Blood mercury reporting in NHANES: identifying Asian, Pacific Islander, Native American, and multiracial groups.INTRODUCTION: Asians, Pacific Islanders, and Native Americans are a potentially high-risk group high-risk group Epidemiology A group of people in the community with a higher-than-expected risk for developing a particular disease, which may be defined on a measurable parameter–eg, an inherited genetic defect, physical attribute, lifestyle, habit, for dietary exposure to methylmercury through fish consumption. However, blood mercury levels in this group have not been identified in recent reports of the National Health and Nutrition Examination Survey (NHANES NHANES National Health and Nutrition Examination Survey (US CDC) ) for the years 1999-2002. METHODS: We used NHANES data from 1999-2002 to obtain population estimates of blood mercury levels among women of childbearing age classified as belonging to the "other" racial/ethnic group (Asian, Pacific Islander, Native American, and multiracial mul·ti·ra·cial adj. 1. Made up of, involving, or acting on behalf of various races: a multiracial society. 2. Having ancestors of several or various races. ; n = 140). Blood mercury levels in this group were compared with those among all other women participants, classified as Mexican American Mexican American n. A U.S. citizen or resident of Mexican descent. Mex  i·can-A·mer , non-Hispanic
black, non-Hispanic white, and "other" Hispanic.RESULTS: An estimated 16.59 [+ or -] 4.0% (mean [+ or -] SE) of adult female participants who serf-identified as Asian, Pacific Islander, Native American, or multiracial (n = 140) had blood mercury levels [greater than or equal to] 5.8 [micro]g/L, and 27.26 [+ or -] 4.22% had levels [greater than or equal to] 3.5 [micro]g/L Among remaining survey participants (n = 3,497), 5.08 [+ or -] 0.90% had blood mercury levels [greater than or equal to] 5.8 [micro]g/L, and 10.86 [+ or -] 1.45% had levels [greater than or equal to] 3.5 [micro]g/L. CONCLUSIONS: Study subjects in NHANES who self-identified as Asian, Pacific Islander, Native American, or multiracial had a higher prevalence of elevated blood mercury than all other racial/ethnic participants in the survey. Future studies should address reasons for the high mercury levels in this group and explore possible interventions for lowering risk of methylmercury exposure in this population. KEY WORDS: Alaskan Natives, American Medical Association American Medical Association (AMA), professional physicians' organization (founded 1847). Its goals are to protect the interests of American physicians, advance public health, and support the growth of medical science. , Asians, Centers for Disease Control, fish, mercury, methylmercury, multiracial, National Health and Nutrition Examination Survey, Native Americans, Pacific Islanders, reference dose, women. ********** There is growing public awareness of risk of methylmercury exposure associated with fish consumption (Hightower and Moore 2003; Knobeloch et al. 2005). Although omega-3 fatty acids This is a list of omega-3 fatty acids. Common name Lipid name Chemical name α-Linolenic acid (ALA) 18:3 (n-3) octadeca-9,12,15-trienoic acid Stearidonic acid 18:4 (n-3) octadeca-6,9,12,15-tetraenoic acid in fish have been associated with healthful health·ful adj. 1. Conducive to good health; salutary. 2. Healthy. health ful·ness n. benefits, there is increasing evidence that the
methylmercury content in some fish, if consumed too frequently, can lead
to adverse health effects. The predominant concerns at this time include
cardiovascular disease Cardiovascular diseaseDisease that affects the heart and blood vessels. Mentioned in: Lipoproteins Test cardiovascular disease (Frustaci et al. 1999; Guallar et al. 2002; Rissanen et al. 2000; Salonen et al. 1995, 2000; Sorensen et al. 1999; Virtanen et al. 2005), autoimmune disease autoimmune disease, any of a number of abnormal conditions caused when the body produces antibodies to its own substances. In rheumatoid arthritis, a group of antibody molecules called collectively RF, or rheumatoid factor, is complexed to the individual's own gamma (Bagenstose et al. 1999; Bernier et al. 1995; Bigazzi 1994; Nielsen and Hultman 2002; Silva et al. 2004; Stejskal and Stejskal 1999; Stejskal et al. 1999; Via et al. 2003), infertility (Choy et al. 2002; Dickman and Leung 1998; Leung et al. 2001; Sheiner et al. 2003), neuropsychiatric neu·ro·psy·chi·a·try n. The medical study of disorders with both neurological and psychiatric features. neu effects (Beuter and Edwards 2004; Yokoo et al. 2003), and subjective complaints (Fukuda et al. 1999). Furthermore, many of these adverse health effects may occur at mercury levels previously thought to be safe. The fetus has been the greatest concern because permanent damage to the developing brain can occur with methylmercury exposure. The U.S. Environment Protection Agency's reference dose for mercury was based on a cord blood cord blood n. Blood present in the umbilical vessels at the time of delivery. concentration of 5.8 [micro]g/L and corresponds to a maternal intake of 0.1 [micro]g Hg/kg body weight/day. However, it has been argued that this concentration should be lowered to 3.5 [micro]g/L, based on more recent observations showing that cord blood mercury concentrations are approximately 70% higher than maternal concentrations (Stern and Smith 2003). It is of importance to note that mercury concentration across the placenta placenta (pləsĕn`tə) or afterbirth, organ that develops in the uterus during pregnancy. It is a unique characteristic of the higher (or placental) mammals. In humans it is a thick mass, about 7 in. was not considered when the reference dose was established (Mahaffey 2005; Rice 2004; Rice et al. 2003). Fish consumption accounts for most of the daily intake of mercury compounds in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , with lesser contributions from elemental mercury from mercury vapor in dental amalgams. Urine mercury is a reflection of inorganic or elemental exposure, as occurs with dental amalgams, magical uses of elemental mercury, and herbs and medicines adulterated a·dul·ter·ate tr.v. a·dul·ter·at·ed, a·dul·ter·at·ing, a·dul·ter·ates To make impure by adding extraneous, improper, or inferior ingredients. adj. 1. Spurious; adulterated. 2. Adulterous. with inorganic mercury. Only small amounts of methylmercury, which is consumed primarily through fish consumption, is metabolized to inorganic mercury and excreted in the urine (Dye et al. 2005). There is also growing recognition within the medical community of the clinical importance of methylmercury exposure and of the connection between blood mercury levels and consumption of fish and shellfish products that are high in mercury. The American Medical Association (AMA (Automatic Message Accounting) The recording and reporting of telephone calls within a telephone system. It includes the calling and called parties and start and stop times of the call. ) has advocated that physicians "assist in educating patients about the relative mercury content of fish and shellfish products and make patients aware of the advice contained in both national and regional consumer fish consumption advisories" (AMA 2004). Since 1999, the National Health and Nutrition Examination Survey (NHANES) has reported total whole-blood mercury levels in children 1-5 years of age and in women 16-49 years of age. Recent reports based on NHANES data for 1999-2002 have examined blood mercury levels among the major racial/ethnic groups but have not examined blood mercury levels among those classified as "other" racial/ethnic group. The "other" group is of interest because it includes people at potentially high risk for methylmercury exposure through fish consumption, such as Asians, Pacific Islanders, and Native Americans (including Alaskan Natives) [Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ) 2004, 2005; National Center for Health Statistics National Center for Health Statistics (NCHS) is part of the Centers for Disease Control and Prevention (CDC), which is part of the United States Department of Health and Human Services. NCHS is the United States' principal health statistics agency. 2005; Sechena et al. 2003]. Materials and Methods This study complies with all applicable requirements of the U.S. human subject and research regulations. This project was reviewed by the Institutional Review Board of the California Pacific Medical Center California Pacific Medical Center (CPMC) is one of the largest private, not-for-profit, academic medical centers in Northern California. The Medical Center is a combination of three of San Francisco's oldest medical institutions: Pacific Presbyterian Hospital, Children's Hospital and was declared exempt. Data were obtained from public access databases and contained no identifiers. Data sources. NHANES is a complex, stratified stratified /strat·i·fied/ (strat´i-fid) formed or arranged in layers. strat·i·fied adj. Arranged in the form of layers or strata. , multistage mul·ti·stage adj. 1. Functioning in more than one stage: a multistage design project. 2. Relating to or composed of two or more propulsion units. probability cluster survey of a representative sample of the noninstitutionalized civilian population (CDC 2005; National Center for Health Statistics 2005). We used data from the most recent NHANES (1999-2002) to compare blood mercury levels among women 16-49 years of age in the "other" racial/ethnic group (this includes all participants who self-identified as Asian, Pacific Islander, Native American, multiracial, or a race/ethnicity other than black, non-Hispanic white, Mexican American, or Hispanic) with those in all other racial/ethnic groups (CDC 2005; National Center for Health Statistics 2005). Study sample. All women 16-49 years of age who were selected for both the interview and examination portions of NHANES and underwent whole-blood mercury testing were eligible for inclusion (n = 3,873). Among these, 236 participants had missing blood mercury results and were thus excluded from the analytic sample (n = 3,637). Among the women included in the analysis, 1,377 self-identified as non-Hispanic white, 1,106 as Mexican American, 794 as non-Hispanic black, and 220 as other Hispanic, and 140 were categorized as "other." Statistical analysis. We obtained population prevalence estimates for blood mercury levels [greater than or equal to] 5.8 [micro]g/L and [greater than or equal to] 3.5 [micro]g/L, respectively, using appropriate sample weights (Stata statistical software for complex survey design; StataCorp., College Station, TX) (CDC 2005; National Center for Health Statistics 2005). We compared the estimated prevalence of elevated blood mercury levels among participants in the "other" racial/ethnic group with those among Mexican Americans This is a list of notable Mexican-Americans. Athletes Baseball players
To determine whether observed differences in whole-blood mercury levels were most likely to reflect differences in dietary fish consumption rather than exposure to elemental or inorganic mercury, we examined self-reported fish consumption (number of fish and shellfish meals in the preceding 30 days) among female NHANES participants 16-49 years of age (n = 3,481) by racial/ethnic group: We also examined mean urine mercury-to-creatinine ratios (micrograms per gram) across racial/ethnic groups (n = 3,551). These analyses were also conducted using sample weights. Results An estimated 16.59 [+ or -] 4.0% [mean [+ or -] SE; 95% confidence interval confidence interval, n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. (CI), 8.41-24.77] of adult female participants who self-identified as Asian, Pacific Islander, Native American, or multiracial (n = 140) had blood mercury levels [greater than or equal to] 5.8 [micro]g/L, and an estimated 27.26 [+ or -] 4.22% (95% CI, 18.63-35.90) had levels [greater than or equal to] 3.5 [micro]g/L. In accordance with the NHANES analytical guidelines, these prevalence estimates are statistically reliable, because the relative SEs did not exceed 30% of the point estimates. The prevalence of elevated blood mercury levels in the "other" group is significantly higher than in all other racial/ethnic groups (Table 1). Among the remaining participants (n = 3,497), an estimated 5.08 [+ or -] 0.90% (95% CI, 3.25-6.92) had blood levels [greater than or equal to] 5.8 [micro]g/L, and an estimated 10.86 [+ or -] 1.45% (95% CI, 7.90-13.83) had mercury levels [greater than or equal to] 3.5 [micro]g/L. The mean number of fish and shellfish meals for the "other" racial/ethnic group was higher than for the remaining groups, although the 95% CIs overlapped with all except Mexican Americans. Fish and shellfish consumption among Mexican Americans is lower than among the "other" population. There were no statistically significant differences between groups in urine mercury:creatinine creatinine /cre·at·i·nine/ (kre-at´i-nin) an anhydride of creatine, the end product of phosphocreatine metabolism; measurements of its rate of urinary excretion are used as diagnostic indicators of kidney function and muscle mass. ratios (Table 2). Discussion In the United States, 4.1 million people identified themselves as Alaskan Native or Native American alone or in combination with one or more races in Census 2000; 12.5 million people identified as Asian or Pacific Islander Asian or Pacific Islander Multiculture A person with origins in any of the peoples of the Far East, Southeast Asia, Indian subcontinent, Pacific Islands–eg China, India, Japan, Korea, the Philippine Islands and Samoa , with 51% residing in the West, 19% in the South, 12% in the Midwest, and 19% in the Northeast. Asians, Pacific Islanders, Alaskan Natives, and Native Americans accounted for approximately 6.0% of live births in 2001, or approximately 242,151 babies born (U.S. Census Bureau Noun 1. Census Bureau - the bureau of the Commerce Department responsible for taking the census; provides demographic information and analyses about the population of the United States Bureau of the Census 2002a, 2002b; Ventura et al. 2003). The prevalence of elevated blood mercury, whether this was defined as [greater than or equal to] 5.8 [micro]g/L or [greater than or equal to] 3.5 [micro]g/L, was significantly higher among members of the "other" racial/ethnic group than among any other racial/ethnic group and primarily reflected differences in organic mercury exposure organic mercury exposure, n mercury exposure from dietary sources such as seafood. , most likely due to fish consumption. Although reports based on the most recent NHANES data from 2001-2002 have not reported mercury levels for this group (CDC 2004), NHANES data for the years 1999-2000 showed a non-statistically significant trend toward higher mercury levels in the "other" ethnic group (Mahaffey et al. 2004). Estimates presented here based on four years of NHANES data, 1999-2002, demonstrate that levels of mercury in this group are statistically significantly higher than for all other groups considered. Our findings are consistent with those of smaller studies that showed a correlation of methylmercury through fish consumption within the racial/ethnic groups that comprise the "other" population of NHANES participants. The groups identified in these studies were Native peoples of the United States and Canada (Beuter and Edwards 2004; Bjerregaard and Hansen 2000; Clarkson 1976; Girard et al. 1996; Harnly et al. 1997; McKeown-Eyssen et al. 1983; Mergler et al. 1998; Muckle et al. 2001; Weihe et al. 2002) and residents of Hong Kong and China (Choy et al. 2002; Dickman and Leung 1998; Leung et al. 2001), Japan (Fukuda et al. 1999), and American Samoa (Marsh et al. 1974). In fact, a recent random-digit-dial fish consumption survey (with subsequent hair mercury levels in women 18-45 years of age from 12 states in the continental United States United States territory, including the adjacent territorial waters, located within North America between Canada and Mexico. Also called CONUS. ) found that Asians had methylmercury exposures greater than the reference dose 83% of the time, compared with 12% for the total survey population (Knobdoch et al. 2005). Although NHANES was not designed to identify small subgroups at risk, it is imperative that significant populations at risk and important trends be identified. Such identification will help health care clinicians apply recommendations from the scientific literature to the patients they see in their communities, where appropriate. Conclusion Study subjects in NHANES who self-identified as Asian, Pacific Islander, Native American, or multiracial had a higher prevalence of elevated blood mercury than all other racial/ethnic participants in the survey. It is important that both patients and clinicians be aware that members of this group are at increased risk for methylmercury exposure. 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Neurobehavioral performance of Inuit children with increased prenatal exposure to methylmercury. Int J Circumpolar cir·cum·po·lar adj. 1. Located or found in one of the Polar Regions. 2. Astronomy Denoting a star that from a given observer's latitude does not go below the horizon. Health 61(1):41-49. Yokoo EM, Valente JG, Grattan L, Schmidt SL, Platt I, Silbergeld EK. 2003. Low level methylmercury exposure affects neuropsychological neu·ro·psy·chol·o·gy n. The branch of psychology that deals with the relationship between the nervous system, especially the brain, and cerebral or mental functions such as language, memory, and perception. functioning in adults. Environ Health 2:8. Available: http://www.ehjournal.net/content/pdf/1476-069-2-8.pdf [accessed 19 December 2005]. Address correspondence to J.M. Hightower, 2100 Webster St., Ste. 418, San Francisco, CA 94115 USA. Telephone: (415) 923-3025. Fax: (415) 749-5722. E-mail: jhightowermd@aol.com G.T.H. is supported by the W.K. Kellogg Scholars in Health Disparities Program. A.O. is supported by a Research Career Development Award from the Health Services Research Health services research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and Development Service, Department of Veterans Affairs. The authors declare they have no competing financial interests. Received 4 July 2005; accepted 21 September 2005. Jane M. Hightower, (1) Ann O'Hare, (2) German T. Hernandez (3) (1) Department of internal Medicine, California Pacific Medical Center, San Francisco, California “San Francisco” redirects here. For other uses, see San Francisco (disambiguation). The City and County of San Francisco (EN IPA: [sænfrənˈsɪskoʊ] , USA; (2) Department of Medicine, Veterans's Administration and University of California The University of California has a combined student body of more than 191,000 students, over 1,340,000 living alumni, and a combined systemwide and campus endowment of just over $7.3 billion (8th largest in the United States). San Francisco, San Francisco, California, USA; (3) Department of Medicine, University of California San Francisco and San Francisco General Hospital San Francisco General Hospital is the main public hospital in San Francisco, California, and the only Level I Trauma Center serving San Francisco and San Mateo. The hospital budget is for only 302 beds at SFGH. , San Francisco, California, USA
Table 1. Prevalence of elevated blood mercury levels among women 16-49
years of age participating in NHANES 1999-2002 [mean [+ or -] SE
(95% CI)].
[greater than or equal to] 3.5
Race/ethnicity No. [micro]g/L (%)
Mexican American 1,106 5.71 [+ or -] 0.98
(3.70-7.72)
Non-Hispanic white 1,377 11.29 [+ or -] 1.91
(7.40-15.19)
Non-Hispanic black 794 12.47 [+ or -] 2.15
(8.08-16.90)
Other Hispanic 220 10.38 [+ or -] 3.63
(2.95-17.81)
Other (a) race/ethnicity 140 27.26 [+ or -] 4.22
(18.63-35.90)
All races/ethnicities
except "other" 3,497 10.86 [+ or -] 1.45
(7.90-13.83)
All participants 3,637 11.69 [+ or -] 1.42
(8.79-14.60)
[greater than or equal to] 5.8
Race/ethnicity [micro]g/L (%)
Mexican American 1.70 [+ or -] 0.41
(0.87-2.53)
Non-Hispanic white 5.77 [+ or -] 1.24
(3.24-8.30)
Non-Hispanic black 4.82 [+ or -] 1.49
(1.78-7.86)
Other Hispanic 3.65 [+ or -] 1.87
(0.00-7.48)
Other (a) race/ethnicity 16.59 [+ or -] 4.0
(8.41-24.77)
All races/ethnicities
except "other" 5.08 [+ or -] 0.90
(3.25-6.92)
All participants 5.66 [+ or -] 0.94
(3.75-7.58)
(a) Participants who self-identified as Asian, Pacific Islander, Native
American, multiracial, or a race/ethnicity other than black,
non-Hispanic white, Mexican American, or Hispanic.
Table 2. Fish/shellfish meals and urine Hg:creatinine ratios
among women 16-49 years of age participating
in NHANES 1999-2002 [mean [+ or -] SE (95% CI)].
No. of fish/shellfish Urine
meals in the Hg:creatinine
Race/ethnicity preceding 30 days ratio ([micro]g/g)
Mexican American 2.86 [+ or -] 0.15 1.31 [+ or -] 0.12
(2.55-3.17) (1.07-1.55)
Non-Hispanic white 4.63 [+ or -] 0.25 1.07 [+ or -] 0.06
(4.13-5.14) (0.95-1.19)
Non-Hispanic black 4.90 [+ or -] 0.27 1.10 [+ or -] 0.12
(4.35-5.45) (0.84-1.34)
Other Hispanic 3.82 [+ or -] 0.53 1.08 [+ or -] 0.11
(2.74-4.90) (0.86-1.31)
Other (a) 8.02 [+ or -] 1.95 1.17 [+ or -] 0.14
(4.03-12.02) (0.88-1.45)
(a) Participants who self-identified as Asian, Pacific Islander,
Native American, multiracial, or as a race/ethnicity other than black,
non-Hispanic white, Mexican American, or Hispanic.
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