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Issues and Opinions

Nutrition Monitoring: Summary of a Statement from an American Society for Nutritional Sciences Working Group¹

Catherine E. Woteki^*2, Ronnette R. Briefel, Catherine J. Klein^**, Paul F. Jacques, P. M. Kris-Etherton, Julie A. Mares-Perlman and Linda D. Meyers

^* Office of the Dean, College of Agriculture, Iowa State University, Ames, IA 50011-1050; Mathematica Policy Research, Inc., Washington, DC; ^** Life Sciences Research Office, Bethesda, MD; Epidemiology Program, Tufts University, U.S. Department of Agriculture-HNRC on Aging, Boston, MA; Department of Nutritional Sciences, Pennsylvania State University, University Park, PA; Department of Ophthalmology, University of Wisconsin, Madison, WI; and Food and Nutrition Board, Institute of Medicine, National Academy of Sciences, Washington, DC

²Chair, ASNS Working Group on Nutrition Monitoring; to whom correspondence should be addressed. E-mail: cwoteki{at}iastate.edu.

	INTRODUCTION

TOP INTRODUCTION CONCLUSIONS OF THE WORKING... Conclusions related to the... Working group recommendations

 
For many years, the United States has had an ongoing interdepartmental program of surveys and surveillance activities, known as the National Nutrition Monitoring and Related Research Program (NNMRRP),³ designed to provide information about the U.S. population’s nutritional status and related food intake and health factors. Since the U.S. Department of Agriculture (USDA) conducted the initial household food surveys in the 1930s, the NNMRRP has expanded in terms of the number and types of surveys conducted and the breadth of dietary, nutrition and health assessments made. Data from these surveys are widely cited and relied on for human nutrition and food safety policy development, for program evaluation and for research. Two of the NNMRRP’s major national surveys, the Continuing Survey of Food Intakes by Individuals (CSFII) conducted by the USDA and the National Health and Nutrition Examination Survey (NHANES) conducted by the U.S. Department of Health and Human Services (HHS), are being merged into an integrated survey intended as the primary source of nationally representative data on dietary intake of foods and nutrients and nutritional status.

The Council of the American Society for Nutritional Sciences (ASNS) is concerned that an inadequate budget and changes in the design and content of the major federal dietary and nutrition surveys may limit the depth, breadth and timeliness of such data needed for population surveillance, monitoring, program policy development and evaluation, risk assessment, and cross-sectional and longitudinal research. The ASNS Council thus formed a Working Group to review the current status and future plans of the NNMRRP and to draft a statement on nutrition monitoring, so as to solicit members’ opinions and serve as a basis for updating the Council’s position on nutrition monitoring. The Working Group was aided by expert advice of liaisons from federal agencies with major nutrition monitoring responsibilities.

Although most of the discussion therein relates to the two largest surveys (CSFII and NHANES), the statement briefly describes the NNMRRP in general, its objectives, and its many accomplishments. It also identifies some objectives not yet met and makes recommendations about how to achieve these unmet objectives and provide for a more robust, responsive and comprehensive NNMRRP in the future.

	CONCLUSIONS OF THE WORKING GROUP

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The Working Group concluded that nutrition monitoring and surveillance are fundamental functions of government and that ways must be found to provide a stable funding base to continue current and planned federal nutrition monitoring activities. The most compelling argument for generous and continued support of the integrated CSFII/NHANES is the number and essentiality of federal policies, program evaluations, regulations and normative standards that rely on survey data. As the country continues to base more food, environmental and health regulatory policies on risk assessments and cost-benefit analyses, there will be a continuing need for observations on dietary intake and nutritional health status obtained from representative samples of the population. A multipurpose survey such as the integrated CSFII/NHANES may be more efficient and cost-effective over the long term than smaller, targeted surveys designed to meet specific needs of individual agencies’ regulatory agendas. However, both avenues may be required for the national nutrition monitoring program, and this issue merits further study.

	Conclusions related to the specific questions posed by the ASNS Council

TOP INTRODUCTION CONCLUSIONS OF THE WORKING... Conclusions related to the... Working group recommendations

 
Timeliness, budget, sampling and content.

As currently crafted, the integrated CSFII/NHANES should improve the quality, timeliness and usability of survey data. The plan of the integrated survey calls for continuous field operation using a variety of measurement modules to collect data on dietary intake and nutritional and health status of a representative sample of 5000 Americans. Multiple years of data may be needed to obtain sample sizes sufficiently large to permit analysis of subgroups of the population. However, it is not clear that sufficient funds are available to do this, or that plans for selective use of different measurement modules from time to time will permit it. The increase for the NHANES from a single-day dietary recall to 2 d of dietary recalls for each survey respondent will permit the estimation of population distributions of usual intake for most nutrients and will meet the needs of many (but not all) users of the survey data. Details about what measurements will always be included, what measures will be collected periodically and what factors should influence introduction of new measurements remain to be worked out, along with budgets. Therefore, the Working Group could not assess the worth of the proposed modular design without more explicit information.

Effect of changes in survey design on usefulness for research and policy.

The integrated survey design disappointed many who use the survey results for research and policy development because they had anticipated a larger yearly sample size. Although many more days of recall information may be needed for estimates of distributions of intakes of infrequently consumed foods and for other research and risk assessment purposes, the Working Group recognizes that no multipurpose national survey can collect multiple days of intake. As a cost-effective strategy to address this unmet need, the Working Group encourages use of advances in dietary assessment methodology that combine daily methods with food-frequency methods to obtain better estimates of usual intake in individuals. It is reasonable to continue the current integrated survey content, perhaps augmented by specific questionnaire modules to assess the frequency of consumption of certain foods or the food habits of interest.

One option for future consideration (if funds can be garnered) is to return to the original 1999 plan for survey integration with an augmented sample size. Also, because data are used to design and evaluate food assistance and nutrition education programs, additional information on individuals’ knowledge related to diet and health and detailed information on participation in food programs should be obtained, as the CSFII did in the past.

Steps for a more comprehensive NNMRRP.

Regular mechanisms should be in place by which the National Center for Health Statistics (NCHS), the Agricultural Research Service (ARS) and their parent departments collaborate with each other, obtain external scientific advice, and review and advise about the design of the NNMRRP. By means of passage of the Nutrition Monitoring and Related Research Act (NNMRRA) in 1990, Congress had intended to strengthen the monitoring system by requiring better coordination and oversight, and to develop a long-term strategy by requiring development of the 10-y plan to guide planning and budgetary decisions. Under this 10-y plan, agencies did make significant progress in survey comparability, food composition data, federal-state relations and information to assess the effects of welfare reform on the nutritional status and food security of the population. However, some Congressional requirements in the plan, such as establishing a competitive grants program for survey analysis and grants to states, never received funding. Although very little of the infrastructure created by the NNMRRA remains in place, there are no statutory obstacles to continuing the activities of an external advisory committee or to coordinating NNMRRP design and budgeting decisions through an internal federal coordinating body

Recommended research.

Establishing relationships between dietary intake and health will remain a central research focus of the integrated CSFII/NHANES. The Working Group ascertained a need for special research studies to develop methods to assess usual intake or biomarkers of usual dietary intake in surveys as well as in other types of epidemiologic research, and the Working Group urges the NIH and ARS to make this a high priority.

	Working group recommendations

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The NNMRRP and its surveys provide data that are of unquestioned utility to the government. Therefore, the Working Group recommends that:

• Congress reauthorize an updated NNMRRA modified to address current public health priorities, data needs and infrastructure requirements with adequate appropriations.
  
• Congress increase the appropriation for NHANES by a sufficient amount to ensure that a stable set of regularly collected nutrition indicators is included on an annual basis, with accompanying report language to this effect. In our professional judgment, an additional $15 million is needed for NCHS with $5 million of this designated for supplementation of the NHANES and related nutrition monitoring activities.
  
• Congress increase the appropriation for ARS by a sufficient amount to provide for augmentation of the integrated design through the addition of 5000 sample persons.
  
• Congress fund the grants program initially authorized under the NNMRRA at a level of $10 million annually. Even without reauthorization of the Act occurring first, NCHS and other NNMRRA partners have existing legislative authority to award grants for this purpose.
  
• The HHS and USDA establish a high-level Board to coordinate the planning and budget development activities of the NNMRRP.
  
• The HHS and USDA continue to seek external joint advice about the design and conduct of the NNMRRP.
  
• Congress direct and appropriate funds to a neutral group such as the Life Sciences Research Office or the Food and Nutrition Board in collaboration with the Board on National Statistics or another group to undertake a study to review the design of the dietary intake component of the integrated CSFII/NHANES to determine how well it will meet the needs of agencies as well as outside users.
  
• Other elements of the nutrition monitoring program (e.g., the vital statistics system and surveys that deal with behaviors and food safety issues) are underfunded and unable to meet current challenges. With input from the mechanisms described above, Congress should provide additional funding to ensure that these elements of the NNMRRP can provide the needed data.
  

	FOOTNOTES

 
¹ This is a summary of the report prepared by the ASNS Working Group on Nutrition Monitoring. The full report can be accessed from the online posting of this article at www.nutrition.org.

³ Abbreviations used: ARS, Agricultural Research Service; ASNS, American Society for Nutritional Sciences; CSFII, Continuing Survey of Food Intakes by Individuals; HHS, Health and Human Services; NCHS, National Center for Health Statistics; NHANES, National Health and Nutrition Examination Survey; NNMRRA, Nutrition Monitoring and Related Research Act; NNMRRP, National Nutrition Monitoring and Related Research Program.

Manuscript received 24 September 2002. Revision accepted 24 September 2002.

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