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3 Zinman College for Physical Education and Sports, Wingate Institute, 42902 Netanya, Israel; Department of Epidemiology and Preventive Medicine, Sackler Medical Faculty, Tel Aviv University, Tel Aviv, Israel; 4 Center for Biostatistics, Methodist Hospital Research Institute, Houston, TX; 5 Aberdeen Area Indian Health Service, Aberdeen, SD 57401; 6 Wagner Indian Health Service, Diabetes Prevention Project, Wagner, SD 57380; 7 Medstar Research Institute, Hyattsville, MD 20783; 8 American Association of Homes and Services for the Aging, Washington, DC; and 9 Georgetown University, Washington, DC 20057
* To whom correspondence should be addressed. E-mail: eilatsi{at}017.net.il.
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ABSTRACT |
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 TOP ABSTRACT IntroductionResearch Design and MethodsResultsDiscussionLITERATURE CITED |
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Introduction |
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TOPABSTRACTIntroductionResearch Design and MethodsResultsDiscussionLITERATURE CITED |
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One of the cornerstones of diabetes therapy is diet. The primary recommendations for medical nutrition therapy for diabetes are published by the American Diabetes Association (ADA)10 and updated annually (2,3). These recommendations are developed to optimize glycemic control, reduce risk factors for macrovascular complications, and control weight.
Reports on diabetes prevalence and incidence from a longitudinal study of 4549 American Indians (4) showed that the age-adjusted diabetes prevalence in American Indians aged 45–74 y range from 33 to 72% (5), several times higher than those of other ethnic groups (6). However, little is known about adherence to dietary recommendations among American Indians with diabetes, information that is potentially important for developing nutrition programs appropriate for this population. The purpose of the current study is to evaluate how well American Indians with diabetes met ADA dietary recommendations and to compare their diet and adherence to recommendations to that of persons with diabetes in the general U.S. population in the NHANES 1999–2000.
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Research Design and Methods |
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TOPABSTRACTIntroductionResearch Design and MethodsResultsDiscussionLITERATURE CITED |
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The 3rd SHS examination included a dietary recall questionnaire and was conducted on 3197 participants. Of these, 1186 (374 men and 812 women) had diabetes and complete dietary data. Those who had diabetes 
1 y (n = 23), consumed total energy 2512 kJ/d (n = 57), or had medical conditions affecting energy intake, such as dialysis treatment, kidney transplant, or liver cirrhosis (n = 98), were excluded. The analysis sample consisted of 1008 (316 men and 692 women) participants with diabetes, ages 51–83 y. The larger proportion of women in the analysis sample is a reflection of the higher mortality in men in this population, the larger number of women originally recruited into the cohort, and the higher levels of diabetes in SHS women (4).
U.S. population data.
To compare adherence to nutritional recommendations among American Indians in the SHS with adults with diabetes in the U.S. as a whole, we used data for adults with diabetes, ages 51–84 y, from NHANES 1999–2000 (n = 441) (9), a national survey that was conducted near the time of the 3rd SHS examination. As in the SHS, total energy intake was estimated in NHANES using a single 24-h dietary recall. We applied the same exclusion criteria to the NHANES data set as we did to the SHS data: those who had diabetes 1 y (n = 7), consumed total energy 
2512 kJ/d (n = 61), or had medical conditions affecting energy intake, such as dialysis treatment, kidney transplant, or liver cirrhosis (n = 0). Fasting blood samples were used in both studies. The NHANES sample for this analysis consisted of 373 (190 men and 183 women) participants with diabetes.
Measurements. Dietary data were collected using a single 24-h dietary recall. Interviewers were centrally trained and certified in data collection and form completion according to standardized methods (10). Dietary intake was analyzed using the Minnesota Nutrition Data System (NDS) (NDS version 2.1) (11,12). Because calculation of trans fatty acids (TFA) was not available in NDS version 2.1, additional calculations were conducted using Nutrition Coordinating Center Nutrient Database version 36 (Nutrition Data System for Research) (13). The NDS for Research database updates analytic data while retaining nutrient profiles true to the version used for data collection.
Overweight was defined as BMI 25 and <30 kg/m2 and obesity as BMI 30 kg/m2 (14,15). At the time of the exam, the National Cholesterol Education Program II lipid goals were LDL-cholesterol (LDL-C) <130 mg/dL,11 HDL-cholesterol >35 mg/dL,11 and triglycerides (TG) <200 mg/dL11 (16). In the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, hypertension was defined as 140 mm Hg systolic or 90 mm Hg diastolic, and mild-to-moderate hypertension was defined as 130–139 mm Hg systolic or 85–89 mm Hg diastolic (17). Nephropathy was defined as urinary albumin/creatinine 30 mg/g. Current alcohol drinkers were defined as persons who indicated that they had consumed alcohol within the last year and those who had not were considered nondrinkers. Approaches to collection of physical activity data were not comparable across the 2 studies.
ADA dietary recommendations in 1997 (2) are summarized in Table 1: protein = 10–20%, SFA <10%, PUFA 10%, and monounsaturated fatty acids (MUFA) 20% of total energy intake. No recommendations were made for TFA and total carbohydrates. Recommended fiber intake was 20–35 g/d, cholesterol intake <200 mg/d, and sodium intake <2400 or 3000 mg/d (6.3–7.8 g/d salt).
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Because SFA and dietary fiber are 2 key nutrients related to both diabetes and CVD, we also determined percentage of participants who met the 1997 or 2006 recommendations.
Statistical analysis. Demographic and physical characteristics were summarized for SHS and NHANES and presented as means or percentages ± SEM or as medians and interquartile ranges if continuous variables were skewed. Macronutrient intake was expressed as percentage of energy, fiber was expressed in g, and cholesterol was expressed in mg. All analyses were performed with SAS version 9.0 (16). NHANES data were analyzed with SAS-Callable SUDAAN software version 9.0 (17), which permits appropriate weighting of NHANES (18). Comparisons between SHS and NHANES were conducted using chi-square test for categorical variables and with t test for continuous variables (reported energy, fiber, cholesterol, and sodium were log-transformed for the analyses). Comparisons between those who met the 1997 ADA recommendations and those who did not were conducted using the logistic regression model, adjusted for age and gender. All P-values were 2-tailed and significance was defined as P < 0.05 for all tests.
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Results |
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TOPABSTRACTIntroductionResearch Design and MethodsResultsDiscussionLITERATURE CITED |
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Table 2 presents baseline characteristics of participants with diabetes in SHS and NHANES. SHS men and women had higher glycosylated hemoglobin (HbA1c) than their counterparts in NHANES. Men in SHS had higher fasting glucose concentrations than men in NHANES. SHS men and women were more likely to be current smokers. There were 15.2 and 7.3% (P < 0.001) participants who were younger (<65 y) and smokers in the SHS and NHANES, respectively. Women in SHS reported higher SFA, MUFA, and lower PUFA intake. Among both the SHS and NHANES samples of participants with diabetes, mean or median intakes of protein, PUFA, carbohydrates, and MUFA met the 1997 ADA recommendations; SFA and sodium intakes were higher and dietary fiber intake was lower than recommended (Table 3). A higher percentage of the SHS sample met the 1997 recommendations for protein, PUFA, carbohydrates, MUFA, alcohol, and dietary fiber, as well as sodium among hypertensive individuals. Recommendations for the combination of SFA and fiber were met by about one-half as many SHS participants [4.6% (45/984)] as NHANES participants [8.5% (21/248)] (P = 0.02). Individuals with diabetes in the SHS who did not meet the ADA (n = 939) recommendations were more obese (BMI = 29.3 ± 0.8 kg/m2 in those who met recommendations vs. 32.3 ± 0.2 kg/m2 in those who did not meet recommendations) and reported consuming more fat, SFA, MUFA, and PUFA but less fiber (data not shown).
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None of the SHS sample met the 2006 nutritional recommendations for SFA and fiber and only 31 of the 373 (8.3%) NHANES participants met these recommendations.
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Discussion |
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TOPABSTRACTIntroductionResearch Design and MethodsResultsDiscussionLITERATURE CITED |
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Compared with NHANES, a higher proportion of the SHS sample met 1997 recommendations for single macronutrients. Although the proportion of both SHS and NHANES diabetic participants met the 1997 guidelines for saturated fat and fiber, about twice as many NHANES participants met this guideline.
To provide insight on whom to target, we compared the characteristics of adherent and nonadherent individuals. The dietary profile of individuals with diabetes in the SHS who did not meet the ADA recommendations (more obese and reported consuming more fat, SFA, MUFA, and PUFA but less fiber) may reflect the fact that American Indians appear to eat more fatty meats and fewer vegetables and whole grains than the general U.S. population (SHS unpublished data). Due to statistically unreliable estimates for the means ± SEM from the small sample size (only 21 met the 1997 recommendations in NHANES), the characteristics for participants who met the 1997 recommendations and those who did not could not be compared. The low percentage of individuals with diabetes in both populations who met the recommended SFA intake, is clinically significant, because individuals with diabetes have a high risk for CVD.
Taken together, the much higher percentage of diabetes prevalence, the higher risk profile of SHS participants, and the lower percentage meeting the 1997 recommendations for the 2 key nutrients of SFA and fiber result in a higher risk for CVD among the SHS sample. Importantly, when the 2006 recommendations are applied to the same data, results appear much less favorable, a finding that likely reflects the increased detail and strictness between the 1997 and 2006 recommendations. No previous analyses of adherence to dietary recommendations have been conducted in a population of American Indians with diabetes. Resnick et al. (19) reported that 48.3% of the NHANES population met the recommendations for SFA (<10% of daily intake), compared with 34.8% in SHS and 23.9% in NHANES in the current analysis. Resnick's (19) analysis consisted of a different sample, age 18 y, from NHANES. This may explain the lower prevalence of nonadherence in the current analysis.
Many aspects of the diet composition (carbohydrate, fat, fiber, vitamins, and alcohol) have been considered important to the modulation of insulin resistance, but in the last few years, more attention has been given to the influence of various dietary fats on insulin sensitivity and, throughout this mechanism, the risk of type 2 diabetes. This interest arose from studies performed with animals in which diets rich in saturated fat worsened insulin sensitivity, whereas diets rich in unsaturated fat, particularly short- and long-chain (n-3) fatty acids, improved insulin action. Although studies in humans have not been as extensive as those in animals (20), a large trial showed that insulin sensitivity improved when saturated fat was replaced in the diet with monounsaturated fat (21). Thus, we chose to study saturated fat and fiber, the latter because it also reflects intake of vegetables, fruits, and grains, currently viewed as the basis for optimum nutrition.
The current analysis, whether focused on adherence to dietary recommendations or to recommended levels of selected nutrients, showed low adherence to key nutrients related to insulin resistance and CVD risk in both American Indians with diabetes and the entire U.S. population with diabetes. These findings point to the need for strategies to improve adherence to dietary recommendations for both American Indians with diabetes and the entire U.S. population with diabetes.
American Indians have a high prevalence of diabetes. Thus, our data indicate that large numbers of individuals in this population need nutritional intervention. Only a few intervention programs have been tested in controlled, randomized trials in different areas, as well as different age groups. Future intervention programs should focus on smoking cessation and increasing physical activity, as well as changes in the Western diet patterns adopted by American Indians. The cultural preferences of this population should also be considered while planning intervention programs.
This study's strengths include the population-based samples and wide range of demographic and nutrient data. Furthermore, the same dietary survey method was used for both populations, including training of staff and standardization of data.
This study was limited by several factors. Dietary patterns, described in the 2006 recommendations [e.g. "people with diabetes are encouraged to eat a variety of fiber-containing foods such as legumes, fiber-rich cereals, as well as fruits, vegetables, and whole-grain products" (3)] cannot be evaluated in the current study, because we do not have data on food sources for the relevant nutrients from the 24-h recalls that were performed in the mid-1990s (the NDS database at that time did not allow extraction of food data). Because this was a cross-sectional analysis, cause and effect cannot be established. The use of a single 24-h recall is limited because of day-to-day individual variability (22). However, measurement of dietary intake usually is conducted for 1 of 3 purposes: to compare average intake of different groups, to rank individuals within a group, and to estimate an individual's usual intake (23). The 24-h recall can provide detailed information on specific foods (24) and is therefore considered ideal for intercultural comparisons of mean dietary intake levels, because it is an open-ended method that allows detailed reporting of heterogeneous types of food (22). On the other hand, it tends to underestimate energy intake. Our aim was to compare the NHANES cohort with the SHS cohort. For this objective, we believe it is sufficient to assume that constant scaling bias is of a relatively constant magnitude, as in NHANES (23).
In summary, our data emphasize the importance of developing interventions targeted particularly at saturated fat and fiber intake for those with diabetes, those with diabetes and other risk factors, or those at high risk for diabetes. These interventions would contribute to lowering the risk for diabetes-induced complications.
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ACKNOWLEDGMENTS |
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FOOTNOTES |
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2 Author disclosures: B. V. Howard has served on the advisory boards of Merck, Shering Plough, the Egg Nutrition Council, and General Mills, and has received research support from Merck and Pfizer; S. Eilat-Adar, J. Xu, E. Zephier, V. O'Leary, and H. E. Resnick, no conflicts of interest.
10 Abbreviations used: ADA, American Diabetes Association; CVD, cardiovascular disease; LDL-C, LDL-cholesterol; MUFA, monounsaturated fatty acid; NDS, Minnesota Nutrition Data System; SHS, Strong Heart Study; TFA, trans fatty acid; TG, triglyceride.
11 Conversion factor, multiply by 0.0259 for mmol/L.
Manuscript received 5 February 2008. Initial review completed 4 March 2008. Revision accepted 20 June 2008.
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LITERATURE CITED |
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