Nutrition Monitoring and Surveillance

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					Nutrition Monitoring and
           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
          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
• Jointly administered by USDA and
• 22 federal agencies involved
• Over 70 surveys and surveillance
• Ten year comprehensive plan for
  Nutrition Monitoring and Related
  Research sent to congress in 1993
   NNMS - Some Agencies
 – 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
  – National Center for Health Statistics
  – CDC-National Center for Chronic Disease
    Prevention and Health Promotion
  – Food and Drug Administration
  – Heath Resources and Services
  – 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
• Food and nutrient composition
• Knowledge, attitudes, and behavior
• Food composition and nutrient
• Food Supply Determinations
 Nutrition and Related Health
• National Health and Nutrition
  Examination Surveys (I-V, and
• National Health Interview Survey
• National Hospital Discharge Survey
• Pediatric Nutrition Surveillance System
        Food and Nutrient
• Nationwide Food Consumption Survey
• Continuing Survey of Food Intakes by
   Knowledge, Attitudes, and
• Behavioral Risk Factor Surveillance
• 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
• 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
• Median iron intakes below recommendations
  for children 1-2, female adolescents, females
• Average daily intake of fruits and vegetables is
  about 4 servings
   Nutrition Monitoring in the
          United States
 The Directory of Federal and
          State Nutrition
Monitoring and Related Research
       An Inventory of Resources
Major Surveys with Nutrition
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
          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:
          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
           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 YRBS
                                             1993 1999

Percentage of students who were trying       34.4 38.3
to lose weight

Percentage of students who exercised or      64.4 64.1
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
Continuing Survey of Food Intake by
Individuals (CSFII)
• 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
             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
• 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.
           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
• Demographics: Gender, age, education,
  race/ethnicity, place of birth, income,
  occupation, and industry
         NHANES - Nutrition
•   Food Security
•   Dietary supplements
•   Weight history
•   Dietary Recall - one 24 hour
      NHANES III Anthropometric
         Procedures Video
•   Body weight           • Buttocks circumference
•   Standing height       • Thigh circumference
•   Sitting height        • Head circumference
•   Upper leg length      • Skinfolds (including
•   Recumbent length        thighs, triceps,
•   Upper arm length        subscapular, and
•   Knee height
                          • Wrist breadth
•   Arm circumference
                          • Elbow breadth
•   Waist circumference
   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
• 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
 Optimists: rate diet quality as better than actually is
 Pessimists: rate diet quality as worse than it is
Household Food Security in the
      United States, 2001
 Food Assistance and Nutrition
     Research Report #29
  Economic Research Service
 U.S. Department of Agriculture
        November 2002
• 89.3 percent of U.S. households were food secure
throughout the entire calendar year 2001.

• 10.7 percent of U.S. households were food insecure
at some time during the year.

• In 3.3 percent of households people were hungry at
times during the year because they couldn’t afford
enough food.

• Rates of food insecurity and hunger in the U.S.
increased during the 2-year period 1999-2001.
         Nutrition Security
• The provision of an environment that
  encourages and motivates society to
  make food choices consistent with short
  and long term good health.
            Food Security
• Assess by all people at all times to
  sufficient food for an active and healthy
  life. Food security includes at a
  minimum: the ready availability of
  nutritionally adequate and safe foods,
  and an assured ability to acquire
  acceptable foods in socially acceptable
          Food Insecurity
• a household had limited or uncertain
  availability of food, or limited or
  uncertain ability to acquire acceptable
  foods in socially acceptable ways (i.e.,
  without resorting to emergency food
  supplies, scavenging, stealing, or other
  unusual coping strategies).
• The uneasy or painful sensation caused
  by a lack of food.
• Involuntary hunger that results from not
  being able to afford enough food
• The recurrent and involuntary lack of
  access to food
• May produce malnutrition over time.
       History of the Food Security
          Measurement Project
1990     NMRR Act recommends a standardized
         mechanism for defining and obtaining data on
         the prevalence of food insecurity
1992     USDA staff review existing research

1994     USDA and DHHS sponsor conference on Food
         Security Measurement and Research
1995     Current Population Survey of US Census
         Bureau includes Food Security Measurement
1996-   Annual Surveys, ERS assumes leadership,
present others encouraged to use FSMS
Washington State, 1999-2001
• Food Insecure without hunger – 12.5%
• Food Insecure with hunger – 4.6
• The West and South Census Regions
  registered somewhat higher
  prevalences than did the Northeast and
• Food insecurity and hunger were more
  prevalent in central cities and in
  nonmetropolitan areas than in suburban
Update with 2003 data
     2003 National Results
• Food Insecurity = 11.2%
  – (increased from 11.1%)
• Food Insecurity with hunger = 3.5%
  – No change from 2002
Food Insecurity with Hunger
       Food Insecure Numbers in
Year               Numbers of

2002               290,000

2003               275,000
   Why did Washington’s rates
• Increased participation in federal
• Between 2001 and 2004 there was a
  59% increase in food stamp
• Improving economy?
    Other National Findings
• 70% of food insecure families had
  visited a food pantry within the past
• Only 18.3% of families with incomes
  below 130% had participated in food
  stamps in the past month.

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