Academy Comments re CDC NHANES Revision

November 9, 2018

Attention: CDC Desk Officer
Office of Management and Budget
725 17th Street NW
Washington, DC 20503

Re: The National Health and Nutrition Examination Survey (NHANES), (OMB Control Number 0920-0950, Expiration Date 12/31/2019)—Revision—National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC)

Dear Sir or Madam:

The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Centers for Disease Control and Prevention related to its May 11, 2018 information collection, "The National Health and Nutrition Examination Survey—Revision" and subsequent notice of October 10, 2018. Representing more than 104,000 registered dietitian nutritionists (RDNs),1 nutrition and dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals and is committed to a world where all people thrive through the transformative power of food and nutrition.

The Academy generally supports the NHANES revision as necessary for the proper performance of the functions of the CDC and believe it will have significant practical utility. Collected data are essential for informing policymakers, researchers, the private sector, and the public on the health and nutrition status of American children and adults and the effectiveness of food and nutrition programs. Knowing what Americans eat and how their diets directly affect their health provides valuable information to guide policies on food safety, food labeling, food assistance, military rations, and dietary guidance. NHANES has helped inform research and policy related to sodium reduction strategies, celiac disease, diabetes risk, obesity, and many other pressing public health issues. We note that the Academy's own Research Dietetic Practice Group is again hosting a 'using NHANES Dietary Data' workshop at our annual Food and Nutrition Conference and Expo (FNCE®) this year.

The national nutrition monitoring system is our nation’s best and most comprehensive method of assessing nutritional health, because the survey continuously collects usual dietary and supplement intake and laboratory indicators of nutrition status from a nationally representative U.S. sample. As detailed below, among the proposed revisions are items we perceive to be improvements and others we perceive as potentially problematic, specifically those changes related to the characterization of the nutritional status of Americans.

I. Improvements

On a positive note, the new sampling strategy and the inclusion of more questions regarding WIC participation has the potential to greatly add to the ability of the survey to capture greater numbers of participants from underserved communities, as well as improve the data collected regarding participation in federal assistance programs among those participants. Since NHANES is uniquely able to evaluate federal programs and the association between program participation and various health outcomes, the proposed changes for the 2019/2020 survey may help to fill knowledge gaps in several areas.

The additional birth – to – 24 months module is also a welcome addition, as dietary information collected regarding infant formula will improve our understanding of dietary intake among the youngest Americans. To further improve that understanding, we recommend that NHANES also begin to include questions about lactation practices in that section. Noting that data on breastfeeding duration and exclusivity already exists for mothers and intake of human milk exists for infants, we believe collecting data specifically on breast milk expression will enable researchers to better characterize the behaviors of lactating women in addition to the information collected about breastfed infants.

II. Concerns

The Academy has concerns with the potential impacts of some of the proposed changes to NHANES. One of the drawbacks with the new sampling strategy is the likelihood that a two-year data collection cycle will not be able to capture changes in the food environment or new products very effectively. We note that NHANES dietary intake data already lags behind what is available and currently eaten by Americans (i.e., the 2013/2014 dietary data is the most recent data at present). The new sampling strategy is also likely to overlook relevant diet trends and products on the market more than it already does (e.g., popular diets such as Paleo or Whole30; trends like mail-order meals from Hello Fresh or Blue Apron; and Greek yogurt, which notably was actually missed during continuous data collection).

Another concern with the proposed change in sampling strategy is how the new data collection strategy impacts data release. If the new data collection results in a longer delay until data is available, the available dietary data may no longer represent relevant intake patterns. The available dietary data would also be unlikely to accurately represent the association between dietary patterns and micronutrient status, resulting in a significant missed opportunity to evaluate current dietary patterns, trends, and intake measures among Americans. We are concerned that a change of this type would severely limit the utility and importance of NHANES data analysis and manuscripts using NHANES data; as one researcher described it, "publishing data that depicts what the American diet was 4 years ago just isn't particularly exciting." Changes in the utility and relevancy of available NHANES data would not only impact established researchers, but has the potential to impact graduate students who use NHANES data for masters and doctoral projects. The Academy would be interested in a conversation with the CDC about these concerns and ways to address them.

III. Alignment with Questions in National Health Interview Survey

The Academy supports efforts by the CDC to better align questions in NHANES and the National Health Interview Survey (NHIS), as we agree with the CDC that the NHIS is "instrumental in providing data to track health status, health care access, and progress toward achieving national health objectives."2 NHIS has recently focused on topics in which nutrition plays a fundamental role in preventing and treating many of the included topics, including alternative and integrative medicine, cognitive disability, and receipt of culturally and linguistically appropriate health care services, epilepsy, Crohn's disease and colitis, diabetes, disability and functioning, family food security, heart disease and stroke treatment and prevention, and children's mental health. These are critical topics and the importance of good nutrition in their prevention and amelioration cannot be overstated. To the extent alignment between the surveys can improve health or provide useful data, the Academy enthusiastically supports the CDC's efforts.

IV. Conclusion

The Academy sincerely appreciates the opportunity to offer comments regarding the NHANES revisions. Please contact either Jeanne Blankenship by telephone at 312/899-1730 or by email at or Pepin Tuma by telephone at 202/775-8277, ext. 6001 or by email at with any questions or requests for additional information.


Jeanne Blankenship, MS, RDN
Vice President
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics

Pepin Andrew Tuma, Esq.
Senior Director
Government & Regulatory Affairs
Academy of Nutrition and Dietetics

1 The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.

2 National Health Interview Survey. National Center for Health Statistics website, updated September 13, 2016. Accessed September 22, 2016.