# 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

3RNM EXEC 12/11/95, 9:49 AM 1

# 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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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 1990Dietary 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 males20-74 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 females20-74 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 ofPercent

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 yearsPercent

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% ofPercent

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 notPercent

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.

Fruitswere 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 1990Dietary 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 adultsPercent

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 drinksthan 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 ofPounds

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 transfatty 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 anemiain 1992.Percent LBW

Very Under- Normal Over- Very 0 5 10 15 20 25 Smoker Nonsmoker

Prepregnancy weight weight weight weight under- 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 thinnessamong 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 weightin 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 overweightand a relatively low prevalence of and anemia are often related to maternal diet and thinnesscompared 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 overweightis 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 overweightwas 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

shortnessin 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 cholesterollevels than males in other racial/ethnic or income groups. In 1988-91, non-Hispanic black males and females had higher age-adjusted prevalences of hypertensionthan did non-Hispanic whites or Mexican Americans (table ES-2). Non-Hispanic white and non-Hispanic black females withincomes below the poverty level had higher ageadjusted prevalences of hypertension than did females with higher incomes in these two groups. Hypertensionremains 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 osteoporosisin females50 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 relationshipsthan 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 experiencedfood with low incomes and of black adults reported insufficiencythan 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 intakeswithin the recommended range ( 30% of calories) were somewhat lower than percentages of higher-income and of white adults (table ES-1).

Median calcium intakesfrom 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 intakesfrom 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 medianfolate intakesfrom food that were below recommended values. Pregnant females had lower-than-recommended mean intakes from food offolate, 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 currentpublic 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 TRONM 1

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 Transfatty acids‡ Calcium Fat substitutes‡ Sodium Protein Vitamin A Antioxidant vitamins Vitamin C Vitamin E Carotenes Folate Vitamin B 6 Vitamin B 12 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 transfatty 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 B , and 6 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 B , to replace fat in the diet with sources of complex 12 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 transfatty 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 whethertrans 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 transfatty 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 B have also been laboratory studies has suggested that low selenium 6 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 B nutritional status so that the above RDA values in 1988-91; however, calcium 6 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 B from food were above phosphorus and protein intakes may increase calcium 12 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 intakesof 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
Transfatty 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 theCatalog 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 listingof 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 includingtransfatty 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 fromadopting 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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### ES-37

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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