Assessing the Nutritional
Health of Populations
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
Chronology
1909
USDA starts food supply series
1930s
USDA Household food consumption survey
started (changed name to Nationwide FCS)
Ten State Nutrition Survey (Nation’s first
comprehensive survey)
NHANES I and II
Pediatric Nutrition Surveillance System
Joint Nutrition Monitoring Evaluation
Committee with USDA and DHHS
Passage of the National Nutrition Monitoring
and Related Research Act
CSFII and NHANES Integrated
1968-70
1970s
1980s
1990
2001
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
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-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
Percent
The Youth Risk Behavior
Surveillance System (YRBSS):
2005
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
• 9th – 12th grade students
• Probability samples of schools and
students
• Anonymous
• Self-administered, computer-scannable
questionnaire or answer sheet
• Completed in one class period (45
minutes)
• Conducted biennially usually during the
spring
2005 National YRBS
• National probability sample of public
and private schools
• Total sample size = 13,917
• School-level response rate = 78%
• Student-level response rate = 86%
• Overall response rate = 67%
Policy and Program
Applications
•
•
•
•
•
•
Describe risk behaviors
Create awareness
Set program goals
Develop programs and policies
Support health-related legislation
Seek funding
Describe Risk Behaviors
• Overall and among subgroups of youth
• How risk behaviors are interrelated
Create Awareness
Among:
• Legislators, boards of education, and school
administrators
• Parents
• Community members
• School staff
• Students
• Media
Set Program Goals
• Strategic plans for school health
programs
• Healthy People 2010 objectives
• CDC’s Performance Plan
Develop Programs and Policies
• School health programs and policies
• Programs and policies for youth in high
risk situations
• Instructional guides and materials
• Professional development programs for
teachers
Support Health-Related
Legislation
• School health program requirements
• School health council requirements
• Drug-free or weapon-free school zone
laws
• Minors’ access laws
• Drinking and driving laws
• Bans on billboards and other advertising
• Competitive food policies
Seek Funding
• Support funding requests to federal, state,
and private agencies and foundations
YRBSS Information
• www.cdc.gov/yrbs
– 2005 questionnaire and item rationale
– Morbidity and Mortality Weekly Report
Surveillance Summaries
– Youth 2005 Online
– Data and codebooks for the national
surveys
– Publications, journal articles, and fact
sheets
2005 YRBS Results
Nutrition
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 ≥ 5
Times/Day,* by Sex** and
100
Race/Ethnicity,*** 2005
Percent
80
60
40
20.1
20
18.7
21.4
18.6
22.1
23.2
Black
Hispanic
0
Total
Female
Male
White
* 100% fruit juice, fruit, green salad, potatoes (excluding French fries, fried potatoes, or potato chips), carrots, or other
vegetables during the 7 days preceding the survey
** M > F
*** B, H > W
National Youth Risk Behavior Survey, 2005
Percentage of High School Students Who
Ate Fruits and Vegetables ≥ 5 Times/Day,*
1999 – 2005
100
Percent
80
60
40
23.9
21.4
22.0
20.1
2001
2003
2005
1
20
0
1999
* 100% fruit juice, fruit, green salad, potatoes (excluding French fries, fried potatoes, or potato chips), carrots, or other
vegetables during the 7 days preceding the survey
1 Significant linear decrease, P < .05
National Youth Risk Behavior Surveys, 1999 – 2005
Percentage of High School Students
Who Drank > 3 Glasses/Day of Milk,* by
100 Sex**and Race/Ethnicity,*** 2005
Percent
80
60
40
20
20.8
16.2
18.7
13.9
11.6
8.6
0
Total
Female
* During the 7 days preceding the survey
** M > F
*** W > H > B
National Youth Risk Behavior Survey, 2005
Male
White
Black
Hispanic
Percentage of High School Students Who
Drank > 3 Glasses/Day of Milk,* 1999 –
2005
100
Percent
80
60
40
20
18.0
16.4
17.1
16.21
1999
2001
2003
2005
0
* During the 7 days preceding the survey
1 No significant change over time
National Youth Risk Behavior Surveys, 1999 – 2005
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 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
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
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
Household Food Security in the
United States
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.”
Definitions of Food Security
Before 2006
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
ways.
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).
Hunger
• 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.
“Food Insecurity and Hunger in the United
States: An Assessment of the Measure.”
(IOM 2006)
• Recommended that USDA continue to
measure and monitor food insecurity regularly
in a household survey
• Affirmed the appropriateness of the general
methodology currently used to measure food
insecurity
• Suggested several ways in which the
methodology might be refined (contingent on
confirmatory research). Research on these
issues is currently underway at ERS
Changes in Definitions – IOM
2006
• “Food insecurity—a household-level economic and
social condition of limited or uncertain access to
adequate food.
• “Hunger is an individual-level physiological condition
that may result from food insecurity - should refer to a
potential consequence of food insecurity that,
because of prolonged, involuntary lack of food,
results in discomfort, illness, weakness, or pain that
goes beyond the usual uneasy sensation."
• To measure hunger in this sense would require
collection of more detailed and extensive information
on physiological experiences of individual household
members than could be accomplished effectively in
the context of the CPS.
2006, New Definitions
2006, Food Security Continuum
• High food security—Households had no problems, or anxiety
about, consistently accessing adequate food.
• Marginal food security—Households had problems at times, or
anxiety about, accessing adequate food, but the quality, variety,
and quantity of their food intake were not substantially reduced.
• Low food security—Households reduced the quality, variety,
and desirability of their diets, but the quantity of food intake and
normal eating patterns were not substantially disrupted.
• Very low food security—At times during the year, eating
patterns of one or more household members were disrupted and
food intake reduced because the household lacked money and
other resources for food.
http://www.ers.usda.gov/Briefing/FoodSecurity/trends.htm
2005 Survey, VL Food Security
(4.4 million households)
• 98 percent reported having worried that their food would run out
before they got money to buy more.
• 96 percent reported that the food they bought just did not last
and they did not have money to get more.
• 94 percent reported that they could not afford to eat balanced
meals.
• 96 percent reported that an adult had cut the size of meals or
skipped meals because there was not enough money for food;
86 percent reported that this had occurred in 3 or more months.
• 44 percent reported having lost weight because they did not
have enough money for food.
• 31 percent reported that an adult did not eat for a whole day
because there was not enough money for food; 22 percent
reported that this had occurred in 3 or more months.
Food Insecurity with Hunger
2002-2004
3.9%
4.3% 11
2003-2005
3.8%
3.9% 30
1999
State-Level Predictors of Food
Insecurity and Hunger Among
Households With Children, 2005
• Used hierarchical modeling to identify
contextual dimensions of food
insecurity:
– Availability and accessibility of federal
nutrition assistance programs
– Policies affecting wellbeing of low income
families
– States economic and social characteristics
http://www.ers.usda.gov/Publications/CCR13/
Important Protective Factors
• Food stamps and summer meals
programs
• Tax policies that support low income
families
• Job opportunities/strong labor market
• “Robust” relationship between median
rent and food insecurity
• Residential stability and social capital
It’s not just poverty…
• Some states have high rates of food
insecurity, but lower rates of poor families and
families headed by a single adult.
• Propose concept of “excess food insecurity”
to determine which states may benefit from
strengthening the food security infrastructure.
Why did Washington’s rates
improve?
• Increased participation in federal programs
• Between 2001 and 2004 there was a 59%
increase in food stamp participation.
• In 2002 56% of eligible families received food
stamps; in 2005 68% received food stamps.
• WA state legislature increased funding for
school lunch, breakfast and summer meals