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Iowa State University, Ames, IA 50011
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ABSTRACT |
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 TOP ABSTRACT Uses of NNMRRP dietary...Future uses in policy...LITERATURE CITED |
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KEY WORDS: • nutrition monitoring • surveys • dietary intake • nutritional status • population surveillance
What we have come to know as the National Nutrition Monitoring and Related Research Program (NNMRRP)3 arose from Congressional concern about a lack of information about the occurrence of two diet-related problems in Americans: undernutrition and its effects on health (particularly children’s health) and diet as a risk factor for chronic diseases. That concern was also evident over two decades earlier when Congress established the Senate Select Committee on Nutrition and Human Needs, which focused national attention on the existence of hunger and malnutrition in the United States during the1970s as well as the growing body of scientific evidence linking diet to heart disease, some cancers and other degenerative diseases of aging. The U.S. Department of Agriculture (USDA) had conducted surveys on household food use since the 1930s and had added a survey of individual food intakes to that survey in 1965–1966. The U.S. Department of Health and Human Services had begun a National Health Examination Survey in 1960 but did not collect information on dietary intake or nutritional status (other than anthropometry). When federal officials could not provide Congress with information about the prevalence of undernutrition and related conditions, the Ten State Nutrition Survey was undertaken. Subsequently, nutritional assessment was incorporated into the national health survey and it was renamed the National Health and Nutrition Examination Survey (NHANES), the first of which was conducted in 1971–1974 (1
).
Congress maintained close oversight of the nutrition monitoring program through the 1980s. In 1990, frustrated by the lack of attention given to the program by the executive branch, Congress passed the Nutrition Monitoring and Related Research Act. The law required the agencies to develop a 10-y plan to guide their cross-departmental planning and budgetary decisions for the surveys and surveillance activities known as "nutrition monitoring": food supply determinations, household and individual dietary surveys, nutritional and health status assessments and related research programs. It was intended to strengthen food and nutrition data collection efforts by requiring better coordination and oversight. It established two standing committees: an external National Nutrition Monitoring Advisory Council and an internal Interagency Board on Nutrition Monitoring and Related Research. The council was intended to get users’ views incorporated into agencies’ planning, and the board was intended to be the place where program management and budget coordination decisions would be made.
Since the 1970s, scientific understanding of the risk factors for chronic disease has improved, the techniques for assessing nutritional status and other biomarkers of disease risk has also improved and computer technology has led to standardized dietary interview techniques and more rapid data analysis. The surveillance and monitoring activities conducted under the NNMRRP incorporated many technological innovations that improved both the quality and the relevance of the information collected. For example, the Agricultural Research Service (ARS) developed a computer-assisted 24-h recall interview that allowed for more standardized interviews with systematic probing for frequently forgotten food items coupled to computer coding of foods that reduced data processing time and also reduced coding errors. The National Center for Health Statistics of the Centers for Disease Control and Prevention (CDC) performed more analyses for nutrition-related factors per unit of blood drawn from survey participants because of the development of sensitive microtesting procedures and these also were automated. Continued concern about food insecurity and its effects on health led CDC and ARS to develop new questionnaires to assess household food insecurity.
Congressional appropriations and executive branch decisions about budget priorities have been the major determinants of the scope and number of nutrition monitoring surveys and surveillance activities fielded and therefore the information available for policy and research uses. In retrospect, the budgets of CDC and ARS did not expand during the 1990s to accommodate the costs of conducting the activities that the agencies had pledged to undertake in the 10-y plan required by the National Nutrition Monitoring and Related Research Act. Indeed, despite the agencies’ careful plan, neither the president’s budget requests nor the congressional appropriations were sufficient to cover the costs of maintaining the major surveys or to provide for new programs such as the grants to states or the competitive grants program for analysis of survey data (2
,3
). By the end of the decade it became clear that CDC and ARS would not be able to continue to conduct separate dietary intake surveys and the continuing discussions of how to coordinate the survey methodology to get more comparable information turned to discussions of how to integrate into one survey to meet the most pressing policy needs.
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Uses of NNMRRP dietary data |
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TOPABSTRACTUses of NNMRRP dietary...Future uses in policy...LITERATURE CITED |
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). The federal agencies use the surveys for public policy purposes as well as for research. Companies with interests in food and nutrition products have used the survey data for understanding consumer trends, product development and justifying label and advertising claims. Academic scientists use the surveys for epidemiological research. Public policy.
The data from surveys conducted under the NNMRRP have proved to be extremely informative for policy development as well as evaluation. The public policy uses fall into three broad categories:
Monitoring and surveillance. When developing policy options, it is important to know how the population compares with norms. Knowing what proportion of the child population is below the desirable height for age or weight for height indicates the prevalence of stunting or wasting and can be used to develop intervention programs. Surveys in which blood specimens are obtained can determine the prevalence of hypercholesterolemia in subpopulations and help to inform educational intervention programs. Similarly, measurements of iron status (e.g., hemoglobin, hematocrit, serum ferritin) can be used to determine the prevalence of iron deficiency anemia and to inform decisions about iron fortification policies. Monitoring and surveillance data are used to assess and evaluate progress in meeting the goals of government-sponsored intervention programs. For example, the dietary surveys are used to assess which segments of the population are eating five fruits and vegetables daily to meet the goal of the 5-A-Day program sponsored by the National Cancer Institute.
Regulation. When developing regulations to implement statutory requirements, regulatory agencies frequently turn to the NNMRRP surveys for data to evaluate exposure to toxic substances in food, and to identify the distribution of exposures within the population. The Environmental Protection Agency (EPA) has been using dietary data in its pesticide risk assessments that form the basis for regulatory decisions. The U.S. Food and Drug Administration (FDA) relied on both dietary and health examination data in its reviews of the need for changes in enrichment and fortification for iron and folate. The FDA also relied on dietary surveys to provide data undergirding its regulation on the Nutrition Facts food label.
Nutrition-related programs. The Food and Nutrition Service uses the NNMRRP survey data to identify vulnerable groups and to evaluate its programs. For example, changes in requirements for the school lunch program designed to provide more health-promoting meals containing lower fat levels and more fruits and vegetables relied in part on observations from NNMRRP surveys.
Population norms.
Population norms derived from the NNMRRP surveys have had incredibly pervasive effects because they are so widely adopted and used in many different settings for many different purposes. Pediatricians and parents use CDC’s child growth charts to follow children’s progress and to identify growth abnormalities. The child growth charts were also adopted by the World Health Organization and distributed worldwide. Data derived from tests of hematological, biochemical and other indicators of nutritional status are used to derive population norms that are used for assessing iron, zinc and folate status. The recently revised Dietary Reference Intakes published by the Food and Nutrition Board also rely on dietary and nutritional status assessment data from the NNMRRP surveys.
Research uses.
Researchers in academic institutions, government laboratories and private industry are making increasing use of data from the NNMRRP surveys. Their research includes cross-sectional and longitudinal studies of dietary and nutritional status, health status, disease morbidity and mortality. Some researchers are concerned about the effects of policies (e.g., welfare reform or changes in food stamp regulations) on food and nutrient intake. Others may be concerned about identifying the attributes of populations with specific dietary patterns (e.g., Who eats fish?) and associations with disease morbidity or mortality. Dietary patterns of specific populations (e.g., program participants vs. nonparticipants, people with hypercholesterolemics vs. normal cholesterol) may be explored. The availability of dietary and nutritional status measurements that are comparable from one survey to the next permits research on trends over time. The availability of household demographic data (e.g., income, education, government program participation) permits studies of household food behaviors and economic and socioeconomic factors related to food demand and consumption. Starting from the survey observations, models can be developed to study the effects of different options on intakes and health status of population subgroups (e.g., predicting the effects of folic acid fortification of different foods on the intakes serum folate levels of women of childbearing age).
Public policy effects.
It would be desirable to have some way to quantify the public policy contributions made by the NNMRRP. Recently, a working group assembled by the American Society of Nutritional Sciences attempted to do so by counting the regulations referencing data from the NNMRRP and published over the past 5 y in the Federal Register. They found 8 final rules and 89 proposed rules over 5 y, some of which were considered major rules having more than a $100 million impact. Examples of these major rules included EPA rules regarding pesticides in food and water that rely on the dietary exposure evaluation model and the Food Safety and Inspection Service rule on nutrition labeling of chopped meat and poultry products.
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Future uses in policy development |
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TOPABSTRACTUses of NNMRRP dietary...Future uses in policy...LITERATURE CITED |
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In conclusion, it is ironic that as valuable as the national health and nutrition surveys are for Federal program and policy decisions, they were starved for funding at the same time that the National Institutes of Health experienced a doubling in its congressional appropriation. Because the country has lapsed from budget surplus to projections of severe budget deficits in less than a year, it is likely that CDC and ARS will continue to face severe budget pressures that will prevent them from funding the nutrition surveys of the NNMRRP at the levels needed to fulfill the 10-y plan.
The surveys and surveillance activities conducted under the NNMRRP have proved to be incalculably valuable for policy purposes and they are increasingly recognized by the scientific community as unique research opportunities. Because budget stringencies are now forcing the merger of the Continuing Survey of Food Intakes by Individuals (CSFII) into NHANES, it is extremely important that the resulting survey, the integrated CSFII/NHANES, be designed in a way that will maximize its utility for users in government, academia and the private sector. The data are essential for sound food and nutrition policy. This is a critical point in time for food and nutrition policies because decisions about the integrated CSFII/NHANES will guide its future development for quite some time to come.
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FOOTNOTES |
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2 E-mail: agdean{at}iastate.edu
3 Abbreviations used: ARS, Agricultural Research Service; CDC, Centers for Disease Control and Prevention; CSFII, Continuing Survey of Food Intakes by Individuals; EPA, Environmental Protection Agency; FDA, Food and Drug Administration; FSIS, Food Safety and Inspection Service; NHANES, National Health and Nutrition Examination Survey; NNMRRP, National Nutrition Monitoring and Related Research Program; USDA, U.S. Department of Agriculture.
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LITERATURE CITED |
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TOPABSTRACTUses of NNMRRP dietary...Future uses in policy...LITERATURE CITED |
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1. Porter, D. V. (1991) A National Nutrition Monitoring System: Background and Legislative Mandate. Congressional Research Service Report No. 91-785 1991 SPR Washington, DC.
2. Woteki, C. E., Briefel, R. R., Klein, C. J., Jacques, P. L., Kris-Etherton, P. M., Mares-Perlman, J. A. & Meyers, L. D. (2002) Nutrition monitoring: summary of a statement from an American Society for Nutritional Sciences Working Group. J. Nutr. 132:3782-3783.
3. American Society for Nutritional Sciences Working Group (2002) Nutrition monitoring: a statement from an American Society for Nutritional Sciences Working Group. May be accessed at http://www.asns.org/.
4. Briefel, R. R. (2001) Nutrition monitoring in the United States. Bowman, B. A. Russell, R. M. eds. Present Knowledge in Nutrition 2001:617-635 ILSI Press Washington, DC. .
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