5427 5427
. Missing 606 6033

DXXTATA - Total abdominal fat area

Variable Name:
DXXTATA
SAS Label:
Total abdominal fat area
English Text:
Total abdominal fat area
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
38.75 to 1210.84 Range of Values 5427 5427
. Missing 606 6033

DXXTATM - Total abdominal fat mass

Variable Name:
DXXTATM
SAS Label:
Total abdominal fat mass
English Text:
Total abdominal fat mass
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
186.81 to 5837.8 Range of Values 5427 5427
. Missing 606 6033

DXXTATV - Total abdominal fat volume

Variable Name:
DXXTATV
SAS Label:
Total abdominal fat volume
English Text:
Total abdominal fat volume
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
201.95 to 6311.13 Range of Values 5427 5427
. Missing 606 6033

DXXVFATA - Visceral adipose tissue area

Variable Name:
DXXVFATA
SAS Label:
Visceral adipose tissue area
English Text:
Visceral adipose tissue area
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
0 to 388.3 Range of Values 5427 5427
. Missing 606 6033

DXXVFATM - Visceral adipose tissue mass

Variable Name:
DXXVFATM
SAS Label:
Visceral adipose tissue mass
English Text:
Visceral adipose tissue mass
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
0 to 1872.08 Range of Values 5427 5427
. Missing 606 6033

DXXVFATV - Visceral adipose tissue volume

Variable Name:
DXXVFATV
SAS Label:
Visceral adipose tissue volume
English Text:
Visceral adipose tissue volume
Target:
Both males and females 8 YEARS - 59 YEARS
Code or Value Value Description Count Cumulative Skip to Item
0 to 2023.87 Range of Values 5427 5427
. Missing 606 6033