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The dietary adherence of a sample of 97 patients with insulin-dependent diabetes mellitus has been quantitatively described. Now, in an effort to understand the poor dietary aherence found, diet-related knowledge and skill and their relationship to dietary adherence among 90 diabetic children have been studied. Diet-related competencies assessed were the ability to: (1) recall the personal diet plan, (2) correctly fill one's plate from a buffet, with the diet plan in hand, and (3) choose an appropriate meal from a restaurant menu. Adherence to the diet was assessed by unobtrusive observations at meals. Error rates on the three tests of knowledge and skill were .21, .28, and .51, respectively. The mean error rate at mealtime was .35, only slightly higher than the error rate for filling a plate when the children knew they were being tested. In a multiple regression analysis, age (r = .37) and sex (R = .48) were associated with adherence to the diet plan. Ability to choose correctly from a menu, duration of diabetes, and ability to correctly fill a plate from a buffet also entered the regression equation (R = .54). The data suggest that many children did not possess the knowledge and skill required for good dietary adherence, regardless of motivation. Health educators may underestimate the complexity of the behaviors expected of chronically ill patients.