Nutrition Monitoring and Surveillance

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Nutrition Monitoring and Surveillance
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Some Definitions

• Joint Nutrition Monitoring Evaluation Committee,
  1986
• Expert Panel on Nutrition Monitoring, 1989

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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

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Nutrition Surveillance

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

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Dietary Status

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

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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.

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Nutrition Monitoring in the United States
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Chronology
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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

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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

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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

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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

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• 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

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• 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

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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

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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

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Food and Nutrient Composition

• Nationwide Food Consumption Survey
• Continuing Survey of Food Intakes by Individuals

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Knowledge, Attitudes, and Behavior

• Behavioral Risk Factor Surveillance System
• Youth Risk Behavior Survey
• Diet and Health Knowledge Survey

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Food Composition and Nutrient Data Bases

• National Nutrient Data Bank (NNDB)

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Food Supply Determinations

• US Food and Nutrition Supply Series

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Major Surveys with Nutrition Content
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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

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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 States discretion
• Rotating core of questions asked every other year
  in all States
• State-added questions developed to address
  State-specific needs

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BRFSS - Data

• National
• State
• Smaller units when local agencies pay for
  additional surveys
• Data system homepage http//www.cdc.gov/nccdphp/b
  rfss

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BRFSS - Nutrition

• Self reported height and weight
• Trying to loose weight?
• 6 fruit and vegetable intake questions
• Activity
• Food security

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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

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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
• http//www.cdc.gov/nccdphp/dash/yrbs/ov.htm

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YRBS - Categories

• injury
• tobacco use
• alcohol and other drug use
• sexual behavior
• diet and nutrition
• physical activity

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YRBS - Nutrition

• Self reported weight and height
• Dieting behaviors
• Eating disorder behaviors
• Fruit and vegetable intake
• Fat intake

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Seattle YRBS
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Rising Rates of Childhood Overweight in Lewis
County
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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.

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CFSII - Sample

• Nationally representative stratified multistage
  area probability sample of U.S.
  noninstitutionalized civilian population, all
  ages.
• Oversampling of low-income households
• For 199496, sample size for 1-day dietary data
  was 16,103 for 2-day dietary data, it was
  15,303.

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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

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CFSII - Data Availability

• National four U.S. Census Bureau regions
  Standard Metropolitan Statistical Areas
• http//www.barc.usda.gov/bhnrc/foodsurvey/home.htm
  

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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

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Trends in Beverage Consumption Youth aged 11-18
years
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Consumption of cereals, added sugars and fats has
gone up (lb per capita)
Note that the major increases was in the cereals
category
Source ERS/USDA FoodReview 2002
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Corn sweeteners have overtaken cane and beet
sugar (lb per capita)
Sucrose 50 fructose 50 glucose HFCS 55
fructose 45 glucose
Source ERS/USDA FoodReview 2002
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Less red meat, fewer eggs, and more poultry and
fish (lb per capita, edible weight)
Source ERS/USDA FoodReview 2002
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Oranges, apples, and bananas account for 50 of
all fruit servings (lb per capita)
Source ERS/USDA FoodReview 2002
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Iceberg lettuce, frozen potatoes, and potato
chips account for 33 of vegetable servings (lb
per capita)
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
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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

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NHANES - Continuous

• Periodic (196094)
• 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.

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http//www.cdc.gov/nchs/about/major/nhanes/mectour
.htm
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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

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NHANES - Content

• anemia
• diabetes
• cardiovascular disease
• osteoporosis
• obesity
• oral health
• physical fitness

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NHANES - New in 1999

• cardiorespiratory fitness
• physical functioning
• lower extremity disease
• full body DXA for body fat as well as bone
  density
• tuberculosis

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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

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NHANES - Nutrition

• Food Security
• Dietary supplements
• Weight history
• Dietary Recall - one 24 hour

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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

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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

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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 surveys dietary
  data collection methodology, maintenance of the
  database used to code and process the data, and
  data review and processing

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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

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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.

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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

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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

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DHKS - URL

• www.barc.usda.gov/bhnrc/foodsurvey/csfii94.htm

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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
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History of the Food Security Measurement Project
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Definitions of Food Security Before 2006
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Nutrition Security

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

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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.

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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).

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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.

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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

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Changes in Definitions IOM 2006

• Food 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.

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2006, New Definitions
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2006, Food Security Continuum

• High 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.

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http//www.ers.usda.gov/Briefing/FoodSecurity/tren
ds.htm
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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.

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Food Insecurity with Hunger
2002-2004 3.9
4.3 11 2003-2005 3.8
3.9 30
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1999
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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/
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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

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Its 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.

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Why did Washingtons rates improve?

• Increased participation in federal programs
• Between 2001 and 2004 there was a 59 increase in
  food stamp participation.
• Improving economy?

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Other National Findings

• 70 of food insecure families had visited a food
  pantry within the past year.
• Only 18.3 of families with incomes below 130
  had participated in food stamps in the past month.