This chapter first provides background information on the National Nutrition Monitoring and Related Research Program. Then, the objectives, scope, and methodology of our review of current and potential approaches to achieving a model program are described. The chapter concludes with an overview of the organization of the rest of the report. The NNMRRP is a complex system of data collection and research activities, including national surveys, state surveillance activities, and a variety of research programs. Over time, the NNMRRP has developed activities focused on five content areas: (1) food and nutrient consumption; (2) nutritional and health status; (3) dietary knowledge, attitudes, and behavior; (4) food composition; and (5) food supply. As shown in table 1.1, the information produced by these activities is used for a variety of purposes, from supporting basic research on human nutritional needs to informing policy decisions about health, agriculture, and food programs. Table 1.2 lists specific activities managed by the Departments of Agriculture and Health and Human Services, which have major responsibilities for the five areas. Other agencies, including Commerce, Defense, and the Environmental Protection Agency, also participate in the NNMRRP. USDA has major responsibilities for collecting information in all of the content areas except nutritional and health status. USDA gathers data on food and nutrient consumption through two national surveys—the Nationwide Food Consumption Survey (NFCS) and the Continuing Survey of Food Intake by Individuals (CSFII). In the past, NFCS has gathered nationally-representative information on the food consumption behavior of households and individuals. It provides detailed data on household costs for food. One of the major uses for these data is the development of the Thrifty Food Plan, which is the basis for calculating food stamp benefits. Implemented decennially, NFCS suffered from severe response rate problems (less than 40 percent) in 1987-88. As a result, the individual food consumption portion of the NFCS is expected to be dropped in the future. Since the mid-1980s, CSFII has supplemented NFCS by providing regular information on individual dietary intake. The data collected in its most recent implementation (1994-96) will be used to describe both general and low-income populations. The Diet and Health Knowledge Survey (DHKS), which collects data on dietary knowledge, attitudes, and behavior, is a follow-up to CSFII. Together, CSFII and DHKS are intended to inform policies relating to food production and marketing, food safety, food assistance, and nutrition education. The USDA activities focused on food composition and food supply are not surveys. For food composition, USDA gathers data from food industries and other sources on the nutrient content of foods. These data support the dietary surveys by translating the foods consumed into their nutrient components. Food supply is estimated by deducting data on exports, year-end inventories, and nonfood use from data on production, imports, and beginning inventories. HHS is responsible for the National Health and Nutrition Examination Survey (NHANES) and the state-based surveillance systems. These data collection activities provide information on the content areas (1) food and nutrient consumption, (2) nutritional and health status, and (3) dietary knowledge, attitudes, and behavior. Like NFCS and CSFII, NHANES collects data from a nationally-representative sample. However, NHANES’ unique contribution is its use of physical examinations and clinical and laboratory tests as well as traditional survey methods to gather information. NHANES’ data support research on the relationship between diet and health and inform health policy decisions, such as the promotion of cholesterol screening. After two earlier implementations in the 1970s, NHANES has just completed its third administration (1988-94). NHANES has been supplemented by the Hispanic Health and Nutrition Examination Survey (HHANES) in the early 1980s, follow-up surveys of respondents to NHANES I, and follow-up matches of the records from NHANES II to the National Death Index and other vital statistics records. The state-based surveillance systems were set up to provide quick information to states to use in planning and managing nutrition and health programs. They include the Pediatric Nutrition Surveillance System (PedNSS), Pregnancy Nutrition Surveillance System (PNSS), and Behavioral Risk Factor Surveillance System (BRFSS). Participating states collect the data for these systems with technical and other kinds of assistance from HHS. Both PedNSS and PNSS rely on data from clinic records from publicly funded health, nutrition, and food assistance programs, primarily the Special Supplemental Food Program for Women, Infants, and Children (WIC). PedNSS monitors nutritional status among low-income, high-risk children, while PNSS focuses on low-income, high-risk pregnant women, measuring nutrition-related problems and behavioral risk factors associated with low birthweight. In contrast to PedNSS and PNSS, data for BRFSS are gathered through telephone interviews, with respondents (adults 18 years and over) sampled through random digit dialing. In addition to a core set of questions on various health risk factors, BRFSS includes optional modules for the assessment of dietary fat and fruit and vegetable consumption. Other major HHS monitoring activities include the Total Diet Study, which analyzes nutrient and contaminant levels in the food supply; the Food Label and Package Survey, which monitors nutrition labeling practices; and the Health and Diet Survey, which assesses dietary knowledge and practices as they relate to health problems. Although the United States has one of the most comprehensive monitoring programs in the world, several problems with nutrition monitoring activities have been identified over the past two decades. Of key concern has been the lack of coordination and compatibility of different data collection activities. This encompasses differences across surveys in methods for assessing dietary intake and nutritional status, sampling designs, population descriptors and other measures, and the timing and reporting of results. To improve the coordination of federal nutrition monitoring activities and the quality of the data collected, the Congress passed the National Nutrition Monitoring and Related Research Act of 1990 (P.L. 101-445). The act established an Interagency Board, jointly chaired by USDA and HHS, to coordinate activities across the various agencies involved in nutrition monitoring. The Interagency Board was charged with developing a strategic plan that would establish a comprehensive nutrition monitoring and related research program. This plan—known as the 10-year comprehensive plan—was published in the Federal Register on June 11, 1993. It outlines a set of planning activities, including a general time frame and lead agencies for each activity. The activities are organized around six objectives, which are to • provide for a comprehensive NNMRRP through continuous and coordinated data collection; improve the comparability and quality of data across the NNMRRP; improve the research base for nutrition monitoring; • develop and strengthen state and local capacity for continuous and coordinated nutrition monitoring data collection that complements national nutrition surveys; improve methodologies to enhance comparability of NNMRRP data across federal, state, and local levels; and improve the quality of state and local nutrition monitoring data. In addition, an Advisory Council of experts from outside the federal government was created to guide the Interagency Board on scientific and technical matters. (Chapter 3 contains more information on the Interagency Board and its activities.) This is the third and final report in a series responding to a request from the former House Committee on Science, Space, and Technology. The first report reviewed past evaluations of federal nutrition monitoring and examined the progress of the NNMRRP since the passage of the 1990 act. It concluded that (1) a coherent program for nutrition monitoring was not yet in place and (2) although there has been progress in coordinating the program, the 10-year plan is incomplete because it does not include a framework for evaluating current and potential activities or detailed plans for achieving the objectives. Based on a survey of users of nutrition monitoring data, the second report described the purposes for which nutrition data are used and summarized respondents’ suggestions for improving NNMRRP activities. These suggestions, which addressed such issues as the timing of the surveys, their coverage of subpopulations, and the ease with which the data could be used, were consistent with the concerns raised by past evaluations of federal nutrition monitoring and indicated a continued need to address the long-standing problems of federal nutrition monitoring. Completing our response to the Committee’s request, this report builds on our earlier work to meet two objectives: (1) define a model nutrition monitoring program and (2) compare the current system with potential options for implementing the components of a model program in the NNMRRP. Before defining the features of a model program, we first limited our review to three of the five content areas covered by the NNMRRP: (1) food consumption and dietary intake; (2) health and nutritional status; and (3) knowledge, attitudes, and behavior. These three variables were selected for both substantive and methodological reasons. Substantively, the selected elements provide the data that support the planning and evaluation of interventions that directly affect health, such as nutrition education and food assistance programs. A substantive argument could also be made for the inclusion of food composition data, which are used to translate the information on what foods are eaten into estimates of nutrient intake. However, because an earlier GAO project focused on the NNMRRP’s food composition activities, we did not include this in our review. Methodologically, the three selected variables are linked because they rely on data obtained from individuals through surveys and physical examinations. In contrast, food composition information is based on chemical analyses of foods, and food supply is determined from macroeconomic data. Our focus on the components of the NNMRRP that rely on surveys facilitates the comparison of current and potential approaches to achieving a model program.