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University of South Carolina, Columbia. A. D. Liese is he primary goal of medical nutrition therapy (MNT)
an assistant professor of epidemiology and biostatistics, for individuals with diabetes mellitus is to help them
University of South Carolina, Columbia. R. A. Bell is an optimize their metabolic control through dietary
associate professor, School of Medicine, Public Health choices that are attainable and sustainable within the
Sciences, Wake Forest University, Winston-Salem, NC. culture, preferences, and capacities of the patients them-
D. M. Dabelea is an assistant professor, Department of selves (1,2). This individualized approach is recom-
Preventive Medicine and Biometrics, University of Colo- mended both for adults and for youth, and MNT is con-
rado Health Sciences Center, Denver. J. M. Johansen is sidered an integral part of diabetes management and
a research nurse, Division of Endocrinology, Cincinnati diabetes self-management education (1,2). The evidence-
Children’s Hospital Medical Center, Cincinnati, OH. C. based American Diabetes Association nutrition recom-
Pihoker is an associate professor of pediatric endocrinol- mendations for youth with diabetes incorporate specific
ogy, University of Washington Pediatrics, Children’s needs for glycemic control and management of lipids,
Hospital Endocrinology Clinic, Seattle. B. L. Rodriguez blood pressure, and weight, concomitant with nutrition
is a professor, Pacific Health Research Institute, Hono- needs to support healthful growth and development.
lulu, HI. D. Williams is with the Division of Diabetes Therefore, recommendations from other major organiza-
Translation, Centers for Disease Control and Preven- tions such as the Institute of Medicine are specifically sup-
tion/National Center for Chronic Disease Prevention ported by the American Diabetes Association. In addition,
and Health Promotion, Atlanta, GA. for youth with type 1 diabetes, coordination of food intake,
Address correspondence to: Ronny A. Bell, PhD, Coor- physical activity, and insulin needs is emphasized to
dinating Center, Wake Forest University Division of achieve blood glucose goals. For youth with type 2 diabetes,
Public Health Sciences, Medical Center Blvd, Winston- recommendations emphasize weight management through
Salem, NC 27157-1063. E-mail: rbell@wfubmc.edu reduced intake of high-fat, high-energy foods and increased
Copyright © 2006 by the American Dietetic physical activity.
Association. To evaluate potential needs for MNT in today’s youth
0002-8223/06/10605-0003$32.00/0 with diabetes, it is important to assess dietary intake in
doi: 10.1016/j.jada.2006.02.002 such youth and to compare intake with recommendations
© 2006 by the American Dietetic Association Journal of the AMERICAN DIETETIC ASSOCIATION 689
for youth. The few available studies among youth with about age 12 years (sixth grade) (15,16); therefore, ad-
diabetes are no longer current and included small sample ministration of this instrument was restricted to youth
sizes (3,4). Among youth without diabetes, dietary intake aged 10 years and older.
has been reported in large numbers of youth (5-7). Al- The SEARCH FFQ uses the same general format as the
though studies varied in dietary assessment methodol- Block Kid’s Food Questionnaire, with an expansion of the
ogy, each found that a majority of youth consumed higher foods queried and an expansion of the nutrients and food
than recommended levels of total and saturated fat, and groups available for analysis. The SEARCH FFQ consists
fewer than 50% of youth met recommendations for intake of approximately 85 food lines, for which the subject in-
of calcium, fiber, fruits, and vegetables. According to re- dicates if the item(s) were consumed in the past week
sults of the Third National Health and Nutrition Exam- (“yes/no”) and if yes, how many days, and average por-
ination Survey (8), among youth aged 12 to 19 years tion. In addition to inclusion of foods identified from the
percent of energy from dietary fat among non-Hispanic Diabetes Prevention Program study of regional or cul-
white, African-American, and Mexican-American youth tural importance, each SEARCH clinical site was queried
were 32.6%, 36.4%, and 35%, respectively. The American regarding local foods commonly consumed among youth
Heart Association recommendation is for dietary fat to to ensure inclusion of culturally appropriate foods (eg,
contribute ⬍30% of daily energy for healthy children and spam musubi reported from the Hawaii site). Like the
adolescents (9). Block instrument, portion size was queried for each line
The SEARCH for Diabetes in Youth study provides an item in a manner relevant to the item either as a number
opportunity to assess usual dietary intake among a large, (eg, number of slices of bread) or as “very small,” “small,”
ethnically and regionally diverse cohort of youth with “medium,” or “large” relative to pictures of food in bowls
diabetes aged 10 years or older. Herein we report esti- or plates provided with the form. A small number of
mated intake of nutrients and foods in the SEARCH additional questions were designed to ascertain if the
cohort according to age and diabetes type, and compare reported week’s intake was typical, use of dietary supple-
intake to recommendations. This information will be use- ments, use of low-fat products, and frequency of eating
ful in identifying potential needs for MNT for youth with out. The nutrient and portion-size databases for this in-
diabetes. strument were modified from the respective Diabetes
Prevention Program databases, using the Nutrition Data
System for Research (database 3 version 4.05/33, 2002,
MATERIALS AND METHODS Nutrition Coordinating Center, University of Minnesota,
A detailed description of SEARCH study methods has Minneapolis) and industry sources.
been published elsewhere (10). The SEARCH study is an Trained, certified research staff members instructed
ongoing multicenter study that began conducting popu- study participants on how to complete the SEARCH FFQ,
lation-based ascertainment of cases of physician-diag- and initiated form administration to confirm that the
nosed diabetes mellitus in youth younger than age 20 subject was able to complete the form on his or her own.
years beginning in 2001 and continuing through the If it was apparent that the subject would have difficulty
present. SEARCH has six centers, located in Ohio, Colo- completing the form, a staff member conducted form ad-
rado, Washington, South Carolina, Hawaii, and southern ministration as an interview. Interviewer administration
California. The study was reviewed and approved by the was needed for approximately 6.6% of youth aged 12
local Institutional Review Board(s) that had jurisdiction years or older and 18.5% of youth younger than age 12
over the local study population. Parents of participants years. The SEARCH FFQ took approximately 20 to 25
under age 18 years at the time of data collection signed minutes to complete, whether completed in a self-admin-
informed consent documentation and these participants istered or interview format.
signed informed assent; all participants aged 18 years or
older signed informed consent documentation. Measurement of Height and Weight
Anthropometric measures were taken with the subject in
light clothing without shoes by trained and certified re-
Assessment of Dietary Intake
search staff. Height was measured to the nearest 0.1 cm
For SEARCH, it was necessary to assess dietary intake in and weight was measured to the nearest 0.1 kg. Over-
a manner that limited subject burden and that was ap- weight was defined by the Centers for Disease Control
propriate for the considerable ethnic, cultural, and re- and Prevention as ⱖ95th percentile of the sex-specific
gional diversity of the SEARCH cohort. Limited valida- body mass index (BMI) for age. At risk for overweight was
tion of food frequency approaches was available for defined as ⱖ85th and ⬍95th percentile. Because Centers
diverse youth (11), including African-American youth for Disease Control and Prevention growth charts use a
(12,13). The Block Kid’s Food Questionnaire was vali- reference of children and adolescents aged 2 to 20 years,
dated among 74 children aged 8 to 10 years, including sex-specific BMI for subjects older than age 20 years
98% African Americans who were living in a low-income (n⫽185) were calculated using age 20 years data and
urban neighborhood (12). In collaboration with Block and classified according to the Centers for Disease Control
drawing heavily from cultural adaptations made to the and Prevention definitions (17).
food frequency questionnaire (FFQ) used in the Diabetes
Prevention Program (14), SEARCH modified the Block
Kid’s Food Questionnaire, hereafter referred to as the Subject Inclusion
SEARCH FFQ. Some studies have shown that the valid- This analysis includes data from 2,001 prevalent and
ity of FFQs may be compromised in youth younger than 2,002 incident cases of subjects who participated in the
Nutrients
% Total fat AHAa and HP 2010b 4™™™™™™™™™™™™™™™™™™™ 30% Total energya ™™™™™™™™™™™™™™™™™™3
4™™™™™™™™™™™™™™™™ target: 75% ⱕ30% total energyb ™™™™™™™™™™3
% Saturated fat AHA, ADAc, and HP 2010 4™™™™™™™™™™™™™™™™™™ ⬍10% Total energyac ™™™™™™™™™™™™™™™™3
4™™™™™™™™™™™™™™™™ target: 75% ⬍10% total energyb ™™™™™™™™™™3
Calcium (mg) IOM DRI–AId 4™™™™™™™™™™™™™™™™ 75% consuming ⱖ1,300 mg/d ™™™™™™™™™™™™3
Vitamin C (mg) IOM DRI–EARe 39 39 63 56 75 60
Vitamin E (mg ␣-tocopherol) IOM DRI–EAR 9 9 12 12 12 12
Iron (mg) IOM DRI–EAR 5.9 5.7 7.7 7.9 6 8.1
Fiber (g) IOM DRI–AI 23.9 20 29.3 29.3 29.3 19.2
Food groups
Fruits HP 2010 4™™™™™™™™™™™™™™™™ target: 75% ⱖ2 servings/d ™™™™™™™™™™™™™™™3
Vegetables HP 2010 4™™™™™™™™™™™™™™™™ target: 50% ⱖ3 servings/d ™™™™™™™™™™™™™™™3
Grains (total) HP 2010 4™™™™™™™™™™™™™™™™ target: 50% ⱖ6 servings/d ™™™™™™™™™™™™™™™3
Whole grains HP 2010 4™™™™™™™™™™™™™™™™ target: 50% ⱖ3 servings/d ™™™™™™™™™™™™™™™3
a
AHA⫽American Heart Association (9).
b
HP 2010⫽Healthy People 2010 (34).
c
ADA⫽American Diabetes Association (33).
d
IOM DRI⫽Institute of Medicine, Dietary Reference Intakes. Based on 0.77⫻Adequate Intake (35) for calcium (36) or fiber (37).
e
EAR⫽Estimated Average Requirement. Based on EAR for vitamin C (38) or vitamin E (38) or iron (39).
SEARCH examination and had complete data available. other”], and frequency of eating out [“⬎3 times per
Of 6,230 registered, valid subjects who were age-eligible, week/other”]) were analyzed using logistic regression,
2,473 youth (39.7%) attended the SEARCH clinic visit. Of considering covariates as described above for the nutrient
these, 2,055 (83.1%) completed the dietary assessment. variables.
Of these 2,055 forms, 111 (5.4%) were excluded due to Comparison of Reported Dietary Intake with Recommended Di-
serious problems with data quality. Because individuals etary Intake. Current nutrition recommendations of the
may change dietary habits in unpredictable ways shortly American Diabetes Association for youth with diabetes
after diagnosis of diabetes, youth with diabetes duration provided the basis for selected recommendations against
less than 12 months (n⫽124) were excluded to focus this which to compare intake as reported by the SEARCH
report on dietary intake in youth with established diabe- participants (1,2), including references to recommenda-
tes. After exclusion of cases of clinically diagnosed hybrid tions by other organizations for healthful growth and
diabetes type (n⫽2), and 80 individuals with missing/ development as appropriate and as suggested by the
unknown clinically diagnosed diabetes type, a total of American Diabetes Association. Table 1 displays the spe-
1,697 youth were included (subjects with provider-deter- cific recommendations used as the basis for calculation of
mined clinical diagnosis of either type 1 or type 1A the percent of SEARCH participants who met dietary
[n⫽1,511] and type 2 [n⫽186] diabetes). recommendations. Logistic regression analysis was used
to compare the proportion of youth with type 1 diabetes
Statistical Methods who met dietary recommendations vs the proportion of
those with type 2 diabetes who met dietary recommenda-
Comparison of Dietary Intake According to Diabetes Type. Analy- tions. Covariates included only clinical site, race/ethnic-
sis of variance was conducted on nutrients and food ity, and parental education because recommendations
groups with total energy, age group, diabetes type, sex, incorporate age, sex, and energy.
race/ethnicity, parental education level, and clinic site as Data displayed that describe dietary habits are unad-
main effects and the interaction of age group and diabetes justed data rather than modeled estimates. However, P
type. If the interaction of age group and diabetes type was values for comparison of intake according to diabetes type
not significant, it was removed from the model and the P were taken from statistical models as described. Due to
value for the diabetes type main effect was reported. BMI the number of statistical tests conducted, ␣⫽.01 was used
was added as an additional step to evaluate if any ob- to determine statistical significance. Analyses were con-
served differences according to diabetes type could be ducted using the Statistical Analysis System (version 8.2,
attributed to obesity. For these models, BMI was included 1999, SAS Institute Inc, Cary, NC).
as BMI Z score derived from the sex- and age-specific
standards published by the National Center for Health
Statistics (18). Dietary behavior variables (use of vita- RESULTS
mins [“yes/no”], use of low-fat products [“always” or “al- Table 2 shows demographic characteristics of SEARCH
most always/other”], typical intake in the past week [“yes/ participants who are included in our analyses (n⫽1,697),
Sex 0.0050
Female (%) 51.7 64.5 51.0 61.9 52.6
Race/ethnicity (%) 0.0001
Non-Hispanic white 81.2 38.7 78.5 16.1 73.2
Hispanic 10.1 12.9 11.0 18.1 11.3
African American 7.0 35.5 7.1 34.2 10.0
American Indian/Alaskan Native 0.04 9.7 1.7 28.4 3.7
Asian/Pacific Islander 1.2 3.2 1.7 3.2 1.6
Parental education (%) 0.0001
More than high school 71.2 61.3 68.6 37.4 66.8
High school 24.3 22.6 26.7 36.1 26.5
Some high school 3.0 6.5 1.9 14.8 3.7
Less than high school 1.3 9.7 1.3 7.1 2.0
Weight statusb (%) 0.0001
Overweight 11.9 67.7 11.5 68.4 17.9
At risk for overweight 22.6 9.7 23.5 19.3 22.5
Normal 65.5 22.6 65.0 12.3 59.6
a
P value for comparison of type 1/1A vs type 2 across age groups, adjusted for total energy, site, sex, race/ethnicity, parental education, and age.
b
Weight status according to Centers for Disease Control and Prevention definitions (40).
according to their age at the time of the SEARCH exam- Considering all subjects together, the Figure shows the
ination, and diabetes type as given by their health care proportion of youth with diabetes mellitus who met cur-
providers. In both age groups as expected, youth with rent nutrition recommendations, according to sex. Pat-
type 1 diabetes were predominately non-Hispanic white, terns of adherence were similar for boys and girls, al-
and most were classified as “normal weight” according to though some statistically significant sex differences were
Centers for Disease Control and Prevention definitions. noted. As shown in Table 5, more than half of all partic-
Youth with type 2 diabetes were predominately minority, ipants (boys and girls combined) met recommendations
and most were classified as “at risk for overweight” or for calcium, vitamin C, and iron. However, recommenda-
“overweight.” tions for intake of total and saturated fat were met by
Estimated mean daily nutrient intakes are given in only 10.6% and 6.5% of youth, respectively. Fewer than
Table 3, according to age and diabetes type. Except for 20% of participants met recommendations for intake of
intake of sucrose, which was higher in youth with type 2 fruits, vegetables, and grains, and none met recommen-
diabetes than among youth with type 1 diabetes dations for intake of whole grains. Compared to youth
(P⬍0.01), intake of macronutrients and fiber did not dif- with type 1 diabetes, a smaller proportion of youth with
fer according to diabetes type (P values all nonsignifi- type 2 diabetes met recommendations for calcium
cant). Percent of energy from total fat was consistent at (P⬍0.01).
37% to 38%, and percent of energy from saturated fat was
approximately 13% for all subgroups. Daily fiber intake
was 13% to 14% across subgroups. Calcium intake was DISCUSSION
lower among youth with type 2 diabetes than among In this large cohort of youth with established diabetes of
those with type 1 diabetes (P⬍0.01), across both age at least 1 year’s duration, dietary intake substantially fell
groups, and after adjustment for total energy, clinical short of meeting current recommendations. For youth
site, sex, race/ethnicity, and parental education. After with either type 1 diabetes or type 2 diabetes, intake of
further adjustment for BMI Z score, the statistical signif- dietary fat was high; specifically, fewer than 15% of youth
icance was reduced from P⬍0.01 to P⫽0.024. Also, intake within each age and diabetes type subgroup met the
of magnesium and vitamin E was lower among youth American Diabetes Association and American Heart As-
with type 2 diabetes compared with those with type 1 sociation recommendations for total and saturated fat
diabetes (P⬍0.01 for each). intake. Intake of fruits, vegetables, and grains was sim-
Table 4 shows intake of selected food groups and di- ilarly inadequate, although a majority of youth did meet
etary behaviors. Intake of sweetened carbonated bever- recommendations for selected micronutrients of calcium,
ages was approximately twice as high for older youth vitamin C, and iron.
with type 2 diabetes (P⬍0.01) when compared with other Comparisons of dietary intake in the SEARCH cohort
subgroups of age and diabetes type (P value for interac- with data from currently available national survey data
tion of age⫻diabetes type ⬍0.01). from samples of youth without diabetes must be made
with caution because the major national surveys that analyses of the SEARCH data will explore dietary habits
include youth (the National Health and Nutrition Exam- in relation to other aspects of diabetes self-management
ination Surveys [NHANES] [6] and the US Department and education to identify correlates of dietary adherence.
of Agriculture Continuing Surveys of Food Intakes by In our study, dietary intake was generally similar for
Individuals [CSFII] [5]) used 24-hour recall data, youth with type 1 diabetes and type 2 diabetes. However,
whereas the SEARCH study used an FFQ. Thus, specific youth with type 2 diabetes consumed significantly less
differences would be difficult to attribute uniquely to the calcium than those with type 1 diabetes (P⬍0.01) regard-
population or to the assessment methodology. Nonethe- less of age, race/ethnicity, and parental education. Inter-
less, average intake of dietary fat was above the recom- estingly, this association was attenuated after addition of
mended upper limit of 30% of energy advocated by both BMI Z score to the statistical model, which suggests that
NHANES III (approximately 34% [6]) and the CSFII (ap- an association of calcium intake with obesity may ex-
proximately 35% [5]), and fewer than 20% of youth aged plain, at least in part, the original observation, consistent
12 to 19 years met the CSFII recommended daily servings with recent epidemiologic studies that have shown an
of fruit. Between 20% and 50% of boys and girls met inverse association of calcium intake with obesity (21,22).
recommended daily servings of grain, vegetables, dairy, The lower intake of calcium (23), vitamin E (24), and
and meats. Both CSFII and NHANES III data are now magnesium (25) among youth with type 2 diabetes com-
more than 10 years old; NHANES 2001-2002 incorpo- pared to youth with type 1 diabetes could reflect under-
rated a food frequency– based dietary assessment; how- lying etiologic associations of inadequate intake of these
ever, these food frequency data have not yet been re- micronutrients with the insulin resistance of type 2 dia-
leased. Neumark-Sztainer (7) reported dietary adequacy betes; future studies will be needed to pursue this issue.
among more than 4,000 youth aged 11 to 18 years based There are no specific recommendations for number of
on an FFQ and comparisons with Healthy People 2010 servings of sweetened carbonated beverages or other
goals. About one half of boys and girls met recommenda- sweets and snacks (not including sweetened beverages),
tions for total fat intake and 45% of girls and 36% of boys except to the extent that these foods should be restricted
met recommendations for saturated fat intake, which was in the interest of glucose control and weight management
notably higher than the proportion of SEARCH partici- for youth with diabetes, especially those with type 2 dia-
pants who met these goals. Reasons for the generally low betes (2). In the SEARCH participants, 1.3 servings of
adherence to nutrition recommendations in the SEARCH carbonated beverage (not including diet varieties) was
cohort are unclear. It is possible that high dietary fat reported among older youth with type 2 diabetes, which
intake was, in fact, a contributor to the development of was about twice the intake of the older youth with type 1
diabetes, both for type 2 diabetes (19) and from a recent diabetes or younger youth regardless of diabetes type. In
report (20) potentially for type 1 diabetes as well. Future addition, youth in each subgroup reported approximately
Nutrients
% Total fat 10.6 11.8 9.7 8.7 14.8 0.2758
% Saturated fat 6.5 5.0 6.5 6.7 12.9 0.6468
Calcium (mg) 56.0 63.2 32.3 54.9 32.3 ⬍0.0001
Vitamin C (mg) 69.3 75.7 54.8 65.2 61.9 0.0453
Vitamin E (mg ␣-tocopherol) 15.6 19.1 12.9 14.5 4.5 0.0250
Iron (mg) 91.1 94.2 87.1 89.5 85.2 0.0238
Fiber (g) 6.4 5.0 6.5 7.3 8.4 0.4850
Food group
Fruits 19.4 20.0 25.8 17.9 22.6 0.2491
Vegetables 13.5 9.9 16.1 15.2 21.9 0.1612
Grains (total) 6.2 3.8 9.7 8.0 8.4 0.1020
Whole grains 0 0 0 0 0 —
a
For comparison of type 1/1A vs type 2, adjusted for site, race/ethnicity, and parental education level.
should eat.” Third, validity results obtained from the origi- dations from the American Diabetes, American Heart
nal Block instrument may not hold in the SEARCH popu- Association, Institute of Medicine, and Healthy People
lation due to changes in the instrument. The changes to the 2010 are based on strong scientific evidence regarding
instrument were an expansion of food items queried, to intake of specific nutrients and foods in relation to phys-
include culturally appropriate foods, and an expansion in iologic health outcomes, including appropriate growth
the underlying nutrient and food group databases. Neither and development through adolescent years and optimiz-
change would be expected to result in marked differences in ing metabolic status for youth with diabetes. In particu-
the validity of the instrument; in fact, lack of modification to lar, the American Diabetes Association recommendation
the foods queried most likely would have harmed the valid- of less than 10% of energy from saturated fat is given
ity by causing systematic underreporting for subgroups of with the highest level of scientific evidence based on
the SEARCH population simply due to omitting foods re- studies of the effect of saturated fat on low-density li-
flective of local food availability and preferences. Validity poprotein cholesterol (33), yet only 6.5% of youth with
may also have been affected by use of interviewer when diabetes in our study met this recommendation. Results
needed, rather than using self-administration for 100% of reported herein indicate a clear need for improvement in
the cohort. We do not have a comparison method of dietary the dietary intake of youth with diabetes, including youth
assessment in this study (eg, multiple 24-hour dietary re- with type 1 and youth with type 2 diabetes. Further work
calls). However, we compared dietary intake for all nutri- to better understand barriers to healthful dietary habits,
ents and food groups shown in Table 5 for individuals with and to identify effective approaches to improving dietary
self-administration vs interviewer administration; no sta- intake in youth with diabetes, is urgently needed.
tistically significant differences were observed according to
mode of administration (data not shown). SEARCH for Diabetes in Youth is funded by the Centers
Finally, nonresponse to the SEARCH clinic visit may for Disease Control and Prevention (PA No. 00097) and
have resulted in selection bias, such that dietary intake supported by the National Institute of Diabetes and Di-
among participating youth may have been different than gestive and Kidney Diseases.
that of youth who did not participate. It may be that
youth who participated were more likely to be concerned
about their health, and thus to either have, or to have References
reported, more healthful dietary habits than their non- 1. Franz MJ, Bantle J, Beebe CA, Brunzell JD, Chias-
participating peers. If this were true, then dietary intake son JL, Garg A, Holzmeister LA, Hoogwerf B, Mayer-
of the whole population of youth with diabetes may be Davis E, Mooradian A, Purnell JQ, Wheeler M. Amer-
somewhat worse than what is reported here. ican Diabetes Association position statement:
Evidence-based nutrition principles and recommen-
CONCLUSIONS dations for the treatment and prevention of diabetes
Data from the SEARCH for Diabetes in Youth study and related complications. J Am Diet Assoc. 2002;
suggest that average habitual intake of foods and nutri- 102:109-118.
ents among members of this large, ethnically diverse 2. Franz MJ, Bantle JP, Beebe CA, Brunzell JD, Chias-
cohort of youth with diabetes falls considerably short of son JL, Garg A, Holzmeister LA, Hoogwerf B, Mayer-
current recommendations for dietary intake. Recommen- Davis E, Mooradian AD, Purnell JQ, Wheeler M.