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A Cross-Sectional Study of the Association of Age, Race And Open Access Research BMJ Open: first published as 10.1136/bmjopen-2012-001315 on 6 October 2012. Downloaded from A cross-sectional study of the association of age, race and ethnicity, and body mass index with sex steroid hormone marker profiles among men in the National Health and Nutrition Examination Survey (NHANES III) Jamie Ritchey,1 Wilfried Karmaus,1 Tara Sabo-Attwood,1 Susan E Steck,1,2 Hongmei Zhang1 To cite: Ritchey J, ABSTRACT ARTICLE SUMMARY Karmaus W, Sabo-Attwood T, Objectives: Since sex hormone markers are et al . A cross-sectional study metabolically linked, examining sex steroid hormones of the association of age, Article focus singly may account for inconsistent findings by age, race/ race and ethnicity, and body ▪ Using cluster analysis, can unique groups of sex mass index with sex steroid ethnicity and body mass index (BMI) across studies. steroid hormones be formed among a nationally hormone marker profiles First, these markers were statistically combined into representative sample of men which would take among men in the National profiles to account for the metabolic relationship between into account that these hormone marker levels Health and Nutrition markers. Then, the relationships between sex steroid are related? Examination Survey hormone profiles and age, race/ethnicity and BMI were ▪ In multinomial logistic regression models rather BMJ Open (NHANES III). explored in multinomial logistic regression models. than linear models, are age, race/ethnicity and 2012;2:e001315. Design: Cross-sectional survey. body mass index (BMI) groups more strongly doi:10.1136/bmjopen-2012- Setting: The US Third National Health and Nutrition associated with different statistically determined 001315 http://bmjopen.bmj.com/ Examination Survey (NHANES III). sex steroid hormone clusters? Participants: 1538 Men, >17 years. ▪ How do the associations from multinomial logis- ▸ Prepublication history for Primary outcome measure: Sex hormone profiles. tic regression models compare to findings this paper are available between sex steroid hormones and age, race/eth- online. To view these files Results: Cluster analysis was used to identify four please visit the journal online statistically determined profiles with Blom-transformed T, nicity and BMI groups using linear regression (http://dx.doi.org/10.1136/ E, sex hormone binding globulin (SHBG), and 3-α diol models? bmjopen-2012-001315). G. We used these four profiles with multinomial logistic Key messages regression models to examine differences by race/ ▪ Received 17 April 2012 To take into account the fact that sex steroid ethnicity, age and BMI. Mexican American men >50 years on September 25, 2021 by guest. Protected copyright. Accepted 21 August 2012 hormone marker levels are related, four distinct were associated with the profile that had lowest T, E and sex steroid hormone profiles were statistically 3-α diol G levels compared to other profiles (p<0.05). This final article is available determined using cluster analysis, described as: – 2 for use under the terms of Non-Hispanic Black, overweight (25 29.9 kg/m )and ‘ ’ 2 low sex hormone binding globulin (SHBG) , the Creative Commons obese (>30 kg/m ) men were most likely to be associated ‘high 3-α diol G’, ‘high T, E and SHBG’ and ‘low Attribution Non-Commercial with the cluster with the lowest SHBG (p<0.05). T, E, and 3-α diol G’ profiles. 2.0 Licence; see Conclusion: The associations of sex steroid hormone ▪ Mexican American men >50 years were associated http://bmjopen.bmj.com profiles by race/ethnicity are novel, while the findings by with the profile that had lowest T, E and 3-α diol G age and BMI groups are largely consistent with levels compared to other profiles (p<0.05). observations from single hormone studies. Future 2 1 Non-Hispanic Black, overweight (25–29.9 kg/m ) Epidemiology and studies should validate these hormone profile groups and 2 Biostatistics, University of and obese (>30 kg/m ) men were most likely to be investigate these profiles in relation to chronic diseases associated with the cluster with the lowest SHBG South Carolina, Columbia, and certain cancers. South Carolina, USA (p<0.05). 2Cancer Prevention and ▪ The associations of sex steroid hormone profiles Control Program, University by race/ethnicity are novel, while findings by age of South Carolina, Columbia, INTRODUCTION and BMI groups are largely consistent with South Carolina, USA Sex steroid hormones, testosterone (T) and results from single hormone studies. Future 17-β estradiol (E), along with sex hormone studies should examine hormone profiles in rela- Correspondence to tion to chronic disease risk. Dr Jamie Ritchey; binding globulin (SHBG), a carrier protein [email protected] Ritchey J, Karmaus W, Sabo-Attwood T, et al. BMJ Open 2012;2:e001315. doi:10.1136/bmjopen-2012-001315 1 Cross-sectional study of the association of age, race and ethnicity and BMI BMJ Open: first published as 10.1136/bmjopen-2012-001315 on 6 October 2012. Downloaded from associated with different sex steroid hormone marker ARTICLE SUMMARY profiles. Strengths and limitation of this study ▪ Nationally representative sample of men in the USA where MATERIALS AND METHODS minority groups were oversampled to ensure adequate repre- Study population sentation in study analyses. ▪ Hormone marker values were used from a single measurement We utilised data from the National Health and Nutrition and covariates like diet and smoking were taken from self- Examination Survey (NHANES) III conducted by the reported data. National Center for Health Statistics (NCHS), and these methods have been described previously.43 44 Briefly, NHANES III was collected in two phases, and this study of T and E and androstanediol glucuronide (3-α diol G), used the phase I data from 1988 to 1991. This cross- fi a metabolite used as a marker for T and dihydrotestos- sectional survey was designed as a multistage strati ed, terone (DHT) metabolism, play critical roles in sexual clustered probability sample, the sampling frame – ≥ development and body function.1 5 These hormone includes US residents 2 months of age, civilian, non- markers are involved in muscle and bone growth, institutionalised population and NHANES III over – adipose tissue function and distribution.6 8 Differences sampled those >65 years, Non-Hispanic Blacks and in the levels of sex hormone markers have been Mexican Americans. hypothesised to contribute to differences in several The NHANES III study population was used to derive chronic diseases and prostate cancer rates observed by the analysis cohort. A total of 16 295 men were inter- 9–20 viewed of which n=14 781 completed a mobile examin- age, race/ethnicity and body mass index (BMI). Yet, 43 44 differences in sex steroid hormone marker levels by age, ation component (MEC) exam. The NHANES III – race/ethnicity and BMI groups have yet to be fully clari- morning portion of the survey phase I (1988 1991), – fied in the literature.21 35 included n=2417 men and n=1637 that provided blood Many previous studies have investigated single sex samples. We removed the males who were under β hormone marker levels in linear regression models by 17 years of age and four outliers with high 17- estradiol fi age, race/ethnicity and BMI. Typically, with increasing levels identi ed by box and whisker plot analysis for a fi age, T and E levels decline and SHBG increases, nal analysis cohort of n=1528 men. although there was evidence to suggest that some older men have hormone marker levels similar to younger Exposure variables – men.19 21 22 26 28 29 35 39 By race/ethnicity, higher Age, race/ethnicity and BMI were the exposures of hormone levels have been reported among interest. The NHANES III data obtained age and race/ http://bmjopen.bmj.com/ non-Hispanic Black men compared to non-Hispanic ethnicity information from the US Census survey 1990 Whites, although this finding was not consistent across to draw the sampling frame, so this information was studies; and, studies sex hormone markers among other 100% complete and was verified during the adult inter- – 43 44 racial/ethnic groups were scant.5 8 30 34 35 40 42 With view survey screening by NHANES III field staff. increasing BMI, T has been reported to decline and E Continuous age (in years) was categorised into the fol- and SHBG increase, yet these findings are not consistent lowing groups: 17–29, 30–49, 50–69 and 70 and over. – across studies.821242628 40 On the basis of somewhat Race/ethnicity was categorised as White non-Hispanic, inconsistent findings across these studies, it is possible Black non-Hispanic, Mexican Americans and All others. on September 25, 2021 by guest. Protected copyright. that investigating factors that influence sex steroid Asian, American Indian/Alaskan Native, or Pacific hormone marker levels singly was inadequate. Islanders were included in the other group. Whites and Sex hormone markers E, T, SHBG and 3-α diol G are Blacks in the analysis reported non-Hispanic ethnicity. known to be related through sex steroid metabolism. Mexican American is considered an ethnicity, and may Since sex hormone markers are related, then differing also report any race group (White, Black, Asian, hormone levels may be related to each other as well. American Indian/Alaskan Native or Pacific Islander). Cluster analysis can identify underlying statistical pat- Hispanics other than Mexican Americans were included terns among sex hormone markers, which may be indi- in the other group, since there were few. BMI (weight in 2 cative of general patterns of sex steroid hormone kg divided by height in m ) was obtained from body markers among men. Investigating statistically related measurements taken during the MEC. BMI information sex steroid hormone profiles may produce different asso- is available for 99.5% (n=1524) of men in the analysis ciations with age, race/ethnicity and BMI groups than cohort.
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