Despite modern approaches to intensive insulin therapy for the management of type 1 diabetes, dietary management remains at the cornerstone of diabetes treatment (1
). Previous research supports the relevance of dietary adherence to diabetes outcomes (16
). The NKS is a brief, reliable, and easy-to-use measure of nutrition knowledge for youth with type 1 diabetes and their families. The NKS was designed for clinical and research use as a measure of nutrition knowledge.
The NKS is one of the first measures specifically developed for youth with type 1 diabetes and their parents that assesses both general nutrition (e.g., healthful choices and label reading) and diabetes-specific (e.g., carbohydrate counting and glycemic response to foods) nutrition knowledge. Previous nutrition measures for youth with type 1 diabetes have focused primarily on carbohydrate counting (5
). Those measures were used to inform the development of the current measure; however, the NKS was developed to be a broader measure that assesses various aspects of nutrition, which are important for optimal diabetes management. Notably, our findings indicate that both general and diabetes-specific dimensions of parents’ nutrition knowledge were associated with glycemic control.
The advantages of the NKS are that it is a brief, self-administered measure that can be completed in ~10 min. The reading level is somewhat higher than that of the youngest participants; however, reading level is based on the number of syllables in the words used. A nutrition knowledge measure for this population requires the use of multisyllable terms such as carbohydrate (used repeatedly in the measure), insulin, vitamins, etc. Due to diabetes education provided to these youth, they very likely understood these terms. When the measure was tested in a relatively large sample of youth with type 1 diabetes managed with modern intensive insulin therapy and their parents, it demonstrated acceptable internal consistency and external validity. Greater nutrition knowledge of parents was associated with both better glycemic control and higher diet quality in youths. In addition, greater youth nutrition knowledge was associated with higher diet quality; however, the association of youth nutrition knowledge with glycemic control was not significant. The mean youth age was 13 years; therefore, it is likely that parents were primarily responsible for food-related decisions, including grocery shopping, meal preparation, and carbohydrate counting. Notably, parent NKS was significantly higher than youth NKS. Associations of higher NKS with higher parent education, older youth age, insulin pump use, and diabetes duration further support the validity of the measure because these factors likely relate to greater exposure to nutrition education. The majority of parents who completed the NKS were mothers so it was not possible to determine whether mothers’ and fathers’ nutrition knowledge scores would have different relationships with youth A1C; this would be an interesting question to examine in future research.
There were several limitations with the current study. The NKS was evaluated in a relatively homogenous sample of youth (e.g., good control and majority on insulin pumps) receiving care at a single diabetes clinic. Although the sample in this study was a convenience sample, the racial distribution reflects the demographics of type 1 diabetes. However, parents were predominantly college educated, and there were few low-income families. In the future, it would be useful to test the measure in a more diverse group of youth from several diabetes centers to determine the measure’s performance in a more heterogeneous sample. Although the measure demonstrated the hypothesized relations with A1C and HEI-2005, there was no gold standard of general and diabetes nutrition knowledge against which to test the measure. It would be useful, however, to determine the association of the carbohydrate-counting domain of the NKS with the PedsCarbQuiz in future research. Another limitation of the study was the possibility of reporting bias in the food records, which is a concern in all diet studies. However, the mean HEI-2005 in this sample was similar to that observed in a representative sample of U.S. youth (20
In conclusion, the NKS is a brief, self-administered measure developed to assess both general and diabetes-specific nutrition knowledge in youth with type 1 diabetes and their parents. Our findings provide strong evidence of preliminary validity of the measure to assess nutrition knowledge, suggesting potential utility in both clinical and research settings. Future research to determine the measure’s utility should include assessing the sensitivity of the measure to change in response to nutrition counseling.