Nutrition Monitoring and Surveillance

March 2, 2004

Some Definitions

Joint Nutrition Monitoring Evaluation Committee, 1986

Expert Panel on Nutrition Monitoring, 1989

Nutrition Monitoring

• Assessment of dietary or nutrition status at intermittent times with the aim of detecting changes in the dietary or nutritional status of a population

Nutrition Surveillance

• Continuous assessment of nutritional status for the purpose of detecting changes in trend or distribution in order to initiate corrective measures

Dietary Status

• The condition of a population’s or an individual’s intake of foods and food components, especially nutrients.

Nutrition Assessment

• Measurement of indicators of dietary status and nutrition related health status to identify the possible occurrence, nature, and extent of impaired nutritional status.

Nutrition Monitoring in the United States

Chronology1909 USDA starts food supply series

1930s USDA Household food consumption survey started (changed name to Nationwide FCS)

1968-70 Ten State Nutrition Survey (Nation’s first comprehensive survey)

1970s NHANES I and II Pediatric Nutrition Surveillance System

1980s Joint Nutrition Monitoring Evaluation Committee with USDA and DHHS

1990 Passage of the National Nutrition Monitoring and Related Research Act

2001 CSFII and NHANES Integrated

Goals of NNMS

• Provide foundations for improvement of nutritional status and quality and healthfulness of food supply

• Collect, analyze, and disseminate timely data on nutrition and dietary status, quality of food supply, food consumption patterns, consumer knowledge and attitudes

NNMS Goals, cont...

• ID high risk groups and geographic areas and trends

• Establish national baseline data and develop standards for monitoring

• Provide data for evaluating implications of changes in agricultural policy

National Nutrition Monitoring System

• Jointly administered by USDA and DHHS

• 22 federal agencies involved• Over 70 surveys and surveillance

activities• Ten year comprehensive plan for

Nutrition Monitoring and Related Research sent to congress in 1993

NNMS - Some Agencies

• USDA– Food and Nutrition Service– Food Safety and Inspection Service– Agricultural Research Service– Economic Research Service– Extension Service– Cooperative State Research Service

• Department of Health and Human Services– National Center for Health Statistics– CDC-National Center for Chronic Disease

Prevention and Health Promotion– Food and Drug Administration– Heath Resources and Services

Administration– Indian Health Services– National Institutes of Health– Substance Abuse and Mental Health

Services Administration

• Others:– Department of Defense– Department of Education– Agency for International Development– Department of Veterans Affairs– Census Bureau– Bureau of Labor Statistics– National Marine Fisheries Service

5 Areas of NNMS

• Nutrition and related health measurements

• Food and nutrient composition

• Knowledge, attitudes, and behavior

• Food composition and nutrient databases

• Food Supply Determinations

Nutrition and Related Health Measurements

• National Health and Nutrition Examination Surveys (I-V, and continuous)

• National Health Interview Survey

• National Hospital Discharge Survey

• Pediatric Nutrition Surveillance System

Food and Nutrient Composition

• Nationwide Food Consumption Survey

• Continuing Survey of Food Intakes by Individuals

Knowledge, Attitudes, and Behavior

• Behavioral Risk Factor Surveillance System

• Youth Risk Behavior Survey

• Diet and Health Knowledge Survey

Food Composition and Nutrient Data Bases

• National Nutrient Data Bank (NNDB)

Food Supply Determinations

• US Food and Nutrition Supply Series

Third Report on Nutrition Monitoring in the United States - December 1995

• Increase in rates of overweight and sedentary lifestyle

• Increase in proportion of adults with desirable serum total cholesterol

• Hypertension remains major public health problem - especially in non-Hispanic blacks

• 9-13% of low income households experience food insecurity

• Rates of femoral osteoporosis in females > 50 years old:– 21% in non-Hispanic whites– 10% in non-Hispanic blacks– 16% in Mexican Americans

• Intakes of % of diet from total fat, saturated fatty acids, and cholesterol have decreased, but remain above recommended levels for large proportion of the population

• Mean calcium intakes are below recommendations - especially in adolescents, adult females, elderly, and non-Hispanic black males

• Median iron intakes below recommendations for children 1-2, female adolescents, females 20-59

• Average daily intake of fruits and vegetables is about 4 servings

Nutrition Monitoring in theUnited States

The Directory of Federal and State Nutrition

Monitoring and Related Research Activities

2000

An Inventory of Resources

Major Surveys with Nutrition Content

Behavioral Risk Factor Surveillance System (BRFSS)

• CDC, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)

• Annually since 1984 (not all states at first)• Telephone interview• Data collection is conducted separately by each

State. Sample design uses State-level, random-digit-dialed probability samples of the adult (aged 18 years and over) population.

• State-specific sample sizes ranged from 1,499 to 6,005

BRFSS - Questions• Behavioral risk factors (for example, alcohol and tobacco

use), preventive health measures, HIV/AIDS, health status, limitation of activity, and health care access and utilization

• Core of questions asked in all States

• Standardized optional questions on selected topics administered at the State’s discretion

• Rotating core of questions asked every other year in all States

• State-added questions developed to address State-specific needs

BRFSS - Data

• National

• State

• Smaller units when local agencies pay for additional surveys

• Data system homepage: http://www.cdc.gov/nccdphp/brfss

BRFSS - Nutrition

• Self reported height and weight

• Trying to loose weight?

• 6 fruit and vegetable intake questions

• Activity

• Food security

Youth Risk Behavior Surveillance System (YRBSS)• CDC, National Center for Chronic Disease Prevention and

Health Promotion (NCCDPHP)

• School based, grades 9-12

• National survey is done in 150 schools, states and local districts conduct their own surveys

• Other components: national alternative school survey, middle school surveys in selected States, and the National College Health Risk Behavior Survey

• Anonymous self-administered questionnaires

• Biennial (odd-numbered years)

• 1999 national survey, N= 15,349

YRBS - Data

• Gender, age, grade, race/ethnicity, urbanicity of school

• National and 4 census regions

• By state for 41 states in 1999

• 16 large metropolitan school districts• http://www.cdc.gov/nccdphp/dash/yrbs/ov.htm

YRBS - Categories

• injury

• tobacco use

• alcohol and other drug use

• sexual behavior

• diet and nutrition

• physical activity

YRBS - Nutrition

• Self reported weight and height

• Dieting behaviors

• Eating disorder behaviors

• Fruit and vegetable intake

• Fat intake

Seattle YRBS1993 1999

Percentage of students who were trying to lose weight

34.4 38.3

Percentage of students who exercised or participated in physical activities for at least 20 minutes that made them sweat and breathe hard on three or more of the past seven days

64.4 64.1

Continuing Survey of Food Intake by Individuals (CSFII)

• USDA• 1994-1996• in-person interviews

• 24-hour dietary recall: 2 nonconsecutive days of food intake data collected 3-10 days apart

• 2 weeks later, one adult from each household asked questions about knowledge and attitudes toward dietary guidance, health, and use of food labels.

CFSII - Sample• Nationally representative stratified multistage area

probability sample of U.S. noninstitutionalized civilian population, all ages.

• Oversampling of low-income households

• For 1994–96, sample size for 1-day dietary data was

16,103; for 2-day dietary data, it was 15,303.

CFSII - Data• kinds and amounts of foods consumed

• sources of foods

• time, name of each eating occasion

• food expenditures, shopping practices

• pregnancy, lactation, nursing status,

• height and weight

• income, poverty status, household size,

• participation in Food Stamp and WIC programs

CFSII - Data Availability

• National; four U.S. Census Bureau regions; Standard Metropolitan Statistical Areas

• http://www.barc.usda.gov/bhnrc/foodsurvey/home.htm

CFSII - Nutrition

• food intakes in grams of 71 USDA-defined food groups and subgroups

• nutrient intakes of 28 nutrients and food components

• nutrient intakes expressed as percentages of the 1989 Recommended Dietary Allowance

• Pyramid servings from 30 food groups

Cleveland et al. Dietary Intake of Whole Grains. J Am Coll Nutr. 2002.

Enns et al. Family Economics and Nutrition Review, 1997.

National Health and Nutrition Examination Survey (NHANES)

• CDC, National Center for Health Statistics (NCHS)• In-person interview in household and mobile

examination center

• stratified multistage probability sample, nationally representative of the U.S. civilian noninstitutionalized population

• Approximately 5,000 people are examined at 15 locations each year

• All ages beginning in 1999

NHANES - Continuous

• Periodic (1960–94);

• annual beginning in 1999

• after 1999 annual sample size will be too small to provide reliable estimates for many measures and for most subgroups. Most analyses will require 3 years

of data for reliable estimates.

http://www.cdc.gov/nchs/about/major/nhanes/mectour.htm

NHANES - Content• Chronic disease prevalence and conditions (including

undiagnosed conditions

• immunization status

• infectious disease prevalence

• health insurance

• measures of environmental exposures

• hearing

• vision

• mental health

NHANES - Content

• anemia

• diabetes

• cardiovascular disease

• osteoporosis

• obesity

• oral health

• physical fitness

NHANES - New in 1999

• cardiorespiratory fitness

• physical functioning

• lower extremity disease

• full body DXA for body fat as well as bone density

• tuberculosis

NHANES - Data

• National; four U.S. Census Bureau regions

• Demographics: Gender, age, education, race/ethnicity, place of birth, income, occupation, and industry

• http://www.cdc.gov/nchs/nhanes.htm

NHANES - Nutrition

• Food Security

• Dietary supplements

• Weight history

• Dietary Recall - one 24 hour

NHANES III Anthropometric Procedures Video

• Body weight• Standing height• Sitting height• Upper leg length• Recumbent length• Upper arm length• Knee height• Arm circumference• Waist circumference

• Buttocks circumference• Thigh circumference• Head circumference• Skinfolds (including

thighs, triceps, subscapular, and suprailiac)

• Wrist breadth• Elbow breadth

NHANES-CFSII Integration

• Staged integration of two surveys underway• 2001 a year of testing, 2002 full integration• Goals: continuous data collection, linkage of diet and

health data, 2 days of dietary data collection (second day by phone 3 to 10 days after initial exam)

• DHKS not part of integrated efforts at this time, but under consideration

Diet and Health Knowledge Survey (DHKS)

• USDA, Agricultural Research Service• Periodically from 1989 to 1996• In conjunction with CSFII• Sample size per year

– ~1300 from 1989 through 1991 – ~2000 per year 1994-1996

• telephone follow up conducted with one adult in each household 2-3 weeks after CFSII

DHKS - Content

• Designed to assess relationships between knowledge and attitudes about dietary guidance and food safety, food choice decisions and nutrient intakes

• Variables can be linked to CFSII variables for individuals.

DHKS - Questions• Self perceived intake levels• awareness of diet/health relationships• use of food labels• perceived importance of following dietary

guidance for specific nutrients and food components

• beliefs about food safety• Knowledge about food sources of nutrients

DHKS - Descriptive Variables

• Individual: gender, age, ethnicity, education, employment status, height and weight

• Household: income, size, cash assets, region, urbanization, tenancy, participation in food stamps and WIC

DHKS - URL

www.barc.usda.gov/bhnrc/foodsurvey/csfii94.htm

Optimists: rate diet quality as better than actually is

Pessimists: rate diet quality as worse than it is

http://www.ers.usda.gov/briefing/DietAndHealth/healthfuldiet.htm