NCHS has linked data from various surveys with death certificate records from the National Death Index (NDI). Linkage of the NCHS survey participant data with the NDI mortality data provides the opportunity to conduct a vast array of outcome studies designed to investigate the association of a wide variety of health factors with mortality. The Linked Mortality Files (LMF) have been updated with mortality follow-up data through December 31, 2019.

Public-use Linked Mortality Files (LMF) are available for 1986-2018 NHIS, 1999-2018 NHANES, and NHANES III. The files include a limited set of mortality variables for adult participants only. The public-use versions of the NCHS Linked Mortality Files were subjected to data perturbation techniques to reduce the risk of participant re-identification. For select records, synthetic data were substituted for follow-up time or underlying cause of death. Information regarding vital status was not perturbed.

ImportanceReligiosity has been associated with positive health outcomes. Hypothesized pathways for this association include religious practices, such as church attendance, that result in reduced stress.ObjectiveThe objective of this study was to examine the relationship between religiosity (church attendance), allostatic load (AL) (a physiologic measure of stress) and all-cause mortality in middle-aged adults.Design, setting and participantsData for this study are from NHANES III (1988–1994). The analytic sample (n = 5449) was restricted to adult participants, who were between 40–65 years of age at the time of interview, had values for at least 9 out of 10 clinical/biologic markers used to derive AL, and had complete information on church attendance.Main outcomes and measuresThe primary outcomes were AL and mortality. AL was derived from values for metabolic, cardiovascular, and nutritional/inflammatory clinical/biologic markers. Mortality was derived from a probabilistic algorithm matching the NHANES III Linked Mortality File to the National Death Index through December 31, 2006, providing up to 18 years follow-up. The primary predictor variable was baseline report of church attendance over the past 12 months. Cox proportional hazard logistic regression models contained key covariates including socioeconomic status, self-rated health, co-morbid medical conditions, social support, healthy eating, physical activity, and alcohol intake.ResultsChurchgoers (at least once a year) comprised 64.0% of the study cohort (n = 3782). Non-churchgoers had significantly higher overall mean AL scores and higher prevalence of high-risk values for 3 of the 10 markers of AL than did churchgoers. In bivariate analyses non-churchgoers, compared to churchgoers, had higher odds of an AL score 2–3 (OR 1.24; 95% CI 1.01, 1.50) or ≥4 (OR 1.38; 95% CI 1.11, 1.71) compared to AL score of 0–1. More frequent churchgoers (more than once a week) had a 55% reduction of all-cause mortality risk compared with non-churchgoers. (HR 0.45, CI 0.24–0.85) in the fully adjusted model that included AL.Conclusions and relevanceWe found a significant association between church attendance and mortality among middle-aged adults after full adjustments. AL, a measure of stress, only partially explained differences in mortality between church and non-church attendees. These findings suggest a potential independent effect of church attendance on mortality.

The National Health and Nutrition Examination Survey (NHANES) provides data and have considerable potential to study the health and environmental exposure of the non-institutionalized US population. However, as NHANES data are plagued with multiple inconsistencies, processing these data is required before deriving new insights through large-scale analyses. Thus, we developed a set of curated and unified datasets by merging 614 separate files and harmonizing unrestricted data across NHANES III (1988-1994) and Continuous (1999-2018), totaling 135,310 participants and 5,078 variables. The variables conveydemographics (281 variables),dietary consumption (324 variables),physiological functions (1,040 variables),occupation (61 variables),questionnaires (1444 variables, e.g., physical activity, medical conditions, diabetes, reproductive health, blood pressure and cholesterol, early childhood),medications (29 variables),mortality information linked from the National Death Index (15 variables),survey weights (857 variables),environmental exposure biomarker measurements (598 variables), andchemical comments indicating which measurements are below or above the lower limit of detection (505 variables).csv Data Record: The curated NHANES datasets and the data dictionaries includes 23 .csv files and 1 excel file.The curated NHANES datasets involves 20 .csv formatted files, two for each module with one as the uncleaned version and the other as the cleaned version. The modules are labeled as the following: 1) mortality, 2) dietary, 3) demographics, 4) response, 5) medications, 6) questionnaire, 7) chemicals, 8) occupation, 9) weights, and 10) comments."dictionary_nhanes.csv" is a dictionary that lists the variable name, description, module, category, units, CAS Number, comment use, chemical family, chemical family shortened, number of measurements, and cycles available for all 5,078 variables in NHANES."dictionary_harmonized_categories.csv" contains the harmonized categories for the categorical variables.“dictionary_drug_codes.csv” contains the dictionary for descriptors on the drugs codes.“nhanes_inconsistencies_documentation.xlsx” is an excel file that contains the cleaning documentation, which records all the inconsistencies for all affected variables to help curate each of the NHANES modules.R Data Record: For researchers who want to conduct their analysis in the R programming language, only cleaned NHANES modules and the data dictionaries can be downloaded as a .zip file which include an .RData file and an .R file.“w - nhanes_1988_2018.RData” contains all the aforementioned datasets as R data objects. We make available all R scripts on customized functions that were written to curate the data.“m - nhanes_1988_2018.R” shows how we used the customized functions (i.e. our pipeline) to curate the original NHANES data.Example starter codes: The set of starter code to help users conduct exposome analysis consists of four R markdown files (.Rmd). We recommend going through the tutorials in order.“example_0 - merge_datasets_together.Rmd” demonstrates how to merge the curated NHANES datasets together.“example_1 - account_for_nhanes_design.Rmd” demonstrates how to conduct a linear regression model, a survey-weighted regression model, a Cox proportional hazard model, and a survey-weighted Cox proportional hazard model.“example_2 - calculate_summary_statistics.Rmd” demonstrates how to calculate summary statistics for one variable and multiple variables with and without accounting for the NHANES sampling design.“example_3 - run_multiple_regressions.Rmd” demonstrates how run multiple regression models with and without adjusting for the sampling design.

Background and aimLong-term adherence to the Mediterranean Diet has been shown to improve cognitive function in patients. However, there is a lack of evidence regarding the impact of the Mediterranean diet and cognitive impairment on long-term mortality outcomes. This study aims to explore whether there is an interaction between the degree of adherence to the Mediterranean diet and cognitive impairment on long-term mortality outcomes.MethodsThe study included 2,520 participants from the National Health and Nutrition Examination Survey (NHANES) conducted between 2011 and 2014. The adherence to the Mediterranean diet was assessed using the 9-point alternative Mediterranean diet index (aMED index). Cognitive function was assessed using the Consortium to Establish a Registry for Alzheimer’s disease (CERAD), the Animal Fluency Test (AFT), and the Digital Symbol Substitution Test (DSST). By accessing public records from the National Death Index (NDI), NHANES participants’ information was linked to death certificate records to determine mortality and causes of death during the follow-up period, up to December 31, 2019, with causes specified according to ICD-10. Participants were categorized based on the median aMED score into low adherence (scores 0–3), moderate adherence (score 4), and high adherence (scores 5–9) groups. Cognitive impairment was assessed by calculating the arithmetic mean of standardized scores (Z-scores) for each cognitive test. Participants with scores below the first quartile of the arithmetic mean were considered to have cognitive impairment. Cox proportional hazards regression models were used to assess the relationship between cognitive impairment, aMED, and all-cause and cardiovascular mortality outcomes. Additionally, the interaction between cognitive impairment and aMED on these outcomes was evaluated.ResultsThe study included 2,520 participants, with 481 deaths during the follow-up period, of which 129 (26.8%) were cardiovascular-related. The median aMED score in the population was 4, and 632 individuals (25.1%) were considered to have cognitive impairment. A higher aMED score was associated with a reduced risk of long-term all-cause mortality and cardiovascular-related mortality (HR, 0.65; 95% CI, 0.52–0.81, p 

The National Health and Nutrition Examination Survey (NHANES) provides data on the health and environmental exposure of the non-institutionalized US population. Such data have considerable potential to understand how the environment and behaviors impact human health. These data are also currently leveraged to answer public health questions such as prevalence of disease. However, these data need to first be processed before new insights can be derived through large-scale analyses. NHANES data are stored across hundreds of files with multiple inconsistencies. Correcting such inconsistencies takes systematic cross examination and considerable efforts but is required for accurately and reproducibly characterizing the associations between the exposome and diseases (e.g., cancer mortality outcomes). Thus, we developed a set of curated and unified datasets and accompanied code by merging 614 separate files and harmonizing unrestricted data across NHANES III (1988-1994) and Continuous (1999-2018), totaling 134,310 participants and 4,740 variables. The variables convey 1) demographic information, 2) dietary consumption, 3) physical examination results, 4) occupation, 5) questionnaire items (e.g., physical activity, general health status, medical conditions), 6) medications, 7) mortality status linked from the National Death Index, 8) survey weights, 9) environmental exposure biomarker measurements, and 10) chemical comments that indicate which measurements are below or above the lower limit of detection. We also provide a data dictionary listing the variables and their descriptions to help researchers browse the data. We also provide R markdown files to show example codes on calculating summary statistics and running regression models to help accelerate high-throughput analysis of the exposome and secular trends on cancer mortality. csv Data Record: The curated NHANES datasets and the data dictionaries includes 13 .csv files and 1 excel file. The curated NHANES datasets involves 10 .csv formatted files, one for each module and labeled as the following: 1) mortality, 2) dietary, 3) demographics, 4) response, 5) medications, 6) questionnaire, 7) chemicals, 8) occupation, 9) weights, and 10) comments. The eleventh file is a dictionary that lists the variable name, description, module, category, units, CAS Number, comment use, chemical family, chemical family shortened, number of measurements, and cycles available for all 4,740 variables in NHANES ("dictionary_nhanes.csv"). The 12th csv file contains the harmonized categories for the categorical variables ("dictionary_harmonized_categories.csv"). The 13th file contains the dictionary for descriptors on the drugs codes (“dictionary_drug_codes.csv”). The 14th file is an excel file that contains the cleaning documentation, which records all the inconsistencies for all affected variables to help curate each of the NHANES datasets (“nhanes_inconsistencies_documentation.xlsx”). R Data Record: For researchers who want to conduct their analysis in the R programming language, the curated NHANES datasets and the data dictionaries can be downloaded as a .zip file which include an .RData file and an .R file. We provided an .RData file that contains all the aforementioned datasets as R data objects (“w - nhanes_1988_2018.RData”). Also in this .RData file, we make available all R scripts on customized functions that were written to curate the data. We also provide an .R file that shows how we used the customized functions (i.e. our pipeline) to curate the data (“m - nhanes_1988_2018.R”).

IntroductionCompared with sleep disorders, no consensus has been reached on whether a subjective complaint of having trouble sleeping is associated with increased all-cause and heart disease mortality risk. Previous studies displayed considerable heterogeneity in population disease characteristics and duration of follow-up. Therefore, the aims of this study were to examine the relationship between sleep complaints and all-cause and heart disease mortality and whether the associations were influenced by follow-up time and population disease characteristics. In addition, we aimed to figure out the influence of the joint effects of sleep duration and sleep complaints on mortality risk.MethodsThe present study utilized data from five cycles of the National Health and Nutrition Examination Survey (NHANES) (2005~2014) linked with the most updated 2019 National Death Index (NDI). Sleep complaints were determined by answers to “Have you ever told a doctor or other health professional that you have trouble sleeping?” and “Have you ever been told by a doctor or other health professional that you have a sleep disorder?”. Those who answered ‘Yes' to either of the aforementioned two questions were considered as having sleep complaints.ResultsA total of 27,952 adult participants were included. During a median follow-up of 9.25 years (interquartile range, 6.75–11.75 years), 3,948 deaths occurred and 984 were attributable to heart disease. A multivariable-adjusted Cox model revealed that sleep complaints were significantly associated with all-cause mortality risk (HR, 1.17; 95% CI, 1.07–1.28). Subgroup analysis revealed that sleep complaints were associated with all-cause (HR, 1.17; 95% CI, 1.05–1.32) and heart disease (HR, 1.24; 95% CI, 1.01–1.53) mortality among the subgroup with cardiovascular disease (CVD) or cancer. In addition, sleep complaints were more strongly associated with short-term mortality than long-term mortality. The joint analysis of sleep duration and sleep complaints showed that sleep complaints mainly increased the mortality risk in those with short (< 6 h/day, sleep complaints HR, 1.40; 95% CI, 1.15–1.69) or recommended (6–8 h/day, sleep complaints HR, 1.15; 95% CI, 1.01–1.31) sleep duration group.DiscussionIn conclusion, sleep complaints were associated with increased mortality risk, indicating a potential public benefit of monitoring and managing sleep complaints in addition to sleep disorders. Of note, persons with a history of CVD or cancer may represent a potentially high-risk group that should be targeted with a more aggressive intervention of sleep problems to prevent premature all-cause and heart disease death.

BackgroundStudies regarding the impact of the Healthy Eating Index-2010 (HEI-2010) on the mortality of adults with hypertension are lacking.ObjectivesThis study aimed to prospectively explore the relationships between HEI-2010 and mortality from heart disease and all causes in adults with hypertension based on the National Health and Nutrition Examination Survey (NHANES), 2007–2014.MethodsThis is a prospective cohort study including 6,690 adults with hypertension from NHANES (2007–2014). National Death Index data up to 31 December 2019 were used to determine the number of deaths due to heart disease and all other causes. We evaluated hazard ratios (HRs) and 95% confidence intervals (CIs) using the Cox proportional hazards model.ResultsA total of 1,259 deaths from all causes, including 338 due to heart disease, were documented over an average follow-up duration of 8.4 years. In comparison with the lowest quartile of HEI-2010 scores, multivariable-adjusted HRs (95% CIs) for all-cause mortality were 0.82 (0.70, 0.97), 0.78 (0.64, 0.95), and 0.68 (0.54, 0.85) for the second, third, and fourth quartiles of the HEI-2010 scores (P-trend < 0.001) and for heart disease mortality were 0.60 (0.44, 0.81), 0.59 (0.40, 0.89), and 0.53 (0.35, 0.80) (P-trend = 0.010). Each increment in natural-log-transformed HEI-2010 scores was linked to a 43% reduction in the risk of all-cause mortality (P < 0.001) and a 55% reduction in the risk of heart disease mortality (P = 0.003). Among the 12 components of HEI-2010, adherence to a higher intake of greens and beans, vegetables, total protein foods, seafood and plant proteins, and unsaturated fatty acids, as well as moderate consumption of empty calories, were related to a 21–29% lower risk of all-cause mortality.ConclusionIn the current study, there was a statistically significant inverse relationship between HEI-2010 and mortality from heart disease and all causes among adults with hypertension. Based on the findings, it may help guide the dietary intake for adults with hypertension.

BackgroundMetabolic syndrome (MetS) and sarcopenia (SP) have emerged as significant public health concerns in contemporary societies, characterized by shared pathophysiological mechanisms and interrelatedness, leading to profound health implications. In this prospective cohort study conducted within a US population, we aimed to examine the influence of MetS and SP on all-cause and cardiovascular mortality.MethodsThis study analyzed data from the National Health and Nutrition Examination Survey (NHANES) III for the years 1999-2006 and 2011-2018, and death outcomes were ascertained by linkage to National Death Index (NDI) records through December 31, 2019. Cox proportional hazard models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) for all-cause and cardiovascular mortality. In addition, subgroup and sensitivity analyses were conducted to test the robustness of the results.ResultsOver a median follow-up period of 13.3 years (95% CI: 12.8-13.8), 1714 deaths were observed. The groups characterized by MetS−/SP+, MetS+/SP−, and MetS+/SP+ exhibited higher all-cause mortality rates in comparison to the MetS-/SP- group, with the MetS+/SP+ group (HR 1.76, 95% CI: 1.37-2.25) displaying the highest all-cause mortality. Increased cardiovascular mortality was observed in the MetS+/SP− (HR 1.84, 95% CI: 1.24-2.72), and MetS+/SP+ groups (HR 2.39, 95% CI: 1.32-4.35) compared to the MetS−/SP− group, whereas it was not statistically significant in the MetS-/SP+ group. However, among males and individuals aged < 60, the presence of both MetS and SP (MetS+/SP+ group) was found to be significantly associated with a higher risk of all-cause and cardiovascular mortality.ConclusionThe coexistence of MetS and SP increased the risk of all-cause and cardiovascular mortality, particularly in males and in nonelderly populations. Individuals with either MetS or SP may require more careful management to prevent the development of other diseases and thereby reduce mortality.

ObjectiveThe exact relationship between the serum uric acid-to-HDL cholesterol ratio (UHR) and mortality rates remains enigmatic among American adults. This study aims to clarify the association between UHR and both all-cause and cardiovascular disease (CVD) mortality in US adults.MethodsThis study enrolled 48054 patients from the National Health and Nutrition Examination Survey (NHANES). Mortality outcomes were determined by linking to National Death Index (NDI) records up to December 31,2019. Multivariate Cox proportional hazards models were constructed to analyze explore the associations between UHR and mortality. Dose-response relationships were explored using restricted cubic splines, and stratified analyses were conducted based on gender, age, race, education, PIR, smoking status, alcohol intake, physical activity, BMI, diabetes and hypertension.ResultsDuring the follow-up period, the overall mortality for all-cause and CVD was 10.9% and 2.7%, respectively. The adjusted HRs in the highest quintile were 1.16 (95% CI: 1.05, 1.29) for all-cause mortality and 1.2 (95% CI: 1, 1.45) for CVD mortality. In diabetes, obese, and CVD subgroups, significantly elevated adjusted HRs were observed for both all-cause and CVD mortality. Specifically, diabetes patients had adjusted HRs of 1.32 (95% CI: 1.11, 1.57) and 1.38 (95% CI: 1.01, 1.90), obese individuals had HRs of 1.32 (95% CI: 1.10, 1.58) and 1.55 (95% CI: 1.06, 2.28), and CVD patients had HRs of 1.29 (95% CI: 1.10, 1.50) and 1.38 (95% CI: 1.06, 1.79), respectively. A non-linear relationship between UHR and mortality was identified, with critical thresholds of 12.4 for all-cause mortality and 10.7 for CVD mortality in the general population. Significant interactions were observed between UHR and stratified variables, including gender, BMI, education, smoking, alcohol use, and hypertension for all-cause mortality, while significant interactions were observed based on gender, smoking, and alcohol intake for CVD mortality. Comparable trends were also observed in patient with diabetes, obese and CVD.ConclusionsIn this cohort study, we provide novel insights into the association between serum UHR concentrations and mortality in the general population. UHR is a strong predictor of all-cause and cardiovascular mortality in the general population.

AimHeart failure (HF) is a severe manifestation or late stage of various heart diseases. As an anti-inflammatory nutrient, dietary fiber has been shown to be associated with the progression and prognosis of cardiovascular diseases (CVDs). However, little is known about the relationship between dietary fiber intake and mortality in HF survivors. This study evaluated the association between dietary fiber intake and all-cause and CVD-caused mortality among HF survivors.MethodsData for the study were extracted from the National Health and Nutrition Examination Survey 1999–2018. Dietary fiber intake information was obtained by a 24-h dietary recall interview. Death outcomes were ascertained by linkage to National Death Index records through 31 December 2019. Covariates, including sociodemographic, lifestyle, disease history, and laboratory data, were extracted from the database. The weighted univariate and multivariate Cox proportional hazard models were utilized to explore the association between dietary fiber intake and mortality among HF survivors, with hazard ratios and 95% confidence intervals. Further stratified analyses were performed to explore this association based on age, gender, a history of diabetes and dyslipidemia, and duration of HF.ResultsA total of 1,510 patients were included. Up to 31 December 2019, 859 deaths had occurred over a mean follow-up of 70.00 months. After multivariable adjustment, a higher dietary fiber intake was associated with a lower risk of all-cause and CVD-caused mortality in HF survivors, especially in male patients, those aged

BackgroundMetabolic dysfunction-associated steatotic liver disease (MASLD) is the most common chronic liver disease. Body mass index (BMI) is the most used obesity index but has important limitations. The weight-adjusted waist index (WWI) is a novel obesity metric and accurately reflects body composition. We explored the association of WWI with all-cause and cardiovascular disease (CVD) mortality in MASLD.MethodsAdult participants with MASLD were included from NHANES 1999-2018. WWI was calculated by dividing the waist circumference (WC) by the square root of body weight. MASLD was diagnosed by the presence of hepatic steatosis and at least one cardiometabolic risk factor in the absence of other causes of steatosis. A fatty liver index ≥60 suggested the presence of hepatic steatosis. Mortality data was obtained by prospectively linking to the National Death Index. Multivariate Cox proportional hazards regression analyses were used to explore these associations and multiple adjustment models were constructed including crude, partial, and fully adjusted models.ResultsAfter adjusting for all covariates including BMI, WWI remained positively and linearly associated with all-cause and CVD mortality in MASLD (hazard ratios [HR] 1.247 and 1.218, respectively). Higher WWI was associated with a significantly increased risk of mortality (both p for trend <0.05). There was an “obesity paradox” between BMI and all-cause mortality in MASLD, with significantly lower all-cause mortality in those with overweight/obesity compared to normal BMI (HR 0.625 and 0.596, respectively, p for trend = 0.024), and no association between BMI and CVD mortality. Interaction analyses indicated that these associations were influenced by several demographic variables and disease status. Time-dependent receiver operating characteristic curves indicated that the predictive value of WWI for mortality in MASLD was higher than that of BMI, WC, and waist-to-height ratio across all follow-up durations.ConclusionsWWI was positively and linearly associated with all-cause and CVD mortality in MASLD, whereas BMI did not accurately reflect mortality risk. WWI provided the optimal predictive value for mortality compared to traditional obesity indicators. These findings emphasize the potential use of WWI as a novel obesity indicator for mortality risk assessment, stratification, and prevention in MASLD.

BackgroundPrevious research has linked systemic inflammatory markers and the Dietary Inflammatory Index (DII) with depression. However, the relationship between DII and these markers, and their impact on mortality risk among depressed adults, remains underexplored. This study aims to explore the association between DII and systemic inflammatory markers and their mediating effect on mortality risk in adults with depression.MethodsThis study analyzed data from 4,981 adults with depression in the National Health and Nutrition Examination Survey (NHANES). This study quantified dietary inflammatory potential with the DII and systemic inflammation with the Systemic Immune-Inflammation Index (SII) and Systemic Inflammation Response Index (SIRI). Cox proportional hazards regression and inverse probability weighting evaluated the impact of DII, SII, and SIRI on mortality risk in depressed adults, as well as their mediating effects. Multiple linear regression analyzed the associations between DII and SII/SIRI. Restricted cubic spline analysis explored the non-linear relationship between DII and mortality risk.ResultsIn adjusted regression models, DII, SII, and SIRI were significantly associated with all-cause mortality risk in depressed adults, with hazard ratios (HRs) (95% CIs) from 1.333 to 1.497 (1.051–1.233, 1.689–1.832). DII was linearly related to SII, with βs (95% CIs) from 0.001 to 0.121 (0.001–0.017, 0.001–0.224). SII significantly mediated the DII-mortality risk link, especially in males (8.07%). The DII-mortality relationship was linear (Pnon-linear = 0.174), with a beneficial threshold at 1.62.ConclusionDII and SII are associated with increased all-cause mortality risk in depressed adults. The DII-related mortality risk in depression can be partially mediated by SII, with a more pronounced effect in males.

IntroductionSerum folate and vitamin B12 levels correlate with the prevalence of fatty liver disease, but it is not clear how they affect mortality. Therefore, this study aimed to investigate the association of serum folate and vitamin B12 concentrations with all-cause mortality in individuals with metabolic dysfunction-associated steatotic liver disease (MASLD).MethodsMASLD subjects were from the Third National Health and Nutrition Examination Survey (NHANES III) in the United States, and mortality follow-up data were obtained by linkage to death records from the National Death Index. Multivariable Cox proportional regression models and restricted cubic spline (RCS) models were used to evaluate the association of serum folate/vitamin B12 with all-cause mortality in the MASLD population.Results3,636 and 2,125 MASLD individuals were included in the analyses related to serum folate and vitamin B12, respectively. During a follow-up period of more than 20 years, the RCS models demonstrated significant nonlinear associations of both serum folate (P <0.001) and vitamin B12 (P =0.016) with all-cause mortality in MASLD. When their serum concentrations were below the median level, the risk of all-cause mortality decreased with increasing concentration, reaching a lowest risk around the median level, and then leveled off. In the multivariable cox regression model, for vitamin B12, the risk of all-cause mortality was reduced by 42% and 28% in the third and fourth quartile groups, respectively, compared with the lowest quartile group (hazard ratio [HR]=0.58, 95% CI: 0.39-0.86, P =0.008; HR =0.72, 95% CI: 0.54-0.96, P=0.026, respectively). For folate, the risk of all-cause mortality was reduced by 28% in the third quartile compared with the lowest quartile (HR =0.72, 95% CI: 0.57-0.91, P =0.005).ConclusionThis longitudinal cohort study suggests that low serum folate and vitamin B12 levels in patients with MASLD are significantly associated with an elevated risk of all-cause mortality.

BackgroundAnemia is a prevalent issue among cancer survivors, which greatly affects their quality of life and overall prognosis. The Naples Prognostic Score (NPS), an inflammation-based prognostic tool, is increasingly acknowledged for its potential in predicting clinical outcomes. This study aims to assess the correlation between anemia status, prognosis, and NPS in cancer survivors.MethodsThis study utilized data from the National Health and Nutrition Examination Survey (NHANES) database spanning from 2003 to 2018, along with death data from the National Death Index (NDI) up to December 31, 2019. A total of 80,312 participants were included, of whom 4,260 were identified as cancer survivors. After applying rigorous exclusion criteria for missing variables, 3,143 participants were retained in the final analysis. NPS was calculated using serum albumin (ALB), total cholesterol (TC), neutrophil to lymphocyte ratio (NLR), and lymphocyte to monocyte ratio (LMR). After adjusting relevant confounding factors, weighted univariable and multivariable logistic regression were utilized to calculate the odds ratios (OR) and 95% confidence intervals (CI). Kaplan-Meier (KM) curves and Log-rank test were employed to compare survival differences among the three patient groups, while Cox proportional regression was utilized to estimate hazard ratio (HR) and 95% CI. Additionally, subgroup analyses were performed to assess the consistency of the outcomes.ResultsUnivariable and multivariable analyses indicated positive correlation between NPS and anemia in cancer survivors (P < 0.05). When NPS was treated as continuous variable, crude model showed that higher NPS scores were linked to higher likelihood of anemia in cancer survivors (OR: 1.77, 95% CI: 1.55 - 2.02; P < 0.001), and this association remained significant even after adjusting for all confounding variables (OR: 1.66, 95% CI: 1.45 - 1.90; P < 0.001). Moreover, with Q1 (score = 0) as the reference category, the analysis demonstrated positive association between NPS and the prevalence of anemia in cancer survivors, regardless of whether the model was crude or fully adjusted (P < 0.001). KM analysis indicated that the decline in overall survival from all causes and other causes was significantly more pronounced among anemic cancer survivors in the Q3 (score = 3 or 4) group (P < 0.05). After accounting for all confounding factors, individuals with the highest NPS had HR of 2.46 (95% CI: 1.81 - 3.34) for all-cause mortality. However, there were no significant differences in mortality trends related to cardiovascular or cancer causes (P > 0.05). Subgroup analyses and sensitivity analysis revealed no statistically significant interactions (P for interaction < 0.05).ConclusionsThe study highlights the correlation between higher NPS and an increased prevalence of anemia in cancer survivors, indicating that NPS may serve as a valuable tool for assessing the prognosis of cancer survivors in clinical practice and for guiding interventions aimed at mitigating anemia-related complications.

BackgroundCalcium is involved in many biological processes, but the impact of serum calcium levels on long-term mortality in general populations has been rarely investigated.MethodsThis prospective cohort study analyzed data from the National Health and Nutrition Examination Survey (1999–2018). All-cause mortality, cardiovascular disease (CVD) mortality, and cancer mortality were obtained through linkage to the National Death Index. Survey-weighted multivariate Cox regression was performed to compute hazard ratios (HRs) and 95% confidential intervals (CIs) for the associations of calcium levels with risks of mortality. Restricted cubic spline analyses were performed to examine the non-linear association of calcium levels with all-cause and disease-specific mortality.ResultsA total of 51,042 individuals were included in the current study. During an average of 9.7 years of follow-up, 7,592 all-cause deaths were identified, including 2,391 CVD deaths and 1,641 cancer deaths. Compared with participants in the first quartile (Q1) of serum calcium level [≤2.299 mmol/L], the risk of all-cause mortality was lower for participants in the second quartile (Q2) [2.300–2.349 mmol/L], the third quartile (Q3) [2.350–2.424 mmol/L] and the fourth quartile (Q4) [≥2.425 mmol/L] with multivariable-adjusted HRs of 0.81 (95% CI, 0.74–0.88), 0.78 (95% CI, 0.71–0.86), and 0.80 (95% CI, 0.73, 0.88). Similar associations were observed for CVD mortality, with HRs of 0.82 (95% CI, 0.71–0.95), 0.87 (95% CI, 0.74–1.02), and 0.83 (95% CI, 0.72, 0.97) in Q2–Q4 quartile. Furthermore, the L-shaped non-linear associations were detected for serum calcium with the risk of all-cause mortality. Below the median of 2.350 mmol/L, per 0.1 mmol/L higher serum calcium was associated with a 24% lower risk of all-cause mortality (HR: 0.76, 95% CI, 0.70–0.83), however, no significant changes were observed when serum calcium was above the median. Similar L-shaped associations were detected for serum calcium with the risk of CVD mortality with a 25% reduction in the risk of CVD death per 0.1 mmol/L higher serum calcium below the median (HR: 0.75, 95% CI, 0.65–0.86).ConclusionL-shaped associations of serum calcium with all-cause and CVD mortality were observed in US adults, and hypocalcemia was associated with a higher risk of all-cause mortality and CVD mortality.

BackgroundNumerous studies have shown that low levels of vitamin D are linked to a higher risk of inflammatory diseases and their progression. However, how vitamin D levels affect mortality in chronic obstructive pulmonary disease (COPD) patients is still unclear. Thus, this study aimed to explore the relationship between serum 25-hydroxyvitamin D [25(OH)D] levels and the risk of death from all causes in U.S. adults with COPD.MethodsThis study analyzed 1,876 adults with COPD from the National Health and Nutrition Examination Survey (2005–2018). Mortality data up to December 31, 2019, were obtained from the National Death Index (NDI) records. Participants were categorized into three groups according to their 25(OH)D levels: Q1 (

BackgroundInflammatory scores are known to reflect the systemic inflammatory burden. Despite this, the association between the inflammatory score and the risk of all-cause and cardiovascular mortality in patients with metabolic syndrome (MetS) remains poorly understood. To address this gap in the literature, this study investigated this potential association between these two factors.MethodsA total of 3401 patients with MetS from the National Health and Nutrition Examination Survey (1999–2010) were enrolled. Survival status and cause of death were obtained by linking data from the National Death Index (NDI). The inflammatory score was calculated based on the sum of the Z-scores for white blood cell (WBC) count and C-reactive protein (CRP) at baseline. The patients were divided into inflammatory score quartiles. Cox proportional hazards regression was used to determine the association between inflammatory score and mortality. Restricted cubic splines (RCS) were used to explore the dose-response relationship between inflammatory score and mortality. Stratified analyses and interaction tests were conducted according to sex, age, body mass index (BMI), alcohol consumption, smoking status, hypertension, diabetes, and stroke status.ResultsAfter a mean follow-up of 145.9 months, 1039 all-cause deaths and 295 cardiovascular deaths were recorded. The results of multivariate Cox regression analysis showed that compared to the lowest quartile (Q1), patients in the highest quartile (Q4) had a 1.74-fold increased risk of all-cause mortality (Model 3: HR = 1.74, 95%CI 1.30–2.32, P < 0.001) and a 1.87-fold increased risk of cardiovascular mortality (Model 3: HR = 1.87, 95%CI 1.12–3.13, P = 0.020). There was a ‘J’-shaped nonlinear relationship between the inflammatory score and all-cause mortality (P for nonlinearity = 0.001), and a marginally significant ‘J’-shaped relationship with cardiovascular mortality (P for nonlinearity = 0.057). The threshold points of the inflammatory score for adverse outcomes were - 0.643 and - 0.621, respectively.ConclusionThe inflammatory score is independently associated with increased all-cause and cardiovascular mortality in patients with MetS, and risk stratification of these patients using inflammatory scores may provide specific therapeutic strategies to improve their prognosis.

Objective: To assess the joint impact of cognitive performance and visual acuity on mortality over 13-year follow-up in a representative US sample.Methods: Data from National Health and Nutrition Examination Survey (NHANES) participants (≥18 years old) were linked with the death record data of the National Death Index (NDI) with mortality follow-up through December 31, 2011. Cognitive performance was evaluated by the Digit Symbol Substitution Test (DSST) and cognitive performance impairment was defined as the DSST score equal to or less than the median value in the study population. Visual impairment (VI) was defined as presenting visual acuity worse than 20/40 in the better-seeing eye. Risks of all-cause and specific-cause mortality were estimated with Cox proportional hazards models after adjusting for confounders.Results: A total of 2,550 participants 60 years and older from two waves of (NHANES, 1999–2000, 2001–2002) were included in the current analysis. Over a median follow-up period of 9.92 years, 952 (35.2%) died of all causes, of whom 239 (23.1%), 224 (24.0%), and 489 (52.9%) died from cardiovascular disease (CVD), cancer, and non-CVD/non-cancer mortality, respectively. Cognitive performance impairment and VI increased the odds for mortality. Co-presence of VI among cognitive impaired elderly persons predicted nearly a threefold increased risk of all-cause mortality [hazard ratios (HRs), 2.74; 95% confidence interval (CI), 2.02–3.70; P < 0.001) and almost a fourfold higher risk of non-CVD/non-cancer mortality (HR, 3.72; 95% CI, 2.30–6.00; P < 0.001) compared to having neither impairment.Conclusion: People aged 60 years and over with poorer cognitive performance were at higher risk of long-term mortality, and were especially vulnerable to further mortality when concomitant with VI. It is informative for clinical implication in terms of early preventive interventions.

BackgroundWhich lifestyle will benefit patients with chronic obstructive pulmonary disease (COPD) has becoming a hot topic in recent years. However, there are currently no recommendations. Life’s Essential 8 (LE8) includes 8 metrics (BMI, non-HDL cholesterol, blood pressure, blood glucose, physical activity, diet, sleep duration, and nicotine exposure), which are considered the foundation of maintaining a healthy life. Here, we aimed to explore the relationship between LE8 and mortality risk in patients with chronic obstructive pulmonary disease (COPD), which may provide advice on how to live better for these patients.MethodsParticipants were from the National Health and Nutrition Examination Survey 2003–2018 at baseline linked to the 2019 National Death Index records. Cox proportional hazards regression models were used to explore the relationship between the LE8 score and mortality risk. All analyses were adjusted for survey design and weighting variables.ResultsWe included 1,593 participants with COPD, representing 9,208,187 US patients. During a median follow-up of 5.8 years, compared with patients with low LE8 scores, those with moderate and high score presented decreased all-cause mortality (both log-rank p 

To clarify the association of sleep duration with all-cause and cardiovascular mortality, and further estimate the population attributable fraction (PAF) for the 10-year risk of cardiovascular disease (CVD) due to inappropriate sleep duration among US adults, we included data of the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2014 by linkage to the National Death Index until December 31, 2015 in a prospective design. Cox proportional hazards models were used for multivariate longitudinal analyses. The Pooled Cohort Equations methods was adopted to calculate the predicted 10-year CVD risk. In the current study, sleep