Update on nutrition monitoring activities in the United States

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in nUnl States MARIE FANELLI KUCZMARSKI, PhD, RD; ALANNA MOSHFEGH,MS, RDL RONETTE BRIEFEL, DrPH, RD

ABSTRICT This article provides an overview of planned and proposed nutrition monitoring activities of the National Nutrition Monitoring and Related Research (NNMRR) Program. Key provisions of the NNMRR Act of 1990 are described, including the roles and responsibilities of the Interagency Board of Nutrition Monitoring and Related Research (IBNMRR) and the National Nutrition Monitoring Advisory Council and the development of the Ten-Year Comprehensive Plan. The Plan, which was developed under the guidance of the IBNMRR and reviewed by the National Nutrition Monitoring Advisory Council, is the basis for planning and coordinating the monitoring activities of 22 federal agencies. Also discussed are the resources generated from nutrition monitoring activities, from publications to conferences, that are available to dietitians and nutritionists. Professionals view the scientific reports that describe the nutritional status of the US population and the directories of federal and state monitoring activities as valuable resources. Suggestions from users of nutrition monitoring data related to their information and research needs have been extremely helpful to federal agencies in the development of future monitoring publications and the Ten-Year Comprehensive Plan. Continued communication between dietitians and the federal agencies responsible for the NNMRR Program is

he National Nutrition Monitoring and Related Research (NNMRR) Act of 1990 (Public Law [PL] 101-445) was signed into law by President George Bush on October 22, 1990 (1). Nutrition monitoring and related research are defined as those activities necessary to provide timely information about the contributions of food and nutrient consumption and nutritional status to the health of the US population (1). The NNMRR Program is composed of interconnected federal and state activities that provide information about the dietary and nutritional status of the US population; conditions existing in the United States that affect the dietary and nutritional status of individuals; and relationships between diet and health. Activities are categorized into five measurement components: nutrition and related health measurements; food and nutrient consumption; knowledge, attitudes, and behavior assessments; food composition and nutrient databases; and food supply determinations. Nutrition monitoring involves regular data collection and linkages with policy making and research (Figure 1). Monitoring provides information and databases for public policy decisions related to nutrition education; public health nutrition programs; food assistance programs; the regulation of fortification, safety, and labeling of the food supply; and food production and marketing. More specifically, nutrition monitoring data have been used to develop the Dietary GuidelinesforAmericans (2) and the Thrifty Food Plan (3), to evaluate progress towards achievement of the 1990 Health. Objectivesfor the Nation (4), and to

important. JAm, Diet Assoc. 1994; 94:753-760. M. F. Kuczrtarski is an associateprofessor i the Departtment of Nutrition and Dietetics, University of Delaware, Newark. A. Moshfegh is the directorof the Office of Policy Coordinationand Special Projects, Human Nutrition Information Service, US Departrentof'Agriculture, Hyattsville, Md. R. Briefel is the coordinatorfbrNutritir/on Monitoring and Related Research, National Ceter.for Health Statistics, CentersforDisease Control and Prevention, Department ofHealth and Hunman .Serovices, Hyattsville, Md. Address correspondence to: M. F Kucznmarski, PhD, RD, 31 7Alison Hall, Department of Nutrition and Dietetics. University of Delaware, Newark, DF 19716. ,J()URNAL OF THE AMERICAN DIETETIC ASSOCIATION / 753

PPECIR IV

PACTICE.

NNMRR ACT OF 1990 PL 101-445 required the establishment of an Interagency Board for Nutrition Monitoring and Related Research (IBNMRR) and a National Nutrition Monitoring Advisory Council, and the development and implementation of a Ten-Year Comprehensive Plan for a coordinated program (1). Section 103 of PL 101-445 specifically lists the minimum components and requirements of the Plan ( ).

FIG 1. Relationships among nutrition policy making, research, and monitoring.

develop the nutrition and health objectives in Healthy People 2000: National Health Promotion and Disease Prevention Objectives (5). As shown in Figure 1, nutrition monitoring data are also vital for the identification of health and nutrition research priorities of public health importance. For example, monitoring data can be used to establish areas needing further research before revising the Recommended Dietary Allowances (6) and to establish the distribution of values for indicators of nutritional and health status in the population. The purposes of PL 101-445 are to strengthen and improve the NNMRR Program (Titles I and II), to foster nutrition education, and to mandate the publication of the Dietary Guidelinesfor Americans every 5 years (Title III). This article provides a brief overview of nutrition monitoring milestones in the United States; presents the key provisions of Titles I and II of PL 101-445, including a description of the federal infrastructure and role of the National Nutrition Monitoring Advisory Council; and highlights federal efforts to interact with users of nutrition monitoring data. NUTRITION MONITORING MILESTONES IN THE UNITED STATES: 1892 TO 1993 Nutrition monitoring activities in the United States date back to 1892 when the US Department of Agriculture (USDA) funded food composition research (7). National dietary surveys were begun in the 1930s. Over the past 60 years, nutrition monitoring activities have been progressively expanded. Today, efforts to monitor dietary and nutritional status in the United States are probably better than those in any other nation. Approximately 45 surveys and surveillance systems will provide nutrition monitoring data and information over the next decade (Table) (8,9). With the expansion of nutrition monitoring surveys, there is an increased need for improved coordination and integration of activities to produce an effective program. Increased efforts to improve and coordinate nutrition monitoring activities have occurred since the late 1970s. Milestones of national nutrition monitoring activities from 1977 to 1993 are provided in Figure 2. A discussion of the milestones has been published elsewhere (10). 754 / JULY 1994 VOLUME 94 NtUJMBER 7

Interagency Board for Nutrition Monitoring and Related Research Title I of the NNMRR Act of 1990 establishes several mechanisms to ensure the collaboration and coordination of federal agencies and state and local governments involved in nutrition monitoring activities. As specified in this Act, the secretaries of the USDA and Department of Health and Human Services (DHHS) have joint responsibility for the implementation of the program and the transmission of required reports to Congress via the President (Figure 3). The assistant Secretary for Food and Consumer Services of the USDA, and the assistant Secretary for Health of the DHHS, have the responsibility of implementing the program and serving as cochairpersons for the IBNMRR. This Board was established in 1991 through the expansion of membership of the Interagency Committee on Nutrition Monitoring. The 22 member agencies of the IBNMRR are listed in Figure 3. As presented in Figure 3, the IBNMRR, similar to its predecessor the Interagency Committee on Nutrition Monitoring, serves as the central coordination point for the federal government's nutrition monitoring program. According to PL 101-445, this Board is required to meet on a regular basis and to coordinate the preparation of various reports to Congress. These include the scientific reports that describe the nutritional ad health status of Americans, the biennial progress reports that include policy implications of scientific findings based on nutrition monitoring data, and the annual budget report (1). To complete the required activities, and to provide a mechanism for increased communication and collaboration among member agencies, the Board has staffworking groups to address selected topics. Currently, there are three IBNMRR working groups: Survey Comparability, Food Composition Data, and Federal-State Relations and Information Disseminationand Exchange. National Nutrition Monitoring Advisory Council The establishment of a National Nutrition Monitoring Advisory Council was stipulated in Title II of PL 101-445. This Council is composed of the cochairpersons of the IBNMRR who are exofficio members, and nine nonfederal members with expertise in the areas of public health, nutrition monitoring research, or food production and distribution. Five members are appointed by the President and four are appointed by Congress. The Speaker and minority leader of the House of Representatives, and the president pro tempore and the minority leader of the Senate each appoint one member. Of the four current members of the Council, three are registered dietitians (Shiriki K. Kumanyika, PhD, MPH, RD; Sue Greig, MS, RD; and Sheryl Lee, MPH, RD). The Council's task is to provide scientific and technical advice on the development and implementation of the coordinated program and the Ten-Year Comprehensive Plan and to serve in an advisory capacity to the secretaries of the USDA and the DHHS (1). The Council is required to report to the secretaries annually on the effectiveness of the NNMRR Program, including recoimmendations for enhancing its effectiveness (1). Ten-Year Comprehensive Plan The Comprehensive Plan is the basis for planning and coordinating activities that complement ad expand ongoing activities of the 22 federal agencies represented on the IBNMRR. The goal of

Table Nutrition monitoring surveys and activities: 1992-2002a Dateb

Department

Agency

Nutrition and related health measurements CDC/NCHS DHHS 1988-94

Survey

Target US population

Third National Health and Nutrition Examination Survey (NHANES III)

US noninstitutionalized, civilian population, aged 2 months or older; oversampling of blacks and Mexican Americans, children up to age 5 years, and individuals aged 60 years and older

1988-94

DHHS

CDC/NCHS, NIH/NIA

NHANES IllSupplemental Nutrition Survey of Older Persons

Individuals aged 50 years and older examined in NHANES III, in households with telephones

1991-92

DHHS

IHS

Navajo Health and Nutrition Survey

Persons aged 12 years and older residing on or near the Navajo reservation inArizona, New Mexico, and Utah

1992

DHHS

CDC/NCHS

National Home and Hospice Care Survey

A sample of home health agencies and hospices along with a subsample of patients

1992

DHHS

CDC/NCHS

NHANES I Epidemiologic Followup Survey

1992

DHHS

CDC/NCHS, NIH/NCI

NHIS on Cancer Epidemiology and Cancer Control

DHHS

CDC/NCHS

National Health Interview Survey (NHIS)

Civilian, noninstitutionalized individuals

DHHS

CDC/NCHS

National Hospital Discharge Survey

Discharges from nonfederal general and shortstay specialty hospitals

DHHS

CDC/NCHS

Vital Statistics Program

--

Individuals examined in NHANES I who were 25-74 years old at baseline --

Annual

Individuals aged 18 years and older --

0

Annual Continuous c

Total US population --

c

DHHS

CDC/NCCDPHP

Pregnancy Nutrition Surveillance System

Low-income, high-risk pregnant women

Continuous c

DHHS

CDC/NCCDPHP

Pediatric Nutrition Surveillance System

Low-income, high-risk children from birth to 17 years

Annual'

DHHS

CDC/NCHS

National Ambulatory Medical Care Survey

Office visits to nonfederal, office-based physicians

1992 (continuous)

DHHS

CDC/NCHS

NHANES II Mortality Followup Survey

Individuals examined in NHANES II who were 35-75 years old at baseline

1992 (continuous)

DHHS

CDC/NCHS

Hispanic Hanes (HHANES) Mortality Followup Survey

Individuals interviewed in HHANES who were 20-74 years old at baseline

1992 (annual)

DHHS

CDC/NCHS

National Hospital Ambulatory Medical Care Survey

Visits to hospital emergency and outpatients departments of nonfederal, short-stay, general and specialty hospitals

1992 (continuous)

DHHS

CDC/NCHS

NHANES IllLongitudinal Followup Survey

Individuals interviewed and examined in NHANES IIIwho were aged 20 years or older at baseline

1993

DHHS

CDC/NCHS

National Mortality Followback Survey

Individuals aged 25 years and older

1994

DHHS

NCHS

National Survey of Family Growth

Women aged 15 to 44 years

1994 (continuous)

DHHS

CDC/NCCDPHP

Adult Nutrition Surveillance System

Adults aged 18 years and older who were participating in local public health programs

1995

DHHS

CDC/NCHS

NHIS on Health Promotion/Disease Prevention

Individuals aged 18 years and older

1995

DHHS

CDC/NCHS

NHANES I Epidemiologic Followup Study

Individuals examined in NHANES I who were 55 to 74 years old at baseline

(1997 +)

DHHS

CDC/NCHS

National Health and Nutrition Examination Survey ) (NHANES 1997 +

US noninstitutionalized population

Continuous

--

Continued on page 756 JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION / 755

PESPCTIVES N PRAICTICE

Table (cont'd) Nutrition monitoring surveys and activities: 1992-2002a Dateb

Department

Agency

Survey

Target US population

Food and nutrient consumption 1988-94

DHHS

CDC/NCHS, NIH/NIA

NHANES IIIand NHANES IIISupplemental Nutrition Survey of Older Persons

See the first and second listings in the Nutrition and Related Health Measurements section

1991-92

DOC

NMFS/NOAA

Development of a National Seafood Consumption Survey Model

Individuals residing ineligible households and recreational/subsistence fishermen

1992

USDA

FNS

School Nutrition Dietary Assessment Study

School-aged children ingrades 1 through 12

1992

USDA

FNS

School Food Authority Menu Modification Demonstration Projects

Students in elementary schools

1992

USDA

FNS

Adult Day Care Program Study

Adult day care centers and adults participating and not participating inthe Child and Adult Care Food Program

Annual

DHHS

FDA

Total Diet Study

Representative diets of specific age-sex groups

Continuous

DOD

USARIEM

Nutritional Evaluation of Military Feeding Systems and Military Populations

Enlisted personnel of the Army Navy, Marine Corps, and Air Force

Continuous

DOL

BLS

Consumer Expenditure Survey

Civilian, noninstitutionalized population and a portion of the institutionalized population inthe United States

Continuous

DOC

Census

Survey of Income and Program Participation

Civilian, noninstitutionalized population of the United States

1994-96 (annual)

USDA

HNIS

Continuing Survey of Food Intakes by Individuals (CSFII)

Individuals of all ages residing in eligible households nationwide. Oversampling of individuals in low-income households

(1997+)

DHHS

CDC/NCHS

NHANES 1997+

US noninstitutionalized civilian population

1997-98

USDA

HNIS

Household Food Consumption Survey

Civilian households and individuals residing in eligible households

1997-98

USDA

HNIS

Low-Income Nationwide Food Consumption Survey

Low-income civilian households and individuals residing in eligible households

Knowledge, attitudes, and behavior assessments Biennial' DHHS CDC/NCCDPHP

Youth Risk Behavior Survey

Civilian, noninstitutionalized adolescents, aged 12 to 18 years

1992

DHHS

FDA

Infant Feeding Practices Survey

New mothers and healthy full-term infants from birth to 1 year old

1992

DHHS

FDA

Consumer Food Handling Practices and Awareness of Microbiological Hazards Screener

Individuals aged 18 years and older in households with telephones

1992

DHHS

CDC/NCHS, CDC/NCCDPHP

NHIS on Youth Risk Behavior

Civilian, noninstitutionalized adolescents, aged 12 to 21years

Continuous

DHHS

CDC/NCCDPHP

Behavioral Risk Factor Surveillance System

Individuals aged 18 years and older residing in participating states in households with telephones

Biennial

DHHS

FDA

Health and Diet Survey

Civilian, noninstitutionalized individuals aged 18 years and older inhouseholds with telephones

1994-96

USDA

HNIS

Diet and Health Knowledge Survey

Selected adults aged 20 years and older in households and noninstitutionalized group quarters participating inthe CSFII

Continued on page 757 756 / JULY 1994 VOLUME 94 NUMBER 7

Table (cont'd) Nutrition monitoring surveys and activities: 1992-2002a Dateb

Department

Agency

Survey

Target US population

Food composition and nutrient databases Annual c DHHS FDA

Total Diet Study

Representative diets of specific age-sex groups

Biennialc

DHHS

FDA

Food Label and Package Survey

NA0

Continuous

DHHS

FDA

Langual

NA

Continuous

c

USDA

HNIS

National Nutrient Data Bank

NA

Continuous

c

USDA

HNIS

Survey Nutrient Data Base

NA

NOAA/NMFS

Fisheries of the United States

NA

US Food and Nutrition Supply Series Estimate of Food Available Estimate of Nutrients

NA

ERS HNIS

Food supply determinations Annual c DOC Annual

USDA USDA

aKey: BLS = Bureau of Labor Statistics; CDC = Centers for Disease Control and Prevention; DHHS = Department of Health and Human Services: DOC = Department of Commerce; DOD = Department of Defense; DOL = Department of Labor: ERS = Economic Research Service; FDA = Food and Drug Administration; FNS = Food and Nutrition Service; HNIS = Human Nutrition Information Service; IHS = Indian Health Service; NCCDPHP = National Center for Chronic Disease Prevention and Health Promotion; NCHS = National Center for Health Statistics; NCI = National Cancer Institute; NIA = National Institute on Aging: NIH = National Institutes of Health; NMFS = National Marine Fisheries Service; NOAA = National Oceanic and Atmospheric Administration: USARIEM = US Army Research Institute of Environmental Medicine; USDA = US Department of Agriculture bDate = tentative date. Clnitiated before 1992. dNA= not applicable.

the Plan is "to establish a comprehensive nutrition monitoring and related research program by collecting quality data that are continuous, timely, and reliable; using comparable methods for data collection and reporting of results; conducting relevant research; and efficiently and effectively disseminating and exchanging information with data users" (8, p 32752). More specifically, the Plan includes three objectives at the national level and three at the state and local levels. The national objectives are to provide for a comprehensive NNMRR Program through continuous and coordinated data collection, to improve the comparability and quality of data across the NNMRR Program, and to improve the research base for nutrition monitoring. The state and local objectives are to develop and strengthen state and local capacity for continuous and coordinated data collection that complements national nutrition surveys; to improve methodologies to enhance comparability of NNMRR Program data across federal, state, and local levels; and to improve the quality of state and local nutrition monitoring data (8). For each national objective, activities within the five measurement component areas are delineated. The Comprehensive Plan contains 68 new activities. Timelines for accomplishment of these activities and responsible federal agencies are provided for both the national and state sections in the Plan. SOURCES OF NUTRITION INFORMATION AVAILABLE TO USERS The five nutrition monitoring components provide a considerable amount of valuable information. However, one of the major limitations in taking full advantage of the monitoring data has been the "limited understanding on the part of the nutrition community as to possible and appropriate uses of NNMS [National Nutrition Monitoring System] data" (11, p 1179). Discussions with selected state public health nutrition directors; Cooperative Extension food and nutrition specialists; nutrition and food science faculty; and researchers in human nutrition, public health, and agriculture revealed that they used nutrition monitoring data

from the scientific reports (12,13) to set nutrition, health-related, and research program priorities; to make policy decisions; and to prepare grant proposals, testimonies, and presentations (14). The following section will highlight sources of nutrition monitloring information available to users. Scientific and Technical Reports The Joint Nutrition Monitoring Evaluation Committee, a federal advisory committee, was established in 1983 to prepare the first scientific report on nutrition monitoring. The report, entitled Nutrition Monitoring in the UnitedStates:A ProgressReport from the Joint NutritionMonitoring EvaluationCommittee, was submitted to Congress in 1986 (12). This report contained information on and an assessment of the nutritional status of the US population based on data from the core nutrition monitoring surveys-the Nationwide Food Consumption Survey (sponsored by the USDA) and the National Health and Nutrition Examination Survey (NHANES) (sponsored by the DHHS). This report was the first attempt to compile data from across the monitoring system for use in assessing the dietary and nutrition-related health status of the US population. The Joint Nutrition Monitoring Evaluation Committee reported that the principal nutrition-related health problems experienced by Americans arose from the overconsumption of fat, saturated fat, cholesterol, and sodium (12). Intakes of iron and calcium were inadequate in selected groups of the population. The report also made specific recommendations for improving nutrition monitoring efforts. The second scientific report to Congress, entitled Nutrition Monitoring in the United States: An Update Report on NutritionMonitoringwas published in 1989 (13). At the request of the USDA and DHHS, this report was prepared by the Life Sciences Research Office of the Federation of American Societies for Experimental Biology, and was based on discussions of, and materials drafted by, an ad hoc Expert Panel on Nutrition Monitoring. The report updated the dietary and nutritional status information presented in the 1986 publication (12) and provided ,I(tJRNAI, ()F THE AMERICAN DI:)ETETIC ASSO()(IATON / 757

P C ........................................................... P PECV........................................................... PPECRa 0 pMCTI

FIG 2. Milestones of the National Nutrition Monitoring System.

an in-depth analysis of the contributions of the National Nutrition Monitoring System to the evaluation of the relationship of dietary and nutritional factors to cardiovascular disease and to the assessment of iron nutriture. In accordance with PL 101-445, the USDA and DHHS are to contract a report on the dietary, nutritional, and health-related status of the US population, with the nutritional quality of food consumed in the United States to be published by a nonfederal, scientific body every 2 to 5 years. The third report is planned for publication in 1995. Chartbooks The Nutrition Monitoring Chartbook will be produced intermediate to the scientific reports to Congress by the National Center for Health Statistics (NCHS) of the DHHS and the Human Nutrition Information Service (HNIS) of the USDA. It will highlight and update nutrition monitoring data, information, and research in a user-friendly format. Data will be displayed with graphics and brief narratives. Information in the first chartbook published in 1993 included: dietary intake data from Continuing Survey of Food Intakes by Individuals (CSFII) in 1989 and 1990 and the Hispanic HANES; food supply changes; dietary knowledge and attitudes of the population related to dietary patterns and health behavior; population data on self-reported overweight, attitudes about weight, and weight loss practices; breast-feedingtrends in the population; and progress in developing food composition methods (15). Directories of Nutrition Monitoring Activities As an effort to improve communication among users, the Interagency Commnittee on Nutrition Monitoring published The Directory of FederalNutrition MonitoringActivities in 1989 (16). 758 / JULY 1994 VOLUME 94 NUMBER 7

This Directory contained information on most of the federal nutrition monitoring and related survey and surveillance activities categorized by the five measurement components (nutrition and related health measurements; food and nutrient consumption; knowledge, attitudes, and behavior assessments; food composition and nutrient databases; and food supply determinations). For each activity, the sponsoring agency, date the survey was conducted, purpose, target population, survey design, measures, control variables, accessibility and availability of data, contact person(s), and selected references were provided. The 1989 Directory has been updated and expanded to include state-based nutrition monitoring activities. The Directory of FederalandStateNutritionMonitoringActivitiesis a guide to the survey, surveillance, and related activities that are a part of the NNMRR Program (9). For each national survey or activity, information is provided about the sponsoring agency, purpose of the survey, years the survey or activity was conducted, target population, sample design, data collection methodologies, sample size, response rates, variables measured for descriptive and analytic purposes, persons to contact for further information, and selected key publications. In the state section of the Directory, a listing of the available federally coordinated nutrition monitoring activities (eg, the Pediatric Nutrition Surveillance System and the Behavioral Risk Factor Surveillance System) in each individual state, along with the name of a contact person is provided. This Directory was released in fall 1992. The Directory will be updated and published every 3 years. The Directory also provides information to help individuals obtain nutrition monitoring data tapes and publications. Alisting of all available public release data tapes and instructions for ordering these tapes from the National Technical Information Service is included. Data are available in various electronic forms such as tapes, diskettes, and CD-ROMs, depending on the survey (17). Other Publications and Communication Mechanisms Data from surveys and surveillance activities are published in several forms, including journal articles and government publications. Many of the NCHS reports are part of the Vital and Health Statistics series, which contains more than 500 individual publications grouped by subseries, Advance Data, Monthly Vital Statistics Report, and special publications such as Health US. These reports, as well as articles published in professional and scientific publications, are summarized annually in the NCHS Catalog of Publications (18). This Catalog and the government reports are available through the Data Dissemination Branch of the NCHS. The Nutrition Monitoring Division of the HNIS publishes a series of reports that contain results from the Nationwide Food Consumption Survey and CSFII. In addition, HNIS is responsible for the series of reports describing the nutrient content of foods, including the Composition ofFoods-Raw, Processed,Prepared: AgriculturalHandbookNo. 8, and theNutritiveValue ofFoods

(Home and Garden Bulletin No. 72). A comprehensive listing of these reports is published in the catalog of machine-readable data sets (19). This catalog is available through the Survey Statistics Branch of the HNIS. The HNIS also sponsors the Nutrient Data Bank Bulletin Board. This electronic bulletin board provides information about current HNIS publications and computer files on the nutrient composition of foods to the general public free of charge (20). The information is presented in the form of bulletins that can be viewed directly or saved on disk for review. Small data files of current publications are also available to download for use on computers. These include data from recently published sections of Agricultural Handbook No. 8, USDA's Nutrient Data Base for Food Consumption Surveys, and Improving Comparability in the National

FIG 3. Structure offirderal coordination of the NationalNutrition Monitoringand Related Research Program.

Nutrition Monitoringand Related Research Program:Population Descriptors (available o request from R. Briefel). The information on the bulletin board is also available through the National Science Foundation's Internet system, in cooperation with the University of Maryland. Imrol:ieg Comnpa ability in the NationalNutritionMonitoring and Related Research Program:PopulationDescriptors, produced by the IBNMRR Survey Comparability Working Group in July 1992, will be useful for the Nutrition Monitoring Program to improve comparability across surveys and for data users t.o use in platlinlg and conducting studies and interpreting study data in light of national data collected with comparable methodologies. Detailed background information on nine population descriptors commonly used in nutrition monitoring surveys was assembled and examined to produce recommendations for data collection. Reconmnenclations were made regarding specific questions for gender; date of birth or age; race and ethnicity; education; household and family income; employment or work status; industry and occupation; marital status; and region and urbanization. These recommendations will be periodically reviewed and revised over time.

conferences provide an opportunityfornutrient database generators to communicate with new and experienced users. Speakers from the food industry, academia, and various federal agencies provide updates on issues related to food composition and dietary intake data. The proceedings from each conference are published; a complete listing of these proceedings is available through the Nutrient Data Bank Bulletin Board (20). In addition, a directory of nutrient databases, which is updated periodically is published (21). Both the USDA and DHHS sponsor conferences to help users manage and analyze survey data. For example, HNIS has held a 2day conference focusing on nutrition monitoring resources and NCHS has sponsored workshops on analyzing data from HHANES. Survey data are also disseminated via presentations at scientific and professional meetings and through the NCHS University Visitation Program (22). This program began in 1983 to allow NCHS staff to travel and give presentations appropriate for university seminars, classes, and special programs. The National Nutrition Monitoring Program is one of the many topics listed in the Catalogof liniversityPresentations(22), which is available through I)ata Dissemination Branch of the NCHS.

User Conferences Since 1976, HNIS has supported and served for several years as a sponsor of the National Nutrient Data Bank Conference. Since 1992, the NCHS has also supported this conference. These annual

USER INPUT User input is a valuable resource for federal agencies when planning new activities and publications related to nutrition monitoring. In 1990, representatives from HNIS and NCHS held .I()tURNAL OF' THE AMERICAN DIETETIC ASS()( IATION / 759

informal discussions with a variety of users of nutrition monitoring data (14) to obtain their opinions about the scope and format of the 1986 and 1989 scientific reports to Congress and to determine what they would like to see in the future. Users commented that they wanted a report that contained more graphics, less text, cross-referencing, and extensive bibliographies, and a separate publication of the executive summary (14). Consequently, plans were initiated to develop a nutrition monitoring chartbook. Although not the focus of discussions, many users stated that the Directory was an excellent resource and hoped that it would be continued (14). This input resulted in the recommendation to update the DIirectory every 3 years. During the development of the Ten-Year Comprehensive Plan, input from users was solicited at various stages. The National Center for Health Promotion and Disease Prevention of the Centers for Disease Control and Prevention sponsored a workshop to provide an opportunity for representatives of state and local agencies and organizations, both public and private, to formulate and share ideas to improve nutrition monitoring activities. This workshop provided a forum for identifying current needs and issues in the areas of maternal and child health, chronic disease, hunger advocacy, and industry at the state and local levels. The suggestions and recommendations provided by the participants were published (23) and used in developing the Plan. Sessions were also held at the annual meetings of The American Dietetic Association and the American Public Health Association to describe the content of the Plan and to allow participants to provide input. Public comments were received in response to the publication of the proposed Plan in the FederalRegister (7). These comments acknowledged the comprehensiveness of this Plan. PI, 101-445 requires that mechanisms employed to identify the needs of users of nutrition monitoring data be established and that the private sector and academic community be encouraged to participate in the development and implementation of the Comprehensive Plan (1). The HNIS and NCHS are planning to sponsor sessions about nutrition monitoring on a continual basis at future professional meetings such as The American Dietetic Association. These sessions will provide users with an opportunity not only to learn about new initiatives and be updated on ongoing activities, but also to provide input. IMPLICATIONS FOR DIETITIANS Nutrition monitoring data are used by many dietitians and nutritionists on a daily basis. Reference standards for weight, height, and growth charts are based on data from the Nutrition Monitoring Program. Currently, the growth charts are being revised using data from the NHANES III. Values for biochemical indicators such as high blood cholesterol levels are based on NHANES distributions. Data on food consumption of the population and subgroups of the population provide dietetics professionals with the information to help them understand trends in food use, dietary patterns, antd nutrient adequacy of diets. The data provided by the USDA on the nutrient composition of foods are critical in planning nutritionally adequate therapeutic diets for patients with nutrition-related conditions and in planning menus for foodservice operations. It is important that dietitians and nutritionists communicate their information and research needs to the federal agencies responsible for the NNMRR Program. Their input may influence the design of future surveys and the content and format of future publications. ·

3rd ed. Washington, DC: US Department of Agriculture, S IDepart ment of Health and Human Services; 1990. Home and Garden Bullet in No. 232. 3. Human Nutrition Information Service. The Thrifty Forod Platn, 198.. Hyattsville, Md: US Department of Agriculture; 1983. 4. The 1990 Health Objectifies for the Nation: A Midcorset Reiee.

Washington, DC: UIS Department of Health and Human Services; 1986. 5. Healthy People 2000: National Health Prom otiol and Di.sease Prevention Objectives. Washington, DC: US Department of Healt;h arnd Human Services; 1991. DHHS (PHS) publication 91-50212. 6. Food and Nutrition Board. Reconrmeurded Dietary Allouonlres. 10th ed. Washington, DC: National Acaderny of Sciences: 1989. 7. Ten-Year Comprehensive Plan for the Nutrition Monitoring and Related Research Program. Federal Register October 29, 1991: 57: 55716-55767. 8. Ten-Year Coinprehensive Plan for the National Nutrition Monitoring and Related Research Program. Federal Register. June 11, 1993; 58:32752-32806.

9. Interagency Board for Nutrition Monitoring and Related Research; Wright J. ed. Nutrition Monitoring in the Ulaited States: The Directory of federalland StateNutritionMonitoringActivities.Hyat tsville,

Md: Public Health Service; 1992. DHHS (PHS) publication 92-1255-1. 10. Kuczmarski MF, Kuczmarski RJ. Nutrition Monitoring in the UJnit.ed States. In: Shils ME, Olson JA, Shike M, eds. Modern Nutrition in lHeallh und Disease. 8th ed. Philadelphia, Pa: Lea &Febiger; 1994:15061516. 11. Calloway W. National Nutrition Monitoring System. .J Ant Diet Assoc. 1984; 84:1179-1180. 12. Nutrition Monitoring in the United States. A Progress Report fiom the Joint NutritionMonitoriugEt 'aluation Cominmittee. Washing-

ton, DC: US department of Health and Human Services, IS departmentt of Agriculture; 1986. DHHS (PHS) publication 86-1255. 13. Life Sciences Research Office, Federation of American Societ;i s for Experimental Biology. NutritionMonitorirng in the United States Anr Lpdate Report onNutritionMonitoring.Washington, DC: US Government Printing Office; 1989. DHHS (PHS) publication 89-1255. 14. Cronin F, Fanelli-Kuczmarski M. Conclusion arnd recommendations related to the format, content, and focus of the interpretive reports to Congress on the dietary and nutritional status of Anmericans. .I Natr Educ. 1993; 25:77-79. 15. Interagency Board for Nutrition Monitoring and Related Research; Ervin B, Reed D, eds. Nutrition Monitoring in the United States. Chartbook 1 Selected Findingsfrom the National NutritionMoni toring and Related Research Programn Hyattsville, Md: Public Health Service: 1993. DHHS (PHS) publication 93-1255-2. 16. Interagency Committee on Nutrition Monitoring. Nutritio Monitoring in the United States. The Directory of Federal Nutrition?, MonitoringActivities. Washington, DC: US Government Printing Office; 1989. DHHS (PHS) publication 89-1255-1. 17. National Center for Health Statistics. Catalog of ElectronicData Products.Washington, DC: National Center for Health Statistics; 1992.

DHHS (PHS) publication 92-1213. 18. Catalog of Publications 1990-1992. Washingtor,

DC: National

Center for Health Statistics; 1993. DHHS (PHS) publication 93-1301. 19. Nutrition Monitoring Division. Muchince-readableData Sets on Composition of Foods and Results Jorn Food Consumption Sur peys. Hyattsville, Md: IS Department of Agriculture; 1992. Administra-

tive report No. 378. 20. Haytowitz DB. Nutrient data resources available from HNIS. In: Murphy SP, cd. 16th National Nutrient DatabankConferevnce Pro ceediigs. New York, NY: The Cbord Group; 1991:39-42. 21. Smith Jl, ed. Nutrient DatabankDirectory. 8th ed. Newark, I)el: University of Delaware; 1992. 22. Catalog of Uiniversity Presertations1990-91. Washington, I)C: National Center for Health Statistics; 1992. DHHS (PHS) publication 921301. 23. I)ivision of Nutrition, National Center for Chronic Disease Prevention and Health Promotion. Report off the State and Local Input Meeting: National Nutrition Monitoring and Related Research

Plan. Atlanta, Ga: US Department of Health and Human Services; 1991. References 1. Pub L. No. 101-445. NationalNutrition Monitoring and Related Research Act of 1990. 136. 2. Nutrition and Your Health: Dietary GuidelinesforAmericans. 760 / JULY 1994 VOLtJME 94 NUMBER 7

Forfurther information regarding NNMRRP activities anred or publicationscontact R. Briefel or A. Moshfegh.