1. Assessing the Nutritional Health of Populations

2. Some Definitions Joint Nutrition Monitoring Evaluation Committee, 1986 Expert Panel on Nutrition Monitoring, 1989

3. 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

4. Nutrition Surveillance Continuous assessment of nutritional status for the purpose of detecting changes in trend or distribution in order to initiate corrective measures

5. Dietary Status The condition of a population’s or an individual’s intake of foods and food components, especially nutrients.

6. 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.

7. Nutrition Monitoring in the United States

8. Chronology

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

18. 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

19. Food and Nutrient Composition Nationwide Food Consumption Survey Continuing Survey of Food Intakes by Individuals

20. Knowledge, Attitudes, and Behavior Behavioral Risk Factor Surveillance System Youth Risk Behavior Survey Diet and Health Knowledge Survey

21. Food Composition and Nutrient Data Bases National Nutrient Data Bank (NNDB)

22. Food Supply Determinations US Food and Nutrition Supply Series

23. Major Surveys with Nutrition Content

24. 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

25. 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

26. BRFSS - Data National State Smaller units when local agencies pay for additional surveys Data system homepage: http://www.cdc.gov/brfss/

27. BRFSS - Nutrition Self reported height and weight Trying to loose weight? 6 fruit and vegetable intake questions Activity Food security

29. Percent

32. The Youth Risk Behavior Surveillance System (YRBSS): 2005 National, State, and Local Data

33. 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

34. 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

35. Characteristics of the National, State, and Local School-Based YRBS 9 th – 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

36. 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%

37. Policy and Program Applications Describe risk behaviors Create awareness Set program goals Develop programs and policies Support health-related legislation Seek funding

38. Describe Risk Behaviors Overall and among subgroups of youth How risk behaviors are interrelated

39. Create Awareness Among: Legislators, boards of education, and school administrators Parents Community members School staff Students Media

40. Set Program Goals Strategic plans for school health programs Healthy People 2010 objectives CDC’s Performance Plan

41. 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

42. 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

43. Seek Funding Support funding requests to federal, state, and private agencies and foundations

44. 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

45. 2005 YRBS Results Nutrition

46. YRBS - Nutrition Self reported weight and height Dieting behaviors Eating disorder behaviors Fruit and vegetable intake Fat intake

47. 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 > W National Youth Risk Behavior Survey, 2005

48. Percentage of High School Students Who Ate Fruits and Vegetables ≥ 5 Times/Day,* 1999 – 2005 National 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

49. 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 > B National Youth Risk Behavior Survey, 2005

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

51. Rising Rates of Childhood Overweight in Lewis County

52. 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.

53. 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.

54. 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

55. CFSII - Data Availability National; four U.S. Census Bureau regions; Standard Metropolitan Statistical Areas http://www.barc.usda.gov/bhnrc/foodsurvey/home.htm

56. 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

57. Trends in Beverage Consumption – Youth aged 11-18 years

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

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

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

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

62. 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

63. 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

64. 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.

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

67. 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

68. NHANES - Content anemia diabetes cardiovascular disease osteoporosis obesity oral health physical fitness

69. NHANES - New in 1999 cardiorespiratory fitness physical functioning lower extremity disease full body DXA for body fat as well as bone density tuberculosis

70. 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

71. NHANES - Nutrition Food Security Dietary supplements Weight history Dietary Recall - one 24 hour

72. 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

74. 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

75. 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

77. 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

78. 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.

79. 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

80. 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

81. DHKS - URL www.barc.usda.gov/bhnrc/foodsurvey/csfii94.htm

82. Household Food Security in the United States

83. History of the Food Security Measurement Project 1990NMRR Act recommends a standardized mechanism for defining and obtaining data on the prevalence of food insecurity 1992USDA staff review existing research 1994USDA and DHHS sponsor conference on Food Security Measurement and Research 1995Current Population Survey of US Census Bureau includes Food Security Measurement scale 1996- present Annual Surveys, ERS assumes leadership, others encouraged to use FSMS 2006Release of IOM report, “Food Insecurity and Hunger in the United States: An Assessment of the Measure.”

84. Definitions of Food Security Before 2006

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

86. 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.

87. 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).

88. 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.

89. “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

90. 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.

91. 2006, New Definitions

92. 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.

95. http://www.ers.usda.gov/Briefing/FoodSecurity/trends.htm

96. 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.

98. Food Insecurity with Hunger 2002-2004 3.9% 4.3% 11 2003-2005 3.8% 3.9% 30

99. 1999

106. 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/

107. 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

108. 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.

109. 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