RESEARCH
Current Research
Dietary Intake among Youth with Diabetes: The
SEARCH for Diabetes in Youth Study
ELIZABETH J. MAYER-DAVIS, PhD, MSPH, RD; MICHELE NICHOLS, MS; ANGELA D. LIESE, PhD; RONNY A. BELL, PhD;
DANA M. DABELEA, MD, PhD; JUDY M. JOHANSEN; CATHERINE PIHOKER, MD; BEATRIZ L. RODRIGUEZ, MD, PhD, MPH;
JOAN THOMAS, MS, RD; DESMOND WILLIAMS, MD, PhD; FOR THE SEARCH FOR DIABETES IN YOUTH STUDY GROUP
ABSTRACT
Objective To describe dietary intake among a large cohort
of youth with type 1 or type 2 diabetes and to compare
their intake with current nutrition recommendations.
Design SEARCH for Diabetes in Youth is a multicenter
study of diabetes in youth. Diet was assessed among
youth aged 10 to 22 years who attended a SEARCH
research clinic visit and completed a previous-week food
frequency questionnaire that included foods to reflect the
ethnic and regional diversity represented by the cohort.
Subjects/setting Included were 1,697 youth with physician-
diagnosed diabetes mellitus (89% type 1 diabetes, 11%
type 2 diabetes), with diabetes mellitus duration of at
least 12 months.
Statistical analyses Descriptive data and comparisons with
nutrition recommendations were unadjusted. Analyses of
covariance with adjustment for total energy, clinic site,
E. J. Mayer-Davis is a professor and the director and
M. Nichols and J. Thomas are research associates, Cen-
ter for Research in Nutrition and Health Disparities,
University of South Carolina, Columbia. A. D. Liese is
an assistant professor of epidemiology and biostatistics,
University of South Carolina, Columbia. R. A. Bell is an
associate professor, School of Medicine, Public Health
Sciences, Wake Forest University, Winston-Salem, NC.
D. M. Dabelea is an assistant professor, Department of
Preventive Medicine and Biometrics, University of Colo-
rado Health Sciences Center, Denver. J. M. Johansen is
a research nurse, Division of Endocrinology, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH. C.
Pihoker is an associate professor of pediatric endocrinol-
ogy, University of Washington Pediatrics, Children’s
Hospital Endocrinology Clinic, Seattle. B. L. Rodriguez
is a professor, Pacific Health Research Institute, Hono-
lulu, HI. D. Williams is with the Division of Diabetes
Translation, Centers for Disease Control and Preven-
tion/National Center for Chronic Disease Prevention
and Health Promotion, Atlanta, GA.
Address correspondence to: Ronny A. Bell, PhD, Coor-
dinating Center, Wake Forest University Division of
Public Health Sciences, Medical Center Blvd, Winston-
Salem, NC 27157-1063. E-mail: rbell@wfubmc.edu
Copyright © 2006 by the American Dietetic
Association.
0002-8223/06/10605-0003$32.00/0
doi: 10.1016/j.jada.2006.02.002
© 2006 by the American Dietetic Association
sex, race/ethnicity, age, and parental education were
used to compare intake according to diabetes type.
Results Percent of energy from total fat was consistent at
37% to 38% across subgroups of age (10 to 14 years, ⬎15
years) and diabetes type (ie, type 1 or type 2). Youth with
type 2 diabetes consumed less calcium, magnesium, and
vitamin E than youth with type 1 diabetes (P⬍0.01 for
each). Intake of sweetened carbonated beverages among
older (aged ⬎15 years) youth with type 2 diabetes was
twice that of older youth with type 1 diabetes (P⬍0.01).
Only 6.5% of the cohort met American Diabetes Associa-
tion recommendations of ⬍10% of energy from saturated
fat. Less than 50% met recommendations for total fat,
vitamin E, fiber, fruits, vegetables, and grains, although
a majority met recommendations for vitamin C, calcium,
and iron.
Conclusions Overall, dietary intake in this large cohort of
youth with diabetes substantially failed to meet current
recommendations. There is a critical need for improve-
ment in dietary intake in youth with diabetes.
J Am Diet Assoc. 2006;106:689-697.
T
he primary goal of medical nutrition therapy (MNT)
for individuals with diabetes mellitus is to help them
optimize their metabolic control through dietary
choices that are attainable and sustainable within the
culture, preferences, and capacities of the patients them-
selves (1,2). This individualized approach is recom-
mended both for adults and for youth, and MNT is con-
sidered an integral part of diabetes management and
diabetes self-management education (1,2). The evidence-
based American Diabetes Association nutrition recom-
mendations for youth with diabetes incorporate specific
needs for glycemic control and management of lipids,
blood pressure, and weight, concomitant with nutrition
needs to support healthful growth and development.
Therefore, recommendations from other major organiza-
tions such as the Institute of Medicine are specifically sup-
ported by the American Diabetes Association. In addition,
for youth with type 1 diabetes, coordination of food intake,
physical activity, and insulin needs is emphasized to
achieve blood glucose goals. For youth with type 2 diabetes,
recommendations emphasize weight management through
reduced intake of high-fat, high-energy foods and increased
physical activity.
To evaluate potential needs for MNT in today’s youth
with diabetes, it is important to assess dietary intake in
such youth and to compare intake with recommendations
Journal of the AMERICAN DIETETIC ASSOCIATION 689
for youth. The few available studies among youth with
diabetes are no longer current and included small sample
sizes (3,4). Among youth without diabetes, dietary intake
has been reported in large numbers of youth (5-7). Al-
though studies varied in dietary assessment methodol-
ogy, each found that a majority of youth consumed higher
than recommended levels of total and saturated fat, and
fewer than 50% of youth met recommendations for intake
of calcium, fiber, fruits, and vegetables. According to re-
sults of the Third National Health and Nutrition Exam-
ination Survey (8), among youth aged 12 to 19 years
percent of energy from dietary fat among non-Hispanic
white, African-American, and Mexican-American youth
were 32.6%, 36.4%, and 35%, respectively. The American
Heart Association recommendation is for dietary fat to
contribute ⬍30% of daily energy for healthy children and
adolescents (9).
The SEARCH for Diabetes in Youth study provides an
opportunity to assess usual dietary intake among a large,
ethnically and regionally diverse cohort of youth with
diabetes aged 10 years or older. Herein we report esti-
mated intake of nutrients and foods in the SEARCH
cohort according to age and diabetes type, and compare
intake to recommendations. This information will be use-
ful in identifying potential needs for MNT for youth with
diabetes.
MATERIALS AND METHODS
A detailed description of SEARCH study methods has
been published elsewhere (10). The SEARCH study is an
ongoing multicenter study that began conducting popu-
lation-based ascertainment of cases of physician-diag-
nosed diabetes mellitus in youth younger than age 20
years beginning in 2001 and continuing through the
present. SEARCH has six centers, located in Ohio, Colo-
rado, Washington, South Carolina, Hawaii, and southern
California. The study was reviewed and approved by the
local Institutional Review Board(s) that had jurisdiction
over the local study population. Parents of participants
under age 18 years at the time of data collection signed
informed consent documentation and these participants
signed informed assent; all participants aged 18 years or
older signed informed consent documentation.
Assessment of Dietary Intake
For SEARCH, it was necessary to assess dietary intake in
a manner that limited subject burden and that was ap-
propriate for the considerable ethnic, cultural, and re-
gional diversity of the SEARCH cohort. Limited valida-
tion of food frequency approaches was available for
diverse youth (11), including African-American youth
(12,13). The Block Kid’s Food Questionnaire was vali-
dated among 74 children aged 8 to 10 years, including
98% African Americans who were living in a low-income
urban neighborhood (12). In collaboration with Block and
drawing heavily from cultural adaptations made to the
food frequency questionnaire (FFQ) used in the Diabetes
Prevention Program (14), SEARCH modified the Block
Kid’s Food Questionnaire, hereafter referred to as the
SEARCH FFQ. Some studies have shown that the valid-
ity of FFQs may be compromised in youth younger than
690 May 2006 Volume 106 Number 5
about age 12 years (sixth grade) (15,16); therefore, ad-
ministration of this instrument was restricted to youth
aged 10 years and older.
The SEARCH FFQ uses the same general format as the
Block Kid’s Food Questionnaire, with an expansion of the
foods queried and an expansion of the nutrients and food
groups available for analysis. The SEARCH FFQ consists
of approximately 85 food lines, for which the subject in-
dicates if the item(s) were consumed in the past week
(“yes/no”) and if yes, how many days, and average por-
tion. In addition to inclusion of foods identified from the
Diabetes Prevention Program study of regional or cul-
tural importance, each SEARCH clinical site was queried
regarding local foods commonly consumed among youth
to ensure inclusion of culturally appropriate foods (eg,
spam musubi reported from the Hawaii site). Like the
Block instrument, portion size was queried for each line
item in a manner relevant to the item either as a number
(eg, number of slices of bread) or as “very small,” “small,”
“medium,” or “large” relative to pictures of food in bowls
or plates provided with the form. A small number of
additional questions were designed to ascertain if the
reported week’s intake was typical, use of dietary supple-
ments, use of low-fat products, and frequency of eating
out. The nutrient and portion-size databases for this in-
strument were modified from the respective Diabetes
Prevention Program databases, using the Nutrition Data
System for Research (database 3 version 4.05/33, 2002,
Nutrition Coordinating Center, University of Minnesota,
Minneapolis) and industry sources.
Trained, certified research staff members instructed
study participants on how to complete the SEARCH FFQ,
and initiated form administration to confirm that the
subject was able to complete the form on his or her own.
If it was apparent that the subject would have difficulty
completing the form, a staff member conducted form ad-
ministration as an interview. Interviewer administration
was needed for approximately 6.6% of youth aged 12
years or older and 18.5% of youth younger than age 12
years. The SEARCH FFQ took approximately 20 to 25
minutes to complete, whether completed in a self-admin-
istered or interview format.
Measurement of Height and Weight
Anthropometric measures were taken with the subject in
light clothing without shoes by trained and certified re-
search staff. Height was measured to the nearest 0.1 cm
and weight was measured to the nearest 0.1 kg. Over-
weight was defined by the Centers for Disease Control
and Prevention as ⱖ95th percentile of the sex-specific
body mass index (BMI) for age. At risk for overweight was
defined as ⱖ85th and ⬍95th percentile. Because Centers
for Disease Control and Prevention growth charts use a
reference of children and adolescents aged 2 to 20 years,
sex-specific BMI for subjects older than age 20 years
(n⫽185) were calculated using age 20 years data and
classified according to the Centers for Disease Control
and Prevention definitions (17).
Subject Inclusion
This analysis includes data from 2,001 prevalent and
2,002 incident cases of subjects who participated in the
 Table 1. Recommended dietary intake for children and adolescents with diabetes
Age 9-13 y Age 14-18 y Age >19 y
Variable Source Boys Girls Boys Girls Men Women

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.
Of 6,230 registered, valid subjects who were age-eligible,
2,473 youth (39.7%) attended the SEARCH clinic visit. Of
these, 2,055 (83.1%) completed the dietary assessment.
Of these 2,055 forms, 111 (5.4%) were excluded due to
serious problems with data quality. Because individuals
may change dietary habits in unpredictable ways shortly
after diagnosis of diabetes, youth with diabetes duration
less than 12 months (n⫽124) were excluded to focus this
report on dietary intake in youth with established diabe-
tes. After exclusion of cases of clinically diagnosed hybrid
diabetes type (n⫽2), and 80 individuals with missing/
unknown clinically diagnosed diabetes type, a total of
1,697 youth were included (subjects with provider-deter-
mined clinical diagnosis of either type 1 or type 1A
[n⫽1,511] and type 2 [n⫽186] diabetes).
Statistical Methods
Comparison of Dietary Intake According to Diabetes Type. Analy-
sis of variance was conducted on nutrients and food
groups with total energy, age group, diabetes type, sex,
race/ethnicity, parental education level, and clinic site as
main effects and the interaction of age group and diabetes
type. If the interaction of age group and diabetes type was
not significant, it was removed from the model and the P
value for the diabetes type main effect was reported. BMI
was added as an additional step to evaluate if any ob-
served differences according to diabetes type could be
attributed to obesity. For these models, BMI was included
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-
mins [“yes/no”], use of low-fat products [“always” or “al-
most always/other”], typical intake in the past week [“yes/
other”], and frequency of eating out [“⬎3 times per
week/other”]) were analyzed using logistic regression,
considering covariates as described above for the nutrient
variables.
Comparison of Reported Dietary Intake with Recommended Di-
etary Intake. Current nutrition recommendations of the
American Diabetes Association for youth with diabetes
provided the basis for selected recommendations against
which to compare intake as reported by the SEARCH
participants (1,2), including references to recommenda-
tions by other organizations for healthful growth and
development as appropriate and as suggested by the
American Diabetes Association. Table 1 displays the spe-
cific recommendations used as the basis for calculation of
the percent of SEARCH participants who met dietary
recommendations. Logistic regression analysis was used
to compare the proportion of youth with type 1 diabetes
who met dietary recommendations vs the proportion of
those with type 2 diabetes who met dietary recommenda-
tions. Covariates included only clinical site, race/ethnic-
ity, and parental education because recommendations
incorporate age, sex, and energy.
Data displayed that describe dietary habits are unad-
justed data rather than modeled estimates. However, P
values for comparison of intake according to diabetes type
were taken from statistical models as described. Due to
the number of statistical tests conducted, ␣⫽.01 was used
to determine statistical significance. Analyses were con-
ducted using the Statistical Analysis System (version 8.2,
1999, SAS Institute Inc, Cary, NC).
RESULTS
Table 2 shows demographic characteristics of SEARCH
participants who are included in our analyses (n⫽1,697),

May 2006 ● Journal of the AMERICAN DIETETIC ASSOCIATION 691

 Table 2. Demographic characteristics of children and adolescents with diabetes: SEARCH for Diabetes in Youth participants in the dietary
assessment protocol, prevalent 2001 and incident 2002
Age 10-14 y Age >15 y
Type 1/1A Type 2 Type 1/1A Type 2 Overall
Characteristic (nⴝ740) (nⴝ31) (nⴝ771) (nⴝ155) (nⴝ1,697) P valuea

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-
ination, and diabetes type as given by their health care
providers. In both age groups as expected, youth with
type 1 diabetes were predominately non-Hispanic white,
and most were classified as “normal weight” according to
Centers for Disease Control and Prevention definitions.
Youth with type 2 diabetes were predominately minority,
and most were classified as “at risk for overweight” or
“overweight.”
Estimated mean daily nutrient intakes are given in
Table 3, according to age and diabetes type. Except for
intake of sucrose, which was higher in youth with type 2
diabetes than among youth with type 1 diabetes
(P⬍0.01), intake of macronutrients and fiber did not dif-
fer according to diabetes type (P values all nonsignifi-
cant). Percent of energy from total fat was consistent at
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
lower among youth with type 2 diabetes than among
those with type 1 diabetes (P⬍0.01), across both age
groups, and after adjustment for total energy, clinical
site, sex, race/ethnicity, and parental education. After
further adjustment for BMI Z score, the statistical signif-
icance was reduced from P⬍0.01 to P⫽0.024. Also, intake
of magnesium and vitamin E was lower among youth
with type 2 diabetes compared with those with type 1
diabetes (P⬍0.01 for each).
Table 4 shows intake of selected food groups and di-
etary behaviors. Intake of sweetened carbonated bever-
ages was approximately twice as high for older youth
with type 2 diabetes (P⬍0.01) when compared with other
subgroups of age and diabetes type (P value for interac-
tion of age⫻diabetes type ⬍0.01).
Considering all subjects together, the Figure shows the
proportion of youth with diabetes mellitus who met cur-
rent nutrition recommendations, according to sex. Pat-
terns of adherence were similar for boys and girls, al-
though some statistically significant sex differences were
noted. As shown in Table 5, more than half of all partic-
ipants (boys and girls combined) met recommendations
for calcium, vitamin C, and iron. However, recommenda-
tions for intake of total and saturated fat were met by
only 10.6% and 6.5% of youth, respectively. Fewer than
20% of participants met recommendations for intake of
fruits, vegetables, and grains, and none met recommen-
dations for intake of whole grains. Compared to youth
with type 1 diabetes, a smaller proportion of youth with
type 2 diabetes met recommendations for calcium
(P⬍0.01).
DISCUSSION
In this large cohort of youth with established diabetes of
at least 1 year’s duration, dietary intake substantially fell
short of meeting current recommendations. For youth
with either type 1 diabetes or type 2 diabetes, intake of
dietary fat was high; specifically, fewer than 15% of youth
within each age and diabetes type subgroup met the
American Diabetes Association and American Heart As-
sociation recommendations for total and saturated fat
intake. Intake of fruits, vegetables, and grains was sim-
ilarly inadequate, although a majority of youth did meet
recommendations for selected micronutrients of calcium,
vitamin C, and iron.
Comparisons of dietary intake in the SEARCH cohort
with data from currently available national survey data
from samples of youth without diabetes must be made

692 May 2006 Volume 106 Number 5

 Table 3. Estimated daily nutrient intake (mean⫾standard deviation) according to age and diabetes type: SEARCH for Diabetes in Youth
participants in the dietary assessment protocol, prevalent 2001 and incident 2002
Age 10-14 y Age >15 y
Type 1/1A Type 2 Type 1/1A Type 2
Nutrient (nⴝ740) (nⴝ31) (nⴝ771) (nⴝ155) P valuea

Kilocalories 1,925.0⫾813.1 1,849.1⫾1,163.7 2,056.2⫾961.4 1,964.3⫾941.3 0.4788

% Fat 36.9⫾5.7 38.2⫾6.8 37.9⫾5.9 37.0⫾6.6 0.7712
% Saturated fat 13.5⫾2.2 13.8⫾2.7 13.7⫾2.4 13.2⫾2.8 0.7958
% Monounsaturated fat 14.8⫾2.8 15.3⫾3.2 15.2⫾2.8 15.0⫾3.0 0.7508
% Polyunsaturated fat 5.7⫾1.4 5.9⫾1.2 5.9⫾1.5 5.6⫾1.6 0.1241
% Trans fat 2.3⫾0.6 2.5⫾0.6 2.3⫾0.6 2.3⫾0.6 0.2277
% Carbohydrate 48.7⫾7.2 47.3⫾8.9 47.7⫾7.6 48.8⫾9.1 0.7706
% Protein 15.7⫾2.2 15.7⫾2.3 15.7⫾2.3 15.2⫾2.9 0.4779
Fiber (g) 13.1⫾6.9 13.5⫾9.3 14.3⫾7.2 13.8⫾8.0 0.5146
Starch (g) 95.1⫾43.9 94.4⫾59.1 100.4⫾49.5 97.2⫾51.2 0.7576
Sucrose (g) 37.5⫾22.9 40.5⫾39.3 40.8⫾27.7 44.5⫾37.3 0.0013
Glucose (g) 24.4⫾15.5 23.1⫾26.7 26.9⫾18.9 32.9⫾28.6 0.0268
Fructose (g) 22.3⫾16.3 21.8⫾25.8 25.0⫾19.9 32.2⫾30.6 0.0277
Calcium (mg) 1,288.3⫾665.6 947.4⫾587.3 1,214.7⫾692.3 887.2⫾587.1 0.0006
Magnesium (mg) 271.6⫾125.5 243.9⫾151.5 283.7⫾140.0 235.5⫾112.9 0.0004
Vitamin C (mg) 86.1⫾60.6 94.3⫾107.0 95.9⫾64.7 107.4⫾97.7 0.0189
Vitamin E (mg ␣-tocopherol) 7.6⫾3.8 6.9⫾4.2 8.2⫾4.3 6.4⫾3.1 0.0040
Vitamin A (␮g RAEb) 666.0⫾386.0 1,125.8⫾784.9 838.0⫾527.9 689.4⫾412.1 0.0707
Iron (mg) 15.2⫾7.0 13.8⫾8.2 15.8⫾7.8 13.8⫾6.8 0.0109
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
RAE⫽retinol equivalents.

with caution because the major national surveys that
include youth (the National Health and Nutrition Exam-
ination Surveys [NHANES] [6] and the US Department
of Agriculture Continuing Surveys of Food Intakes by
Individuals [CSFII] [5]) used 24-hour recall data,
whereas the SEARCH study used an FFQ. Thus, specific
differences would be difficult to attribute uniquely to the
population or to the assessment methodology. Nonethe-
less, average intake of dietary fat was above the recom-
mended upper limit of 30% of energy advocated by both
NHANES III (approximately 34% [6]) and the CSFII (ap-
proximately 35% [5]), and fewer than 20% of youth aged
12 to 19 years met the CSFII recommended daily servings
of fruit. Between 20% and 50% of boys and girls met
recommended daily servings of grain, vegetables, dairy,
and meats. Both CSFII and NHANES III data are now
more than 10 years old; NHANES 2001-2002 incorpo-
rated a food frequency– based dietary assessment; how-
ever, these food frequency data have not yet been re-
leased. Neumark-Sztainer (7) reported dietary adequacy
among more than 4,000 youth aged 11 to 18 years based
on an FFQ and comparisons with Healthy People 2010
goals. About one half of boys and girls met recommenda-
tions for total fat intake and 45% of girls and 36% of boys
met recommendations for saturated fat intake, which was
notably higher than the proportion of SEARCH partici-
pants who met these goals. Reasons for the generally low
adherence to nutrition recommendations in the SEARCH
cohort are unclear. It is possible that high dietary fat
intake was, in fact, a contributor to the development of
diabetes, both for type 2 diabetes (19) and from a recent
report (20) potentially for type 1 diabetes as well. Future
analyses of the SEARCH data will explore dietary habits
in relation to other aspects of diabetes self-management
and education to identify correlates of dietary adherence.
In our study, dietary intake was generally similar for
youth with type 1 diabetes and type 2 diabetes. However,
youth with type 2 diabetes consumed significantly less
calcium than those with type 1 diabetes (P⬍0.01) regard-
less of age, race/ethnicity, and parental education. Inter-
estingly, this association was attenuated after addition of
BMI Z score to the statistical model, which suggests that
an association of calcium intake with obesity may ex-
plain, at least in part, the original observation, consistent
with recent epidemiologic studies that have shown an
inverse association of calcium intake with obesity (21,22).
The lower intake of calcium (23), vitamin E (24), and
magnesium (25) among youth with type 2 diabetes com-
pared to youth with type 1 diabetes could reflect under-
lying etiologic associations of inadequate intake of these
micronutrients with the insulin resistance of type 2 dia-
betes; future studies will be needed to pursue this issue.
There are no specific recommendations for number of
servings of sweetened carbonated beverages or other
sweets and snacks (not including sweetened beverages),
except to the extent that these foods should be restricted
in the interest of glucose control and weight management
for youth with diabetes, especially those with type 2 dia-
betes (2). In the SEARCH participants, 1.3 servings of
carbonated beverage (not including diet varieties) was
reported among older youth with type 2 diabetes, which
was about twice the intake of the older youth with type 1
diabetes or younger youth regardless of diabetes type. In
addition, youth in each subgroup reported approximately

May 2006 ● Journal of the AMERICAN DIETETIC ASSOCIATION 693

 Table 4. Estimated daily intake (servings per day) of selected food groups and dietary behaviors according to age and diabetes type: SEARCH
for Diabetes in Youth participants in the dietary assessment protocol, prevalent 2001 and incident 2002
Age 10-14 y Age >15 y
Type 1/1A Type 2 Type 1/1A Type 2
Food group (nⴝ740) (nⴝ31) (nⴝ771) (nⴝ155) P valuea

Dairy 2.0⫾1.2 1.4⫾1.0 1.7⫾1.1 1.3⫾1.2 0.6961

Fruits 1.3⫾1.1 1.5⫾1.7 1.3⫾1.1 1.5⫾1.5 0.0534
Vegetables 1.5⫾1.2 2.2⫾2.1 1.8⫾1.4 2.0⫾1.7 0.0502
Low-fiber grains 3.1⫾1.6 2.9⫾1.8 3.3⫾1.8 3.2⫾1.8 0.8643
High-fiber grains 0.1⫾0.3 0.1⫾0.1 0.1⫾0.3 0.1⫾0.2 0.0659
Meat 1.6⫾1.1 1.6⫾1.2 1.9⫾1.4 1.8⫾1.1 0.9383
Fish 0.04⫾0.1 0.03⫾0.05 0.05⫾0.1 0.1⫾0.2 0.1052
Poultry 0.3⫾0.4 0.4⫾0.4 0.4⫾0.5 0.4⫾0.5 0.1769
Sweetened carbonated beverage 0.4⫾0.7 0.3⫾0.8 0.6⫾1.1 1.3⫾2.0 0.0198/0.0010*
Sweets/snacks 1.0⫾0.9 1.1⫾1.6 1.0⫾1.1 0.9⫾1.1 0.1531
Vitamins
Yes (%) 27.8 29 27.9 11.6 0.1387
Low-fat products
Always/almost always (%) 9.2 12.9 10.8 15.5 0.0300
Typical week 0.1467
Yes (%) 85 74.25 85.3 76.1
Ate a lot less (%) 0.9 0.0 1.7 2.6
Ate a little less (%) 3.8 12.9 3.6 7.1
Ate a little more (%) 7.7 6.4 6.9 7.7
Ate a lot more (%) 2.4 6.4 2.5 6.4
Eat out more than three times
during/week
Yes (%) 33 22.6 50.3 33.5 0.0009
a
P value for comparison of type 1/1A vs type 2 diabetes mellitus across age groups, adjusted for total energy, site, sex, race/ethnicity, parental education, and age.
*For interaction term age⫻diabetes type P⬍0.01; for comparison of type 1/1A vs type 2 P⬍0.01 only for youth age ⬎15 y.

with higher energy intake, higher intake of soft drinks,

Figure. Percent of male and female youth with diabetes who meet
dietary recommendations: SEARCH for Diabetes in Youth participants in
the dietary assessment protocol, prevalent 2001 and incident 2002.
*P⬍0.01 for comparison of males vs females, adjusted for clinical site,
race/ethnicity, and parental education level.
1 sweet or snack serving per day; thus, total servings of
sweetened carbonated beverage and sweet/snack was ap-
proximately equal to servings per day of fruit.
Between 1977 and 1996, the proportion of food con-
sumed by children in restaurants (including fast food)
increased nearly threefold, and intake of soft drinks in-
creased notably (26). Fast food use has been associated
and lower intakes of fruit, vegetables, grains, and milk
(27). Among the SEARCH participants, compared with
youth with type 1 diabetes, a smaller proportion of youth
with type 2 diabetes reported eating out three times per
week or more; reasons for this are unclear.
An important limitation of the work presented herein
relates to sources of inaccuracy in self-report of dietary
intake by youth (28). Three issues may be especially
relevant to this report. First, studies of adults have
shown that underreporting of energy intake increases
with BMI (29,30). Among adolescents, the Youth/Adoles-
cent Questionnaire (similar to the SEARCH FFQ) was
determined to provide accurate estimation of mean en-
ergy intake for a group (energy intake by doubly labeled
water vs the Youth/Adolescent Questionnaire, P⫽0.91),
but not for an individual (31). However, underreporting of
energy intake was observed to a greater extent among
those with higher percent body fat (r⫽⫺0.24, P⫽0.08).
Second, some individuals may respond to questionnaire
items in what they perceive to be a socially desirable
manner (32); however, this phenomenon has not been
studied among adolescents. Youth with diabetes may, due
to their condition, be particularly prone to biased reporting
related to social desirability, despite specific instructions on
the SEARCH FFQ that indicate investigators are “inter-
ested in what you actually eat, not what you think you

694 May 2006 Volume 106 Number 5

 Table 5. Percent of children and adolescents with diabetes who meet dietary recommendations according to age and diabetes type: SEARCH
for Diabetes in Youth participants in the dietary assessment protocol, prevalent 2001 and incident 2002
Age 10-14 y Age >15 y
% Meeting All Type 1/1A Type 2 Type 1/1A Type 2
recommendation (nⴝ1,697) (nⴝ740) (nⴝ31) (nⴝ771) (nⴝ155) P valuea

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-
nal Block instrument may not hold in the SEARCH popu-
lation due to changes in the instrument. The changes to the
instrument were an expansion of food items queried, to
include culturally appropriate foods, and an expansion in
the underlying nutrient and food group databases. Neither
change would be expected to result in marked differences in
the validity of the instrument; in fact, lack of modification to
the foods queried most likely would have harmed the valid-
ity by causing systematic underreporting for subgroups of
the SEARCH population simply due to omitting foods re-
flective of local food availability and preferences. Validity
may also have been affected by use of interviewer when
needed, rather than using self-administration for 100% of
the cohort. We do not have a comparison method of dietary
assessment in this study (eg, multiple 24-hour dietary re-
calls). However, we compared dietary intake for all nutri-
ents and food groups shown in Table 5 for individuals with
self-administration vs interviewer administration; no sta-
tistically significant differences were observed according to
mode of administration (data not shown).
Finally, nonresponse to the SEARCH clinic visit may
have resulted in selection bias, such that dietary intake
among participating youth may have been different than
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
reported, more healthful dietary habits than their non-
participating peers. If this were true, then dietary intake
of the whole population of youth with diabetes may be
somewhat worse than what is reported here.
CONCLUSIONS
Data from the SEARCH for Diabetes in Youth study
suggest that average habitual intake of foods and nutri-
ents among members of this large, ethnically diverse
cohort of youth with diabetes falls considerably short of
current recommendations for dietary intake. Recommen-
dations from the American Diabetes, American Heart
Association, Institute of Medicine, and Healthy People
2010 are based on strong scientific evidence regarding
intake of specific nutrients and foods in relation to phys-
iologic health outcomes, including appropriate growth
and development through adolescent years and optimiz-
ing metabolic status for youth with diabetes. In particu-
lar, the American Diabetes Association recommendation
of less than 10% of energy from saturated fat is given
with the highest level of scientific evidence based on
studies of the effect of saturated fat on low-density li-
poprotein cholesterol (33), yet only 6.5% of youth with
diabetes in our study met this recommendation. Results
reported herein indicate a clear need for improvement in
the dietary intake of youth with diabetes, including youth
with type 1 and youth with type 2 diabetes. Further work
to better understand barriers to healthful dietary habits,
and to identify effective approaches to improving dietary
intake in youth with diabetes, is urgently needed.
SEARCH for Diabetes in Youth is funded by the Centers
for Disease Control and Prevention (PA No. 00097) and
supported by the National Institute of Diabetes and Di-
gestive and Kidney Diseases.
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