Assessing the Nutritional Health of Populations

Some DefinitionsJoint Nutrition Monitoring Evaluation Committee, 1986Expert Panel on Nutrition Monitoring, 1989

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

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

Dietary StatusThe condition of a populations or an individuals intake of foods and food components, especially nutrients.

Nutrition AssessmentMeasurement 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)

1968-70

Ten State Nutrition Survey (Nations 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 NNMSProvide foundations for improvement of nutritional status and quality and healthfulness of food supplyCollect, 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 monitoringProvide data for evaluating implications of changes in agricultural policy

National Nutrition Monitoring SystemJointly administered by USDA and DHHS22 federal agencies involvedOver 70 surveys and surveillance activitiesTen year comprehensive plan for Nutrition Monitoring and Related Research sent to congress in 1993

NNMS - Some AgenciesUSDAFood and Nutrition ServiceFood Safety and Inspection ServiceAgricultural Research ServiceEconomic Research ServiceExtension ServiceCooperative State Research Service

Department of Health and Human ServicesNational Center for Health StatisticsCDC-National Center for Chronic Disease Prevention and Health PromotionFood and Drug AdministrationHeath Resources and Services AdministrationIndian Health ServicesNational Institutes of HealthSubstance Abuse and Mental Health Services Administration

Others:Department of DefenseDepartment of EducationAgency for International DevelopmentDepartment of Veterans AffairsCensus BureauBureau of Labor StatisticsNational Marine Fisheries Service

5 Areas of NNMSNutrition and related health measurementsFood and nutrient compositionKnowledge, attitudes, and behaviorFood composition and nutrient databasesFood Supply Determinations

Nutrition and Related Health MeasurementsNational Health and Nutrition Examination Surveys (I-V, and continuous)National Health Interview SurveyNational Hospital Discharge SurveyPediatric Nutrition Surveillance System

Food and Nutrient CompositionNationwide Food Consumption Survey Continuing Survey of Food Intakes by Individuals

Knowledge, Attitudes, and BehaviorBehavioral Risk Factor Surveillance SystemYouth Risk Behavior SurveyDiet and Health Knowledge Survey

Food Composition and Nutrient Data BasesNational Nutrient Data Bank (NNDB)

Food Supply DeterminationsUS 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 interviewData 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 - QuestionsBehavioral risk factors (for example, alcohol and tobacco use), preventive health measures, HIV/AIDS, health status, limitation of activity, and health care access and utilizationCore of questions asked in all StatesStandardized optional questions on selected topics administered at the States discretionRotating core of questions asked every other year in all StatesState-added questions developed to address State-specific needs

BRFSS - DataNationalStateSmaller units when local agencies pay for additional surveysData system homepage: http://www.cdc.gov/brfss/

BRFSS - NutritionSelf reported height and weightTrying to loose weight?6 fruit and vegetable intake questionsActivity Food security

Percent

The Youth Risk Behavior Surveillance System (YRBSS): 2005

National, State, and Local Data

Purposes of the YRBSSFocus the nation on behaviors among youth causing the most important health problemsAssess how risk behaviors change over timeProvide comparable data

Behaviors That Contribute to the Leading Causes of Morbidity and MortalityBehaviors that contribute to unintentional injuries and violenceTobacco use Alcohol and other drug useSexual behaviorsUnhealthy dietary behaviorsInadequate physical activity

Characteristics of the National, State, and Local School-Based YRBS9th 12th grade studentsProbability samples of schools and studentsAnonymousSelf-administered, computer-scannable questionnaire or answer sheetCompleted in one class period (45 minutes)Conducted biennially usually during the spring

2005 National YRBSNational probability sample of public and private schoolsTotal sample size = 13,917School-level response rate = 78%Student-level response rate = 86%Overall response rate = 67%

Policy and Program Applications Describe risk behaviorsCreate awarenessSet program goalsDevelop programs and policiesSupport health-related legislationSeek funding

Describe Risk BehaviorsOverall and among subgroups of youthHow risk behaviors are interrelated

Create AwarenessAmong: Legislators, boards of education, and school administratorsParentsCommunity membersSchool staffStudentsMedia

Set Program GoalsStrategic plans for school health programsHealthy People 2010 objectivesCDCs Performance Plan

Develop Programs and PoliciesSchool health programs and policiesPrograms and policies for youth in high risk situationsInstructional guides and materialsProfessional development programs for teachers

Support Health-Related LegislationSchool health program requirementsSchool health council requirementsDrug-free or weapon-free school zone lawsMinors access lawsDrinking and driving lawsBans on billboards and other advertisingCompetitive food policies

Seek FundingSupport funding requests to federal, state, and private agencies and foundations

YRBSS Informationwww.cdc.gov/yrbs2005 questionnaire and item rationaleMorbidity and Mortality Weekly Report Surveillance SummariesYouth 2005 OnlineData and codebooks for the national surveysPublications, journal articles, and fact sheets

2005 YRBS ResultsNutrition

YRBS - NutritionSelf reported weight and heightDieting behaviorsEating disorder behaviorsFruit and vegetable intakeFat intake

Percentage of High School Students Who Ate Fruits and Vegetables 5 Times/Day,* by Sex** and Race/Ethnicity,*** 2005* 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 > WNational Youth Risk Behavior Survey, 2005

Percentage of High School Students Who Ate Fruits and Vegetables 5 Times/Day,* 1999 2005National Youth Risk Behavior Surveys, 1999 2005 * 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

Percentage of High School Students Who Drank > 3 Glasses/Day of Milk,* by Sex**and Race/Ethnicity,*** 2005* During the 7 days preceding the survey ** M > F *** W > H > BNational Youth Risk Behavior Survey, 2005

Percentage of High School Students Who Drank > 3 Glasses/Day of Milk,* 1999 2005National Youth Risk Behavior Surveys, 1999 2005 * During the 7 days preceding the survey 1 No significant change over time

Rising Rates of Childhood Overweight in Lewis County

Continuing Survey of Food Intake by Individuals (CSFII)USDA1994-1996in-person interviews24-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 - SampleNationally representative stratified multistage area probability sample of U.S. noninstitutionalized civilian population, all ages. Oversampling of low-income householdsFor 199496, sample size for 1-day dietary data was 16,103; for 2-day dietary data, it was 15,303.

CFSII - Datakinds and amounts of foods consumedsources of foodstime, name of each eating occasionfood expenditures, shopping practicespregnancy, lactation, nursing status, height and weightincome, poverty status, household size, participation in Food Stamp and WIC programs

CFSII - Data AvailabilityNational; four U.S. Census Bureau regions; Standard Metropolitan Statistical Areashttp://www.barc.usda.gov/bhnrc/foodsurvey/home.htm

CFSII - Nutritionfood intakes in grams of 71 USDA-defined food groups and subgroupsnutrient intakes of 28 nutrients and food componentsnutrient intakes expressed as percentages of the 1989 Recommended Dietary AllowancePyramid servings from 30 food groups

Trends in Beverage Consumption Youth aged 11-18 years

Consumption of cereals, added sugars and fats has gone up (lb per capita)Source: ERS/USDA FoodReview 2002Note that the major increases was in the cereals category

Corn sweeteners have overtaken cane and beet sugar (lb per capita)Source: ERS/USDA FoodReview 2002Sucrose = 50% fructose; 50% glucose; HFCS = 55% fructose; 45% glucose

Less red meat, fewer eggs, and more poultry and fish (lb per capita, edible weight)Source: ERS/USDA FoodReview 2002

Oranges, apples, and bananas account for 50% of all fruit servings (lb per capita)Source: ERS/USDA FoodReview 2002

Iceberg lettuce, frozen potatoes, and potato chips account for 33% of vegetable servings (lb per capita)Starchy vegetables: corn, carrots, peas, sweet potatoes, beansFresh vegetables: tomatoes, onions, cucumbers, peppers, cabbage, celeryDark green leafy: Leaf lettuce, broccoli, spinach, squashSource: 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 centerstratified multistage probability sample, nationally representative of the U.S. civilian noninstitutionalized populationApproximately 5,000 people are examined at 15 locations each yearAll ages beginning in 1999

NHANES - ContinuousPeriodic (196094);annual beginning in 1999after 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 - ContentChronic disease prevalence and conditions (including undiagnosed conditionsimmunization statusinfectious disease prevalencehealth insurancemeasures of environmental exposureshearingvisionmental health

NHANES - Contentanemiadiabetescardiovascular diseaseosteoporosisobesityoral healthphysical fitness

NHANES - New in 1999cardiorespiratory fitnessphysical functioninglower extremity diseasefull body DXA for body fat as well as bone densitytuberculosis

NHANES - DataNational; four U.S. Census Bureau regionsDemographics: Gender, age, education, race/ethnicity, place of birth, income, occupation, and industryhttp://www.cdc.gov/nchs/nhanes.htm

NHANES - NutritionFood SecurityDietary supplementsWeight historyDietary Recall - one 24 hour

NHANES III Anthropometric Procedures Video Body weightStanding heightSitting heightUpper leg lengthRecumbent lengthUpper arm lengthKnee heightArm circumferenceWaist circumferenceButtocks circumferenceThigh circumferenceHead circumferenceSkinfolds (including thighs, triceps, subscapular, and suprailiac)Wrist breadthElbow breadth

WHAT WE EAT IN AMERICA: NHANES-CFSII IntegrationStaged integration of the two surveys2001 a year of testing, 2002 full integrationGoals: 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 AmericaFood 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 surveys 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 ServicePeriodically from 1989 to 1996In conjunction with CSFIISample size per year ~1300 from 1989 through 1991 ~2000 per year 1994-1996telephone follow up conducted with one adult in each household 2-3 weeks after CFSII

DHKS - ContentDesigned to assess relationships between knowledge and attitudes about dietary guidance and food safety, food choice decisions and nutrient intakesVariables can be linked to CFSII variables for individuals.

DHKS - QuestionsSelf perceived intake levelsawareness of diet/health relationshipsuse of food labelsperceived importance of following dietary guidance for specific nutrients and food componentsbeliefs about food safetyKnowledge about food sources of nutrients

DHKS - Descriptive VariablesIndividual: gender, age, ethnicity, education, employment status, height and weightHousehold: income, size, cash assets, region, urbanization, tenancy, participation in food stamps and WIC

DHKS - URLwww.barc.usda.gov/bhnrc/foodsurvey/csfii94.htm

Household Food Security in the United States

History of the Food Security Measurement Project

Definitions of Food Security Before 2006

Nutrition SecurityThe provision of an environment that encourages and motivates society to make food choices consistent with short and long term good health.

Food SecurityAssess 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 Insecuritya 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).

HungerThe 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 foodMay 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 2006Food insecuritya 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 ContinuumHigh food securityHouseholds had no problems, or anxiety about, consistently accessing adequate food.Marginal food securityHouseholds 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 securityHouseholds 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 securityAt 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 Hunger2002-2004 3.9% 4.3% 112003-2005 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 programsPolicies affecting wellbeing of low income familiesStates economic and social characteristics

http://www.ers.usda.gov/Publications/CCR13/

Important Protective FactorsFood stamps and summer meals programsTax policies that support low income familiesJob opportunities/strong labor marketRobust relationship between median rent and food insecurityResidential stability and social capital

Its not just povertySome 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 Washingtons rates improve?Increased participation in federal programsBetween 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

This slide set contains information about and data from the Youth Risk Behavior Surveillance System or YRBSS. It includes national, state, and local data from the 2005 surveys.The purposes of the YRBSS are threefold:To focus the nation on behaviors among youth causing the most important health problems;To assess how risk behaviors change over time; andTo provide comparable data.The YRBSS measures behaviors that contribute to the leading causes of morbidity and mortality among youth and adults. These are behaviors that contribute to Unintentional injuries and violence;Tobacco use;Alcohol and other drug use;Sexual behaviors;Unhealthy dietary behaviors; andInadequate physical activity.

The national, state, and local Youth Risk Behavior Surveys are administered to 9th through 12th grade students drawn from probability samples of schools and students. The questionnaire is anonymous and self-administered. The questionnaire booklet or answer sheet is computer-scannable. The surveys are completed in one 45-minute class period, and are conducted biennially usually during the spring.The 2005 National YRBS survey was administered to a national probability sample of public and private schools. The sample size is 13,917 students. The school-level response rate is 78% and the student-level response rate is 86%. The school response rate multiplied by the students response rate produces an overall response rate of 67%.YRBS data are used at the national, state, and local levels in a variety of policy and program applications. YRBS data can be used to do the following:Describe risk behaviors;Create awareness;Set program goals;Develop programs and policies;Support health-related legislation; andSeek funding.The YRBSS describes risk behaviors that affect youth, including select subgroups of youth that may be of interest. YRBS data also are used to demonstrate how risk behaviors are interrelated.YRBS data are useful for creating awareness about health challenges and successes for youth among such varied audiences asLegislators, boards of education, and school administrators;Parents;Community members;School staff;Students; andMedia.YRBS data also are used often to set program goals. Examples of how YRBS data have been used areto establish and monitor strategic plans for school health programs;to monitor progress toward national Healthy People 2010 objectives; andto evaluate components of CDCs Performance Plan.

YRBS data have proven useful to help develop programs and policies, includingSchool health programs and policies;Programs and policies for youth in high risk situations;Instructional guides and materials; andProfessional development programs for teachers.Data from the YRBS also are cited often to support health-related legislation. Examples includeSchool 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; andCompetitive food policies.YRBS data are a valuable resource to support funding requests to federal, state, and private agencies and foundations.Comprehensive information about the YRBSS can be found on CDCs Web site at www.cdc.gov/yrbs. The site includes information such as a copy of the 2005 questionnaire and item rationale; links to the Morbidity and Mortality Weekly Report Surveillance Summaries that highlight YRBS data; Youth 2005 Online; the data and codebooks for the national YRBS; and related publications, journal articles, and fact sheets.The following slides highlight results from the 2005 YRBS.Nationwide in 2005, 20.1% of high school students had eaten fruits and vegetables (100% fruit juice, fruit, green salad, potatoes (excluding French fries, fried potatoes, or potato chips), carrots, or other vegetables) 5 times/day during the seven days preceding the survey. Overall, the prevalence of having eaten fruits and vegetables 5 times/day was higher among male than female students and higher among black and Hispanic than white students.This slide shows the percentage of high school students over time who had eaten fruits and vegetables (100% fruit juice, fruit, green salad, potatoes (excluding French fries, fried potatoes, or potato chips), carrots, or other vegetables) 5 times/day during the seven days preceding the survey. During 1999 to 2005, a significant linear decrease was identified.

Nationwide in 2005, 16.2% of high school students had drunk three or more glasses/day of milk during the seven days preceding the survey. Overall, the prevalence of having drunk three or more glasses/day of milk was higher among male than female students, higher among white than black and Hispanic students, and higher among Hispanic than black students.This slide shows the percentage of high school students over time who had drunk three or more glasses/day of milk during the seven days preceding the survey. During 1999 to 2005, no significant change was identified.