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The Joint Nutrition Monitoring Evaluation Committee SUSAN WELSH The Joint Nutrition Monitoring Evaluation Committee (JNMEC), es- tablished on October 11, 1983, is a federal advisory committee jointly sponsored by the U.S. Department of Agriculture ([JSDA) and the U.S. Department of Health and Human Services (DHHS). The committee's overall mission is to develop at 3-year intervals a series of reports, prin- cipally intended for Congress, on the nutritional status of the U.S. pop- ulation. Data for these evacuations will be collected by the National Nutrition Monitoring System, and the committee will continue to function as long as it provides the best means of achieving its mission. JNMEC FUNCTIONS The primary function of the JNMEC, as stated in its charter, is to integrate and interpret information from the component parts of the Na- tional Nutrition Monitoring System and to draw conclusions regarding the nutritional status of the U.S. population. This assessment will include a detailed analysis of the nutritional health and dietary status of the general population, analyses of particular subgroups that appear to have nutritional problems or nutrition-related health problems, and discussion of the factors that may influence nutritional health and dietary status. The secondary function of the JNMEC is to assess the adequacy of the National Nutrition Monitoring System. As the committee reviews the nutritional status of the U.S. population and the factors that influence it (its primary function), it will also identify deficiencies, discrepancies, or 7
8 EATING PATTERNS, NUTRITION, AND HEALTH U.S. CONGRESS U.S. Department of Agriculture (USDA) Secretary, / I U5DA Assistant Secretary for Food and Consumer Services Coordinating Officer, Human Nutrition Information Service U.S. Department of Health and Human Services (USDHHS) \ Secretary, USDH HS Assistant Secretary of Health _. . . _. . . , / ~ ~ / JOINT NUTRITION MONITORING EVALUATION COMMITTEE / \ y \r Coordinating Officer, National Center for Health Statistics FIGURE 1 The Joint Nutrition Monitonng Evaluation CommiKee's organizational relationship with the U.S. Department of Agriculture and the U.S. Department of Health and Human Services. unnecessary duplications in the monitoring system. The committee will apprise the USDA and DHtIS of these problems and suggest methods for improvement. JNMEC ORGANIZATION The JNMEC's relationship to USDA and DHHS is shown in Figure 1. The committee members, four nongovernmental experts in nutrition or nutrition-related disciplines, are appointed for 2-year terms by the Assis- tant Secretary for Food and Consumer Services, USDA, and the Assistant Secretary for Health, DHHS, who jointly chair the committee. Both de- partments provide staff support. The USDA Human Nutrition Information Service (lINIS) provides an official to act as Executive Secretary of the committee and to coordinate the provision of information from USDA's nutrition-monitoring efforts. The DHHS National Center for Health Sta- tistics (NCHS) provides an official to assist in fulfilling the responsibilities of the secretariat and to coordinate the provision of information from DHHS's nutrition-monitonug efforts.
JOINT NUTRITION MONITORING EVALUATION COMMITTEE 9 During its first year of existence, the committee was cochaired by USDA's Assistant Secretary for Food and Consumer Service, Mary C. Ja~Tatt, and by DHHS's Assistant Secretary for Health, Edward N. Brandt, Jr.~ The duties of He INMEC members are solely advisory. The USDA and DHHS staffs provide to the committee information from department- conducted surveys and studies. Following its evaluation of this informa- tion, the committee will report, through the USDA Assistant Secretary for Food and Consumer Services and the DHHS Assistant Secretary for Health, to the Secretary of Agriculture and the Secretary of Health and Human Services. The appropriate USDA and DHHS clearance channels will be used. When final, the reports will be issued jointly by USDA and DHHS to Congress. Fiscal and administrative support for the JNMEC was assumed within existing USDA and DHHS programs. No additional resources were al- lotted to USDA or DHHS for support of the JNMEC. Nongovernmental committee members serve without pay, and USDA and DHHS share committee members' travel expenses and costs of publishing and distrib- uting reports. (For the first report, USDA will Dav Gavel expenses and DHHS will pay publication costs.) HISTORY OF THE JNMEC ~ J ~ r The Food and Agriculture Act (U.S. Code, 1977) instructed the Sec- retary of Agriculture and the Secretary of Health, Education, and Welfare (HEW) (now Heals and Human Services) to submit to Congress a proposal for a comprehensive nutrition status monitoring system that would inte- grate He ongoing nutrition survey activities of both departments. The original proposal, entitled "A Comprehensive Nutritional Status Moni- tonng System" (USDA and DHEW, 1978), acknowledged deficiencies and recommended improvement and expansion of the existing system. The proposal was an important working document for USDA and DHEW, prompting the establishment of various coordinating mechanisms, bow formal and informal, for identifying and managing common areas of con- cern. floe committee members were Helen A. Guthrie, Professor of Nutrition, Pennsylvania State University; Jean-Pie're Habicht, Professor of Nutrition, Cornell University; Stanley R. Johnson, Professor of Economics, Iowa State University; and Theodore B. Van Itallie, Professor of Medicine, Columbia University at St. Luke's Roosevelt Hospital Center. Advisors to the com- niittee were Robert L. Rizek, HNIS, USDA, and Robert S. MuIphy, NCHS, DHHS. DHHS staff support to the committee was coordinated by Catherine E. Woteki, NCHS, DHHS. USDA staff support was coordinated by Susan Welsh, who also served as Executive Secretary.
10 EATING PATTERNS, NUTRITION, AND HEALTH Following submission of the proposal to Congress, the Committee on Science and Technology requested that the General Accounting Office (GAO) review the proposal. Subsequently, GAO (1978) recommended the development of a comprehensive implementation plan, and the House and Senate of the U.S. Congress also instructed USDA and DHHS to proceed with the plan. Implementation Plan USDA and DHHS submitted the Joint Implementation Plan for a Com- prehensive National Nutrition Monitonng System to Congress in 1981 (USDA and DHHS, 19811. This plan integrated the nutrition-monitonng goals of USDA and DHHS, explained how USDA's and DHHS's separate nutrition-monitor~ng activities fit together to form a comprehensive mon- itoring system, and set specific objectives for improving the system. Goals and Objectives. The goals of the National Nutrition Monitoring System, as set forth in the Joint Implementation Plan, were: · to provide the scientific foundation for the maintenance and improve- ment of the nutritional status of the U.S. population and of the nutritional quality and healthfulness of the national food supply; · to collect, analyze, and disseminate timely data on the nutritional and dietary status of the U.S. population, the nutritional quality of the food supply, food consumption patterns, and consumer knowledge and attitudes concerning nutrition; 0 to identify high-risk groups of individuals and geographic areas, as well as nutrition-related problems and trends, in order to facilitate prompt implementation of nutrition intervention activities; · to establish national baseline data for the National Nutrition Moni- tonng System and to develop and improve uniform standard methods, criteria, policies, and procedures for nutrition monitoring; and · to provide data for evaluating changes in agricultural policy related to food production, processing, and distnbution that may affect the nu- tritional quality and healthfulness of the U.S. food supply. To achieve these goals, nutrition monitoring includes a variety of mea- surement activities that assess periodically and systematically the health and dietary status of the American people and the factors that may influence health and dietary status. Thus, comprehensive nutrition monitoring is not one simple task, but a complex and interconnected set of measurements. The objectives presented in the Implementation Plan had as their in- tended result the integration of existing components of the nutntion-mon-
JOINT NUTRITION MONITORING EVALUATION COMMITTEE 11 itoring system to form a truly operational, comprehensive monitoring system. The first objective was that USDA and DHHS achieve the best possible coordination between the two largest and most important com- ponents of the system: the Nationwide Food Consumption Survey (NFCS) and the National Health and Nutrition Examination Survey (NHANES). Several specific activities were outlined, the completion of which would greatly improve the coordination of the surveys. The second major objective of the Implementation Plan was the estab- lishment of the JNMEC, a committee that would function as an evaluation and reporting mechanism for the National Nutrition Monitoring System. The USDA Assistant Secretary for Food and Consumer Services and the DHHS Assistant Secretary for Health solicited members for the committee in June 1982. USDA and DHHS prepared the committee's charter and, to comply with the Federal Advisory Committee Act (U.S. Code, 1972), submitted it for review by the General Services Administration and the Office of Management and Budget and published it in the Fedleral Register (USDA, 1983) for public comment. The committee was officially estab- lished in the fall of 1983; six meetings were held during the first year, and all were open to the public with prior announcement in the Federal Register. November 1984 was proposed in the Implementation Plan as a target date for the first report. Despite the diligence of the committee and the commitment of USDA and DHHS, the less than 1 year of preparation time was not sufficient. The committee and the departments are concerned that the first report on the nutritional status of the U.S. population set the proper precedent for future reports. Therefore, the first report is scheduled to be completed late in 1985. FIRST JNMEC REPORT Because the JNMEC is a permanent national advisory committee and will publish reports periodically, the members decided that their first report should focus on baseline, descriptive information on which subsequent reports might build. The information available to the committee for this report includes data collected by the National Nutrition Monitoring Sys- tem, a complex, interconnected set of measurements that comprise five major categories: · health status measurements · food consumption measurements · food composition measurements · dietary knowledge and attitude assessments · food supply determinations
2 EATING PAlTERNS, NUTRITION, AND HEALTH Measurements of health status and food consumption are the primary nutrition-monitoring activities, and information gathered through such ef- forts will be the major focus of the first report. Implicit in these two categories are all related research activities on human dietary needs, survey methodology, physiological measures, biochemical analyses, and stan- dards for assessing dietary and health data. Food composition measurements can be used to convert food con- sumption measurements into information about dietary levels of nutrients, which also may be related to health status measurements. In addition, food composition data are necessary for dietary planning and guidance. All the research necessary for the development of food composition data is implicit in this category. Assessments of nutrition knowledge and attitudes concerning foods provide information on some of the factors that may influence nutritional status and also provide important clues to the best methods for improving nutritional status. This important aspect of nutrition monitoring will be briefly discussed in the first committee report. Food supply determinations provide information on per capita quantities of food available for consumption since 1909. The assessment of trends in the levels of nutrients and other food components in the food supply is an important part of evaluating the nutritional status of Americans and will be included in the first committee report. Other activities that might be classified under one of the five major categories include regular de- terminations of food retail sales patterns and results from special evalu- ations of food programs, such as the Food Stamp Program and the School Lunch Program. Data Sources The primary data sources for the first committee report are the NFCS and NHANES. These two surveys are the cornerstones of the National Nutrition Monitoring System: Their sample sizes are large relative to other federal nutrition-monitoring efforts, and they provide representative pic- tures of diets and major public health problems in the United States. NFCS. The most recent NFCS was conducted by the USDA's Human Nutrition Information Service (HNIS) in 1977-1978.2 A national proba- Information about the NFCS and other USDA nutrition-monitoring activities has been pub- fished. For specific citations, write to the U.S. Department of Agriculture, Human Nutrition Information Service, Federal Building, Room 325-A, lIyausville, MD 20782.
JOINT NUTRITION MONITORING EVALUATION COMMITTEE 13 bility sample of U.S. households was surveyed, and information was collected both on the food used at home by the entire household and on food eaten at home and away from home by individual household mem- bers. Included were the kinds, amounts, and costs of foods brought into a household during a 7-day period and foods actually ingested by house- hold members during a 3-day period. Data also were collected on numerous socioeconomic variables, such as income, education, and participation in food assistance programs; on source of food and eating occasion; and on household members' self-assessment of their diets and health. Beginning in 1935, USDA conducted similar surveys at roughly 10- year intervals. In the first four surveys, information was collected on household food use only. In the last two surveys, information was also collected on the diets of individual household members. In the 1965-1966 survey, 1-day dietary recalls were collected from household members, and in 1977-1978, dietary recall was extended to 3 days. NHANES. The NHANES is conducted periodically by the NCHS.3 In this monitoring activity, representative samples of the U.S. population are surveyed and data are collected from health histories, physical ex- aminations, venous body measurements and biochemical analyses, and a 24-hour dietary recall and food frequency questionnaire. Two surveys have been completed: HANES I, conducted between 1971 and 1974, and NHANES Il. conducted between 1976 and 1980. A Hispanic Health and Nutrition Examination Survey was conducted between 1982 and 1984. Other Activities. In addition to the NFCS and NHANES, both USDA and DHHS have other nutrition-monitonng activities. For example, USDA's HNIS maintains the historical series of the nutrient content of the U.S. food supply as well as the National Nutrient Data Bank a computerized source of food composition data. In its five nutrition research centers, USDA's Agricultural Research Service conducts basic research on human nutritional requirements and methods for determining food composition. In some states, DHHS's Centers for Disease Control collect information on the health status of persons using public health facilities. The Total Diet Study conducted by DHHS's Food and Drug Administration (FDA) determines levels of selected nutrients and contaminants in diets prepared from standard market baskets of foods in several regions of the county. The FDA and the USDA's Economic Research Service collect 3Inforrnation about the NHANES and other DHHS nutrition~monitoring activities has been published. For specific citations write to Scientific and Technical Infonnation Branch, National Center for Health Statistics, Public Health Service, Hyattsville, MD 20782.
14 EATING PATTERNS, NUTRITION, AND HEALTH information on the public's knowledge and attitudes concerning food. Over DHHS activities include nasality and mortality statistics. Both USDA and DHHS conduct research on methods and standards for nutritional assessment. The quantity and quality of dietary and health data available to the committee for their first report varied among food components and related health conditions. The availability of standards for evaluating the data and the ease of interpreting the data also varied. Table 1 shows the relative completeness of dietary and health data from the major sources of infor- mation used in the report. Food components not listed in Table 1 will not be included in the first JNMEC report because available data were not considered sufficient. PROGRESS USDA and DHHS have made progress toward the goals of the National Nutrition Monitoring System as set forth in the Joint Implementation Plan. It is anticipated that the quantity and quality of dietary and health data and the ease of interpretation will change considerably in the years to come as a result of current research efforts. NFCS and NHANES Two important activities that have led to better coordination between the most important components of the National Nutrition Monitoring Sys- tem the NFCS and the NHANESbegan in 1977. At that time, USDA and DHHS formed the Working Group on Surveys of Food Consumption, Nutrition, and Health and initiated work on the National Nutrition Mon- itoring System. In 1981, USDA and DHHS appointed a committee of statisticians to study coordination of NFCS and NHANES, and in Sep- tember 1982, 9 months after its appointment, the NFCS-NHANES Co- ordination Committee completed its work. Their recommendations for the future, which are currently being implemented, include (1) use of the same coding system; (2) coordination of questions and interviewer instructions and training; (3) use of compatible nutrient data base, sex and age cate- gories, and standards for analyzing data; and (4) use of sampling plans that will ensure the comparability of the data. Under a grant from USDA and DHHS, the Food and Nutrition Board (FNB) of the National Research Council recently published a report on the priority uses of national survey data on food consumption (NRC, 19841. USDA and DHHS are taking into consideration the findings of this
JOINT NUTRITION MONITORING EVALUATION COMMITTEE 15 study, including the recommendations for more effective means of ob- taining data, in planning USDA and DHHS surveys. Methodlology Studies Studies in which venous methods of survey data collection are tested and that ultimately result in improved data are an important part of the research programs of (JSDA and DHHS. In 1982, USDA began two major pilot studies necessary for the development of a continuous survey meth- odology. One study included tests of nine alternative procedures for col- lecting intake data from persons for up to 12 days over a 1-year period. Data were collected by personal interview, telephone, mail, and combi- nations of these methods. The second was a pilot study of these procedures with selected low-income populations. Some findings from these studies have already been incorporated in plans for future surveys, but analyses of all results have not been completed. Other methodology studies have been recently completed or are in progress at several universities under agreements with USDA. For ex- ample, the effect of some of the methodological differences between USDA and DHHS surveys have been studied. Methods for improving the dietary recall process have also been analyzed. In some studies, household food discard and food frequency were measured, and the use of food models and other quantity guides was determined. The association of diet with economic factors is also being studied. In an administrative report now being planned, the results from recent methodological studies con- ducted by USDA will be summarized. Nutritional Status Standards One of the difficulties encountered by USDA and DHHS has been the availability of appropriate standards for the assessment of nutritional status from dietary and health data. The nutrient levels of diets reported in surveys are usually compared to the FNB's Recommended Dietary Allowances (RDA) (NRC, 19801. The nutrient needs of almost all healthy people are met by diets that provide the RDA, but the degree of risk associated with nutrient intakes below the RDA is uncertain. A special committee estab- lished by the FNB and funded by a grant from USDA is examining the methodology for assessing such risks. The committee's report is scheduled for release in late 1985.
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18 Health Status EATING PATTERS, NUTRITION, AND HEALTH The availability and ease of interpreting physiological and biochemical measures of nutritional status also vary. Some measures, e.g., body weight and height, are obtained and interpreted relatively easily and inexpen- sively. Although several available clinical tests of iron nutrition vary in complexity and cost, their interpretation is difficult. For vitamin B6, there are no simple tests of nutritional status, and for many of the trace elements, what should be measured as a test of adequate nutrition is not now known. The prevalence of certain diseases, such as hypertension or diabetes, is easier to measure than the prevalence of other diseases, such as athero- sclerosis or osteoporosis especially in the early stages of development. The FDA has devoted considerable resources to the analysis of data collected in the NHANES program. Three reports have assessed nutritional status related to folacin, iron, and zinc (FASEB, 1984a,b,c). DHHS is also planning a Surgeon General's report on nutrition for l9X6; this report will focus on the relationship between nutrition and disease. Nutrient Composition of Foods Since the last nationwide surveys by USDA and DHHS, information on food composition has increased considerably. In 1977-1978, the nu- trient data base for approximately 4,000 food items contained values for energy and 14 nutrients: protein, fat, carbohydrate, calcium, iron, mag- nesium, phosphorus, vitamin A value (IU), thiamin, riboflavin, niacin, vitamin B6, vitamin Bit, and vitamin C. Since then, USDA's computerized National Nutrient Data Bank has become fully operational, and the fol- lowing additional nutrients and food components will be added to the data base: sodium, potassium, zinc, copper, folacin, cholesterol, total saturated faKy acids, total monounsaturated fatty acids, total polyunsaturated fatty acids, vitamin A as retinal equivalents, carotene as retinal equivalents, alpha-tocopherol equivalents, dietary fiber, and alcohol. Future Surveys Four major nutrition surveys are in various stages of progress or plan- ning. Data collection for DHHS's Hispanic Health and Nutrition Exam- ination Survey was completed in December 1984. This is the first large- scale survey of an ethnic group believed to be at nutritional risk. Plans for DHHS's third NHANES have been initiated, and it is scheduled to begin in 1988. The Continuing Survey of Food Intakes by Individuals (CSFII), a major
JOINT NUTRITION MONITORING EVALUATION COMMITTEE 19 new thrust of USDA's monitoring efforts, began in April 1985. This continuing food consumption survey, which is the first nationwide dietary survey to be conducted yearly in the United States, was recommended in the Joint Implementation Plan (USDA and DHHS, 1981) and in the Re- search Council's report on the uses of food consumption data (NRC, 19841. The survey's objective is to measure the food and nutrient content of U.S. diets over time, to signal changes in food and nutrient intake, and to provide certain other information pertinent to evaluations of nutritional status. It will complement the decennial NFCS by providing continuous data on the dietary status of selected population subgroups, especially those who may be at nutritional risk. The ability to observe trends and anticipate potential problems from the results of the surveys will allow policymakers to formulate sound policies and programs with respect to agriculture, food assistance, nutrition education, and food fortification. For the first year of the CSFlI, the core-monitoring group will consist of women aged 19 to 50 years and their children aged 1 to 5 years in nationally representative samples of all income groups and of low-income groups. Six days of dietary data will be collected on each participant. Women were selected for the core-monitonng group because they are generally household food managers who know most about the food eaten- for example, how it was prepared and the kinds and amounts of ingre- dients. Also, women of childbearing age and young children were among the sex-age categories in the 1977-1978 survey with food intakes that most often failed to provide recommended amounts of nutrients. One day of dietary data will also be collected on a nationally representative sample of males 19 to 50 years of age. Other population subgroups considered to be at nutritional risk may be included in future surveys. USDA's comprehensive decennial NFCS is planned for 1987. In this survey, comparable to NFCS 1977-1978, information will be collected on household food consumption and the monetary value of food as well as on 3-day food intakes of each household member. Nationally repre- sentative samples of households across all incomes and low-income house- holds will be surveyed. Both USDA and DHHS will strive to process He incoming data rapidly. Increased automation of He interview process is planned and under way, and standardized reporting formats that will facilitate comparisons of data from the NFCS and the NHANES will be developed. CONCLUSIONS Increases are anticipated in the quantity and quality of information obtained from the National Nutrition Monitoring System. The staffs of
20 EATING PATTERS, NUTRITION, AND HEALTH USDA and DHHS are committed to this purpose and are working together to achieve common goals. As the amount of information from the com- ponent parts of the Monitonng System increases, He need for a reporting system to integrate and interpret the information will also increase. Efforts to meet this need will be aided by the work of the Joint Nutrition Mon- itor~ng Evaluation Committee. REFERENCES FASEB (Federation of American Societies for Experimental Biology). 1984a. Assessment of the Folate Nutritional Status of the U.S. Population Based on Data Collected in the Second National Health and Nutrition Examination Survey, 1976-1980. Life Sciences Research Office. FASEB Special Publications Office, Bethesda, Md. FASEB (Federation of American Societies for Experimental Biology). 1984b. Assessment of the Iron Nutritional Status of the U.S. Population Based on Data Collected in the Second National Health and Nutrition Examination Survey, 1976-1980. Life Sciences Research Office. FASEB Special Publications Office, Bethesda, Md. FASEB (Federation of American Societies for Experimental Biology). 1984c. Assessment of the Zinc Nutritional Status of the U.S. Population Based on Data Collected in the Second National Health and Nutrition Examination Survey, 1976-1980. Life Sciences Research Office. FASEB Special Publications Office, Bethesda, Md. GAO (General Accounting Office). 1978. Future of the National Nutrition Intelligence System. Staff study, CED-79-5. General Accounting Office, Washington, D.C. NRC (National Research Council). 1980. Recommended Dietary Allowances, 9th ed. A report of the Food and Nutrition Board, National Research Council. National Academy of Sciences, Washington, D.C. NRC (National Research Council). 1984. National Survey Data on Food Consumption: Uses and Recommendations. A report of the Food and Nutrition Board, National Research Council. National Academy Press, Washington, D.C. U.S. Code. 1972. Federal Advisory Committee Act. P.L. 92-463, 86 Stat. 770. U.S. Code. 1977. Food and Agnculture Act of 1977. P.L. 95-113, 91 Stat. 913, Sect. 1428. USDA (U.S. Department of Agriculture). 1983. Joint Nutrition Monitoring Evaluation Com- mittee; Establishment. Fed. Regist. 48:38263-38264. USDA and DHEW (U.S. Department of Agriculture and U.S. Department of Health, Education, and Welfare). 1978. Proposal- A Comprehensive Nutritional Status Monitoring System. Re- port submitted to U.S. Congress, March 6. Available from Human Nutrition Information Service, U.S. Department of Agriculture, Hyattsville, Md. USDA and DHHS (U.S. Department of Agriculture and U.S. Department of Health and Human Services). 1981. Joint Implementation Plan for a Comprehensive National Nutrition Monitoring System. Report submitted to U.S. Congress. Available from Human Nutrition Information Service, U.S. Department of Agriculture, Hyattsville, Md. DHHS (U.S. Department of Health and Human Services). 1981. Alcohol and Health. Fourth special report. National Institute on Alcoholism and Alcohol Abuse, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Md.
