Executive Summary

Prepared by the Life Sciences Research Office,

Federation of American Societies for Experimental Biology

Interagency Board for Nutrition Monitoring and Related Research

3RNM EXEC 1 12/11/95, 9:49 AM
Third Report on Nutrition Monitoring 

in the United States

Executive Summary

Prepared by the Life Sciences Research Office, 

Federation of American Societies for Experimental Biology

Interagency Board for Nutrition Monitoring and Related Research
Federation of American Societies for Experimental Biology, Life Sciences Research Office. Prepared

for the Interagency Board for Nutrition Monitoring and Related Research. 1995. Third Report on

Nutrition Monitoring in the United States: Executive Summary. U.S. Government Printing Office,

Washington, DC, 51 pp.

This report was written, edited, and designed by the contractor and was printed directly from the copy

supplied by the contractor.

Copies of this publication and its companion—the complete two-volume report—may be purchased

from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402.

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opportunity employer. 

Issued December 1995
Foreword

This report is the third in a series on nutrition monitoring in the United States. The first report, Nutrition

Monitoring in the United States: A Progress Report from the Joint Nutrition Monitoring Evaluation Committee,

was published in 1986. The second, Nutrition Monitoring in the United States: An Update Report on Nutrition

Monitoring, was published in 1989. The third report reviews the dietary and nutritional status of the U.S.

population, as well as the factors that determine status, based on the data available through the National

Nutrition Monitoring and Related Research Program (NNMRRP) by June 1994.

The NNMRRP includes surveys, surveillance systems, and other monitoring activities that provide information

about the dietary, nutritional, and nutrition-related health status of Americans; the relationship between diet and

health; and the factors that influence dietary and nutritional status. The program was established by the U.S.

Congress in the National Nutrition Monitoring and Related Research Act of 1990 (Public Law 101-445). The

act specified that the U.S. Department of Health and Human Services (HHS) and the U.S. Department of

Agriculture (USDA) jointly implement and coordinate the activities of the NNMRRP. The legislation further

specified that the agencies “contract with a scientific body, such as the National Academy of Sciences or the

Federation of American Societies for Experimental Biology, to interpret available data analyses, and publish . . .

a report on the dietary, nutritional, and health-related status of the people of the United States and the nutritional

quality (including the nutritive and nonnutritive content) of food consumed in the United States . . . at least once

every five years. ”

The third report on nutrition monitoring was developed at the request of USDA and HHS in accordance with the

provisions of a joint contract, No. USDA 53-3K06-5-020, with the Federation of American Societies for

Experimental Biology (FASEB). The report was prepared by the Federation’s Life Sciences Research Office

(LSRO), The report was drafted and edited by Sue Ann Anderson, Ph.D., R.D., Associate Director, and Janet H.

Waters, M.S., R.D., Staff Scientist, LSRO, FASEB, with the assistance of Expert Consultants, scientists who

were chosen by FASEB for their qualifications, experience, and judgment, with due consideration for balance

and breadth in appropriate disciplines. The Expert Consultants examined and reviewed data, suggested

interpretations, and reviewed and edited drafts of the report during its preparation. LSRO extends its

appreciation to the Expert Consultants, whose expertise, insights, and encouragement were invaluable in the

preparation of this report.

The LSRO staff and Co-Project Officers met with the Expert Consultants between December 1993 and

March 1995 to obtain background information on the NNMRRP, to review analyses of NNMRRP data prepared

for this report, and to review drafts of the report. The Expert Consultants reviewed each draft of the report and

provided additional documentation of conclusions and viewpoints to incorporate into the report; however, the

participation of these individuals in the project does not imply that each Expert Consultant specifically endorses

all statements in the report.

The efforts of the Expert Consultants were augmented by contributions from two Special Consultants-George

H. Beaton, Ph.D., University of Toronto, Toronto, Ontario, Canada and Barbara A. Underwood, Ph.D., World

Health Organization, Geneva, Switzerland. LSRO also thanks these individuals for their assistance. Similarly,

listing of individuals as Special Consultants does not imply that they necessarily agree with interpretations and

conclusions in the report.

. . .

111
iv

The contractual activities were overseen and assistance was provided to LSRO and its Expert Consultants by a

Steering Committee, consisting of representatives of Federal agencies submitting data for this report. The

Committee provided oversight for the report on behalf of the Interagency Board for Nutrition Monitoring and

Related Research (IBNMRR). Members of the IBNMRR and the Steering Committee reviewed drafts of the report

for technical accuracy. Members of the National Nutrition Monitoring Advisory Council provided input to the

format and also reviewed selected drafts. The cooperation and the careful, conscientious reviews provided by these

groups were essential to the successful completion of this project. LSRO accepts responsibility for the study

conclusions and the accuracy of the report. 

Expert Consultants and LSRO staff who participated in the project are listed below. 

Expert Consultants

Oral Capps, Jr., Ph.D. Kiang Liu, Ph.D.

Department of Agricultural Economics Department of Preventive Medicine

Texas A&M University Northwestern University Medical School

College Station, Texas Chicago, Illinois

Barbara Dennis, Ph.D., R.D. Aviva Must, Ph.D.

Department of Nutrition Department of Community Health

School of Public Health Tufts University School of Medicine

University of North Carolina Boston, Massachusetts 

Chapel Hill, North Carolina 

Kathryn Dewey, Ph.D. Consumer Sciences Department

Department of Nutrition University of California

University of California Davis, California

Davis, California

William H. Dietz, Jr., M.D., Ph.D. Department of Biochemistry

Department of Clinical Nutrition and Anaerobic Microbiology

New England Medical Center Hospitals Virginia Polytechnic Institute

Boston, Massachusetts and State University 

Marie Fanelli Kuczmarski, Ph.D., R.D.

Department of Nutrition and Dietetics

University of Delaware

Newark, Delaware

Howard G. Schutz, Ph.D.

Kent Stewart, Ph.D.

Blacksburg, Virginia
Life Sciences Research Office Staff

Marvin Snyder, Ph.D.

Director

Sue Ann Anderson, Ph.D., R.D.

Associate Director

Cynthia Allen, M.A.

Technical Editor

Kenneth D. Fisher, Ph.D.

Senior Scientific Consultant

J. Elaine Huey

Scientific Literature Specialist

Robin D. Johnson

Administrative Secretary

Coleen Kitaguchi

Administrative Secretary

Carol A. Rilley

Administrator

Donald G. Smith, Ph.D.

Scientific Literature Librarian

E. Theresa Smith

Word Processing System Specialist

Rosemarie Soulen

Administrative Secretary

John M. Talbot, M.D.

Senior Medical Consultant

Janet H. Waters, M.S., R.D.

Staff Scientist

Jeri L. Welch

Administrative Assistant

Daniel J. Raiten, Ph.D.

Senior Staff Scientist

The final report was reviewed and approved by the LSRO Advisory Committee (which consists of

representatives of each constituent society of FASEB) under authority delegated by the Executive Committee of

the Federation Board. Upon completion of these review procedures, the report was approved and transmitted to

USDA and HHS by the Executive Director, FASEB.

Although this is a report of the Federation of American Societies for Experimental Biology, it does not

necessarily reflect the opinion of each individual member of the FASEB constituent Societies.

Marvin Snyder, Ph.D.

Director

Life Sciences Research Office
vii

Table of Contents for Executive Summary

Foreword .............................................................................. iii

List of tables and figures .................................................................. ix

Preface ................................................................................ xi

Overview of findings .................................................................... xii

Introduction ......................................................................... ES-1

Major Themes and Findings ............................................................ ES-1

Nutrition-related health status ...................................................... ES-1

Dietary status ................................................................. ES-14

Concerns for low-income, high-risk populations ....................................... ES-21

Assessments ........................................................................ ES-23

Current public health issues ....................................................... ES-24

Potential public health issues for which further study is required .......................... ES-26

Not current public health issues .................................................... ES-29

Recommendations for future monitoring and research activities ........................... ES-30

Recommendations for the National Nutrition Monitoring and Related Research Program ........ ES-30

General ...................................................................... ES-33

National food supply determinations and household-based food expenditures ................ ES-34

Food composition and nutrient data bases ............................................ ES-34

Food consumption and nutrient intakes .............................................. ES-35

Nutritional status and nutrition-related health status .................................... ES-35

Knowledge, attitudes, and behavior assessments ....................................... ES-35

Selected references .................................................................. ES-36

Figure notes ........................................................................ ES-37

Acronyms and abbreviations .......................................................... ES-38
ix

List of tables and figures

Figure ES-1. Relationship of food to health, highlighting the NNMRRP's 

major components ..................................................................... ES-2

Figure ES-2. Age-adjusted percentage of males 20-74 years of age with desirable, 

borderline-high-risk, and high serum total cholesterol levels, 1960-62, 1971-74, 

1976-80, and 1988-91 .................................................................. ES-3

Figure ES-3. Age-adjusted percentage of females 20-74 years of age with desirable, 

borderline-high-risk, and high serum total cholesterol levels, 1960-62, 1971-74, 

1976-80, and 1988-91 .................................................................. ES-3

Table ES-1. Percentage of people with total fat intake 30% of calories, >30% and 

40% of calories, and >40% of calories during 3 days, by age, race, income level, 

Food Stamp Program (FSP) participation, and sex, 1989-91 (%) .................................. ES-4

Figure ES-4. Age-adjusted percentage of people 20-74 years of age who are overweight 

(high BMI), by sex and race, 1960-62, 1971-74, 1976-80, and 1988-91 ............................ ES-5

Figure ES-5. Percentage of children and adolescents 2-19 years of age who have high weight 

for height (2-5 years of age) or are overweight (6-19 years of age), by age and sex, 1971-74, 

1976-80, 1988-91 ...................................................................... ES-5

Figure ES-6. Prevalence of physical activity among people 20 years of age and older and 

percentage meeting the Healthy People 2000 (HP2000) objective for vigorous physical 

activity, by sex, 1992 ................................................................... ES-6

Figure ES-7. Frequency of participation in vigorous physical activity over the past 14 days 

among high school students, by sex and race/ethnicity, 1990 ..................................... ES-6

Figure ES-8. Self-perceived overweight: percentage of overweight people 20 years 

of age and older who think they are overweight, by age, sex, and race/ethnicity, 1988-91 .............. ES-7

Figure ES-9. Self-perceived overweight: percentage of people 20 years of age 

and older who think they are overweight but are not overweight, by age, sex, and 

race/ethnicity, 1988-91 ................................................................. ES-8

Figure ES-10. Percentage of people 20 years of age and older who have tried to lose 

weight during the past 12 months, by age, sex, and race/ethnicity, 1988-91 ......................... ES-8
x

Figure ES-11. Age-adjusted percentage of people 20-74 years of age who have hypertension, 

by sex and race, 1960-62, 1971-74, 1976-80, 1988-91 .......................................... ES-9

Table ES-2. Percentage of people 20 years of age and older who have hypertension, by sex, 

age, and race/ethnicity, 1988-91 .......................................................... ES-10

Table ES-3. Prevalence of breastfeeding among mothers 15-44 years of age and proportion 

of their babies who were breastfed for 4 or more months, by year of baby's birth and selected

characteristics of the mothers, 1978-80 and 1984-86 (%) ....................................... ES-12

Table ES-4. Prevalence of shortness, thinness, high weight for recumbent length, high weight

for height, and overweight in children and adolescents in the U.S. population, by age and sex,

1988-91 (%) ......................................................................... ES-13

Figure ES-12. Percent distribution of daily servings of fruits and vegetables consumed by people 

18 years of age and older, by age and sex, 1991 .............................................. ES-15

Figure ES-13. Annual per capita consumption of meat, poultry, and fish and shellfish, 

by year, 1972-92 ...................................................................... ES-16

Figure ES-14. Annual per capita consumption of milk, yogurt, and cheese, by year, 1972-92 ........... ES-16

Figure ES-15. Annual per capita consumption of selected nonalcoholic beverages, by year, 1972-92 ..... ES-17

Table ES-5. Prevalence of a reported family food-sufficiency problem in individuals, 

by race/ethnicity and poverty status, 1988-91 (%) ............................................ ES-19

Table ES-6. Household food sufficiency of the low-income population, by Food Stamp Program (FSP)

participation and race, 1989-91 (%) ....................................................... ES-19

Figure ES-16. Average annual expenditures per person in urban households for frozen prepared 

foods, 1980, 1984, 1988, and 1992 ........................................................ ES-20

Figure ES-17. Percentage of total food expenditures spent on food away from home, 

by race, 1977-78 and 1987-88 ............................................................ ES-20

Figure ES-18. Percentage of total food expenditures spent on food away from home, 

by income quintile, 1977-78 and 1987-88 ................................................... ES-20

Figure ES-19. Low-birth-weight (LBW) prevalence among low-income, high-risk females who 

smoked and did not smoke during pregnancy, by prepregnancy weight, 1992 ....................... ES-22

Figure ES-20. Decision-making process used to categorize food components by monitoring 

priority status ........................................................................ ES-24

Table ES-7. Classification of food components as public health issues in the TRONM ................ ES-25

Table ES-8. Recommendations for further research for nutrition monitoring in the United States ........ ES-31
Preface

The U.S. Congress has defined nutrition monitoring and related research as "the set of

activities necessary to provide timely information about the role and status of factors that

bear on the contribution that nutrition makes to the health of the people of the United States." 

The National Nutrition Monitoring and Related Research Program (NNMRRP) was

established by Congress in the National Nutrition Monitoring and Related Research Act of

1990 (Public Law 101-445). In that legislation, Congress directed the U.S. Department of

Health and Human Services (HHS) and the U.S. Department of Agriculture (USDA) to share

responsibility for implementing the program and to "contract with a scientific body, such as

the National Academy of Sciences or the Federation of American Societies for Experimental

Biology, to interpret available data analyses, and publish . . . a report on the dietary,

nutritional, and health-related status of the people of the United States and the nutritional

quality (including the nutritive and nonnutritive content) of food consumed in the United

States . . . at least once every five years." 

This Third Report on Nutrition Monitoring in the United States (TRONM) was prepared by

the Life Sciences Research Office (LSRO) of the Federation of American Societies for

Experimental Biology (FASEB) under contract with USDA and under the joint leadership of

HHS and USDA. The first report, Nutrition Monitoring in the United States: A Progress

Report from the Joint Nutrition Monitoring Evaluation Committee, written by HHS and

USDA in 1986, and the second report, Nutrition Monitoring in the United States: An Update

Report on Nutrition Monitoring, prepared by LSRO in 1989, summarized nutrition

monitoring information from the National Nutrition Monitoring System, the NNMRRP's

predecessor. Between publication of the second and third reports on nutrition monitoring,

the Interagency Board for Nutrition Monitoring and Related Research (IBNMRR) published

Chartbook I: Selected Findings from the National Nutrition Monitoring and Related

Research Program.

LSRO prepared the TRONM with the assistance of Expert Consultants with specialties in 

dietary intake and food consumption patterns, food composition and analysis, public health

nutrition, community nutrition, clinical nutrition, nutrition monitoring and surveillance

research, behavioral aspects of the interrelationships of nutrition and health, agricultural

economics, and statistics and biostatistics. The data for the TRONM came from surveys and

surveillance systems in the interconnected Federal and State activities that are part of the

NNMRRP. A description of each NNMRRP survey and surveillance system can be found in

Nutrition Monitoring in the United States: The Directory of Federal and State Nutrition

Monitoring Activities, a 1992 report by the IBNMRR. Major components of the NNMRRP

discussed in the TRONM include

 nutritional status and nutrition-related health measurements;

 food and nutrient consumption;

 knowledge, attitudes, and behavior assessments;

 food composition and nutrient data bases; and

 food-supply determinations.

Food components are evaluated and classified as current public health issues, potential

public health issues for which further study is required, or not current public health issues. 

Finally, the report summarizes the recommendations made by the Expert Consultants and

LSRO for strengthening the NNMRRP, based on their experiences with analyzing and

interpreting the data as they prepared the TRONM.
Third Report on Nutrition Monitoring in the United States (1995)1

Overview of Findings

What is the nutrition-related health status of the U.S. population?

Nutritional status is associated with conditions such as overweight, high serum cholesterol levels, hypertension,

and osteoporosis (decreased bone mass). These diet-related conditions increase the risk of certain chronic disease

outcomes, including coronary heart disease, stroke, and bone fracture.

Markedly higher percentages of Americans are overweight now than in the late 1970s. Many adults also

report sedentary life-styles. Because overweight is associated with many chronic diseases and adverse health

outcomes, the increased prevalence of overweight is a cause for public health concern.

Although the proportion of adults who have desirable serum total cholesterol levels is increasing steadily, 

many people still have high levels. High serum cholesterol is a major risk factor for coronary heart disease.

Hypertension remains a major public health problem in middle-aged and elderly people. Non-Hispanic

blacks have a higher age-adjusted prevalence of hypertension than non-Hispanic whites and Mexican

Americans. Hypertension is the most important risk factor for stroke and a major risk factor for coronary

heart disease.

Femoral osteoporosis in females 50 years of age and older in the United States occurs in 21% of non-Hispanic

whites, 10% of non-Hispanic blacks, and 16% of Mexican Americans. Low calcium intake and lack of

weight-bearing exercise, among other factors, contribute to bone loss.

What is the nutritional quality of the U.S. diet?

Americans are slowly changing their eating patterns toward more healthful diets. A considerable gap remains,

however, between public health recommendations and consumers' practices. In particular, intakes of foods that

should be changing—according to the recommendations in the Healthy People 2000 objectives, the Food Guide

Pyramid, and the 1990 Dietary Guidelines for Americans—have not yet reached the targeted goals.

The increase in the prevalence of overweight in the U.S. population since the 1970s indicates that energy

balance remains a problem for many Americans. About one-third of adults and one-fifth of adolescents in the

United States are overweight, suggesting that they have higher energy intakes than expenditures.

Although the intakes of total fat, saturated fatty acids, and cholesterol have decreased, they remain above

recommended levels for a large proportion of the population.

Median sodium intakes from food are higher than recommended values for most Americans 6 years of age

and older. (These intakes excluded salt added at the table.)

Median calcium intakes from food are below recommended values, particularly for adolescents, adult

females, elderly people, and non-Hispanic black males. Many Americans are not getting the calcium they

need to maintain optimal bone health and prevent age-related bone loss.

Median iron intakes from food are below recommended values for children 1-2 years of age, female

adolescents 12-19 years of age, and females 20-59 years of age. The prevalence of anemia is generally higher

in these groups than in other age-sex groups.

Average daily intake of fruits and vegetables for the general population is about 4 servings. Fewer than onethird of American adults meet the recommendation to consume 5 or more servings of fruits and vegetables per

day.

Some Americans are not always getting enough to eat, although the availability of food and nutrients in the

U.S. food supply, on a per capita basis, is generally adequate to prevent undernutrition and deficiency-related

diseases. About 9-13% of people living in low-income households or families experience some degree of

food insufficiency.

Data for this report were provided by the National Nutrition Monitoring and Related Research Program. 1
ES-1

Executive Summary

Introduction

The United States has the most sophisticated national

nutrition monitoring system in the world. The system

can be used to examine food and nutrition issues that

are important to the health of Americans (fig. ES-1). 

This executive summary highlights the major themes

and findings of the latest comprehensive report of

information from the monitoring system—the Third

Report on Nutrition Monitoring in the United States

(TRONM) (see preface). The report is based on data

gathered by the National Nutrition Monitoring and

Related Research Program (NNMRRP) since the

second nutrition monitoring report was completed,

giving special emphasis to low-income and high-risk

population subgroups. Focusing on nutrients of

public health concern, the report provides an update

on the dietary, nutritional, and nutrition-related health

status of Americans; the relationships between diet

and health; and the factors that influence dietary and

nutritional status. Readers are referred to the main

report for a detailed presentation of NNMRRP data.

Major themes and findings

The TRONM's major themes and findings are grouped

below into three categories: nutrition-related health

status, dietary status, and concerns for low-income,

high-risk populations.

Nutrition-related health status

Data collected in the NNMRRP surveys and

surveillance systems provide information about the

nutrition-related health status of the U.S. population. 

Nutritional status is associated with conditions such

as overweight, high blood pressure, elevated serum

cholesterol levels, and osteoporosis (decreased bone

mass). These diet-related conditions increase the risk

of certain chronic diseases and health outcomes, such

as coronary heart disease, some types of cancer,

stroke, gallbladder disease, non-insulin-dependent

diabetes, and bone fracture. 

The assessment of nutritional status includes taking

anthropometric body measurements, collecting results

of hematological and biochemical tests, monitoring

clinical signs of nutritional deficiency or excess, and

assessing dietary intake. Anthropometric body

measurements are used to assess low birth weight and

growth parameters in children as well as overweight

in the general population. Biochemical and

hematological measures, such as concentrations of

hemoglobin and serum vitamin A, are used in

conjunction with dietary intake data to assess

conditions such as iron-deficiency anemia and

vitamin A status in the population and in high-risk

subgroups, such as young children and pregnant

women. Major findings on nutrition-related health

status are highlighted below.

Lipids and health

Americans are decreasing their high serum

cholesterol levels. High serum cholesterol is a major

risk factor for coronary heart disease. Lower dietary

intakes of total fat and cholesterol contribute to

reduced serum cholesterol levels.

Between 1960 and 1991, the proportion of adults

aged 20-74 years who had high serum total

cholesterol levels decreased steadily. Likewise, the

proportion of adults who had desirable serum total

cholesterol levels increased (figs. ES-2 and ES-3).

Over the same time period, the proportion of black

and white females 20-74 years of age with high

serum total cholesterol was higher than that of their

male counterparts.

Percent

High serum cholesterol ( 240 mg/dL)

Borderline-high serum cholesterol (200-239 mg/dL)

Desirable serum cholesterol (<200 mg/dL)

NHES I NHANES I NHANES II NHANES III

0

10

20

30

40

50

60

70

80

90

100

1960-62 1971-74 1976-80 1988-91

Percent

High serum cholesterol ( 240 mg/dL)

Borderline-high serum cholesterol (200-239 mg/dL)

Desirable serum cholesterol (<200 mg/dL)

NHES I NHANES I NHANES II NHANES III 0

10

20

30

40

50

60

70

80

90

100

1960-62 1971-74 1976-80 1988-91

ES-3

Figure ES-2. Age-adjusted percentage of males

20-74 years of age with desirable, borderline-highrisk, and high serum total cholesterol levels, 1960-62,

1971-74, 1976-80, and 1988-91

SOURCE: HHS, NHES I, 1960-62; NHANES I, 1971-74;

NHANES II, 1976-80; NHANES III, 1988-91.

Figure ES-3. Age-adjusted percentage of females

20-74 years of age with desirable, borderline-highrisk, and high serum total cholesterol levels, 1960-62,

1971-74, 1976-80, and 1988-91

SOURCE: HHS, NHES I, 1960-62; NHANES I, 1971-74;

NHANES II, 1976-80; NHANES III, 1988-91.

Concurrently, intakes of total fat have decreased Median cholesterol intakes were generally within

slightly for adults and intakes of saturated fatty the recommended range (<300 mg/d), except 

acids have stayed about the same or decreased among non-Hispanic black and Mexican-American

slightly. In 1988-91, median total fat intake as a males 16-59 years of age.

percentage of calories was about 34%, down from

about 36% in 1976-80. In 1988-91, median Most people who were told that their serum

saturated fatty acid intake as a percentage of cholesterol level was high report that they are

calories was 12-13%, compared with the 13% found following a health professional's advice to lower it. 

in 1976-80. However, only about one-half of U.S. adults in

Intakes of total fat and saturated fatty acids remain cholesterol level checked. 

above recommended levels for a large proportion of

the population. Of those who were told that their serum cholesterol

Fewer than 20% of children 6-11 years of age and other health professional to change their diet,

of adolescents and only 21% of adult males and 54% were told to exercise, 47% were told to lose

25% of adult females consumed diets containing weight, and 20% were told to take medications to

recommended levels of total fat ( 30% of calories) lower their high serum cholesterol level.

in 1989-91 (table ES-1).

Median intakes of total fat and saturated fatty acids 89% said that they were currently following the

(as percentages of calories) were similar for males advice; of people told to lose weight, exercise,

and females of different racial/ethnic groups but and/or take medications, more than 70% said that

tended to be somewhat lower in older than younger they were currently following the advice given.

adults. 

1988-91 reported that they had ever had their serum

level was high, 85% were told by a physician or

Of people who were told to change their diet,
ES-4

Table ES-1. Percentage of people with total fat intake 30% of calories, >30% and 40% of calories, and >40%

of calories during 3 days, by age, race, income level, Food Stamp Program (FSP) participation, and sex, 1989-91 (%)

30% >30% and 40% >40% 1

Age in years, race, income level,

and FSP participation Male Female Male Female Male Female

Age

6-11 18.2 17.7 64.2 66.9 17.6 15.4

12-19 14.0 17.9 67.5 61.1 18.6 21.0

20 20.9 25.2 53.8 53.6 25.3 21.1

Race, 20 years

White 20.6 25.3 53.1 53.7 26.3 21.0

Black 17.0 21.3 62.5 55.5 20.5 23.3

Income level, 20 years

<131% poverty 21.7 25.9 50.9 53.0 27.4 21.2

131-350% poverty 18.2 26.0 56.0 54.7 25.8 19.3

>350% poverty 22.3 23.6 52.0 53.4 25.7 23.0

FSP participation, 20 years

Participant 21.5 23.5 48.6 52.7 30.0 23.8

Nonparticipant 21.8 26.9 51.5 53.1 26.7 20.0

Recommended intake. 1

SOURCE: USDA, CSFII, 1989-91.

Despite widespread nutrition education efforts, many relationship between dietary "fat" and "saturated

consumers still do not know enough about dietary fats fat" and health.

and cholesterol to make food choices that are consistent

with dietary recommendations. Eighty-seven percent of female main meal planners

Only 26% of U.S. adults in 1990 knew that problems related to cholesterol intake, 80% said

"saturated fats" and "polyunsaturated fats" were that they were aware of health problems related to

similar in their caloric values or that fats and oils "fat" intake, and 65% said that they were aware of

become more saturated when they are health problems related to "saturated fat" intake.

hydrogenated, 36% knew that "polyunsaturated 

fats" were more likely to be liquid than solid, and In general, female main meal planners and 

54% knew that cholesterol was not the same thing preparers who were white, middle-aged, more

as "saturated fats" or "polyunsaturated fats." educated, and from higher income levels were more

(Quotation marks denote actual terms used in aware of relationships between health and intake of

questionnaires.) "fat," "saturated fat," and cholesterol than were

Only 32% knew that cholesterol is found only in 60 years of age and older, less educated, and from

animal products, and 69% knew that "saturated lower income levels.

fats" are usually found in animal products.

About 60% were aware that "saturated fats" are track the progress toward achieving the U.S. 

more likely to raise "blood" cholesterol levels than Department of Health and Human Services' (HHS's)

are "polyunsaturated fats." Healthy People 2000 objectives for dietary "fat and

More people are aware of the relationship between calories from total fat and saturated fatty acids have

dietary cholesterol and health than of the decreased slightly over time, additional progress is 

and preparers said that they were aware of health

those who were black, less than 40 years of age or

Data from the NNMRRP have made it possible to 

saturated fat" intake. Although the percentages of
Percent

 

White Black White Black 

0

20

40

60

80

100 NHES I

NHANES I

NHANES II

NHANES III

Male Female

Sex and race

Percent

 

2-5 6-11 12-19 2-5 6-11 12-19 

0

5

10

15

20

25 NHANES I

NHANES II

NHANES III

Male Female

Age in years and sex

ES-5

Figure ES-4. Age-adjusted percentage of people 20-

74 years of age who are overweight (high BMI), by

sex and race, 1960-62, 1971-74, 1976-80, and 1988-

91

SOURCE: HHS, NHES I, 1960-62; NHANES I, 1971-74;

NHANES II, 1976-80; NHANES III, 1988-91.

Figure ES-5. Percentage of children and

adolescents 2-19 years of age who have high weight

for height (2-5 years of age) or are overweight (6-19

years of age), by age and sex, 1971-74, 1976-80,

and 1988-91

SOURCE: HHS, NHANES I, 1971-74; NHANES II,

1976-80; NHANES III, 1988-91.

needed to meet population targets set in Healthy The prevalence of overweight also increased in

People 2000 Objective 2.5: to reduce dietary fat children and adolescents between 1971 and 1991,

intake to an average of 30% of calories or less and regardless of the criteria used to define overweight. 

average saturated fatty acid intake to less than 10% In two analyses of data from the third National

of calories. Health and Nutrition Examination Survey

Overweight used to define overweight. (BMI is a ratio relating

Markedly higher percentages of American adults, weight in kilograms by the square of height in

adolescents, and children are overweight now than meters.) On the basis of cutoff values associated

in 1976-80. Because overweight is associated with with the 95th percentiles in the first NHANES

many chronic diseases and adverse health outcomes, (NHANES I 1971-74), the prevalence of

the increased prevalence of overweight is a cause overweight was 9% for males and 13% for females

for public health concern. 6-11 years of age, and about 10% for adolescent

The age-adjusted prevalence of overweight for adult of age (fig. ES-5). When the BMI cutoff values

males and white females increased from about 25% corresponding to the 85th percentiles from the

between 1960 and 1980 to 33% in 1988-91. The second NHANES (NHANES II 1976-80) were

major portion of the change appeared to occur used, the prevalence of overweight in 1988-91 was

between 1976-80 and 1988-91. Over the entire 20% for adolescent males and 22% for adolescent

time span, the prevalence of overweight was higher females 12-19 years of age. In 1976-80, 15% of

for black adult females (42-44% between 1960 and adolescents were overweight. This definition was

1980 and 49% in 1988-91) than for any other group used for tracking Healthy People 2000 Objective

(fig. ES-4). 2.3, which specifies that the prevalence of 

(NHANES III 1988-91), body mass index (BMI)

above certain age- and sex-specific percentiles was

body weight to height. It is calculated by dividing

males and 9% for adolescent females 12-19 years
Percent

 

None Irregular Regular Meets HP2000 0

10

20

30

40

50 Male

Female

Objective 1.4

Percent

 

None 1-2 3-5 6-8 9 None 1-2 3-5 6-8 9

0

10

20

30

40

50 Non-Hispanic white

Non-Hispanic black

Hispanic

Other (non-Hispanic)

Sex and number of days

Male Female

ES-6

Figure ES-6. Prevalence of physical activity among

people 20 years of age and older and percentage

meeting the Healthy People 2000 (HP2000) objective

for vigorous physical activity, by sex, 1992

SOURCE: HHS, BRFSS, 1992.

Figure ES-7. Frequency of participation in vigorous physical activity over the past 14 days among high school

students, by sex and race/ethnicity, 1990

SOURCE: HHS, YRBS, 1990.

overweight in adolescents 12-19 years of age be no Hispanic females, 22% of non-Hispanic white

more than 15%. (See also "Maternal and Child females, and nearly 40% of females of other

Health and Nutrition" and "Concerns for Low- races/ethnicities (non-Hispanic) reported no

Income, High-Risk Populations," below.) vigorous physical activity in the past 14 days. 

The prevalence of overweight has increased

considerably despite only small changes in reported

food energy intakes. However, reported food 

energy intakes were not above recommended 

values. Overweight is caused by energy imbalance

(food energy intake in excess of energy

expenditure). More than half of adults have a

sedentary life-style. Fewer than one-third

participate in regular physical activity (fig. ES-6). 

These observations, along with data from

experimental and clinical studies and other surveys,

suggest that 1) recommended food energy intakes

are too high in relation to physical activity,

2) underreporting occurs when some people report

their food consumption, and/or 3) levels of physical

activity are low. 

Among students in grades 9-12 in 1990, nonHispanic white and Hispanic males were more 

likely than non-Hispanic black males and males of

other races/ethnicities (non-Hispanic) to report that

they did not participate in any vigorous physical

activity in the past 14 days (fig. ES-7). Nearly 

40% of non-Hispanic black females, 29% of
Percent

 

20-39 40-59 60 20-39 40-59 60

0

20

40

60

80

100 Non-Hispanic white

Non-Hispanic black

Mexican American

Male Female

* * *

Age in years and sex

ES-7

Figure ES-8. Self-perceived overweight: percentage of overweight people 20 years of age and older who think they

are overweight, by age, sex, and race/ethnicity, 1988-91

SOURCE: HHS, NHANES III, 1988-91.

Disturbingly lower levels of vigorous activity were The reasons for the sharp increase in the prevalence

noted with each subsequent year of high school, of overweight since 1976-80 are not clear. Ageespecially in females. adjusted prevalence of overweight for adults was

People often did not perceive their body weight surveys collected during this time period suggests

status correctly (figs. ES-8 and ES-9). Regardless that energy intakes exceed energy expenditures,

of weight status, the proportion of non-Hispanic probably because of low levels of physical activity.

white females 20 years of age and older who

considered themselves overweight was higher than The goal of Healthy People 2000 Objective 1.4 is to

that of females in other racial/ethnic groups in increase to at least 20% the proportion of people

1988-91. Body weight was less of a concern for aged18 years and older—and to at least 75% the

non-Hispanic black adolescent females than it was proportion of children and adolescents aged

for female adolescents of other racial/ethnic 6-17 years—who engage in vigorous physical activity

backgrounds. Among a military population of that promotes the development and maintenance of

enlisted female trainees surveyed in 1993, a fairly cardiorespiratory fitness 3 or more days per week for

high percentage (29%) of relatively lean women 20 or more minutes per occasion. In 1992, only 13% 

perceived themselves as overweight. of male and 16% of female adults reported physical

On average, 30% of males and 53% of females in objective (fig. ES-6). In 1990, 36% of male and 

1988-91 reported that they had tried to lose weight 15% of female high school students, on average,

in the past 12 months (fig. ES-10). Dieting and reported that they exercised vigorously for 20 or more

exercise were the weight-loss practices most minutes on 9 or more days in the past 14 days. 

frequently reported by people 18 years of age and

older. Women were more likely than men to cite The goal of Healthy People 2000 Objective 1.5 is to

use of vitamins, meal replacements, or over-the- reduce to no more than 15% the proportion of people 

counter products for weight loss and to participate 6 years of age and older who engage in no leisurein organized weight-loss programs. time physical activity. In 1992, 27% of male and 

33% in 1988-91. Evidence from several NNMRRP

activities or exercise vigorous enough to meet this

31% of female adults surveyed said that they did not 
Percent

 

20-39 40-59 60 20-39 40-59 60 

0

20

40

60

80

100 Non-Hispanic white

Non-Hispanic black

Mexican American

Male Female

Age in years and sex

Percent

 

20-29 30-39 40-49 50-59 60-69 70-79 80 20-29 30-39 40-49 50-59 60-69 70-79 80 

0

20

40

60

80

100 Non-Hispanic white

Non-Hispanic black

Mexican American

Age in years and sex

Male Female

*

*

**

ES-8

Figure ES-9. Self-perceived overweight: percentage of people 20 years of age and older who think they are

overweight but are not overweight, by age, sex, and race/ethnicity, 1988-91

SOURCE: HHS, NHANES III, 1988-91.

Figure ES-10. Percentage of people 20 years of age and older who have tried to lose weight during the past

12 months, by age, sex, and race/ethnicity, 1988-91

SOURCE: HHS, NHANES III, 1988-91.
Percent

 

White Black White Black 

0

20

40

60

80

100 NHES I

NHANES I

NHANES II

NHANES III

Male Female

Sex and race

ES-9

Figure ES-11. Age-adjusted percentage of people

20-74 years of age who have hypertension, by sex

and race, 1960-62, 1971-74, 1976-80, and 1988-91

SOURCE: HHS, NHES I, 1960-62; NHANES I, 1971-74;

NHANES II, 1976-80; NHANES III, 1988-91.

participate in any physical activity in the past month. 

The goal of Healthy People 2000 Objective 1.3 is to

increase to at least 30% the proportion of people 

6 years of age and older who engage regularly,

preferably daily, in light to moderate physical activity

for at least 30 minutes per day. In 1992, 30% of 

male and 27% of female adults reported that they

participated in regular physical activity (fig. ES-6). 

Judging by the trends observed, Americans will not

attain Healthy People 2000 Objective 2.3—to reduce 

the prevalence of overweight in adults to no more 

than 20% and in adolescents, to no more than 

15%—by the year 2000. Increases in overweight are

likely to increase health-care costs. Similarly, current

levels of physical activity make it unlikely that 

Healthy People 2000 objectives related to activity 

(1.3, 1.4, and 1.5) will be achieved. It is unlikely 

that the prevalence of overweight will decrease 

without making substantial progress toward meeting 

the Healthy People 2000 physical-activity objectives.

Hypertension

Although the prevalence of hypertension has contribution cannot be determined. Some of the

decreased since 1960, hypertension remains a public decrease has been attributed to primary prevention,

health problem. As many as 50 million Americans such as following advice from health-care

have elevated blood pressure or take professionals to lower sodium intake, to lose weight 

antihypertensive medications. Epidemiological if overweight, and to increase physical activity.

studies have linked prevalence of hypertension to

dietary intakes of several essential minerals. For Hypertension remains a substantial problem in

example, consistent positive associations have been middle-aged and elderly people (table ES-2). In

shown between higher dietary salt (sodium) intake 1988-91, the overall prevalence of hypertension was

and hypertension. Low calcium and potassium 25% in adults 20 years of age and older. The

intakes have been associated with higher prevalence prevalence of hypertension was higher with each

of hypertension. Inverse associations have been decade of age for both males and females, and it 

reported between serum magnesium and blood was higher for males than for females 20-59 years 

pressure. of age. In older people, the prevalence of

Between 1960 and 1980, the prevalence of females 80 years of age and older had high blood

hypertension remained relatively stable. However, pressure compared with 60% of males in the same

by 1988-91, a striking drop in prevalence was age group.

observed (fig. ES-11). This finding was

unexpected, given the positive association between In 1988-91, median intakes of sodium from food 

overweight and hypertension and the increase in the were above recommended levels, and median

prevalence of overweight in the U.S. population intakes of calcium and potassium from food were

between 1976-80 and 1988-91. The age-adjusted below recommended levels. Sodium intakes were

prevalence of hypertension between 1960 and 1991 similar for non-Hispanic whites, non-Hispanic

was consistently higher in blacks than in whites. blacks, and Mexican Americans. However, median

Procedural differences among the surveys may potassium and calcium intakes were lower for nonaccount for part of the decrease in prevalence seen Hispanic blacks, who are at highest risk for

in recent years, although the extent of their development of hypertension, than for the other two

hypertension was higher in females. About 75% of

groups.
ES-10

Table ES-2. Percentage of people 20 years of age and older who have hypertension, by sex, age, and race/ethnicity,

1988-91 (%)1

Sex and age in years All groups white black American

Non-Hispanic Non-Hispanic Mexican 

Overall population

 Total, crude 25.4 25.8 30.9 15.6

 Total, age-adjusted 25.4 24.5 34.0 23.8

Male

 20-29 5.1 4.3* 8.2 3.3

 30-39 13.0 12.8 20.9 9.3

 40-49 24.4 23.4 36.8 22.4

 50-59 42.2 41.8 55.9 36.0

 60-69 52.1 51.3 63.6 53.8

 70-79 60.7 60.3 68.0 52.1

 80 60.5 60.3 62.4 70.5*

 Total, crude 25.7 26.4 31.6 15.5

 Total, age-adjusted 27.0 26.4 35.3 24.4

Female

 20-29 1.0* 0.8* 2.4* 1.1*

 30-39 6.2 5.0 12.1 6.5

 40-49 14.4 12.7 30.5 10.7

 50-59 38.8 36.8 47.9 33.5

 60-69 53.5 50.9 77.8 59.3

 70-79 67.6 66.9 72.6 67.0

 80 74.7 74.3 80.5 71.0

 Total, crude 25.1 25.3 30.2 15.7

 Total, age-adjusted 23.7 22.4 32.6 22.9

Excludes pregnant females. "All groups" includes data for racial/ethnic groups not shown separately. "Hypertension" was defined as mean 1

systolic blood pressure 140 mm Hg, mean diastolic blood pressure 90 mm Hg, or under current treatment for hypertension with a prescription

medication. These values represent the mean of six or fewer blood pressure measurements. An asterisk (*) indicates a statistic that is potentially

unreliable because of small sample size or large coefficient of variation.

SOURCE: HHS, NHANES III, 1988-91.

In 1989-91, 88% of female main meal planners and hypertension were told to lose weight to control

preparers were aware of health problems related to their blood pressure, and about three-quarters of

salt or sodium intake. The proportion of women in these individuals reported that they were complying

this group who were aware of this diet-health with this advice. About 30% were told to increase

relationship was higher among those with higher exercise, stop smoking, restrict alcohol

incomes. A substantial proportion of Americans consumption, reduce stress, and/or change some

appears to be trying to limit salt used at the table; other aspect of their life-style to control their blood

about 58% of males and 68% of females reported pressure; almost two-thirds said that they were

never using salt, using "lite" salt, or rarely using following the advice given.

ordinary table salt.

In 1988-91, most people with diagnosed decrease salt and sodium intake so at least 65% of

hypertension were told by a physician to take home meal preparers prepare food without adding 

medications and/or to change their diet. About salt, at least 80% of people avoid using salt at the 

90% reported that they were complying with advice table, and at least 40% of adults regularly purchase

to change their diet, and 76% reported that they food with modified or lower sodium

were complying with advice to take medications. content—Americans will have to decrease their intake

About half of those who were told they had of salt and sodium. Many people are apparently 

To achieve Healthy People 2000 Objective 2.9—to
ES-11

trying to avoid using salt at the table. However, About 67% of female main meal planners and

because the major portion of dietary sodium is preparers were aware of health problems associated

provided by sodium added to processed foods and with the quantity of calcium consumed. About 

home-, deli-, and restaurant-prepared foods, greater 50% of female main meal planners and preparers

reductions in sodium consumption may be achieved from households with incomes <131% of the

by reducing sodium used to process and prepare Federal Poverty Income guidelines (i.e., low

foods and by encouraging consumers to select incomes) were aware of these associations.

products that are lower in sodium.

Calcium and osteoporosis

Many Americans are not getting the calcium they mothers, and children continue to be causes for 

need to maintain optimal bone health and prevent public health concern.

age-related bone loss. Development of osteopenia

(less-than-optimal bone density) and osteoporosis Data on the dietary intakes of pregnant women in

(decreased bone mass) is associated with loss of bone 1988-91 indicate that mean intakes from food were

mineral, including calcium. Low calcium intake and lower than recommended levels for several key

lack of weight-bearing exercise, among other factors, nutrients (folate, calcium, vitamin B , iron, zinc, 

contribute to bone loss. and magnesium). This is evident across 

Many people, particularly adolescents, adult include vitamin and mineral supplements.)

females, and elderly people across racial/ethnic

groups and non-Hispanic black adult males, The prevalences of breastfeeding among mothers

consumed less than the recommended amount of 15-44 years of age and the proportion of their

calcium from food in 1988-91. Mean calcium babies who were breastfed for 4 or more months

intakes from food in the U.S. population have not were lower among mothers who were black,

changed substantially since 1977-78. younger, or living below the poverty level

In 1988-91, median calcium intakes from foods 55% were breastfed, up from 46% of infants born

were below recommended levels for male and in 1978-80. Although it appears that the overall

female adolescents other than non-Hispanic white prevalence of breastfeeding is increasing slightly

males. Achieving peak bone mass and maintaining over time, it is still below the goals set in Healthy

bone mass appear to be related to adequate calcium People 2000 Objective 2.11, which states that at

intake in adolescence and early adulthood. Because least 75% of mothers breastfeed their babies in the

of the high rates of bone accretion during early postpartum period. It also states that at least

adolescence, continued monitoring of calcium 50% of all mothers breastfeed until their babies are

intake is important. 5-6 months of age. About 30% and 34% of all

In 1988-91, bone density was measured for the first 1984-86, respectively (data not shown). Although 

time in a nationally representative sample of there has been some increase in the percentage of

Americans. Among females 50 years of age and infants who are breastfed, greater emphasis is

older, femoral osteopenia occurred in 39% of non- needed to encourage more mothers to initiate

Hispanic whites, 29% of non-Hispanic blacks, and breastfeeding and to breastfeed longer.

36% of Mexican Americans. Prevalence estimates

for osteoporosis in these three groups were 21%, In 1988-91, the prevalences of shortness and

10%, and 16%, respectively. Significant bone thinness among children and adolescents were about

accretion occurs during adolescence and early 5% or lower, indicating that these conditions did 

adulthood. The low calcium intakes from food by not occur with greater frequency than expected for

many adolescents and adults, particularly females, children and adolescents in the overall population

suggest that many Americans are not getting the (5%) (table ES-4). The prevalence of overweight in

calcium they need to maintain optimal bone health children and adolescents is discussed as a part of 

and prevent age-related bone loss. the findings under "Overweight" (above).

Maternal and child health and nutrition

Diets and nutritional status of pregnant women,

6

racial/ethnic groups. (The intake data did not

(table ES-3). Among infants born in 1984-86,

infants were breastfed for this long in 1978-80 and
ES-12

Table ES-3. Prevalence of breastfeeding among mothers 15-44 years of age and proportion of their babies who were

breastfed for 4 or more months, by year of baby's birth and selected characteristics of the mothers, 1978-80 and

1984-86 (%)1

Ever breastfed Breastfed for 4 months

Characteristics of mother 1978-80 1984-86 1978-80 1984-86

Overall population 46.1 55.0 65.3 61.9

Race

 White 50.3 59.9 65.4 62.6

 Black 22.8 23.4 60.1 50.1

Educational level

 <9 years 26.4* 49.1 52.3

 9-11 years 33.7 34.5 72.2 66.5

 12 years 42.8 51.9 57.8 55.5

 13 years 63.4 75.0 71.7 66.9

Age

 <20 years 25.0 16.6 50.7 46.2

 20-29 years 48.4 57.2 61.3 58.7

 30-39 years 52.1 66.7 83.1 71.0

 40-44 years

Region of residence

 Northeast 38.4 63.5 59.3 69.1

 South 49.8 45.6 64.4 55.5

 Midwest 35.5 51.3 64.0 56.6

 West 65.7 68.8 70.4 68.0

Poverty status

 <100% poverty 30.7 27.3 54.4 55.5

 100% poverty 50.0 62.3 66.9 62.7

An asterisk (*) indicates a statistic that is potentially unreliable because of small sample size or large coefficient of variation; indicates that 1

minimum-sample-size requirements were not met.

SOURCE: HHS, NSFG, 1982 and 1988.
ES-13

Table ES-4. Prevalence of shortness, thinness, high weight for recumbent length, high weight for height, and

overweight in children and adolescents in the U.S. population, by age and sex, 1988-91 (%)1

Growth-status indicators

for selected age groups Male Female

Shortness

 Low recumbent length for age

 2-5 months 4.9* 3.7*

 6-11 months 4.4 3.9*

 12-23 months 3.8 3.5

 Low height for age

 2-5 years 5.2 5.1

 6-11 years 4.7 4.1

 12-17 years 6.1 1.5*

Thinness

 Low weight for recumbent length

 2-5 months 1.3* —

 6-11 months 1.6* 2.7*

 12-23 months 3.4 3.2*

 Low weight for height

 2-5 years 2.7 0.6*

 6-9 years 2.6* 3.6

High weight for recumbent length

 2-5 months 11.9 12.0

 6-11 months 8.5 11.5

 12-23 months 10.5 10.6

High weight for height

 2-5 years 4.2 7.5

Overweight

 6-11 years 9.4 12.6

 12-19 years 10.1 9.0

Excludes pregnant females. For low recumbent length for age and low weight for recumbent length for children 6-23 months of age, 1

percentages are those below the NCHS growth chart 5th percentiles (Hamill et al., 1979). For high weight for recumbent length for children 6-

23 months of age, and for high weight for height for children 2-5 years of age, percentages are those above the NCHS growth chart 95th

percentiles (Hamill et al., 1979). For low height for age for children 2-17 years of age and low weight for height for children 2-9 years of age,

percentages are those below the NCHS growth chart 5th percentiles (Hamill et al., 1979). For overweight children 6-19 years of age, percentages

are those above the NHANES I 95th percentile of body mass index for age (Must et al., 1991). An asterisk (*) indicates a statistic that is

potentially unreliable because of small sample size or large coefficient of variation; a dash (—) indicates that the observed percentage was 0.0. 

SOURCE: HHS, NHANES III, 1988-91.
ES-14

Dietary status

Data collected in the NNMRRP surveys and

surveillance systems provide information on the 

dietary status of the U.S. population. Dietary status 

is assessed by examining the types and amounts of

foods, food components, and nutrients consumed. An

evaluation of total nutrient intake requires that both

food and nonfood nutrient sources be considered.

Data are available from the NNMRRP on several

levels of food consumption—individual intake,

household food use, and national food supply—and

on dietary supplement use. In addition, data are

available from the NNMRRP on related dietary

measurements, including food expenditures, food

insufficiency, breastfeeding practices, weight-loss

practices, reported levels of physical activity,

nutrition knowledge, and the awareness of

relationships between diet and health.

Estimates of nutrient intakes from food in this report

represent only partial estimates because they do not

include nutrient intakes from dietary supplements,

drinking water, discretionary salt use, or medications

and because underreporting of intake may occur. 

The resulting data may affect estimates of food 

energy intakes and food and nutrient intakes in

relation to recommended levels. Nonetheless, such

dietary intake estimates serve a critical role in

assessing dietary status and, in turn, in assessing

nutritional and nutrition-related health status. The

major themes and findings on the dietary status of the

U.S. population are highlighted below.

Food consumption, nutrient intakes from food,

and dietary supplement use

The abundant U.S. food supply allows most

Americans many food choices. Although there are

many similarities in the food choices of people in

different age, sex, racial, and income groups, there

are also some notable differences. 

Virtually all people reported that they consumed

meat, poultry, and fish:

— higher percentages of white than black adults

reported consuming beef, whereas the opposite

was true for pork and poultry, and

— higher percentages of adults with higher than

lower incomes reported consuming beef and

fish and shellfish.

Differences in the types of milk and milk products

consumed were observed across age, racial, and

income groups:

— higher percentages of black than white adults

reported consuming whole milk, whereas higher

percentages of white than black adults reported

consuming low-fat and skim milks;

— higher percentages of adults with lower than

higher incomes reported consuming whole 

milk; and

— a higher percentage of adults than children

reported consuming skim milk.

Fruits were consumed less frequently than

vegetables. Over a 3-day period, about 30% of

adolescents and of adult males and 24% of adult

females did not eat any fruits, and about 6% of

individuals did not eat any vegetables. These

values do not include fruits and vegetables eaten as

part of food mixtures. Furthermore,

— higher percentages of older than younger adults

of both sexes reported consuming dark-green and

deep-yellow vegetables, lettuce, and other

vegetables;

— higher percentages of adults with higher than

lower incomes reported consuming dark-green

and deep-yellow vegetables, lettuce, tomatoes,

and other vegetables; and

— higher percentages of black than white adults

reported consuming dark-green vegetables, and

higher percentages of white than black adults

reported consuming deep-yellow vegetables,

lettuce, and other vegetables.

The goal of Healthy People 2000 Objective 2.6 is that

people consume 5 or more servings of fruits and

vegetables per day. This objective reflects the

recommendation shown in the 1990 Dietary

Guidelines for Americans and the Food Guide

Pyramid to eat a minimum of 2 servings of fruits and

3 servings of vegetables daily. Fewer than one-third

of American adults meet this recommendation

(fig. ES-12). Data from 1989-91 suggest that the

average daily intake of fruits and vegetables for the

general population is about 4 servings.

Virtually all people of all ages consumed grain

products:

— higher percentages of children and adolescents

than adults reported consuming mixtures in

which the main component is grain, such as

pizza, enchiladas, and egg rolls, and adults
Percent

18-39 40-59 60 18-39 40-59 60 

0

20

40

60

80

100 5 servings

2.5-<5 servings

<2.5 servings

Male Female

Age in years and sex

ES-15

Figure ES-12. Percent distribution of daily servings of fruits and vegetables consumed by people 18 years of age

and older, by age and sex, 1991

SOURCE: HHS, 5 A Day for Better Health Baseline Survey, 1991.

70 years of age and older were least likely to Higher percentages of white than black adults and 

report consuming these products; of adults with higher than lower incomes reported

— higher percentages of children 6-11 years of consuming salad dressings, which often contain oil.

age and adults 70 years of age and older

reported consuming cereals and pasta than did Higher percentages of adults with higher than lower

adolescents and other adults; incomes, higher percentages of whites than blacks,

— higher percentages of white than black adults and higher percentages of younger than older 

and of adults with higher than lower incomes people reported consuming candy.

reported consuming cakes, cookies, pastries,

and pies and crackers, popcorn, pretzels, and Higher percentages of adolescents and young adults

corn chips; reported consuming regular soft drinks than did

— the percentages of adults reporting consumption other age groups.

of yeast breads and rolls and cereals and pasta

were similar across race, sex, and income Trends in the amounts of food available for

levels; and consumption suggest that Americans are slowly

— the percentages of adults reporting consumption changing their eating patterns toward more 

of quick breads, pancakes, and French toast healthful diets. However, a considerable gap still

were similar for whites and blacks. appears to exist between what Americans are eating

Higher percentages of black than white adults and

of adults with lower than higher incomes reported On a per capita basis, less red meat and more

consuming eggs (including whole eggs, egg poultry were available for consumption in 1992

substitutes, and eggs in other forms). than in 1972 (fig. ES-13). Per capita annual

Use of table fats, such as butter and margarine, considerably, from 268 in 1972 to 180 in 1992.

was reported by higher percentages of white than

black adults, of older than younger adults, and of Per capita availability of lower-fat milk increased

adults with higher than lower incomes. while availability of whole milk decreased

and what they should be eating.

availability of shell eggs also decreased

(fig. ES-14). However, the greater availability of 
Pounds

Year

1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992

0

50

100

150

200

250

0

50

100

150

200

250 Whole milk, plain

Low-fat milk, plain

Skim milk, plain

Cheese

Yogurt

Pounds

Year

1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992

0

20

40

60

80

100

120

0

20

40

60

80

100

120 Beef

Pork

Chicken

Fish and shellfish

Turkey

ES-16

Figure ES-14. Annual per capita consumption of milk, yogurt, and cheese, by year, 1972-92

SOURCE: USDA, U.S. Food Supply, 1970-92 (Putnam and Allshouse, 1993).

Figure ES-13. Annual per capita consumption of meat, poultry, and fish and shellfish, by year, 1972-92

SOURCE: USDA, U.S. Food Supply, 1970-92 (Putnam and Allshouse, 1993).
Gallons

Year

1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992

0

10

20

30

40

50

0

10

20

30

40

50 Coffee

Milk

Soft drinks

Fruit juices

Bottled water

ES-17

Figure ES-15. Annual per capita consumption of selected nonalcoholic beverages, by year, 1972-92

SOURCE: USDA, U.S. Food Supply, 1970-92 (Putnam and Allshouse, 1993).

lower-fat fluid milk appears to have been and adults in 1988-91. However, the increased

accompanied by an increase in the availability of prevalence of overweight suggests that this finding

fluid-cream products and cheese. reflects underreporting in surveys as well as low

Per capita availability of grains, fruits, vegetables, (see "Overweight" discussion, above). The lack of

and legumes increased between 1972 and 1992. change in the prevalence of nutrient intakes below

Caloric sweeteners available for consumption has not changed substantively.

reached a high of 143 lb per capita in 1992. A

large portion of this increase can be attributed to Median intakes of vitamin A, vitamin E, vitamin B ,

the use of corn sweeteners, mainly high-fructose zinc, and copper from food were below

corn syrup. Per capita availability of low-calorie recommended values for most age, sex, and

sweeteners (mainly aspartame and saccharin) has racial/ethnic subgroups.

more than tripled since 1980.

Between 1972 and 1992, availability of regular and recommended values for non-Hispanic black

low-calorie soft drinks climbed from 26 to 44 gal children 1-11 years of age, all adolescents except

per capita. By 1976, per capita availability of soft non-Hispanic white males 12-15 years of age, all

drinks had become greater than that of milk, fruit females aged 20 years and older, non-Hispanic 

juices, coffee, or bottled water (fig. ES-15). black males 20-59 years of age, and all males

Certain population subgroups are consuming diets

that provide less-than-recommended amounts of Median iron intakes from food were below

some nutrients. recommended values for children 1-2 years of age,

Reported median food energy intakes were below adults 20-59 years of age across racial/ethnic

recommended energy intakes for most adolescents groups.

energy expenditures, rather than underconsumption

recommended values suggests that dietary quality

6

Median calcium intakes from food were below

60 years of age and older.

female adolescents 12-19 years of age, and female
ES-18

Median intakes of magnesium from food were About 9-13% of people living in low-income

below recommended values for all adolescents and households or families experience some degree of

adults except adolescent males 12-15 years of age. food insufficiency. 

Median folate intakes from food were below In 1988-91, Mexican Americans and non-Hispanic

recommended values for non-Hispanic black blacks were more likely than non-Hispanic whites to

females 16 years of age and older and for Mexican- report that they sometimes or often did not have

American females 60 years of age and older. enough food to eat (table ES-5). For low-income

Lunches provided in the National School Lunch 1989-91 was higher among blacks than whites, and

Program contributed more fat in 1992 than Food Stamp Program participants were more likely

recommended in the 1990 Dietary Guidelines for to report a food-insufficiency problem than

Americans. nonparticipants (table ES-6). 

Many Americans take dietary supplements. 

At least 35-40% of Americans took dietary

supplements between 1988 and 1991. Females Americans changed their patterns of spending for

were more likely to take supplements than males, different types of food and for food away from home

and non-Hispanic whites and older adults were between 1980 and 1992. 

more likely to take supplements than non-Hispanic

blacks and younger adults. Per person spending (expressed in 1988 dollars

In 1986, people with incomes at or above the and 19% for pork between 1980 and 1992, whereas

poverty level were more likely to use supplements spending for poultry climbed 20%. Yearly

than those with incomes below the poverty level. fluctuations between 1980 and 1992 were seen for

Use was also higher in adults who were more fish and seafood. Purchases of eggs declined by

educated and their children than in adults who about one-third, and purchases of fresh whole milk

were less educated and their children. fell by one-half during that same period.

In 1986, more than 70% of all supplements used Per person spending for fresh fruits and vegetables

by adults and children were taken daily. The in urban households dropped between 1980 and

supplements most commonly used by adults were 1992. The decline for fresh vegetables (11%) was

vitamin-mineral combinations and single vitamins not as dramatic as the decline for fresh fruits 

and minerals (specifically, vitamin C and calcium), (22%). Purchases of processed fruits and 

whereas for children 2-6 years of age, the most vegetables remained relatively stable during this

commonly used supplements were multivitamins. time.

The ability to examine excessive intakes of Between 1980 and 1992, per person spending for

vitamins and minerals in the TRONM was limited frozen prepared food in urban households nearly

because a product-specific data base to use for doubled (fig. ES-16). During this time, purchases 

calculating quantitative intakes of nutrients from of potato chips, nuts, and similar types of snack

supplements has not been developed. foods climbed nearly 60%, and purchases of

Food insufficiency Between 1980 and 1992, urban households spent

Some Americans are not always getting enough to food away from home.

eat. Nutritional status is a critical factor in children's

development. Recent research findings indicate that The share of total food expenditures for food away

inadequate food intake due to lack of money or from home increased during the 1980s across racial

resources (i.e., food insufficiency) is likely to impair and income groups (figs. ES-17 and ES-18). 

growth and cognitive development.

households, the prevalence of food insufficiency in

Household food expenditures

here) in urban households decreased 37% for beef

carbonated drinks rose by 21%. 

more than one-third of their total food expenses on
ES-19

Table ES-5. Prevalence of a reported family food-sufficiency problem in individuals, by race/ethnicity and poverty

status, 1988-91 (%)1

Race/ethnicity and poverty status food not enough enough

Enough Sometimes Often not

Overall population 96.1 3.3 0.6*

Race/ethnicity

 Non-Hispanic white 97.4 2.1 0.5*

 Non-Hispanic black 92.7 6.7 0.6*

 Mexican American 84.5 14.2 1.3

Poverty status

 100% poverty 98.3 1.5 0.1*

 <100% poverty 84.1 13.2 2.7*

 <131% poverty 87.0 10.7 2.2*

An asterisk (*) indicates a statistic that is potentially unreliable because of a large coefficient of variation. 1

SOURCE: HHS, NHANES III, 1988-91. 

Table ES-6. Household food sufficiency of the low-income population, by Food Stamp Program (FSP) participation

and race, 1989-91 (%)1

FSP participation and race food we want always what we want not enough enough

Enough of the kinds of Enough, but not Sometimes Often not

Overall low-income population 53.9 36.7 7.2* 1.9*

FSP participation

 Participant 43.0 43.3 10.2* 3.5*

 Nonparticipant 58.7 33.8 5.9* 1.2*

Race

 White 58.2 34.4 5.9* 1.2*

 Black 44.3 42.7 8.9* 4.0*

Based on households with gross incomes <131% of the Federal Poverty Income guideline. An asterisk (*) indicates a statistic that is potentially 1

unreliable because of small sample size or large coefficient of variation.

SOURCE: USDA, CSFII, 1989-91.
1988 dollars

Year

1980 1984 1988 1992

0

5

10

15

20

25

30

Percent

 

NFCS NFCS

0

10

20

30

40

50 White

Black

Other

1977-78 1987-88

Percent

 

NFCS NFCS

0

10

20

30

40

50 First (lowest)

Second

Third (middle)

Fourth

Fifth (highest)

1977-78 1987-88

ES-20

Figure ES-16. Average annual expenditures per

person in urban households for frozen prepared

foods, 1980, 1984, 1988, and 1992

SOURCE: DOL, CES, 1980-92 (Smallwood et al., 1994).

Figure ES-17. Percentage of total food expenditures

spent on food away from home, by race, 1977-78

and 1987-88

SOURCE: USDA, NFCS, 1977-78 and 1987-88 

(Lutz et al., 1992). 

Figure ES-18. Percentage of total food expenditures

spent on food away from home, by income quintile,

1977-78 and 1987-88

SOURCE: USDA, NFCS, 1977-78 and 1987-88 

(Lutz et al., 1992).

Spending for food away from home peaked in relationships among female main meal planners and

1990, began to decline in 1991, and continued to preparers in 1989-91 was lowest for those who 

decrease in 1992. were black, less educated, and from lower-income

In urban households, the share of total food likely to be aware of diet and health relationships

expenditures between 1980 and 1992 for food away than were middle-aged women.

from home was generally higher in white

households than in black and other-race households

and was higher in households with higher incomes.

Eating away from home is also common among

children, who often eat lunch and sometimes

breakfast at school. In 1992, the National School

Lunch Program and School Breakfast Program

provided two of the three major meals for 1 in 10

school-age children, and one of the three major

meals for more than half of school-age children on

school days.

Turning awareness into action

People who are aware of diet and health 

relationships may be motivated to follow eating 

habits consistent with dietary recommendations.

However, awareness does not automatically translate

into action.

In general, awareness of diet and health

households. Younger and older women were less
ES-21

Even though, in general, female main meal There is no "gold standard" method for determining

planners and preparers who were aware of diet and total fat, and there are considerable differences in 

health relationships were more likely than those the results obtained with the different methods and

who were not aware of diet and health relationships by different laboratories. Because the total fat

to believe that following the principles of the 1990 content of foods affects nutrition monitoring and

Dietary Guidelines for Americans was highly public health issues—such as the energy content of

important to them personally, little difference was foods and the percent of calories from fat—it is

found between the dietary intakes of those who important that accurate and comparable data be

were aware and those who were not aware of diet available for the total fat content of foods in the

and health relationships. This finding underscores American diet. 

the need for research about what causes people to

change their dietary behavior. Consistency in the measurement of the total fat

Food composition data "total fat" and that used in the Nutrition Labeling

High-quality data on the composition of foods as 101-535). Accepted assay methods for "total fat,"

they are actually eaten are critical for estimating as defined by the NLEA, have yet to be developed. 

nutrient intakes of Americans and for comparing Efforts will have to be made to ensure that a

intakes over time. However, it is difficult to consistent definition of "total fat" is used for foods

maintain a complete and current food composition incorporated into the U.S. Department of

data base because the types of foods available in the Agriculture (USDA) Nutrient Data Base for

marketplace are constantly changing and the food Standard Reference and the USDA Nutrient Data

composition data available by brand name are Base for Individual Food Intake Surveys (Survey

limited. Nutrient Data Base). 

Maintaining a complete and current food

composition data base requires that all foods,

including traditional ethnic foods and new foods

introduced into the marketplace, be characterized

and that the data be updated continually, as

improved methodologies are developed. Priority

must be given to analyzing commonly consumed

foods and foods that are primary sources of nutrients

associated with public health issues in the United

States. 

 

The high cost of analyzing the nutritional

composition of foods makes maintaining an

accurate food composition data base difficult. The

development of acceptable assay methods that are

faster and less expensive than current methods will

help to bring down the costs of food analysis. 

For nutrition monitoring purposes, the food

composition data for total fat, fatty acids including

trans fatty acids, dietary fiber, carotenes, folate,

sodium, and cholesterol need to be improved and

expanded. Data on the selenium content of foods

should be added to the Survey Nutrient Data Base. 

The methodology for determining the total fat

content of foods is in critical need of improvement. 

content of foods is becoming problematic because

of differences in the traditionally used definition of

and Education Act (NLEA) of 1990 (Public Law

Concerns for low-income, high-risk

populations

NNMRRP surveys provide information on the 

dietary, nutritional, and nutrition-related health status

of different population groups. By comparing the

prevalence estimates of these groups, characteristics 

of the groups most at risk for nutrition-related health

problems can be identified. Selected findings on

populations at nutritional risk are listed below. The 

groups at risk differ depending on the risk factor 

being considered. 

The risk of nutrition-related health problems is high

among people with low incomes. Certain

subpopulations, such as elderly people, some

minorities, pregnant women, infants, and children,

are also at nutritional risk, particularly those with

low incomes. 

Among low-income pregnant females, non-Hispanic

blacks of all ages and adolescents across

racial/ethnic groups had the highest prevalences of

anemia in 1992. 
Percent LBW

 

Very Under- Normal Over- Very

0

5

10

15

20

25 Smoker

Nonsmoker

Prepregnancy weight

under- weight weight weight overweight weight

ES-22

Figure ES-19. Low-birth-weight (LBW) prevalence

among low-income, high-risk females who smoked

and did not smoke during pregnancy, by

prepregnancy weight, 1992

SOURCE: HHS, PNSS, 1992.

Among low-income women participating in thinness among low-income children was about

government-supported service programs, the 3%, which is less than expected for the overall U.S.

prevalence of low birth weight in 1992 was higher population (5%) but similar to that found in the

for those who smoked (fig. ES-19) or who had low overall U.S. population (about 3%) (table ES-4). 

prepregnancy weight, less-than-ideal weight gain

during pregnancy, or anemia during pregnancy than Mexican-American children and adolescents

it was for other women in that sample. Low 6-19 years of age had a relatively high prevalence 

prepregnancy weight, less-than-ideal weight gain, of overweight and a relatively low prevalence of

and anemia are often related to maternal diet and thinness compared with the U.S. population of

nutrient intake. Effective prenatal care can children and adolescents as a whole. 

beneficially affect the latter two nutrition-related

factors. The mean BMI of American Indian school children

Mothers who were younger, black, or living below overall U.S. population in 1988-91, suggesting that

the poverty level were less likely to breastfeed the prevalence of overweight is likely to be higher 

their babies than were other mothers (table ES-3). in American Indian children than in other American

In 1992, about 10% of a population of low-income

children and adolescents participating in In 1988-91, the prevalence of overweight was

government-supported service programs had high highest in females with incomes below 131% of

weight for height, which is higher than the poverty in all racial/ethnic groups, ranging from

percentage expected for the overall U.S. population 45% for non-Hispanic whites to 50% for Mexican

(5%) but similar to the percentage found in Americans and 51% for non-Hispanic blacks. For

children in the overall U.S. population (10%). The non-Hispanic blacks, the prevalence of overweight

prevalence of shortness in this subpopulation was much higher in females than in males (28%). 

—about 9%—may reflect, in part, the racial/ethnic For non-Hispanic black and Mexican-American

composition of low-income families who males, the prevalence of overweight was lowest in

participated in these programs. The prevalence of the low-income group. 

in 1990-91 was higher than that of children in the

children. 

Non-Hispanic white males with incomes below

poverty in 1988-91 had a higher age-adjusted

prevalence of high serum total cholesterol levels

than males in other racial/ethnic or income groups. 

In 1988-91, non-Hispanic black males and females

had higher age-adjusted prevalences of

hypertension than did non-Hispanic whites or

Mexican Americans (table ES-2). Non-Hispanic

white and non-Hispanic black females with 

incomes below the poverty level had higher ageadjusted prevalences of hypertension than did

females with higher incomes in these two groups. 

Hypertension remains a substantial problem in

middle-aged and elderly people. In 1988-91, about

75% of females 80 years of age and older had high

blood pressure compared with 60% of males in that

group (table ES-2). 

The prevalence of femoral osteoporosis in females

50 years of age and older was 21% for nonHispanic whites, 10% for non-Hispanic blacks, and

16% for Mexican Americans in 1988-91. Although
ES-23

the prevalence of osteoporosis was only 6% among nutrition monitoring report—vitamin A, vitamin C,

non-Hispanic white females 50-59 years of age, it vitamin B , folate, calcium, iron, and zinc—than 

rose in each succeeding decade of age, reaching did adolescents and adults from higher-income

52% among the group 80 years of age and older. groups. However, mean intakes of the low-income

Female main meal planners and preparers who were Recommended Dietary Allowance (RDA) values 

black or from low-income households were less than mean intakes of higher-income groups. 

likely to be aware of diet-health relationships than

were females who were white or from higher- People in low-income households or families were

income households. Higher percentages of adults more likely to report that they experienced food

with low incomes and of black adults reported insufficiency than people in households or families

eating certain foods containing higher levels of with higher incomes (tables ES-5 and ES-6). 

total fat (e.g., whole milk) and cholesterol (e.g., About 9-13% of people in low-income households

whole milk and eggs) than of adults with higher experienced some degree of food insufficiency,

incomes and of white adults. Lower percentages of compared with about 4% in the overall U.S.

adults with low incomes and of black adults population. Mexican Americans and non-Hispanic

reported using fats and oils. blacks were more likely than non-Hispanic whites 

Percentages of low-income adults and of black enough food to eat. 

adults who had total fat intakes within the

recommended range ( 30% of calories) were

somewhat lower than percentages of higher-income

and of white adults (table ES-1). 

Median calcium intakes from food were below

recommended values for non-Hispanic black

children 1-11 years of age, all adolescents except

non-Hispanic white males 12-15 years of age,

females 20 years of age and older, non-Hispanic

black males 20-59 years of age, and males 60 years

of age and older. 

Children 1-2 years of age, female adolescents, and

female adults 20-59 years of age had median iron

intakes from food that were below recommended

values. 

Non-Hispanic black females 16 years of age and

older and Mexican-American females 60 years of

age and older had median folate intakes from food

that were below recommended values.

Pregnant females had lower-than-recommended

mean intakes from food of folate, calcium, vitamin

B , iron, zinc, and magnesium. Pregnant non- 6

Hispanic black females had a mean calcium intake

that was lower than that of non-Hispanic white and

Mexican-American pregnant females. 

Low-income adolescents and adults (but not

children) in 1989-91 had lower mean intakes of

vitamins and minerals that were considered current

or potential public health concerns in the second

6

groups were not more likely to be below

to report that they sometimes or often did not have

Assessments

The decision-making process developed for the 

second nutrition monitoring report was used to assess

monitoring priority status for food components in the

TRONM. As shown in figure ES-20, the evaluation 

of each food component begins with the dietary 

intake data. However, the evidence for adverse 

health consequences ultimately determines the

categorization of the component. NNMRRP data that

were available as of June 1994 were used for 

assessing monitoring priority status. The decision to

start evaluating each food component by considering 

the dietary intake data was made because such data 

were available for most of the food components by 

June 1994. Analyses of much of the biochemical and

clinical data on nutritional status were not completed 

by then. 

Nutrient intake data collected in NHANES III 

1988-91 and the Continuing Survey of Food Intakes

by Individuals (CSFII) 1989-91 were used with

contemporaneous information on nutritional status

and nutrition-related health status from the NNMRRP

and, in some instances, the general biomedical

literature, to update the assessment of the public

health monitoring priority for each food component. 

When nutrient intake data were not available from

these surveys, data from the Food and Drug

Administration's (FDA's) Total Diet Study (1982-89)

were used. Each food component was considered

independently.
NUTRIENT INTAKE FROM FOOD

Low or High Neither Low nor High

Biochemical,

anthropometric

evidence of

adverse health

conditions

Limited

biochemical,

clinical, or

anthropometric

evidence of

adverse health

conditions

Little or no

biochemical,

clinical, or

anthropometric

evidence of

clinical, or

conditions

Current Public

adverse health

Health Issue

Potential Public

Health Issue

Not a Current Public

Health Issue

ES-24

Figure ES-20. Decision-making process used to

categorize food components by monitoring priority

status

SOURCE: Modified from LSRO (1989).

Evidence for health consequences was provided

mainly by the biochemical and clinical data from the

NNMRRP. The criteria established by authoritative

groups for assessing specific diseases and health

conditions were used to evaluate these data. As

noted by the Joint Nutrition Monitoring Evaluation

Committee of HHS and USDA in the first nutrition

monitoring report in 1986, "Much can be inferred

about the nutritional status of the population, even

with imperfect data judged by imperfect criteria,

especially when a wider knowledge of nutrition is

brought to bear." In this regard, the Expert

Consultants and the Life Sciences Research Office

(LSRO) used their experience and judgment in

categorizing food components. 

Food components were assigned to three categories

of public health issues: current public health issues,

potential public health issues for which further study

is required, and not current public health issues

(table ES-7). High-priority monitoring status is

recommended for food components considered

current public health issues. Monitoring efforts for

these components should include biochemical,

clinical, and anthropometric assessments, as 

appropriate. Moderate-priority monitoring status is

recommended for food components considered

potential public health issues, with continued

assessment in at least those subgroups suspected to

be at risk. Food components not considered current

public health issues are recommended for lowerpriority monitoring status; continued assessment

should include, at a minimum, estimation of dietary

intake. Assigning food components to this category

does not necessarily indicate that there are no known

health problems associated with these components,

but that the prevalence of such problems on a

national basis is known or expected to be so low that

a lower level of monitoring effort than for food

components in the other categories is appropriate.

The assignments of food components to particular

monitoring classifications should be regarded as

provisional. It is likely that as new data from the

NNMRRP and other sources become available, future

assessments of public health significance and of the

levels of monitoring needed will result in changes in

the categorization of some food components. More

detailed assessments of individual nutrients can be

found in the main report.

Current public health issues

The following criteria were used to assign current

public health issue status to a food component. If

median intakes of a food component fell below the

recommended values (usually the 1989 RDA),

undernutrition was considered to be a possible

problem. Additional evidence of a nutritional

problem based on clinical or biochemical data from

the NNMRRP was needed to determine that the

component should be considered a current public

health issue. Such clinical and biochemical data were

accorded more weight than were the dietary intake

data. If such data were not available from the

NNMRRP, information in the general medical

literature was used to assess the possibility that the

specified component be considered a current public

health issue. The interpretation of dietary intake data

was complicated by the lack of information on total

nutrient intakes (i.e., intakes from dietary

supplements and from foods).

High intakes of food components were also assessed,

although the RDA was less useful in identifying

potential public health problems related to excessive

intake. If the median intake was near or above the

recommended value and the distribution of intakes

was skewed to the side of high intakes, the
ES-25

Table ES-7. Classification of food components as public health issues in the TRONM1

Current public health issues for which further study is required Not current public health issues

Potential public health issues 

Food energy Total carbohydrate Thiamin

Total fat Dietary fiber Riboflavin

Saturated fatty acids Sugars‡ Niacin

Cholesterol Polyunsaturated and Iodine‡

Alcohol monounsaturated fatty acids‡

Iron Trans fatty acids‡

Calcium Fat substitutes‡

Sodium Protein

Vitamin A

Antioxidant vitamins

 Vitamin C

 Vitamin E

 Carotenes

Folate

Vitamin B6

Vitamin B12

Magnesium

Potassium

Zinc

Copper

Selenium‡

Phosphorus

Fluoride

Arrows ( ) point to components whose monitoring priority status has changed since the second report on nutrition monitoring was published 1

(LSRO, 1989). Double daggers (‡) indicate components that are being evaluated for the first time for the NNMRRP.

SOURCE: LSRO, 1995.

possibility of deleterious health effects was evaluated. Food components meeting the criteria for

Consumption from dietary supplements should also classification as current public health issues are food

be considered when effects of high intakes are energy, total fat, saturated fatty acids, cholesterol,

considered. However, estimates of total nutrient alcohol, iron, calcium, and sodium (table ES-7). 

intakes from foods and dietary supplements were not Except for iron and calcium, these food components

available for the preparation of the TRONM, so were classified as current public health issues because

estimates of nutrient intakes were based only on of evidence of adverse effects of high intakes. The

nutrients provided by food. Standards established by classification of these nutrients as current public

other expert groups and specified in the assessments health issues was consistent with their classification

below were applied to evaluate components for which in the first and second nutrition monitoring reports. 

there is evidence that excessive intakes are harmful,

such as food energy, total fat, saturated fatty acids,

cholesterol, and sodium. Confirmatory clinical or Food energy

biochemical evidence from the NNMRRP data or

from other sources about adverse effects resulting Although median intakes of food energy reported by

from high intakes is required for the categorization of adolescents and adults in 1988-91 were below

high intakes as current or potential public health recommended levels, approximately one-fifth of the

issues. adolescents and one-third of the adults were 
ES-26

overweight. The high prevalence of overweight insufficient to attain optimal peak adult bone mass

indicates that energy balance is a continuing public and to prevent age-related loss of bone mass. 

health problem (i.e., that food energy intakes exceed

energy expenditures for many Americans). 

Total fat, saturated fatty acids, and cholesterol In 1988-91, median intakes of sodium from food

Median intakes of total fat and saturated fatty acids the recommended maximum value of 2,400 mg/d. 

for most adults, adolescents, and children older than High sodium intakes are associated with high

2 years of age in 1988-91 were above recommended prevalences of hypertension. 

values ( 30% of calories for total fat and 8-10% of

calories for saturated fatty acids). Median intakes of

cholesterol were generally within the recommended

range of 300 mg/d or less. Although serum total

cholesterol levels and median intakes of total fat,

saturated fatty acids, and cholesterol appear to be

decreasing, substantial proportions of the U.S.

population still have high serum total cholesterol

levels and high intakes of total fat, saturated fatty

acids, and cholesterol. High intakes of total fats,

saturated fatty acids, and cholesterol are associated

with elevated blood lipids, a risk factor for coronary

heart disease. 

Alcohol

Intake of alcohol is considered a current public health

issue because alcoholic beverages are a source of

food energy and may displace other sources of

nutrients and because of the serious public health and

social consequences of excessive alcohol intake. 

Iron and calcium

Low intakes of iron and calcium are of public health

concern. Median intakes of iron from food were

below RDA values for children 1-2 years of age and

for adolescent and adult females in 1988-91. 

Prevalences of low hemoglobin levels indicative of

anemia were generally higher in these groups than in

other age-sex groups. A comprehensive assessment

of iron status will require that multiple biochemical

and hematologic indicators of iron status be

evaluated. 

Median calcium intakes from food were consistently

below RDA values for adolescent and adult females

and for males of most age and racial/ethnic groups. 

Current calcium intakes by these groups may be

Sodium

alone, excluding salt added at the table, were above

Potential public health issues for which

further study is required

The following criteria were used to classify a food

component as a potential public health issue for

which further study is required to determine the

nature and extent of the potential problem. If median

intakes were low by the criteria described above and

data on health or nutritional status were not available

from the NNMRRP or any other source to assess the

potential for deficiency, then the component was

considered a potential public health issue for which

further study is required. If the median intakes were

above the recommended values (usually the 1989

RDA) for a population subgroup, then in most cases,

few individuals would be at risk of deficiency in that

subgroup. However, if additional evidence from the

NNMRRP or other sources indicated that the

potential for deficiency existed in at least some

groups in the population, the food component was

considered a potential public health issue for which

further study is required. 

The following food components met the criteria for

classification as potential public health issues for

which further study is required (table ES-7): total

carbohydrate and certain carbohydrate constituents

(dietary fiber and sugars); certain fat constituents

(polyunsaturated and monounsaturated fatty acids and

trans fatty acids) and substances used as fat

substitutes, including modified fats, proteins, gums,

and dietary fiber; protein; vitamin A; antioxidant

vitamins (vitamin C, vitamin E, and carotenes); 

certain water-soluble vitamins (folate, vitamin B6, and

vitamin B ); and several minerals (magnesium, 12

potassium, zinc, copper, selenium, phosphorus and

fluoride). This group of food components is diverse

and the reasons for classifying them as potential

public health issues are varied. (These reasons are 
ES-27

summarized for each component in the main report.) sugar content may increase and result in higher

Some changes occurred since the second report in the intakes of sugars by people who consume fat-free,

evaluation of nutrients considered to be potential low-fat, or reduced-fat foods. Because there is

public health issues. The classifications changed for concern about high intakes of sugars, it is preferable

total carbohydrate, protein, vitamin E, vitamin B12, to replace fat in the diet with sources of complex

magnesium, copper, and phosphorus, now potential carbohydrates such as fruits, vegetables, and grain

public health issues rather than not current public products, rather than sugars. The monitoring of

health issues. The change in the classification of total sugars intake is needed to track the sources of

carbohydrate was made on the basis of Healthy carbohydrates in the U.S. diet. 

People 2000 Objective 2.6—to increase consumption

of fruits, vegetables, and grains, which are rich

sources of complex carbohydrates and dietary fiber. Polyunsaturated and monounsaturated fatty

This objective reflects the recommendations shown in acids, trans fatty acids, and fat substitutes

the 1990 Dietary Guidelines for Americans and the

Food Guide Pyramid to eat a minimum of 2 servings Median intakes of polyunsaturated and saturated fatty

of fruit and 3 servings of vegetables daily and 6 or acids were within recommended ranges ( 10% of

more daily servings of grain products. Changes in calories and 15% of calories, respectively) in

the classification of the other nutrients were made on 1988-91. When substituted for saturated fatty acids

the basis of evidence from the general biomedical in the diet, polyunsaturated and monounsaturated

literature, rather than on the basis of evidence of fatty acids lower serum low-density-lipoprotein

changes in intakes of these nutrients or of changes in (LDL) cholesterol (elevated serum levels of LDL

the nutritional and nutrition-related health status of cholesterol are a risk factor for coronary heart

the U.S. population. This is the first assessment for disease). 

the NNMRRP of monitoring priority status for

polyunsaturated and monounsaturated fatty acids, High dietary levels of trans fatty acids, another type 

trans fatty acids, fat substitutes, sugars, selenium, and of unsaturated fatty acid found naturally in meat and

iodine. dairy products and produced during hydrogenation of

Total carbohydrate and carbohydrate remain, however, about whether trans fatty acids

constituents actually have this effect. Intakes of trans fatty acids

In 1989-91, median intakes of total carbohydrate and composition data are not yet available. Intakes of

dietary fiber (a carbohydrate constituent) were lower polyunsaturated, monounsaturated, and trans fatty

than recommended values. Eating fruits, vegetables, acids should be monitored in conjunction with the

and grain products, which contain complex monitoring of total fat, saturated fatty acids, and

carbohydrates including dietary fiber, is associated cholesterol and with the assessment of the levels of

with maintenance of health. Higher intakes of serum total, high-density-lipoprotein (HDL), and LDL

soluble and insoluble fiber fractions have been cholesterol. 

associated with lower serum cholesterol levels and a

lower risk of colon cancer, respectively. The With the many new developments in fat substitutes

consumption of carbohydrate-containing foods needs and high consumer demand for low-fat and fat-free

to be monitored so that progress toward meeting foods, fat substitutes (including modified fats,

Healthy People 2000 Objective 2.6 (for increasing proteins, gums, and dietary fiber) are being

consumption of fruits, vegetables, and grain products) incorporated into many foods. Because the increased

can be evaluated. consumption of these substances could result in

Sugars (simple carbohydrates) provide food energy, fat intakes, lower intakes of fat-soluble vitamins, and

may contribute to energy intakes in excess of energy higher intakes of carbohydrates, consumption of 

expenditures, and may displace other sources of foods containing these substances should be

nutrients. The consumption of sucrose in particular monitored. 

is also associated with the development of dental

caries. When the fat content of food is reduced, the 

vegetable oils to produce solid fats, may increase

levels of serum total and LDL cholesterol. Questions

cannot be determined because the necessary food

significant changes in the U.S. diet, including lower
ES-28

Protein range of intakes necessary for optimal antioxidant

Median intakes of protein from food were well above 2) interpretive criteria are needed for serum

RDA values for most demographic groups in vitamin C values obtained with the more sensitive

1988-91. Clinical studies have provided evidence and specific methods used in NHANES III 1988-91. 

that high protein intakes increase urinary calcium

excretion when calcium intakes are low, and some Median intakes of vitamin E from food were below

epidemiological evidence suggests that higher intakes RDA values for all population subgroups of people

of animal protein are associated with higher 1 year of age and older. Dietary vitamin E intakes

prevalences of hip fractures in women over 50 years are difficult to interpret, however, because of the

of age. addition to foods of vitamin E as -tocopherol (to

In adults 60 years of age and older, median protein form (to provide a dietary source of vitamin E). 

intakes were somewhat lower than they were for Thus, the vitamin E contents of a food when the food

other age groups, although they were still at or above is analyzed and when it is eaten are likely to differ, so

the RDA. Protein requirements of older people may the food composition data on vitamin E have little

be higher when food energy intakes are low. meaning in the evaluation of vitamin E intakes. 

Because of high protein intakes by most age-sex Serum levels of vitamin E were measured in

groups, including those who have low calcium NHANES III 1988-91, but criteria for their

intakes, and because of the potential for low protein interpretation remain to be developed. 

and low food energy intakes by elderly people, the

monitoring of dietary protein intakes should continue. The nutritional status of carotenes was not evaluated

Vitamin A evaluation of the antioxidant vitamin status of the

Median intakes of vitamin A from food in 1988-91 evaluation of dietary intake and serum concentrations

were below RDA values for adults and some of antioxidant nutrients. Additional research is

subgroups of older children, but the prevalence of needed on the biochemical and health effects of diets

low serum levels of vitamin A was very low in these containing specified levels and combinations of

groups. Median vitamin A intakes of younger antioxidant nutrients.

children were above RDA values, but the prevalence

of low serum vitamin A levels in younger children

was relatively high when the cutoff values for adults Certain water-soluble vitamins (folate, vitamin

and adolescents were used. The misuse of high doses B , and vitamin B )

of preformed vitamin A in dietary supplements may

lead to high intakes of vitamin A. Because of Median intakes of folate from food were higher than

adverse health effects associated with low and high 1989 RDA values for all age, sex, and racial/ethnic

intakes of vitamin A, it continues to be classified as a groups except non-Hispanic black females 16 years

potential public health issue. of age and older and Mexican-American females

Antioxidant vitamins (vitamin C, vitamin E, and 1988-94, but because of analytical problems related

carotenes) to the kit used in NHANES III 1988-91, the

Epidemiological and clinical studies suggest that evaluated in time for consideration in this report. In

antioxidants in food can lower the risk of heart light of epidemiological evidence that low serum

disease, some forms of cancer, cataracts, and macular folate levels are associated with elevated serum

degeneration, one of the leading causes of visual loss homocysteine levels (a risk factor for atherosclerosis)

among people aged 65 years and older. In 1988-91, and that the use of dietary supplements containing

median intakes of vitamin C from food were above folate by females before they become pregnant and

RDA values for population subgroups, but during early pregnancy is associated with a decreased

interpreting these data is difficult because 1) the incidence of some types of neural-tube defects in 

activity of vitamin C remains unknown and

provide antioxidant functions) and in an esterified

because of a lack of interpretive criteria for assessing

dietary intakes and serum levels of carotenes. The

U.S. population requires improved criteria for the

6 12

60 years of age and older. Serum and red blood cell

levels of folate were measured in NHANES III

biochemical indices of folate status were not
ES-29

some populations, monitoring of folate status is Data from the Total Diet Study (1982-89) indicate

needed. However, the prevalence of neural-tube that mean selenium intakes from food were above

defects in the U.S. population is sufficiently low that RDA values for all age and sex groups assessed. 

national surveys and surveillance systems would not Serum selenium levels were measured in

be able to detect changes in that prevalence in NHANES III 1988-91, but the analyses were not

response to changes in folate intakes. completed in time for consideration in this report. 

Low serum levels of vitamin B6 have also been laboratory studies has suggested that low selenium

associated with elevated homocysteine levels, as well levels are associated with higher risk of cancer or

as with biochemical and clinical signs of deficiency. heart disease and because incidents of selenium

Median intakes of vitamin B from food were below toxicity have been reported in the United States, 6

RDA values for adults and adolescents in 1988-91, monitoring of selenium status should be included in

more so for females than males, and for females nutrition monitoring activities. 

6-11 years of age. Further research is needed on

vitamin B requirements and on techniques for Median phosphorus intakes from food were near or 6

assessing vitamin B6 nutritional status so that the above RDA values in 1988-91; however, calcium

public health importance of these intakes can be intakes from food were below RDA values for

interpreted effectively. adolescent and adult females and for males of most

Median intakes of vitamin B12 from food were above phosphorus and protein intakes may increase calcium

RDA values in 1988-91 for all age, sex, and losses when calcium intakes are low, phosphorus was

racial/ethnic groups in the U.S. population. However, classified as a potential public health issue. (See

intakes from food and dietary supplements may not "Protein," above.) 

provide sufficient vitamin B if absorption is 12

impaired, as it appears to be in some elderly people. Data are not currently available in the NNMRRP

Serum concentrations of vitamin B , which will be surveys for evaluating fluoride intakes from food or 12

available for NHANES III 1991-94, may prove to be water. However, food contributes only small

more useful than dietary data for evaluating amounts of fluoride, and monitoring the diet for

vitamin B status. Further investigations and fluoride intake is not very useful for current public 12

monitoring of activities should focus on elderly health concerns. Because mild dental fluorosis

people. (mottled teeth) is associated with high fluoride

Certain minerals (magnesium, potassium, zinc, NHANES III 1988-91 may provide a means to

copper, selenium, phosphorus, and fluoride) estimate the prevalence of mottled teeth and, thus, of

In 1988-91, median intakes of magnesium, potassium,

zinc, and copper from food were lower than RDA or

Estimated Safe and Adequate Daily Dietary Intake

(ESADDI) values for some population subgroups. 

The significance of the observed low dietary intakes

of these minerals for nutritional status or nutritionrelated health status cannot be evaluated from survey

data until adequate biochemical and/or clinical

indicators are available. Meanwhile, because

epidemiological and clinical studies have suggested

that certain of these minerals are associated with

hypertension (potassium and, possibly, magnesium),

growth retardation in children (zinc), and ventricular

arrhythmias (copper), these minerals were classified

as potential public health issues. 

Because evidence from epidemiological and

age and racial/ethnic groups. Because high

intakes, fluoride was classified as a potential public

health issue. Dental-examination data from

high fluoride intakes. 

Not current public health issues

The following criteria were used to classify food

components as not current public health issues. For

mean intakes above the recommended values (usually

the 1989 RDA) for a population subgroup, in most

cases, few individuals would likely be at risk of

deficiency in that subgroup. If the biochemical and

clinical evidence available from the NNMRRP or

other sources did not suggest the presence of a

nutritional-deficiency problem for a particular

component, it was not considered to be a current

public health issue with respect to deficiency in the 
ES-30

population surveyed. For intakes below cholesterol, iron, calcium, and sodium. For food

recommended values, if data from the NNMRRP or components that are potential public health concerns,

elsewhere did not indicate that there was a the program should monitor appropriate biochemical

nutritional-deficiency problem for a component, it and clinical indices of nutritional status and nutritionwas not considered to be a current public health related health status. The monitoring of biochemical

issue. Nutrients considered not to be current public and clinical indices is not recommended for food

health issues were thiamin, riboflavin, niacin, and components that are not current public health issues;

iodine (table ES-7). however, the monitoring of dietary intakes of those

Classification of thiamin, riboflavin, and niacin as

nutrients that are not current public health issues is

consistent with the monitoring priority assignments in Research needs

the second nutrition monitoring report. This is the

first assessment for the NNMRRP of the monitoring During the course of interpreting and evaluating

priority status of iodine. NNMRRP data for the TRONM, the Expert

Thiamin, riboflavin, and niacin research is required to obtain this information. The

Median intakes of thiamin, riboflavin, and niacin interpretive criteria to link nutrition monitoring data 

from food were generally above RDA values in to functional or health outcomes, 2) to improve

1988-91, and no other evidence suggests that intakes biochemical assays, and 3) to improve food

of these vitamins pose a public health problem. composition data. Table ES-8 presents

However, because there is some indication that recommendations for those food components

intakes may be low in some groups of Hispanic requiring further research. If more than one research

females, monitoring intakes of these vitamins should need is indicated for a given food component, the

continue, with a focus on these subpopulations. research need considered of highest priority for use in

Iodine However, all research action listed for each nutrient

Data from the Total Diet Study (1982-89) indicated

that mean iodine intakes from food were above RDA

values for all age and sex groups assessed. No

epidemiological or clinical evidence suggests that low

or high iodine intakes are currently of public health

concern in the United States. 

Recommendations for future monitoring and

research activities emphasis on high-risk subgroups, such as low-income

Monitoring needs of the NNMRRP (CSFII and NHANES) provide a

The NNMRRP should monitor intakes from food and coordinated evaluation of the dietary, behavioral,

dietary supplements for all of the food components anthropometric, clinical, and biochemical status of the

evaluated in the TRONM with the exception of U.S. population and certain subgroups considered to

fluoride and, possibly, vitamin E. In addition, for be at high risk for nutrition-related problems. 

food components that are current public health issues,

the program should monitor appropriate The need to continue these two cornerstone surveys

anthropometric, biochemical, and clinical indices of and adjunct activities at a national level is critical for

nutritional status and nutrition-related health status several reasons. First, within each survey cycle, data

for food energy, total fat, saturated fatty acids, on many factors related to diet and health are 

components should continue. 

Consultants and LSRO identified information needed

to improve future monitoring efforts. Additional

most immediate research needs are 1) to develop

interpreting existing data and in comparisons with

data collected in future surveys is listed first. 

should be considered of high priority.

Recommendations for the National Nutrition

Monitoring and Related Research Program

The United States' national nutrition monitoring

system takes a broad, multidisciplinary approach to

monitoring the nutritional and nutrition-related health

status of the U.S. population, with particular 

and certain minority groups. The cornerstone surveys

unique opportunity for the comprehensive and
ES-31

Table ES-8. Recommendations for further research for national nutrition monitoring in the United States

Classification and food component Recommended research action 1 2

Current public health issue

 Food energy Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes.

 Total fat Improve food composition data. 

 Saturated fatty acids Improve food composition data. 

 Cholesterol Improve food composition data. 

 Iron Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes.

 Calcium Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes. 

 Sodium Improve food composition data. 

Potential public health issue for

which further study is required

 Total carbohydrate Improve food composition data. 

 Dietary fiber Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes.

Improve food composition data. 

 Sugars Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes (e.g., metabolic effects of sugars such as high-fructose

corn syrup).

Improve food composition data. 

 Monounsaturated Improve food composition data. 

 fatty acids

 Polyunsaturated Improve food composition data. 

 fatty acids

 Trans fatty acids Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes. 

Improve food composition data. 

 Protein Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes (e.g., effects of high phosphorus and high protein intakes

on bone density when calcium intakes are low).

 Fat substitutes Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes (e.g., cutoff values for serum retinol in children).

Improve food composition data. 

 Vitamin A Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes.

Improve food composition data. 
Table ES-8. Recommendations for further research for national nutrition monitoring in the

United States —continued

Classification and food component Recommended research action 1 2

ES-32

 Carotenes Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes.

Improve food composition data. 

 Vitamin C Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes.

Improve biochemical assays. 

Improve food composition data. 

 Vitamin E Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes.

 Folate Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes.

Improve biochemical assays. 

Improve food composition data. 

 Vitamin B Develop interpretive criteria to link monitoring data to functional outcomes 6

or health outcomes.

Improve biochemical assays. 

 Magnesium Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes. 

 Potassium Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes. 

 Zinc Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes. 

Improve biochemical assays. 

 Copper Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes. 

Improve food composition data. 

 Selenium Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes. 

 Phosphorus Develop interpretive criteria to link monitoring data to functional outcomes

or health outcomes (e.g., effects of high phosphorus and high protein on

bone density when calcium intakes are low).

Further research actions are not recommended at this time for nutrition monitoring purposes for food components not listed here (alcohol, 1

fluoride, iodine, vitamin B , thiamin, riboflavin, and niacin), although further monitoring is recommended for all of them. 12

Recommended research actions are listed in descending order from the most immediate need for interpreting existing data and for comparisons 2

with data collected in future surveys; however, all research actions listed for each nutrient should be considered high priority. The Expert

Consultants and LSRO regarded recommended monitoring activities as separate from recommended research actions. Further monitoring was

recommended for all food components (see text).

SOURCE: LSRO, 1995.
ES-33

collected from a single, large, nationally improvement. Key publications that include these

representative sample of people. Meaningful recommendations are 

comparisons of health effects can be made within and National Survey Data on Food Consumption: Uses

among many age, sex, racial/ethnic, and income-level and Recommendations, 

groups. Such comparisons cannot be made with as Nutrition Monitoring in the United States: A

much confidence with data from surveys that do not Progress Report from the Joint Nutrition

use nationally representative samples. Second, Monitoring Evaluation Committee, 

continuing to use the complex survey designs of the Nutrition Monitoring in the United States: An

cornerstone surveys, which require large sample Update Report on Nutrition Monitoring, 

sizes, will minimize such potentially confounding Ten-Year Comprehensive Plan for the National

effects as population mobility and variabilities in the Nutrition Monitoring and Related Research

distribution of domestic and imported foods Program; notice,

throughout the country. Third, centralized laboratory Nutrition Monitoring: Progress in Developing a

analyses with well-defined protocols and quality- Coordinated Program, 

control procedures, although difficult, can be carried Nutrition Monitoring: Data Serve Many Purposes;

out in large surveys such as NHANES, but achieving Users Recommend Improvements, and

this uniformity of procedures and quality control Nutrition Monitoring: Establishing a Model

across several surveys is much more difficult. Program.

Finally, collecting data in future nutrition surveys at

the national level should permit comparisons with To strengthen the program and overcome some

information from other cycles of these surveys. limitations of the present system, specific gaps in

Trends in the dietary, nutritional, and nutrition-related knowledge and recommendations for enhancing the

health status of the U.S. population can then be usefulness of the survey data are identified in 

identified and monitored, and the information can be chapters 3 through 9 of the main report. 

used to recommend appropriate interventions to Recommendations that apply broadly to the 

improve Americans' health. NNMRRP are listed below.

Comparability among the surveys has been improved

since the publication of the second nutrition

monitoring report in 1989. To allow more direct

comparisons among surveys, a common set of

population descriptors and guidelines for statistical

and reporting categories for those descriptors were

recommended by the Interagency Board on Nutrition

Monitoring and Related Research Survey

Comparability Working Group in 1992. A joint

policy on variance estimation and statistical reporting

standards for NHANES III 1988-91 and CSFII 1989-

91 reports was developed by an HNIS/NCHS 

Analytic Working Group in 1993. That group also

developed a set of statistical guidelines for reporting

data for the TRONM. As the Expert Consultants and

LSRO reviewed data provided for the TRONM, they

found the use of the common descriptors and

reporting categories vital for comparing results across

surveys. Use of these common entities should

continue, and further consideration should be given to

developing more common descriptors that could be

recommended for across-survey comparisons.

The NNMRRP is still evolving. At various points

during its evolution, expert committees and other

groups have made recommendations for its

General 

Support basic research and epidemiological studies

by Federal agencies and academia or assume the

responsibility to do so in order to maximize the

NNMRRP's usefulness in nutrition and health

monitoring. Conducting basic research or

epidemiological studies to establish or evaluate the

scientific validity of various interpretive criteria of

biochemical and behavioral parameters of nutrition

and health is not a primary mission of the

NNMRRP. However, the interpretation and use of

NNMRRP data for public policy decisions rely

upon the validity of the interpretive criteria. Part 

of the mission of the NNMRRP should be the

development of interpretive criteria. The program

should provide for research to improve

methodology for all aspects of nutritional

assessment, including food composition, food

consumption, biochemical evaluations, and

behavioral indices so that interpretive criteria can 

be based on the best and most current 

methodology. 
ES-34

Develop statistical models to examine relationships Start planning for the fourth report on nutrition

and interactions among the many types of data monitoring immediately. The quantity of data

collected for NNMRRP surveys. generated by the NNMRRP is substantial and the

Encourage and support efforts of agencies that analyses. Early initiation of planning, including a

participate in the NNMRRP to publish survey and sharper focus on topics to be included in the next

surveillance system data in agency reports and comprehensive 5-year report, is critical.

peer-reviewed scientific journals. Although

resources for these activities are limited, making

data available in a timely fashion to the public, the

scientific community, and for public policy

consideration is an essential component of the

NNMRRP. The agencies should also release the

primary data (i.e., reports and data tapes) to the

research community as quickly as possible.

Conduct special studies of high-risk population

subgroups (e.g., American Indians, pregnant

females, and migrant populations) concurrently with

national surveys using comparable data-collection

methodologies.

Develop, standardize, and disseminate nutrition

methodologies for comparable use at national, 

State, local, and community levels to allow for

appropriate data comparisons. 

Improve the system for the electronic transfer of

nutrition survey data to data base users. This

capability enhances the States' abilities to use

NNMRRP data. Consideration should be given to

implementing a system in which States can obtain

NNMRRP data that pertain to their specific needs. 

Any system for electronic data transfer must 

require strict adherence to quality-control criteria 

for inclusion of data and would have to include

protection against change by unauthorized

individuals or organizations. 

Support the development of a comprehensive

catalog of the types of data and analyses available

from all surveys and surveillance systems of the

NNMRRP. Such a catalog should be patterned 

after the Catalog of Electronic Data Products. The

currently available Nutrition Monitoring in the

United States: The Directory of Federal and State

Nutrition Monitoring Activities could be expanded

or supplemented by a more comprehensive listing 

of data that are available on tape, diskette, or CDROM or as published reports. Such a

comprehensive source document on the entire

NNMRRP would be quite valuable to research

investigators, State agencies, and others.

data are complex, requiring careful planning of

National food-supply determinations and

household-based food expenditures

Continue to collect reliable food-supply data from a

variety of government and private sources and to

calculate estimates of the total available food

supply, per capita consumption, and nutrient

availability annually.

Continue to collect and analyze data on household

food use and expenditures for food at home,

including preprepared foods (foods purchased in a

ready-to-eat form and taken home for 

consumption).

Continue to gather information on the amount of

money spent for food away from home. Expand

efforts to capture information for food away from

home by type of food item and by facility where

food is eaten (e.g., school cafeteria, restaurant with

counter service, restaurant with waiter-waitress

service, and vending machine).

Food composition and nutrient data bases

Develop acceptable assay methods that are faster

and less expensive than current methods. Efforts

should involve coordination with the food industry

and other groups to increase the accuracy of

methods, improve data quality, and make food

composition data more accessible.

Enhance communication between government and

the food industry so that the development of food

composition methodologies used for food-safety

and food-labeling (i.e., regulatory) purposes and

those used to generate food composition data for

food composition data bases can be coordinated.

Such coordination should allow for greater use of

brand-specific information in the Survey Nutrient

Data Base.
ES-35

Improve and expand food composition data for Support research to determine the extent of

total fat, fatty acids including trans fatty acids, fat underreporting of food consumption that occurs in

substitutes, dietary fiber, vitamin A, carotenes, nutrition surveys, improve food consumption

vitamin C, folate, sodium, copper, cholesterol, total survey methodology and instruments that minimize

carbohydrate, and sugars. Incorporate food underreporting, and develop analytic approaches to

composition data for selenium into the Survey adjust for underreporting.

Nutrient Data Base.

Continue to collect and compile food composition food insufficiency in future nutrition monitoring

data for analytical research purposes and to use, surveys. Identify groups within low-income and

develop, and maintain nutrient data bases for other populations at risk for food insufficiency and

estimating nutrient intakes from food consumption examine factors that influence the development of

surveys. Maintain the USDA Nutrient Data Base food insufficiency.

for Standard Reference and the Survey Nutrient

Data Base as two separate entities because their

data are used in very different ways. 

Continue to develop a survey nutrient data base for

trend analysis that will permit food composition

data added in the future to be used to analyze food

consumption data collected earlier.

Create and maintain a product-specific data base for

the nutrient composition of dietary supplements so

that nutrient intakes from supplements—as well as

from foods—can be analyzed.

Food consumption and nutrient intakes 

Continue monitoring foods consumed by

individuals to examine differences in food

consumption patterns among population subgroups

and to track progress toward meeting Healthy

People 2000 objectives and adopting dietary

recommendations in the Food Guide Pyramid and

the Dietary Guidelines for Americans.

Monitor nutrient intakes from foods and from

dietary supplements.

Support research to determine the mean and

variance of requirements for each nutrient. This

information is needed to adequately assess the risk

of dietary inadequacies and excesses in the U.S.

population.

Support research to determine whether nutrient

requirements of population subgroups differ. Give

higher priority to groups at nutritional risk and

whose numbers are increasing in the population,

such as elderly people.

Continue monitoring the magnitude and severity of

Nutritional status and nutrition-related health

status

Continue monitoring indicators of nutritional status,

including anthropometric, biochemical,

hematologic, and clinical measures, and of

nutrition-related health conditions, including low

birth weight, growth status in children, overweight

in adults, serum lipids, hypertension, osteoporosis,

and anemia. Monitoring efforts should not be

restricted to these conditions and should continue to

include other diseases that have a nutritional

component, such as diabetes mellitus, dental

conditions, and gallbladder disease. 

Develop interpretive criteria to link nutrition

monitoring data to functional or health outcomes.

Conduct studies to improve the validity of

biochemical and other methodologies used to assess

nutritional status and nutrition-related health status.

Explore links between nutritional status, particularly

anthropometric indicators, and food insufficiency.

In future nutrition monitoring reports, nutrition

monitoring assessments should be based on health

conditions and intakes of nutrients of public health

concern.

Knowledge, attitudes, and behavior

assessments

Continue coordination among Federal agencies to

enhance the collection and use of survey data on 

diet, nutrition, and health-related knowledge,

attitudes, and behavior. Such efforts help reduce
ES-36

information gaps and duplication of effort, identify

and prioritize monitoring needs, and strengthen the

links between national surveys and programs that 

use these data for program planning and evaluation.

Collect information on people's perceptions of 

dietary and nutrition issues and of health-related

behaviors to improve approaches to translating

knowledge into action. Determine the perceived

internal and external barriers that keep people from

adopting and maintaining healthier food and lifestyle choices.

Establish better measures to evaluate physicalactivity levels in children, adolescents, and adults.

Identify and monitor factors that contribute to the 

low levels of physical activity in the general

population and in population subgroups and factors

that influence people to become more active and to

maintain more active life-styles.

Collect in-depth information from consumers on 

their use and understanding of information on the

food label, and analyze the data for the general

population and for population subgroups. For

nutrition monitoring purposes, focus on the impact 

of the food label's nutrition panel on food 

purchases and consumption, on what specific

information on the nutrition panel is used and 

found to be valuable, on where food-label

information is used (at home and/or in the

supermarket), and on the effect of food-label use on

subsequent food purchases. Treatment of High Blood Pressure. 1993. The Fifth Report of the

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Expert Panel on Detection, Evaluation, and Treatment of High 

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The Second Report of the Expert Panel on Detection, Evaluation, 

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DHHS Publication No. (PHS)93-1255-2. Public Health Service,

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Figure notes

Figure ES-4. "Overweight" was defined for males as body mass

index (BMI) 27.8 kg/m and for females as BMI 27.3 kg/m . 

2 2

Pregnant females were excluded from analyses.

Figure ES-5. Percentages for children 2-5 years of age were 

based on weight for height greater than the NCHS growth chart

95th percentile for age (Hamill et al., 1979). Percentages for

children and adolescents 6-19 years of age were based on body

mass index greater than the NHANES I 95th percentile for age

(Must et al., 1991). Excludes pregnant females. 

Figure ES-6. "None" was defined as no physical activity in the

past month. "Irregular" was defined as any physical activity or 

pair of activities done for <20 minutes or fewer than 3 times per

week. "Regular" was defined as any physical activity or pair of

activities done for 20 minutes 3 or more times per week at 

<50% of functional capacity. The HP2000 definition for 

"vigorous physical activity" is any rhythmic, repetitive physical

activity that uses large muscle groups at 60% of maximum heart

rate for age 3 or more days per week for 20 minutes per 

occasion. Maximum heart rate for age equals roughly 220 beats

per minute minus age.

Figure ES-7. "Vigorous physical activity" was described to

respondents as hard exercise done for at least 20 minutes that

causes one to breathe heavily and makes the heart beat fast

(e.g., playing basketball, jogging, fast dancing, and fast 

bicycling).
ES-38

Figure ES-8. "Overweight" was defined for males as body mass

index (BMI) 27.8 kg/m and for females as BMI 27.3 kg/m . 

2 2

Excludes pregnant females. An asterisk (*) indicates a statistic 

that is potentially unreliable because of small sample size or 

large coefficient of variation. 

Figure ES-9. "Overweight" was defined for males as body mass

index (BMI) 27.8 kg/m and for females as BMI 27.3 kg/m . 

2 2

Male and female respondents had a measured BMI <27.8 and 

<27.3 kg/m , respectively. Excludes pregnant females. 2

Figure ES-10. An asterisk (*) indicates a statistic that is 

potentially unreliable because of small sample size or large

coefficient of variation.

Figure ES-11. "Hypertension" was defined as systolic blood

pressure 140 mm Hg, diastolic blood pressure 90 mm Hg, or

under current treatment for hypertension with a prescription

medication. Excludes pregnant females.

Figure ES-13. Data are based on boneless, trimmed equivalent.

Figure ES-15. "Fruit juices" includes citrus juices (orange,

grapefruit, lemon, and lime) and noncitrus juices (apple, grape, 

and prune).

Figure ES-19. Data were collected from low-income, high-risk

pregnant females who participated in government-funded prenatal

nutrition and food-assistance programs. Measured height and

prepregnancy weight were used to calculate body mass index

(BMI). Prepregnancy weight categories, as specified for this

analysis, were very underweight (BMI 10.0-17.9 kg/m ), 2

underweight (BMI 18.0-19.7 kg/m ), normal weight (BMI 2

19.8-27.3 kg/m ), overweight (BMI 27.4-31.0 kg/m ), and very 2 2

overweight (BMI 31.1-74.9 kg/m ). 2

Figure ES-20. Whenever nutrient intake data were available from

surveys, they were used and evaluated by established criteria. 

When survey data were not available, Total Diet Study data were

used and evaluated by established criteria. Dashed lines indicate

less likely outcomes.

Acronyms and abbreviations

ARS: Agricultural Research Service, USDA

BMI: body mass index

BRFSS: Behavioral Risk Factor Surveillance System

CDC: Centers for Disease Control and Prevention, HHS

CES: Consumer Expenditure Survey

CSFII: Continuing Survey of Food Intakes by Individuals

DHKS: Diet and Health Knowledge Survey 

DOD: U.S. Department of Defense

DOL: U.S. Department of Labor

ESADDI: Estimated Safe and Adequate Daily Dietary Intake

FASEB: Federation of American Societies for Experimental 

 Biology

FDA: Food and Drug Administration, HHS

HANES: Health and Nutrition Examination Survey

HHANES: Hispanic Health and Nutrition Examination Survey

 1982-84

HHS: U.S. Department of Health and Human Services

HNIS: Human Nutrition Information Service, USDA

 (now part of ARS, USDA)

IBNMRR: Interagency Board for Nutrition Monitoring and

 Related Research 

LSRO: Life Sciences Research Office, FASEB

NCHS: National Center for Health Statistics, CDC, HHS

NFCS: Nationwide Food Consumption Survey

NHANES I: first National Health and Nutrition Examination

 Survey (1971-74)

NHANES II: second National Health and Nutrition Examination

 Survey (1976-80)

NHANES III: third National Health and Nutrition Examination

 Survey (1988-94)

NHES: National Health Examination Survey

NLEA: Nutrition Labeling and Education Act of 1990

NNMRRP: National Nutrition Monitoring and Related Research

 Program

NSFG: National Survey of Family Growth

PedNSS: Pediatric Nutrition Surveillance System

PNSS: Pregnancy Nutrition Surveillance System

RDA: Recommended Dietary Allowance

TRONM: Third Report on Nutrition Monitoring in the 

 United States

USDA: U.S. Department of Agriculture

YRBS: Youth Risk Behavior Survey