Caballero B. (ed.) Encyclopaedia of Food Science, Food Technology and Nutrition. Ten-Volume Set

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.0088 grip strength;

0089 weight gain as lean tissue;

0090 weight gain as fat tissue;

0091 maximal oxidative capacity;

0092 maximal work capacity;

0093 urinary malonaldehyde excretion;

0094 methyl selenol/methyl trimethyl selenomium ratio

in urine;

0095 pulmonary excretion of volatile hydrocarbons

(ethane or pentane);

0096 peripartum hemorrhage;

0097 sperm count.

The spontaneous function of organs and tissues,

without provoking special handling of substrates or

external stimuli, such as taste acuity and dark adap-

tation, constitute the least invasive and complex, and

the most acceptable (to the person examined) of the

range of functional tests of nutritional status.

0098 Responses at the level of the whole individual or

population

0098 linear growth velocity;

0099 total weight gain velocity;

0100 work productivity and spontaneous play activity;

0101 birthweight;

0102 Apgar score at birth;

0103 infant developmental scale performance;

0104 infant temperament;

0105 cognitive performance;

0106 scholastic performance;

0107 athletic performance;

0108 social competence;

0109 development of secondary sex characteristics;

0110 lactation performance;

0111 fertility rate;

0112 fecundity rate;

0113 infant mortality rate;

0114 disease resistance or susceptibility.

Finally, a series of functions of the whole individual or

the average statistics for a community population can

be used to assess nutritional status, as well as the

impact of improvement or deterioration of health

and dietary conditions on individual or collective

nutriture. However, the more complex and integral

the function, the greater is the number of factors –

both nutritional and nonnutritional – that influence,

mediate, and determine the performance. The quality

of educational materials, the skill and motivation

of teachers, and the state of civil tranquility are

among the covariables that might influence the scho-

lastic performance of children, in addition to the

nutrition of the school population. If the first limiting

factor in scholastic performance lies among these

variables, it is doubtful that any limitation to max-

imal output from malnutrition could be demon-

strated or exposed.

Newer

In vitro

Approaches to Functional

Assessment of Nutritional Status Based

on Molecular Biological (Genomics,

Proteomics) Techniques

0115The decade since the publication of the first edition of

this volume has been marked by dramatic advances in

the molecular biology of characterizing and express-

ing the genetic potential and regulation of the cell at

the level of the genetic code information (genomics)

and the expression of messenger RNA for specific

protein (proteomics). Because nutrients can become

limiting in the basic mechanisms, and can induce or

repress genetic expression, genomics and proteomics

protend a series of approaches to functional assess-

ment:

0116nutritional expression of nutrient-dependent or

nutrient-containing enzymes or proteins;

0117nutritional expression of homeostatic regulatory

protein;

0118nutritional modification of regulatory elements;

0119nutritional pattern of upregulation (or downregu-

lation) of gene expression.

In fact, several laboratories have begun to exploit the

second of these methods, in tests for human zinc

status based on the expression of mRNA for metallo-

thionein, the intracellular binding protein of divalent

metals, in peripheral nucleated blood cells.

Advantages and Disadvantages of

Functional Assessment

Advantages

0120In terms of screening tests in epidemiology and clin-

ical nutrition, functional indices of nutritional status

have potential advantages of noninvasiveness, indi-

vidual accuracy of diagnosis, timeliness and inter-

pretability of nutritional interventions, and policy

relevance.

0121Noninvasiveness Almost by definition, static in-

dices involve the sampling of blood or tissue. Many

of the tests of performance are noninvasive in so far as

no skin punctures or scrapings are involved. This

factor may account for more compliance and cooper-

ation on the part of potential clients or subjects. In an

era of hepatitis B and human immunodeficiency virus

viral endemicity, nonpenetrating procedures are also

welcomed by investigators and laboratory personnel.

4194 NUTRITIONAL ASSESSMENT/Functional Tests

0122 Individual accuracy of diagnosis The supreme ad-

vantage of functional tests is their potential to provide

an accurate diagnosis of status for the individual

patient, client, or subject. However, this can be ac-

complished only through serial testing before and

after a trial of physiological or therapeutic doses of

the nutrient in question. Whereas static indices, or

functional indices measured in a cross-sectional fash-

ion, must be interpreted as normal or abnormal in a

normative fashion, in relation to the distribution in

a standard reference population, functional tests

repeated in the same individual can be assessed with

respect to the degree of incremental change. Thus, an

accurate assessment of status in an individual is

possible. Those with a nutrient-responsive improve-

ment or normalization in a function are truly defi-

cient. For example, consider two persons with the

same dark adaptation threshold, in the highest 10th

percentile of the reference population; both receive a

course of vitamin A therapy, but only one subject

improves. If there is no intrinsic retinal disease in

the latter, we can conclude that the threshold is a

normal variant. In the former, it is a manifestation

of vitamin A deficiency.

0123 Temporal sensitivity in detecting nutritional

deficits Another advantage of the functional test is

the temporal sensitivity in detecting nutritional def-

icits. We generally recognize a hierarchy of sequence

in the stage development of depletion. The earliest

changes are those in nutrient-dependent function

at the peripheral tissue level, often detectable before

the nutrient levels in the tissues themselves have

declined. Thus, between a functional deficit or a

tissue-concentration decline, conventional wisdom

favors the former as the earliest detectable alteration

during nutritional depletion. As noted earlier, the

signs and symptoms of the clinical deficiency syn-

drome appear much later in the course of depletion.

0124 Interpretability of nutritional intervention Demon-

strating the efficacy and effectiveness, that is whether

or not a nutritional intervention, such as the fortifica-

tion of a food, the distribution of a supplement, or the

application of a nutrient-sparing program such as

deparasitization or immunizations, is actually having

an impact, has been the bane of public health nutri-

tion. Even when normative references are used to

determine ‘abnormals,’ in a baseline survey, a marked

shift in the distribution of a population toward a

normal distribution after the implementation of an

intervention can allow success to be interpreted. The

failure to observe any change can be taken as tenta-

tive evidence for a null effect. However, in serial

testing, one must account for any ‘learning effect’ or

spontaneous improvement that would be expected

from prior exposure to, or experience with, the test

procedure.

0125Policy relevance The policy relevance of functional

assessment derives, in part, from the consequence of

the foregoing discussion. For policy-makers, the dem-

onstration that some aspect of performance was im-

proved by a public health intervention generates more

conviction and sustainability than simply showing

that the level of the nutrient had increased in blood,

hair, or urine. It provides a ready answer to the ‘so

what?’ questions that those in charge of legislation or

expenditures for health will ask.

Disadvantages

0126Functional assessment of nutritional status, however,

is not a panacea; there are also notable disadvantages

in their application. These include poor interpretabil-

ity in cross-sectional studies, lack of specificity for

nutritional status, and specific considerations in

young children.

0127Poor interpretability in cross-sectional studies Sta-

tus and functional indices share a common limitation

when the issue is the nutritional interpretation of a

result from a single clinical examination or a cross-

sectional study. This limitation is the difficulty in

accurately separating those with suboptimal nutri-

tional status from those with adequate status by

simple reference to an arbitrary cut-off level. It is a

probabilistic issue in which only a certain level of risk

of pertaining to a truly deficient or truly sufficient

population can be concluded from a single point-in-

time evaluation.

0128Lack of specificity for nutritional status Almost all

of the functions that are measured to assess nutri-

tional status can also be impaired by other (nonnutri-

tional) causes. Thus, in a cross-sectional or single

measurement assessment using a functional index of

nutritional status, it is impossible to be sure that an

impaired or abnormal function is related to nutri-

tional deficiency or to some other pathology or a

genetic abnormality. Moreover, even if a longitudinal

study with supplementation is employed with a func-

tional index, if the person has multiple nutrient defi-

ciencies, and only a single nutrient is supplemented,

the remaining deficits may impair a full recovery of

the functional abnormality.

0129Considerations in young children For obvious

reasons, tests related to reproductive biology are

not applicable to children. Moreover, the use of

radioisotopes in vivo is relatively or absolutely

NUTRITIONAL ASSESSMENT/Functional Tests 4195

contraindicated in young children. Stressful stimuli,

such as vasopressors or electrical conductivity elec-

trodes, or stressful performance challenges, such as

maximal oxidative capacity, should be proscribed

from the assessment of children.

0130 Separating pharmacological from nutritional

effects Even when serial or comparative measure-

ments of a functional outcome are coupled to a

nutrient-intervention format, the interpretation of the

preexisting or prevalent nutritional state must be made

with caution and judgment. What is a ‘nutrient-

responsive’ situation, and what is a ‘nutrient-deficient’

condition? By way of analogy to personal esthetics, the

application of make-up to a physically unattractive

individual can make them ‘presentable.’ The appear-

ance of a person already attractive by consensus stand-

ards can be enhanced with cosmetics to a state of

‘ravishing,’ however. Where are the valid boundaries

to define an ‘esthetic deficit’? Similarly, in household

economy, what constitutes a ‘deficient’ income: when

one cannot afford a Mercedes-Benz car? When one

cannot afford any vehicle? Or when the funds do not

allow for purchase of the basic necessities of food,

clothes, shelter, and care? Additional wisdom and a

grounded philosophical perspective are needed to

differentiate enhancement (nutrient-responsive) from

reversal of true deficits (nutrient-deficiency).

Important Applications of Functional

Status Assessment

Assessment of Risk from Surgery and Other Major

Therapies

0131 Recently, grip strength, i.e., the development of con-

tractive force by the hand musculature, has been

shown to have some bearing on the prediction of

survival or mortality, or the risks of complications in

recovery from surgery or radiation or chemotherapy

in association with static indices of anthropometry,

immune status, and protein concentrations. Tests of

active internal lipid peroxidation, such as the ethane

or pentane breath tests, have theoretical promise as

complementary indices for the prediction of risk of

major therapy of precariously nourished patients.

Evaluation of Public Health Impact of Interventions

0132 Faithful to the spirit of Study Team IX, the 1990s saw

an increasing incorporation of functional assessment

into the evaluation of public health interventions.

Child growth in height and weight is the most com-

monly used variable. Other indicators of interest

in public health nutrition are infection resistance,

lactation performance, fertility, work output, and

mortality. (See Infection, Fever, and Nutrition; Chil-

dren: Nutritional Requirements.)

0133Functional assessment can also be used to gain

inferences for improving the balance of nutrients in

traditional regional diets. As field intervention studies

with supplements of protein and energy failed to

show major functional improvements, but the associ-

ation with animal protein did, the quality of the diet

in terms of micronutrient (vitamin, mineral) malnu-

trition was focused on in the 1980s.

Assessment of Dietary Nutrient Intake

Requirements

0134Functional assessment is gaining a place in the con-

tinued fine-tuning of our knowledge of human nutri-

tional requirements and dietary recommendations.

The dominant concept of where to set the recommen-

dation for the daily intake of a nutrient is at the

amount that will prevent the development of signs

and symptoms of deficiency in the majority or a

population. When possible, the concept of the

amount that supports a specific pool size of total-

body nutrient content has been introduced. Given

that functional alterations are generally the earliest

detectable changes with the onset of depletion, the

logical approach to defining intake requirements of a

nutrient is that level which prevents functional

changes in the majority of a population. As experi-

ence is gained with interpreting and avoiding pitfalls

in the application of functional tests, they will be used

increasingly to refine our present understanding of

what nutrient intakes to recommend to maintain

adequate nutriture. (See Dietary Requirements of

Adults.)

New Frontiers for Functional Assessment

0135Functional indicators of adverse interactions from

excesses or toxicity associated with high doses of

intakes of nutrients for use in nutritional toxicology

have lagged behind the progress in diagnosis of defi-

cient and marginal states. More thought and research

need to go into this domain.

0136The late James Olson has made a pithy distinction

between the functions and actions of constituents in

the diet. The former relate to the essential functions

that define a nutrient. However, at higher doses, these

nutrients begin to have actions to favor health or

prevent disease that go beyond their capacities to

nourish. Bioactive (nutriceuticals, phytochemicals)

compounds in foods such as flavonoids, carotenoids,

etc. have assumed growing interest. Since the chem-

ical nature of the active substances is often unknown,

functional markers seem to be the only variables with

which to assess the status of consumers.

4196 NUTRITIONAL ASSESSMENT/Functional Tests

Conclusions

0137 The clinician, epidemiologist, investigator, and public

health professional – all those involved with

nutritional status diagnosis – should be aware of

functional assessment, its potential, and its limita-

tions. Any approach to nutritional assessment has its

advantages, disadvantages, and limitations. The use

of functional indices of nutritional status tends to be

less invasive, and more client-friendly, than static

assessment tests that seek to measure nutrients

directly in body fluid or tissues.

0138 Impairment of a peripheral nutrient-dependent

function or the body’s response to regulation often

occurs before nutrient levels decline in blood and

tissues, and well before clinical manifestations of de-

ficiency emerge. When coupled to a trial of nutrient

supplementation, the functional approach, unlike the

static approach, can provide a definitive, retrospect-

ive assessment of the original nutritional status of the

host. Functional tests can be classified by the physio-

logical or anatomical system that is measured, or by

the level of investigation of the test. As the nature of

the metabolism and physiological and biochemical

functions of nutrients becomes better understood,

newer strategies to exploit the functional assessment

of nutritional status will be suggested.

See also: Anemia (Anaemia): Iron-deficiency Anemia;

Ascorbic Acid: Physiology; Children: Nutritional

Requirements; Cobalt; Dietary Requirements of Adults;

Epidemiology; Exercise: Metabolic Requirements;

Growth and Development; Immunology of Food;

Infection, Fever, and Nutrition; Lactation: Physiology;

Lactic Acid Bacteria; Premenstrual Syndrome:

Nutritional Aspects; Retinol: Physiology; Scurvy

Further Reading

Calloway DH (1982) Functional consequences of malnutri-

tion. Reviews of Infectious Diseases 4: 736–745.

Chandra RK (1981) Immunocompetence as a functional

index of nutritional status. British Medical Bulletin

37: 89–94.

Chandra RK (2001) Effect of vitamin and trace-element

supplementation on cognitive function in elderly sub-

jects. Nutrition 17: 709–712.

Pollitt E (1996) Timing and vulnerability in research on

malnutrition and cognition. Nutrition Reviews 54:

455–549.

Solomons NW (1985) Assessment of nutritional status:

functional indicators of pediatric nutriture. Pediatric

Clinics of North America 32: 319–334.

Solomons NW and Allen LH (1983) The functional assess-

ment of nutritional status: principles, practices and

potential. Nutrition Reviews 41: 33–50.

Nutritional Management See Elderly: Nutritional Management of Geriatric Patients; Food

Intolerance: Types; Food Allergies; Milk Allergy; Lactose Intolerance; HIV Disease and Nutrition; Hypertension:

Nutrition in the Diabetic Hypertensive; Infection, Fever, and Nutrition; Multiple Sclerosis – Nutritional

Management; Pregnancy: Nutrition in Diabetic Pregnancy

Nutritional Policies See Nutrition Policies in WHO European Member States

NUTRITIONAL ASSESSMENT/Functional Tests 4197

NUTRITIONAL SURVEILLANCE

In Industrialized Countries

K F A M Hulshof, M R H Lo

wik and D C Welten,

TNO Nutrition and Food Research, The Netherlands

Introduction

0001 Especially during the last two decades, evidence has

accumulated that prevailing dietary patterns have ad-

verse health effects. Nutritional assessment has

become an important topic on the health-policy

agenda. This article describes the aim of nutritional

surveillance, the availability and usefulness of nutri-

tional surveillance indicators (especially food con-

sumption), and some trends, risk groups, and risk

areas. Nutrition-related health problems and surveil-

lance systems differ among countries, in particular

between developed and developing countries. This

article deals only with industrialized countries in

Europe, Canada, Japan, Australia, and the USA.

This paper reports the situation in the early 2000s.

Aim of Nutritional Surveillance

0002 As stated by a Joint FAO/UNICEF/WHO Expert

Committee, the objectives of nutritional surveillance

are as follows: to describe the nutritional status of the

population, with particular reference to groups at

risk, to contribute to the analysis of causes for changes

and differences, to promote decisions by governments

on food and nutrition policy issues, to predict future

trends, and to evaluate the effects of nutritional

programs.

0003 The international conference on Nutrition held in

Rome in 1992, adopted a ‘World declaration on

Nutrition’ and a ‘Plan of actions for Nutrition.’ In

this plan, one of the nine action-oriented themes was

‘Assessing, analysing and monitoring nutrition situ-

ations.’ According to these themes, governments

should, among other things: identify the priority of

nutritional problems in their country, analyze their

causes, plan and implement appropriate remedial

situations, and monitor and evaluate efforts to im-

prove the situation. Moreover, as a consequence of

recent adopted directives of the European Union, the

member states have to create systems that will

monitor the use and intake of additives.

0004 As illustrated in Figure 1, nutritional surveillance

ideally provides information on a wide range of

variables, from food availability, distribution and

consumption and nutrient utilization (as reflected in

nutritional status) to, ultimately, health status and

mortality. This results in identification of public

health problems that call for specific action and lead

to nutrition research priorities (both applied and more

fundamental). The data can be obtained from either

existing sources, including administrative data, or

surveys undertaken specifically for surveillance

purposes.

Sources of Dietary Information

0005Insight into dietary patterns is a core target of nutri-

tional surveillance, since this provides a comprehen-

sive basis for nutritional risk assessment. In principle,

three different types of data can be used: food supply

data, data from household consumption surveys, and

data from dietary surveys among individuals. Each

type of data corresponds with a different stage in the

food chain and is obtained by different methods.

Food-supply Data

0006Food-supply data provide information on the type

and amount of food available for human consump-

tion, to the country as a whole. The supply is calcu-

lated in food balance sheets (FBSs), which are

accounts, on a national level, of annual production

of food, changes in stocks, imports and exports, and

agricultural use and industrial use. Food supply is

usually expressed per head of the population in

kilograms per year, or grams per day. The per-capita

consumption of energy and some additional nutrients

is calculated using food composition tables.

0007Food-supply data refer to food availability, which

gives only a crude (overestimated) impression of po-

tential consumption. Food and nutrient losses prior to

consumption, owing to processing, spoilage, trim-

ming and waste, may not be adequately accounted

for. Furthermore, these data provide no information

about the distribution of food among population

groups or districts.

0008International FBSs are prepared and published by

the FAO, the Organization for Economic Cooper-

ation and Development (OECD) and the statistical

office of the Commission of the European Union

(EUROSTAT). The FAO has published FBSs since

1949, also covering the period 1934–1948. Since

1949, FBSs have been compiled on an annual basis

from data supplied by about 200 countries. Informa-

tion is available for all European countries, Australia,

4198 NUTRITIONAL SURVEILLANCE/In Industrialized Countries

Canada, Japan, New Zealand, and the USA. Since

1971, the FAO has included its FBS data in the

Interlinked Computer Storage and Processing System

of Food and Agricultural Commodity Data (ICS).

EUROSTAT publishes FBSs for the 15 member

countries of the European Union. The OECD FBSs

cover, besides several European countries, Australia,

Canada, Japan, New Zealand, and the USA. Al-

though FBSs are compiled in a similar way, they differ

in coverage, food grouping and level of processing of

commodities (e.g., FAO lists 300 food items classified

into 17 food group categories; OECD 70 items in 13

categories) and in nutrient conversion. The FAO and

OECD usually publish summaries of FBSs every 3–5

years, with a lag time of 3–4 years between data

collection and publication. The ICS supplies figures

on magnetic tape, on floppy disk and on Internet

(http://apps.fao.org). EUROSTAT publishes supply

balance sheets in the Agricultural Statistical Year-

book.

0009 In addition to the international FBSs, many coun-

tries publish national FBSs, mostly in statistical year-

books or special statistical publications. For example,

US food-supply statistics are available from 1909

onwards. National FBSs tend to be more up to date.

Owing to different methodologies underlying their

compilation and presentation, these data can differ

from international FBSs.

0010Despite their limitations, FBSs are useful in that

they indicate the (in)adequate aspects of food supply,

provide material for planning food supply (produc-

tion, imports and exports) and give crude indications

of (un)desirable changes in terms of potential (ad-

verse) expected health impact. As a result of their

long history, FBSs are especially used for assessing

trends over time. In contrast to national FBSs, the

international FBSs can be used for comparative stud-

ies, provided that the FAO and OECD data sets are

used separately. Figure 2 illustrates the use of FBS

data (FAO) for comparison across countries and for

trends over time. This table shows the consumption

of meat in five selected countries. Only in the UK has

the consumption of meat and meat products

remained remarkably steady since 1965. In the other

countries, the total consumption of meat has in-

creased considerably, especially in Spain. The same

tendency has been observed in other southern Euro-

pean countries and reflects one of the important

changes in the Mediterranean diet over the past

decades. Such comparisons implicitly assume that

the demographic changes across the countries are

similar.

NATIONAL FOOD SUPPLY

FOOD DISTRIBUTION

CONSUMPTION

NUTRIENT UTILIZATION

HEALTH OUTCOME

Environmental factors

Agricultural factors

Economic factors

Policy considerations

Food production

Food supply

Exports

Imports

Storage

Away-from-home

food available

Away-from-home

food acquired

Away-from-home

food consumed

Income − Price

Sociocultural factors

Demographic factors

Educational factors

Environmental factors

Physiological factors

Characteristics of food

Household food

available

Household food

acquired

Household food

consumed

Food preferences,

cognitions, attitudes

Food consumed

by individual

Smoking

Medication, drug use

Alcohol use

Genetic factors

Nutrient interactions

Physiological status

Activity, exercise

Age − Sex − Race

Sanitation

Housing

Occupation

Other factors

Infection

Disease

Nutrient

requirement

Nutrient

intake

Nutrient

utilization

Supplement use

Primary representative action or consequence

Influencing or mitigating factors

Nutritional status

• biochemical

• hematological

• anthropometric

• clinical

Health/disease

outcome

fig0001 Figure 1 General conceptual model for food choice, food and nutrient intake, and nutritional and health status. Source: Life Sciences

Research Office, FASEB (1989) Nutrition and Monitoring in the United States. An Update Report on Nutrition Monitoring. Prepared for

the US Department of Agriculture and the US Department of Health and Human Services. DHS Publication No. (PHS) 89–1255. Public

Health Service. Washington, US Government Printing Office, September 1989.

NUTRITIONAL SURVEILLANCE/In Industrialized Countries 4199

Household Surveys

0011 Food available at the household level may be esti-

mated by budget surveys and by consumption surveys.

The first type of survey gives information on the

purchases of food in terms of expenditure and is

used for economic policy. For example, weights for

the construction of consumer price indices can be

calculated. In household-consumption surveys, the

amounts of foods and drinks brought into the house-

hold are also recorded. For the most part, only the

expenditures of meals taken outdoors are noted.

Some household surveys may even measure changes

in food stocks, in addition to acquisition.

0012 In general, household surveys do not provide infor-

mation on how food is handled within the household,

or on actual consumption by its members. Sometimes,

the consumption data are converted to individual

intake levels. The methods vary from simply dividing

the total consumption by the number of people in the

households, to assigning factors (consumer units) to

persons weighed according to age and sex. In contrast

to FBSs, household surveys can supply information on

food (and nutrient) patterns in subgroups of house-

holds. These groups may be classified by economic,

demographic, and other factors, which provide the

opportunity for risk group identification.

0013 In most countries, household surveys started in the

1940s or 1950s. Only few countries have a continu-

ous system, some repeat surveys every 3–4 years, and

others repeat surveys only every 5–10 years. In The

Netherlands, the household budget surveys started in

1951, and since 1978, they have been conducted

annually. In Europe, the best-known study is the spe-

cialized and ongoing household food consumption

survey of the UK. Australia, Canada, and Japan

have regularly conducted household consumption

surveys. In the USA, the first national household

consumption survey was conducted in 1936–1937.

Between 1942 and 1965, four nation-wide studies

on household consumption were carried out. Since

1965, US household food-consumption surveys have

also provided information on food intake at the indi-

vidual level of household members. At present, a wide

range of data on household surveys are available, as

shown in the FAO Food and Nutrition Policy Papers

and WHO publications. Since the dietary data are

based on a variety of methods, the surveys are not

very suitable for comparisons among countries. Dif-

ferences exist in sampling procedures, food grouping,

conversion to nutrients and period, frequency, and

technique of data collection. Snacks, sweets, soft

drinks, and alcoholic beverages are excluded from

some studies. Data on the quantity of and/or expend-

iture on food may be collected by record keeping, by

interviews or by both methods. Household accounts

for nonfood items can cover a period of 4 weeks, but

for foodstuffs, 2 weeks is more usual. The results of

household surveys play an important role in nutri-

tional surveillance at the national level, particularly

when surveys are carried out annually, which reveals

trends in food consumption.

0014To improve the possibilities for international com-

parison of these data in Europe, since 1993, an on-

going project of the European Union (DAFNE, DAta

Food NEtworking) is harmonizing at the inter-

national level dietary exposure data from household

budget surveys. DAFNE aims to create a pan-Euro-

pean food databank based on national household

budget surveys by the development of the most ap-

propriate way of using food and related data from

these surveys. Methods were designed to calculate,

for instance, the overall average availability per

person per day of comparable food items or groups

among DAFNE countries as well as average availabil-

ity by degree of urbanization and educational level of

household head. Distribution and cumulative distri-

110

1965 1970 1975 1980 1985 1990 1995

Line based on 3 years' moving average

Consumption (kg per head per year)

Austria

Spain

Netherlands

Norway

fig0002 Figure 2 Available consumption of meat and meat products (kg per head per year) in five European countries. Source: FAO

StatisticalDatabases:FoodBalanceSheets.http://apps.fao.org.(10.03.2000).

4200 NUTRITIONAL SURVEILLANCE/In Industrialized Countries

bution functions of the availability of food items were

estimated. Table 1 shows the differences in availabil-

ity of fruit and vegetables (fresh and processed) in

Greece, Ireland, Luxembourg, Norway, Spain, and

the UK.

Individual Dietary Surveys

0015 In contrast to FBSs and household surveys, data from

individual surveys provide information on average

food and nutrient intake and their distribution over

various well-defined groups of individuals. Data

more closely reflect actual consumption and can pro-

vide additional information on meal patterns, etc.

0016 To collect dietary intake data on an individual level,

several methods can be used. Briefly, the methods can

be divided into two categories: record and recall

methods. Record methods collect information on

current intake, keeping a record of all foods and

drinks based on menu, household measures and/or

weighing, over one or more days. Recall methods

reflect past consumption, varying from intake over

the previous day (24-h recall) to usual food intake

(dietary history or food frequency). Each form has its

own strengths and weaknesses, and there is no single

ideal method. Details of the available methods for

assessing food consumption of individuals are given

in numerous reviews and manuals.

0017 To characterize the average intake of food and

nutrients and their distribution over various groups

of individuals one 24-h recall or 1-day food record is

appropriate, provided that the sample is representa-

tive of the population under study, and day-of-the-

week and seasonal variations are taken into account.

To determine the proportion ‘at risk’ of inadequate

intake, the food consumption of each subject must

be measured over more than one day, or retrospective

information on intake over a longer period may

be used (e.g., dietary history method). The appropri-

ate period depends on the purpose of making an

estimate, the precision desired, the food compon-

ent(s) of interest, the intra- and interindividual vari-

ation components, and the period over which an

intake has to be low or high before health risks are

introduced.

0018 Probably all (industrialized) countries, if not all,

have carried out small-scale dietary surveys. These

surveys provide valuable information, but owing to

samples of convenience and different food consump-

tion methods, their usage in national nutrition policy

and nutritional surveillance is often limited. Since the

mid-1980s, the number of countries that have con-

ducted individual dietary surveys is growing. The

USA has one of the most comprehensive nutrition

monitoring programs in the world and already has

a longer tradition in the field of nutritional surveil-

lance. The National Nutrition Monitoring and

Related Research Program (NNMRRP) provides in-

formation 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. The Continuing Survey of Food Intakes by

Individuals (CSFII) conducted by the US Department

of Agriculture (USDA), and the National Health and

Nutrition Examination Survey (NHANES) con-

ducted by the Health and Human Services (HHS)

are the two cornerstones of the NNMRRP surveys.

They provide national estimates of food and nutrient

intakes in the general US population and in subgroups.

The CSFII emphasizes the food and nutrient

intake defined by various socio-economic factors. In

NHANES, information on dietary intake and health

status in the same individuals is available. These

surveys also provide the potential for assessing con-

sumption of additives and pesticides in the diet.

0019Also Australia and several European countries have

performed individual surveys on a national basis.

Table 2 presents examples from studies conducted

since 1985. The surveys differ in coverage of popula-

tion, methods used to collect dietary data, nutrition-

related health indices, etc. In several countries, diet-

ary data were collected using a record method, but

the number of record days varied from 1 to 7. A 7-day

weighed record is thought to be the most accurate

method of dietary assessment. However, this method

has a high respondent burden, which can have conse-

quences for the response rate, representativeness of

the sample and data quality. Response rates vary

widely. Sometimes, weighing factors are used to

adjust for sources of nonresponse. Some subgroups

(such as ethnic minorities, pregnant or lactating

women) do not occur in the population in sufficient

numbers to appear in the survey with sufficient repre-

sentation to allow for separate estimates of their diet

and nutritional status that are reliable. Extra sam-

pling can improve the precision of estimates in nutri-

tional assessment in specific groups and is used in

several studies, including those in the United States.

Special (vulnerable) groups can also be examined in

separate studies. For example, in 1998, in The Neth-

erlands, a nation-wide survey was conducted among

8-year-old Turkish and Moroccan children and their

tbl0001 Table 1 Average availability of fruit and vegetables (fresh and

processed) in DAFNE countries (grams per person per day)

Greece Ireland Luxemburg Norway Spain UK

Fruit 283 103 234 174 307 133

Vegetables 229 130 180 102 179 157

Source: DAFNE II project, 1998.

NUTRITIONAL SURVEILLANCE/In Industrialized Countries 4201

tbl0002 Table 2 Examples of nation-wide food-consumption surveys with nutrient-intake data on an individual level since 1985

Country Year Survey Population Sample

size

Response

rate (%)

Dietary

method

Sex Age

Australia 1985 National Dietary Survey of Schoolchildren FþM 10–15 5 224 65 1d Rcd

Austria 1992 Austrian Study on Nutritional Status (ASNS) FþM 6–18 2 173 na 7d Rcd

1993–1997 Austrian Study on Nutritional Status (ASNS) FþM 19–65 2 065 69 24h Rcl, DH

Denmark 1985 Dietary Habits in Denmark FþM 15–80 2 242 na DH

1995 National Dietary Survey FþM 1–80 3 098 65 7d Rcd

Finland 1992 Dietary Survey of Finnish Adults FþM 25–64 1 861 60 3d Rcd

1997 Dietary Survey of Finnish Adults FþM 25–64 2 862 72 24h Rcl

FþM 65–74 290 24h Rcl

France 1993–1994 National Food Consumption Survey

(ASPCC Survey)

FþM18þ 1 229 na 7d Rcd

1993–1994 National Food Consumption Survey

(ASPCC Survey)

FþM 2–85 1 500 na 7d Rcd

1998–1999 Individual National Food Consumption

Survey (INCA)

FþM 3–14 1 018 na 7d Rcd

FþM15þ 1 985 7d Rcd

Germany 1985–1989 National Nutrition Survey in Former

West Germany

FþM 4–70þ 24 632 71 7d Rcd

1991–1992 National Health Survey in East Germany FþM 18–80 1 897 71 DH

1998 German Nutrition Survey FþM 18–79 4 030 61 DH

Hungary 1985–1988 First Hungarian Representative Nutrition

Survey

FþM 14–60þ 16 641 61 2 24h RclþFFQ

1992–1994 Hungarian Randomized Nutrition Survey FþM 18–60þ 2 559 na 3 24h RclþFFQ

Iceland 1990 Icelandic National Nutrition Survey FþM 15–80 1 240 72 DH

Ireland 1990 Irish National Nutrition Survey (INNS) FþM 8–18þ 1 214 na DH

1998 North–South Food Consumption Survey FþM 18–64 1 379 66 7d Rec

Italy 1994–1996 INN-CA1995 FþM 2 734 47 7d Rcd

Lithuania 1997 Baltic Nutrition and Health Survey FþM 20–65 2 183 73 24h RclþFFQ

The Netherlands 1987–1988 Dutch National Food Consumption Survey

(DNFCS-1)

FþM 1–79 5 898 79 2d Rcd

1992 Dutch National Food Consumption Survey

(DNFCS-2)

FþM 1–92 6 218 72 2d Rcd

1997–1998 Dutch National Food Consumption Survey

(DNFCS-3)

FþM 1–97 6 250 69 2d Rcd

Norway 1993–1994 National Dietary Survey Among Adults

(Norkost)

FþM 16–79 3 144 63 FFQ

1997 National Dietary Survey Among Adults

(Norkost)

FþM 16–79 2 672 54 FFQ

1999 National Dietary Survey (Norkost) FþM6þ12

months

2 400 80 FFQ

1999 National Dietary Survey (Norkost) FþM 2 years 2 010 67 FFQ

Northern Ireland 1986–1987 Diet, Life-style and Health in Northern Ireland FþM 16–64 616 na 7 d Rcd

Poland 1991–1994 Dietary Habits and Nutritional Status of

Selected Populations

FþM 11–14 1 126 na 24h Rcl

18 2 193

20–65 4 945

Slovak Republic 1991–1994 Asessment of Food Habits and Nutritional

Status, etc.

FþM 11–14 3 337 na 24h RclþFFQ

1995–1998 15–18 4 556

1999–2001 19–88 4 807

Sweden 1989 HULK FþM 1–74 2 036 70 7d Rcd

1997–1998 Riksmaten FþM 18–74 1 215 60 7d Rcd

Switzerland 1992–1993 Swiss Health Survey FþM 15–74 26 000 71 FFQ

UK 1986–1987 The Dietary and Nutritional Survey of

British Adults

FþM 16–64 2 197 70 7d Rcd

1992–1993 National Diet and Nutritional Survey:

Children Aged 1½–4½ years

FþM 1½–4½ 1 675 80 4d Rcd

1994–1995 National Diet and Nutrition Survey: People

Aged 65 Years and Over

FþM65þ 1 687 80? 4d Rcd

1997 National Diet and Nutrition Survey: Young

People Aged 4–18 Years

FþM 4–18 1 701 64 7d Rcd

24h Rcl, 24-h recall; 1d Rcd, 1-day record; FFQ, food-frequency questionaire; DH, dietary history method; na, not available. See also: Lo

wik MRH and

Brussaard JH (2002) EFCOSUM.

4202 NUTRITIONAL SURVEILLANCE/In Industrialized Countries

mothers, with a Dutch control group. Norway plans

to carry out a survey among migrants in 2000–2001.

0020 The presented national dietary surveys provide

valuable information for usage in national policy

and are central in nutritional surveillance, and,

when repeated in a proper way, trends over time can

be studied. However, for a detailed evaluation of

dietary intake in Europe, there is a need for increasing

comparability of sampling designs, dietary methods,

and selected population descriptors. The establish-

ment of a Health Monitoring Program in Europe

should make it possible to measure health status,

trends, and determinants throughout the Commu-

nity; facilitate the planning, monitoring and evalu-

ation of Community programmes and actions;

provide Member States the appropriate health infor-

mation to make comparisons; and support their

national health policies. As part of this program,

since the end of 1999, the project European Food

Consumption Survey Method (EFCOSUM) has

aimed to define a (minimum) set of dietary compon-

ents that are relevant determinants of health. More-

over, the study aimed to define a method for the

monitoring of food consumption in nationally repre-

sentative samples of all age–sex categories in Europe

in order to provide internationally comparable data.

This method can be used alone, or as a calibration

method for ongoing studies. The project made use of

progress in relevant projects carried out until now,

such as DAFNE and EPIC, and addressed the possi-

bility for data fusion with other health monitoring

studies. Fourteen EU Member States as well as eight

other EU countries are participating in EFCOSUM.

Nutritional Status and Health Indices

0021 The assessment of nutritional status includes, in add-

ition to dietary intake, indicators of nutrition-related

health status, such as anthropometric measurements,

hematological and biochemical tests, clinical signs of

deficiencies, and risk factors for diseases associated

with diet (e.g., overweight). Furthermore, determin-

ants of food and health-related behavior, such as

nutritional knowledge and attitudes, may be studied

as well. These indicators can be included in the

surveys or studied in separate samples. Several na-

tional studies listed in Table 2 studied both dietary

intake and nutrition-related health-status indicators.

In most surveys, anthropometric data were collected

(sometimes self-reported data on body weight and

body height); in some countries, also, medical exam-

ination and/or biochemical and hematological tests

(e.g., Germany, Hungary, UK) were carried out, and

information on physical activity was included (e.g.,

Norway, Sweden).

0022A major advantage of collecting comprehensive

(broad oriented) information at the individual level

is that interrelationships can be studied. In studying

correlations between diet and nutritional status indi-

cators, one of the characteristics of a cross-sectional

study is that mostly low correlations are found. This

is attributable to, among other things, intraindividual

variation and inaccurate assessment of intake and

status indicators. In a cross-sectional design, the ob-

servation that a particular dietary factor is positively

or inversely associated with relevant variable is mean-

ingful, even when there is a low P-value, since this

provides suggestive evidence for diet–health relation-

ships which should be studied in more detail. To

establish a causal link between diet and health, both

intervention and (semi)-longitudinal studies are ne-

cessary. Endpoints, such as morbidity and mortality

data, provide valuable additional information on the

role of nutritional factors in diseases.

Risk Areas and Risk Groups

0023Nutritional assessment includes a normative evalu-

ation of dietary intake and nutritional status indica-

tors in order to estimate, for instance, the proportion

of the population at risk. Nutritional-status indices

can be evaluated by comparing them with reference

values mostly obtained from healthy adults. Alterna-

tively, predetermined cut-off points (based on consen-

sus reports) can be used. In evaluating dietary intake,

the reference values applied in recommended dietary

allowances (RDAs) or dietary guidelines are often

used. However, the usage of cut-off values is prone

to some misclassification owing to (biological)

variation within and among individuals. Despite the

weaknesses of cut-off points, these criteria are com-

monly used and often needed to evaluate dietary

intake as well as nutritional status parameters.

0024In most industrialized countries, the principal

nutrition-related health problems are related to un-

balanced (mostly overconsumption) of some nutri-

ents, particularly energy, fat, and saturated fatty

acids. Although the mean intake of energy among

adults is mostly lower than the recommendations,

the data available from nutritional surveillance indi-

cate a high prevalence of overweight and obesity in

several countries. Obesity, defined as a body mass

index greater than 30 kg m

2

, is a common condition

in Europe and also in the USA. Although Table 3

gives only a rough impression (age groups are not

always comparable, the periods in which studies

were conducted differ slightly, exclusion criteria

might vary, etc.), the data show that the proportion

of subjects classified as obese varies among countries.

Despite the differences, however, in recent decades,

the prevalence of obesity has increased in most

NUTRITIONAL SURVEILLANCE/In Industrialized Countries 4203