Assessing the Nutritional Health of Populations. Some Definitions Joint Nutrition Monitoring...

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, food safety

Laws & regulations

Individual Behavior

Behaviors & Lifestyle

Individual behavior change interventions

Macro social/economic environments

Fundamental determinants of health

Social and economic policies

Brief 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

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 2000

CSFII and NHANES Integrated 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 Years

School Health Policies and Programs Study

CDC, Division of Adolescent and School Health

1994, 2000, 2006

Survey of Maternity Practices in Infant Nutrition and Care (mPINC)

CDC, Division of Nutrition, Physical Activity and Obesity

2007

Nutrition, Physical Activity and Obesity Legislative Database

CDC, Division of Nutrition, Physical Activity and Obesity

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-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/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 The Youth Risk Behavior Surveillance System (YRBSS) Surveillance System (YRBSS)

National, State, and Local DataNational, 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% 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

22.918.8

24.9 24.021.419.9

0

20

40

60

80

100

Total Female Male White Black Hispanic

Per

cen

t

Percentage of High School Students Who Ate Fruits and Vegetables Five or More Times/Day,* 1999 –

2007

National Youth Risk Behavior Surveys, 1999 – 2007

23.9 21.4 22.0 21.4120.1

0

20

40

60

80

100

1999 2001 2003 2005 2007

Pe

rce

nt

* 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

Percentage of High School Students Who Drank Three or More Glasses/Day of Milk,* by

Sex** and Race/Ethnicity,*** 2007

* During the 7 days before the survey. ** M > F*** W > H > B

National Youth Risk Behavior Survey, 2007

19.416.1

9.712.7

14.1

8.8

0

20

40

60

80

100

Total Female Male White Black Hispanic

Per

cen

t

Percentage of High School Students Who Drank Three or More Glasses/Day of Milk,*

1999 – 2007

National Youth Risk Behavior Surveys, 1999 – 2007

18.0 16.4 16.2 14.1117.1

0

20

40

60

80

100

1999 2001 2003 2005 2007

Per

cen

t

* During the 7 days before the survey. 1 Decreased 1999-2007, p < .05

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

* Not including diet soda or diet pop, during the 7 days before the survey. ** M > F*** B > H

National Youth Risk Behavior Survey, 2007

38.634.0

37.633.433.8

29.0

0

20

40

60

80

100

Total Female Male White Black Hispanic

Per

cen

t

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 Race/Ethnicity,*** 2007

* During the 30 days before the survey.** F > M *** H > W, B

National Youth Risk Behavior Survey, 2007

7.311.2 10.3

14.111.8 16.3

0

20

40

60

80

100

Total Female Male White Black Hispanic

Per

cen

t

Percentage of High School Students Who Vomited or Took Laxatives to Lose Weight or to Keep From Gaining Weight,* by Sex** and

Race/Ethnicity,*** 2007

* During the 30 days before the survey.** F > M*** H > B

National Youth Risk Behavior Survey, 2007

2.2 4.1 3.0 5.34.3 6.4

0

20

40

60

80

100

Total Female Male White Black Hispanic

Per

cen

t

Percentage of High School Students Who Vomited or Took Laxatives to Lose Weight or to Keep From Gaining Weight,* 1995 –

2007

National Youth Risk Behavior Surveys, 1995 – 2007

* During the 30 days before the survey.1 No change 1995-2003, decreased 2003-2007, p < .05

4.8 4.5 4.8 4.314.56.05.4

0

20

40

60

80

100

1995 1997 1999 2001 2003 2005 2007

Pe

rce

nt

Rising Rates of Childhood Overweight in Lewis County

0

2

4

6

8

10

12

14

Perc

en

t B

MI

>95%

LC 8thgrade

LC 10thgrade

LC 12thgrade

State 10thgrade

2002

2004

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

0

200

400

600

800

1000

1200

g p

er

day

1965 1977 1989 1996

Soft Drinks

Fruit Drinks

Total Milk

050

100150200250300350400450

1970-4 1975-9 1980-4 1985-9 1990-4 1995-9 2000

Flour and cereals Added sugars Added fats

Consumption of cereals, added sugars Consumption of cereals, added sugars and fats has gone up and fats has gone up (lb per capita)(lb per capita)

Source: ERS/USDA FoodReview 2002

Note that the major increases was in the cereals category

0

20

40

60

80

100

120

140

160

1970-4 1975-9 1980-4 1985-9 1990-4 1995-9 2000

Cane and beet sugar Corn sweeteners

Corn sweeteners have overtaken cane and Corn sweeteners have overtaken cane and beet sugar beet sugar (lb per capita) (lb per capita)

Source: ERS/USDA FoodReview 2002Sucrose = 50% fructose; 50% glucose; HFCS = 55% fructose; 45% glucose

0

50

100

150

200

250

1970-9 1980-9 1990-9 2000

Beef Pork Veal Poultry Fish Beans Nuts

Less red meat, fewer eggs, and more Less red meat, fewer eggs, and more poultry and fish poultry and fish (lb per capita, edible weight) (lb per capita, edible weight)

Source: ERS/USDA FoodReview 2002

0

40

80

120

160

200

240

1970-4 1975-9 1980-4 1985-9 1990-4 1995-9 2000

Fresh citrus OJ Bananas Apples

Apple juice Melons Berries Grapes

Oranges, apples, and bananas account for Oranges, apples, and bananas account for 50% of all fruit servings 50% of all fruit servings (lb per capita)(lb per capita)

Source: ERS/USDA FoodReview 2002

0

80

160

240

320

400

480

1970-4 1975-9 1980-4 1985-9 1990-4 1995-9 2000

Potatoes Starchy Tomatoes cnd

Fresh veg Leafy veg Iceberg

Iceberg lettuce, frozen potatoes, and potato chips account for 33% of vegetable servings

(lb per capita)(lb per capita)

Starchy vegetables: corn, carrots, peas, sweet potatoes, beansFresh vegetables: tomatoes, onions, cucumbers, peppers, cabbage, celeryDark 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 Project1990 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

1996-present 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