Assessing the Nutritional
Health of Populations
Some Definitions
Joint Nutrition Monitoring Evaluation Committee, 1986
Expert Panel on Nutrition Monitoring, 1989
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
• 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
Nutrition Monitoring in the
United States
Public Health “Revolutions”
Focus
Intervention
Physical
Environment
Public sanitation, Laws &
food safety
regulations
Individual
Behavior
Behaviors &
Lifestyle
Individual
behavior change
interventions
Macro
social/economic
environments
Fundamental
determinants of
health
Social and
economic
policies
Brief Chronology
1909
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
1980s
Behavioral Risk Factor Surveillance System
1990s
Household Food Security Questions added to Current
Population Survey
1990
Passage of the National Nutrition Monitoring and
Related Research Act
2001
CSFII and NHANES Integrated
2000
CDC begins surveillance of policies and environments
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
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
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 – now integrated into What
We Eat in America
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
– Interactive web site for nutrient content of
the US food supply from 1909 to 2006:
http://65.216.150.146/
– Gerrior & Bente. Dietary Guidance, 1970 to
1999: Does the U.S. Food Supply Support
It? Family Economics and Nutrition
Review. 2002
Gerrior & Bente, 2002
Gerrior & Bente, 2002
Federal Assessment of Policies and Practices
Agency
School Health Policies CDC, Division of
and Programs Study
Adolescent and
School Health
Survey of Maternity
CDC, Division of
Practices in Infant
Nutrition, Physical
Nutrition and Care
Activity and
(mPINC)
Obesity
Nutrition, Physical
CDC, Division of
Activity and Obesity
Nutrition, Physical
Legislative Database Activity and
Obesity
Years
1994,
2000,
2006
2007
Annual
since
2001
Major Public Health 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-digitdialed 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 Statespecific needs
BRFSS - Data
• National
• State
• Smaller units when local agencies pay
for additional surveys
• Data system homepage:
http://www.cdc.gov/brfss/
BRFSS - Nutrition
•
•
•
•
•
Self reported height and weight
Trying to loose weight?
6 fruit and vegetable intake questions
Activity
Food security
BRFSS 2008 – percentage of
respondents reporting BMI < 24.9
The Youth Risk Behavior
Surveillance System (YRBSS)
National, State, and Local Data
Purposes of the YRBSS
• Focus the nation on behaviors among
youth causing the most important health
problems
• Assess how risk behaviors change over
time
• Provide comparable data
Behaviors That Contribute to the Leading
Causes of Morbidity and Mortality
• Behaviors that contribute to
unintentional injuries and violence
• Tobacco use
• Alcohol and other drug use
• Sexual behaviors
• Unhealthy dietary behaviors
• Inadequate physical activity
Characteristics of the National, State,
and Local School-Based YRBS
• 2007 sample was 14,041, 9th – 12th grade students
• 2007 response rates
– School = 81%
– Student = 84%
– Overall 68%
• Anonymous, computer-scannable questionnaire or
answer sheet
• Completed in one class period (45 minutes)
• Conducted biennially usually during the spring
Policy and Program
Applications
•
•
•
•
•
•
Describe risk behaviors
Create awareness
Set program goals
Develop programs and policies
Support health-related legislation
Seek funding
YRBS - Nutrition
•
•
•
•
•
Self reported weight and height
Dieting behaviors
Eating disorder behaviors
Fruit and vegetable intake
Fat intake
Percentage of High School Students Who Ate Fruits
and Vegetables Five or More Times/Day,* by Sex**
and Race/Ethnicity,*** 2007
100
Percent
80
60
40
21.4
19.9
22.9
20
24.9
24.0
Black
Hispanic
18.8
0
Total
Female
Male
White
* 100% fruit juices, fruit, green salad, potatoes (excluding French fries, fried potatoes, or potato chips), carrots, or other
vegetables during the 7 days before the survey.
** M > F
*** B, H > W
National Youth Risk Behavior Survey, 2007
Percentage of High School Students Who Ate Fruits
and Vegetables Five or More Times/Day,* 1999 –
2007
100
Percent
80
60
40
23.9
21.4
22.0
20.1
21.41
2001
2003
2005
2007
20
0
1999
* 100% fruit juices, fruit, green salad, potatoes (excluding French fries, fried potatoes, or potato chips), carrots, or other
vegetables during the 7 days before the survey.
1 Decreased 1999-2007, p < .05
National Youth Risk Behavior Surveys, 1999 – 2007
Percentage of High School Students Who
Drank Three or More Glasses/Day of Milk,* by
Sex** and Race/Ethnicity,*** 2007
100
Percent
80
60
40
20
19.4
14.1
16.1
9.7
8.8
12.7
0
Total
Female
* During the 7 days before the survey.
** M > F
*** W > H > B
National Youth Risk Behavior Survey, 2007
Male
White
Black
Hispanic
Percentage of High School Students Who
Drank Three or More Glasses/Day of Milk,*
1999 – 2007
100
Percent
80
60
40
20
18.0
16.4
17.1
16.2
14.11
1999
2001
2003
2005
2007
0
* During the 7 days before the survey.
1 Decreased 1999-2007, p < .05
National Youth Risk Behavior Surveys, 1999 – 2007
Percentage of High School Students Who Drank a
Can, Bottle, or Glass of Soda or Pop at Least One
Time/Day,* by Sex** and Race/Ethnicity,*** 2007
100
Percent
80
60
40
38.6
33.8
34.0
37.6
29.0
33.4
20
0
Total
Female
Male
* Not including diet soda or diet pop, during the 7 days before the survey.
** M > F
*** B > H
National Youth Risk Behavior Survey, 2007
White
Black
Hispanic
Percentage of High School Students Who Did Not
Eat for 24 or More Hours to Lose Weight or to Keep
From Gaining Weight,* by Sex** and
100
Race/Ethnicity,*** 2007
Percent
80
60
40
20
11.8
16.3
7.3
11.2
10.3
White
Black
14.1
0
Total
Female
* During the 30 days before the survey.
** F > M
*** H > W, B
National Youth Risk Behavior Survey, 2007
Male
Hispanic
Percentage of High School Students Who
Vomited or Took Laxatives to Lose Weight or
to Keep From Gaining Weight,* by Sex** and
100
Race/Ethnicity,*** 2007
Percent
80
60
40
20
4.3
6.4
Total
Female
2.2
4.1
3.0
Male
White
Black
5.3
0
* During the 30 days before the survey.
** F > M
*** H > B
National Youth Risk Behavior Survey, 2007
Hispanic
Percentage of High School Students Who
Vomited or Took Laxatives to Lose Weight
or to Keep From Gaining Weight,* 1995 –
100
2007
Percent
80
60
40
20
4.8
4.5
4.8
5.4
6.0
4.5
4.3
1995
1997
1999
2001
2003
2005
2007
1
0
* During the 30 days before the survey.
1 No change 1995-2003, decreased 2003-2007, p < .05
National Youth Risk Behavior Surveys, 1995 – 2007
Rising Rates of Childhood
Overweight in Lewis County
14
Percent BMI >95%
12
10
8
2002
2004
6
4
2
0
LC 8th
grade
LC 10th
grade
LC 12th
grade
State 10th
grade
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
Trends in Beverage Consumption
– Youth aged 11-18 years
1200
g per day
1000
800
Soft Drinks
Fruit Drinks
Total Milk
600
400
200
0
1965
1977
1989
1996
Consumption of cereals, added sugars
and fats has gone up (lb per capita)
Flour and cereals
Added sugars
Added fats
450
400
350
300
250
200
150
100
50
0
1970-4 1975-9 1980-4 1985-9 1990-4 1995-9
Note that the major increases was in the cereals category
Source: ERS/USDA FoodReview 2002
2000
Corn sweeteners have overtaken cane and
beet sugar (lb per capita)
Cane and beet sugar
Corn sweeteners
160
140
120
100
80
60
40
20
0
1970-4 1975-9 1980-4 1985-9 1990-4 1995-9
2000
Sucrose = 50% fructose; 50% glucose; HFCS = 55% fructose; 45% glucose
Source: ERS/USDA FoodReview 2002
Less red meat, fewer eggs, and more
poultry and fish (lb per capita, edible weight)
Beef
Pork
Veal
Poultry
Fish
Beans
Nuts
250
200
150
100
50
0
1970-9
1980-9
Source: ERS/USDA FoodReview 2002
1990-9
2000
Oranges, apples, and bananas account for
50% of all fruit servings (lb per capita)
240
Fresh citrus
Apple juice
OJ
Melons
Bananas
Berries
Apples
Grapes
200
160
120
80
40
0
1970-4
1975-9 1980-4
Source: ERS/USDA FoodReview 2002
1985-9 1990-4
1995-9
2000
Iceberg lettuce, frozen potatoes, and potato
chips account for 33% of vegetable servings
(lb per capita)
Potatoes
Fresh veg
Starchy
Leafy veg
Tomatoes cnd
Iceberg
480
400
320
240
160
80
0
1970-4
1975-9
1980-4
1985-9
1990-4
1995-9
2000
Starchy vegetables: corn, carrots, peas, sweet potatoes, beans
Fresh vegetables: tomatoes, onions, cucumbers, peppers, cabbage, celery
Dark green leafy: Leaf lettuce, broccoli, spinach, squash
Source: ERS/USDA FoodReview 2002
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 too small to provide
reliable estimates for many measures and for most
subgroups. Most analyses 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 - 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
WHAT WE EAT IN AMERICA:
NHANES-CFSII Integration
• Staged integration of the two surveys
• 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
What We Eat in America
• Food intake data can be linked to health
status data from other NHANES components
• HHS is responsible for the sample design and
data and USDA is responsible for the survey’s
dietary data collection methodology,
maintenance of the database used to code
and process the data, and data review and
processing
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 scale
1996present
Annual Surveys, ERS assumes leadership, others encouraged
to use FSMS
2006
Release of IOM report, “Food Insecurity and Hunger in the
United States: An Assessment of the Measure.”
Sample of Other Population
Surveillance Systems with Nutrition
Components
• Breastfeeding: National Immunization
Survey
• Growth in Low Income Children:
Pediatric Nutrition Surveillance System
• Pregnancy Risk Assessment Monitoring
System