Physical Activity and Nutrition

Interventions for Type 1 Diabetes:

A Meta-analysis
Shefaly Shorey, PhD,a,b Esperanza D. Ng, BPsySc (Hons), Evelyn C. Law, MD,b,c,d John C.M. Wong, MBBS, MMed (Psych),e
Kah Yin Loke, MBBS, MMed (Paeds),c Wilson W.S. Tam, PhDa

BACKGROUND AND OBJECTIVES:Current evidence is lacking on physical activity and nutrition-based abstract
interventions focusing on the management of type 1 diabetes mellitus (T1DM) and health-
related quality of life among children. To assess the effects of physical activity interventions
and nutrition-based interventions for children with T1DM.
METHODS: Data sources include the Cochrane Central Register of Controlled Trials, Medline,
clinicaltrials.gov, the World Health Organization International Clinical Trials Registry Platform,
CINAHL through January 2022. Study selection includes randomized controlled trials of
children aged 18 years and below with T1DM comparing either a physical activity
intervention, a nutrition-based intervention, or hybrid physical activity and nutrition-based
intervention with placebo or no-treatment control. Data were pooled using a random-effects
model. Primary outcomes were hemoglobin A1c (HbA1c), and health-related quality of life.
RESULTS:Eighteen trials were included. Physical activity compared with the no-treatment group
showed a lack of effect on HbA1c (mean difference 5 0.58, 95% confidence interval 1.20
to 0.05; P value 5 .07). Nutrition-based intervention compared with no-treatment control for
HbA1c level revealed a lack of effect (mean difference 5 0.61, 95% confidence interval
1.48 to 0.26; P value 5 .17). Limitations include paucity of studies and low quality of
evidence caused by the risk of bias.
CONCLUSIONS: Despite the lack of significant evidence, the generally favorable results highlight
the potential of such interventions in enhancing glycemic control and health-related quality of
life. Additionally, promising results from a single physical activity-nutrition-based hybrid
intervention in terms of glycemic control indicate the plausible effectiveness of a mixed
intervention.

Full article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2022-056540

a
Alice Lee Center for Nursing Studies, and cDepartments of Pediatrics, and ePsychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; bNational
University Health System, Singapore; and dTranslational Neuroscience Program, Agency for Science, Technology, and Research, Singapore Institute for Clinical Sciences, Singapore

Dr Shorey conceptualized and designed the study, coordinated and supervised data collection, and reviewed and revised the manuscript; Ms Esperanza Ng
conducted the data collection, extraction, initial analyses, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Law conceptualized and
designed the study and critically reviewed the manuscript for important intellectual content, and edited and revised the manuscript; Dr Wong critically
reviewed the manuscript for important intellectual content, and edited and revised the manuscript; Dr Yin critically reviewed the manuscript for important
intellectual content, and edited and revised the manuscript; Dr Tam coordinated and supervised data collection, data extraction, and data analyses, and
reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
DOI: https://doi.org/10.1542/peds.2022-056540

To cite: Shorey S, Ng ED, Law EC, et al. Physical Activity and Nutrition Interventions for Type 1 Diabetes:
A Meta-analysis. Pediatrics. 2022;150(3):e2022056540

PEDIATRICS Volume 150, number 3, September 2022:e2022056540 REVIEW ARTICLE

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 Full article can be found online at
www.pediatrics.org/cgi/doi/
10.1542/peds.2022-056540
Type 1 diabetes mellitus (T1DM)
was previously known as juvenile
diabetes or insulin-dependent
diabetes. It is a disease of
disordered immune function in
genetically susceptible people
involving the destruction of b cells
that secrete insulin in the
pancreas.1,2 Children diagnosed with
T1DM are especially at risk for
diabetic ketoacidosis and severe
hypoglycemia, resulting from insulin
deficiency or low blood glucose
levels,3 which can happen in
situations where a child is more
physically active than usual after a
meal, or if they consume less food
than usual for a meal. Such changes
to daily routines could complicate
children's blood glucose
management while at school.4 Apart
from physical well-being, children
and adolescents with T1DM tend to
have a lower general health-related
quality of life, compared with
healthy-matched children and
adolescents.5 Being older, a girl, and
having late-onset T1DM are often
associated with low health-related
quality of life among children with
T1DM.6,7 Meanwhile, children with
fewer diabetic complications, and
better glycemic control, treatment
adherence, and treatment
satisfaction have a relatively higher
health-related quality of life.8,9
Therefore, interventions targeting
glycemic control and health-related
quality of life among children and
adolescents with T1DM are crucial
in enhancing their physical and
mental wellbeing in the critical
developmental years.
Despite the availability of
pharmacological and
nonpharmacological treatment,
treatment of T1DM is especially
difficult during adolescence because
of marked hormonal, metabolic,
cognitive, and psychosocial changes
2 SHOREY et al
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that are associated with puberty.10
Although hormonal changes can
reduce sensitivity to insulin,11 other
factors (psychosocial, peer influence,
or self-identity) may cause poor
glycemic control among
adolescents.4,12–15 The struggle to
manage T1DM during this turbulent
phase is challenging, therefore
interventions targeting children and
adolescents with T1DM should
consider psychosocial and “lifestyle”
factors to improve their health-
related quality of life.
Physical Activity and Nutrition-
Based Interventions
Behavior change interventions for
children and adolescents with T1DM
are designed to address knowledge
and skills, increase self-efficacy, and
promote healthy behaviors.16
Behavior change interventions are
wide-ranging and can target more
than 1 behavioral component, such
as diet choices, meal frequency,
physical activities, sedentary
behaviors, glucose monitoring, and
insulin compliance.17 In our review,
the focus of behavior change
interventions is limited to physical
activity interventions and nutrition-
based interventions.
Physical activity interventions focus
on improving the well-being of
children and adolescents with
T1DM; they aim to maintain safe
levels of hemoglobin A1c (HbA1c),
improve lipoprotein profiles, and
increase maximal aerobic capacities
or maximum rate of oxygen
consumption.18–23 Recommended
physical activities include aerobic
exercise of low to vigorous intensity,
flexibility and balance exercise, and
resistance exercise.19,24–26 Apart
from promoting physical activities,
some physical activity interventions
aim to reduce sedentary behaviors
through motivational
interviewing,27–29 cognitive
restructuring,27 and electronic
health tools.27,30,31 In the meta-
analysis by Quirk and colleagues,32
physical activity interventions for
children and adolescents with T1DM
were generally found to have good
engagement rates and were effective
in increasing physical activity,
improving cardiovascular health,
and decreasing HbA1c levels.
On the other hand, medical nutrition
therapies for children and
adolescents with T1DM usually
focus on avoiding hyperglycemia
and achieving near-normal blood
glucose levels without severe
hypoglycemia. One major aim is to
achieve normal growth and
development to keep metabolic
parameters within normal limits.33
Interventions to achieve good
glycemic control are often
educational and include counting
carbohydrates, nutrition counseling,
and diet adjustment using
individualized meal plans, printed
diet charts, food plates, or food
pyramids.34–36 Overall, nutrition-
based interventions that educate
and equip children and adolescents
with the necessary skills to better
manage T1DM were reported to
increase their sense of self-efficacy
and adherence to diabetes regimens,
such as self-monitoring of blood
glucose and following prescribed
medications.34,37
Given the benefits of physical
activity and nutrition-based
interventions for children and
adolescents with T1DM, a thorough
review is warranted to pool existing
data and examine the overall effect
of physical activity interventions on
the physical and psychosocial well-
being of children and adolescents
with T1DM. However, current
systematic reviews focusing on
physical activity interventions and
nutrition-based interventions in the
management of T1DM in children
and adolescents produced mixed
results based on age group and sex,
and are not up-to-date with
research findings from the past
 5 years.19,32,38,39 Moreover, reviews
on the effects of nutrition-based
interventions for children or
adolescents with T1DM are severely
lacking. Existing nutrition-based
intervention reviews combined
samples of adults and children,
included both individuals with
T1DM and type 2 diabetes mellitus,
and mainly focused on the effects of
low-carbohydrate or low-glycemic-
index diets.40–42
Therefore, this review aims to
assess the effects of physical activity
interventions and nutrition-based
interventions on children and
adolescents with T1DM in terms of
glycemic control and health-related
quality of life.
METHOD
Search Strategy
This systematic review was
conducted following PRISMA
guidelines.43 A systematic search
was conducted across 5 electronic
databases (CINAHL, Cochrane
Central Register of Controlled Trials
[CENTRAL], Medline,
ClinicalTrials.gov, and World Health
Organization International Clinical
Trials Registry Platform) from the
inception of each database to
January 2022. Embase was excluded
in the search, as studies indexed in
Embase are now prospectively
added to CENTRAL via a highly
sensitive screening process.44 No
restrictions were placed on the
language of any publication. With
the assistance of a health sciences
librarian, key search terms were
generated based on 4 concepts,
population (eg, adolescent, child,
infant, and pediatrics), intervention
(eg, exercise, physical activity, diet
therapy, and nutrition), condition
(T1DM), and study type (eg,
randomized controlled trial [RCT]).
The full search strategy for a
database is available in
Supplemental Information. Gray
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literature was identified by
searching trial registries. A hand
search of the reference lists of
included studies, systematic reviews,
meta-analyses, and health
technology assessment reports was
also conducted to identify potential
studies.
Eligibility Criteria
Studies were included if they met
the selection criteria of each
category: study type, participants,
intervention type, and outcome
measures.
Study Design
Only RCTs or randomized crossover
studies were included.
Participants
As the Cochrane Child Health Field
defines infants, children, and youth
as individuals aged 0 to 18 years,
studies with a sample of children or
adolescents aged 18 years and
below with a T1DM diagnosis at the
time of the study were included.45
Studies involving participants of any
age but with a subgroup analysis of
those aged 18 or below were
included, and relevant data were
extracted. Studies examining
interventions of interest among a
mixed sample of children and
adolescents with T1DM and other
comorbidities or chronic diseases
were excluded.
Intervention Type
Studies that compared physical
activity interventions or nutrition-
based interventions or physical
activity and nutrition-based
interventions with placebo, usual
care, or no intervention were
included in this review. Studies with
active comparators were excluded.
Physical activity interventions were
included if they were administered
for at least 4 weeks. Nutrition-based
interventions were included
regardless of the administration
duration because of the design of
most studies (ie, crossover design or
1 day education). Duration of
follow-up was also not restricted to
physical activity interventions and
nutrition-based interventions.
Outcome Measures
In this review, glycemic control will
be determined by HbA1c levels.
Studies were included if they report
1 of the following primary outcomes
of interest: health-related quality of
life or HbA1c level. Outcomes can be
measured by parent-report or self-
report data or investigator-assessed.
Studies with insufficient data or
those that did not report statistical
data were excluded from this
review.
Study Selection
Initial search results were exported
to a reference manager, Endnote X9
(Clarivate Analytics, 2021), where
duplicates were removed. The titles
and abstracts of records were
screened for context relevance by 2
reviewers independently (E.N. and
S.S.), and full texts of articles were
retrieved and screened for
eligibility. Interrater agreement was
approximately 96%. Any
disagreements were resolved by
consulting other authors on the
team until a consensus was
achieved.
Assessment of Risk of Bias
The risk of bias in included studies
was assessed independently by 2
reviewers (E.N. and S.S.) using the
Cochrane’s Risk of Bias assessment
tool,46 which assessed 5 types of
biases: selection bias, performance
bias, detection bias, attrition bias,
and reporting bias. Self-reported
(subjective) and investigator-
assessed (objective) outcome
measures were assessed separately.
Each domain was graded a “high,”
“low,” or “unclear” risk if insufficient
details were provided. Any
disagreements between the 2
reviewers were resolved by
3
 consulting other authors on the
team until a consensus was reached.
The overall certainty of the evidence
for each outcome was rated as high,
“moderate,” or low according to the
Grades of Recommendation,
Assessment, Development, and
Evaluation (GRADE) approach.
Ratings of RCTs dropped if any
component of internal validity (risk
of bias, inconsistency, imprecision,
and publication bias) or external
validity (eg, directness of results)
scored “serious.”47
Data Extraction
Two reviewers conducted data
extraction independently. Important
study information such as the
author, year of publication, the
country where the study was
conducted, study design and
conditions, intervention design,
sample characteristics, and outcome
measures were extracted and are
presented in Table 1. Data findings
are extracted for each outcome in
terms of mean and standard
deviation (SD) or median and range,
or interquartile range (IQR) when
available. Data on adverse events
(eg, diabetic ketoacidosis and severe
hypoglycemia) and treatment
adherence were also extracted, if
available.
Dichotomous data were expressed
as a risk ratio (RR) with 95%
confidence intervals (CI). For
continuous outcomes measured on
the same scale (eg, HbA1c), the
intervention effect was estimated
using the mean difference (MD) with
95% CI. For continuous outcomes
that measured the same underlying
concept (eg, health-related quality of
life) but used different measurement
scales, the standardized mean
difference was calculated. In case
median and range or IQR were
reported in the studies, the mean
and SD would be converted from the
median and range or IQR using the
4 SHOREY et al
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formula in Wan and colleagues’
study.48
Data Analysis
Using the RevMan 5.4 software, a
meta-analysis was conducted under
the random-effects model to pool
the data. The findings were
presented as forest plots that
visually displayed the distribution of
effects and presented a prediction
interval.49–51 If a meta-analysis
could not be conducted; a narrative
summary was conducted according
to each outcome measure. Reports
on adverse events, such as diabetic
ketoacidosis and severe
hypoglycemia, were pooled
narratively across studies.
Heterogeneity was measured using a
standard v2 test with a significance
level of a 5 .152 and the I2 statistic,
which quantifies inconsistency
across studies and interprets them
as low (#40%), moderate (30% to
60%), substantial (50% to 90%),
and considerate (75% to 100%)
importance.47,53,54 Reasons for
heterogeneity were scrutinized by
examining individual characteristics
of the study and subgroups.
However, subgroup and sensitivity
analyses were not performed
because of few available studies.
Additionally, as each outcome of
interest was reported by less than
10 studies, funnel plots were not
used to assess small-study effects.
RESULTS
Description of Studies
The initial search yielded 3956
records. After the removal of
duplicates, 1338 titles and abstracts
were screened, and 70 full texts were
shortlisted. Eighteen studies were
finalized and included in the
systematic review and 15 studies
were included in the meta-analysis.
The study selection process is
presented in Fig 1.
The included studies were
performed from the year 1984 to
2021. Out of the 18 studies, 3 were
conducted in the UK,29,31,55 3 in the
middle east (Iran and Saudi
Arabia),56–58 2 in the United
States,59,60 2 in Egypt,23,61 2 in
Austria,62,63 2 in Turkey,64,65 and 1
each in New Zealand,66 France,67
Finland,68 and Belgium.18 Fourteen
RCTs had a parallel design, 2 had a
factorial design,23,56 and 2 had a
crossover design.61,68 This review
analyzed the data of 817
participants from 18 studies, with
individual study sample sizes
ranging from 13 to 196. Out of the
15 studies that reported the sex of
participants, 325 were boys and 313
were girls. The mean age of study
participants ranged from 8.5 to
17.8 years. Participants from all
studies were recruited from
pediatric diabetes clinics or
hospitals and had a diagnosis of
T1DM for at least 3 months, with
the mean duration ranging from 2.6
to 8.4 years. All participants in
included studies were on an insulin
regimen. Details of the included
studies are presented in Table 1.
Description of Interventions
Comparators in all 18 studies
received no treatment usual care. Of
the 18 studies, 12 are physical
activity interventions, 5 are nutrition-
based interventions,60,61,63,64,68 and 1
is both physical activity and a
nutrition-based intervention.56 Out of
12 physical activity interventions, 8
involved physical exercise training in
different variations and combinations
of aerobic, strength, and resistance
exercises and endurance training. The
length of interventions ranged from 4
weeks to 6 months. Physical exercise
training took place 1 to 3 times a
week, with each session ranging from
30 minutes to 120 minutes. Two
studies adopted the Steps to Active
Kids with Diabetes program, which
comprised an online educational
component, group physical activities,
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TABLE 1 Characteristics of Included Studies
Author (Year),
No. Country Title
1. Abdulrhman Metabolic effects of honey in To evaluate the metabolic
et al (2013), type 1 diabetes mellitus: a
Egypt61 randomized crossover
pilot study
2. Campaigne et al Effects of a physical activity To determine the effects of a RCT, I: vigorous exercise,
(1984), USA59 program on metabolic
control and cardiovascular
fitness in children with
insulin-dependent diabetes
mellitus
PEDIATRICS Volume 150, number 3, September 2022
3. D’hooge et al Influence of combined
(2011), aerobic and resistance
Belgium18 training on metabolic
control, cardiovascular
fitness, and quality of life
in adolescents with type 1
diabetes: a randomized
controlled trial
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4. Goksen et al Effects of carbohydrate
(2014), counting method on
Turkey64 metabolic control in
children with type 1
diabetes mellitus
5. Heyman et al Exercise training and
(2007), cardiovascular risk factors
France67 in T1DM adolescent girls
5
Study Design and
Aim Conditions Intervention Design Sample Characteristics Outcome Measures
Randomized crossover 12-wk dietary intervention: consumed 20 children, 10 boys (1) Fasting postprandial
effects of 12-wk honey pilot, I: honey 0.5mL and 10 girls aged 4 serum glucose and C-
consumption on patients consumption, C: no honey per kg body wt daily for to 18 y (mean 4.7), peptide (2) HbA1c (3)
suffering from T1DM intervention 12 wk T1DM for at least serum lipid profile, T0:
12 mo (1 to 16.5 y) baseline, T1: 12 wk, T2:
24 wk
12-wk physical exercise intervention; 19 children (9 (1) Metabolic control, HbA1c
regular vigorous physical C: no intervention 30minutes 3 times a week of intervention, 10 and fasting blood
activity program on running, games, and movements to control) 12 boys glucose (2) oxygen
children with T1DM. music and 7 girls aged 5 consumption
to 10 y (mean 8.5),
T1DM for at least 6
mo (3.89 to 5.11 y)
To evaluate the effect of RCT, I: exercise program, 20-wk training program containing 16 children (8 (1) Anthropometric
combined exercise training C: no treatment aerobic and strength exercises; intervention, 8 variables (2) metabolic
on metabolic control, twice a week for 70 mins: 5mins control) 7 boys and control (3) aerobic
physical fitness, and warm up, 10 mins upper limbs 9 girls aged 10 to capacity (4) strength (5)
quality of life in strength, 10 mins lower limbs 18 y (mean 13.6), quality of life: General
adolescents with type strength, 10 mins abdominal T1DM at least a Health Survey Short
1 diabetes strength, 10 mins cycling, 10 mins year (mean 5.3 to Form (SF-36) (detailed
running, 10 mins stepping, 5 mins 5.4 y) subcategories in original
cool down; aerobic training start at paper)
60% of max heart rate, to 70%
(6 wk), then 75% (12 wk)
To investigate the effects of RCT, I: carb counting, C: 2-wk carbohydrate counting program, 84 children (52 (1) Body measurements (2)
carb counting on no intervention 2 years follow up; the first week: intervention 32 insulin requirements (3)
metabolic control, body learn about nutritional contents, control) aged 7 to HbA1c (4) serum lipids
measurements, and serum estimate amount of carbohydrates 18 y, T1DM
lipid levels in children and in each meal; the second week: diagnosis >1 y,
adolescents with T1DM learn to manage simple carbs and basal bolus insulin
snack and adjust insulin doses regimens
To examine the effects of 6 RCT, I: training, C: 6-mo physical exercise training 16 adolescent girls (9 (1) Body composition
mo of physical training on nontraining program, control: no training, intervention 7 (skinfold thickness) (2)
their quality of life, intervention: one 1hr unsupervised control) aged 13 to physical or aerobic
physical fitness, body session, and one 2hour supervised 18 y (mean 16) fitness, PWC170 (3)
composition, lipid, and session per week, the combination HbA1c (%) mean 8 plasma lipids (4) serum
apolipoprotein profiles, of aerobic and strength exercise (1.4) apolipoproteins,
and adiponectin and leptin (2:1), the first session 80% of max lipoprotein(a), leptin, and
levels heart rate, last session 90% max adiponectin (5) QoL,
heart rate Diabetes Quality-of-Life
questionnaire, T0:
baseline, T1: 6 mo
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6
TABLE 1 Continued
Author (Year),
No. Country Title
6. Knox et al SKIP (supporting kids with
(2019), UK69 diabetes in physical
activity): feasibility of a
randomized controlled
trial of a digital
intervention for 9 to 12 y
olds with type 1
diabetes mellitus
7. Mitchell et al Feasibility and pilot study of To
(2018), UK55 an intervention to support
active lifestyles in youth
with type 1 diabetes: the
ActivPals study
8. Mohammed et al Effects of 12 wk of To
(2021), Saudi recreational football
Arabia56 (soccer) with caloric
Study Design and
Aim Conditions Intervention Design Sample Characteristics Outcome Measures
To assess the feasibility and RCT, I: usual care 1 6 mo online intervention (STAK-D web 49 children (24 (1) Self-efficacy: self-report
acceptability of an interactive intervention site): physical activity goal setting, intervention, 25 (2) physical activity: self-
internet-based physical (STAK-D web site and feedback and increasing knowledge control) aged 9 to report (PAQ), predilection
activity and self- Polaractive activity with the aim of increasing 12 y (mean 10.63), of physical activity
monitoring program for watch), C: usual care participant’s self-efficacy for 22 girls and 27 (CSAPPA) (3) HbA1c (4)
children with T1DM diabetes self-management (eg, boys; 42 White, 1 insulin dosage (5) BMI
confidence around the management Black, 2 Asian, and (6) fear of hypoglycemia
of physical activity alongside diet, 3 mixed; 14 multiple (HFS parent and child
and regular blood glucose self- injections a day, 31 version) (7) perceived
monitoring), C: usual care insulin pumps, 2 health (CHU-9D; CHQ), T0:
insulin pen, T1DM baseline, T1: 8 wk, T2:
for at least 3 mo 6 mo
determine the preliminary RCT, I: physical activity 4-wk physical activity intervention 20 participants (10 (1) Physical activity:
evidence of the effect of intervention, C: waiting (ActivPals): physical activity intervention, 10 Actigraph GT3×1
the intervention on list control group consultation using social cognitive waitlist) 12 girls monitor (2) QoL:
physical activity, sedentary theory 1 goal setting with diary and 8 boys aged 7 pediatric QoL (3)
behavior, and QoL booklet 1 motivational video to 16 y (mean 12) sedentary behaviors (4)
message 1 pedometer BMI, T0: baseline, T1:
4 wk
determine the effects of RCT, I1: football 1 diet, I2: 12-wk physical activity and diet 40 participants (10 per (1) Blood pressure (2) lipid
recreational football football only, I3: diet intervention; diet groups: received group), all boys profile (TC, LDL, HDL, TG)
combined with caloric only, C: no intervention caloric control regimen from aged 12 to 18 y (3) Fasting blood glucose

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control on the glycemia
and cardiovascular health
of adolescent boys with
type 1 diabetes
9. Nazari et al The effect of concurrent To
(2020), Iran57 resistance-aerobic training
on serum cortisol level,
anxiety, and quality of life
in pediatric type 1
diabetes
10. Newton (2009), Pedometers and text
New Zealand66 messaging to increase
physical activity
control on glycemia and
cardiovascular health of
adolescent boys with type
1 diabetes.
explore the effect of RCT, I: exercise, C: no
concurrent resistance-
aerobic training on serum
cortisol level, anxiety, and
quality of life among
pediatric T1DM
To assess whether RCT, I: open pedometer
pedometers and text
messaging increase
physical activity in
adolescents with T1DM
(usual care) nutritionist, not to exceed (mean 14.4 to 17.8), (4) HbA1c (5) total daily
recommended daily number of T1DM for at least insulin (6) hypoglycemia
calories; football groups: 1.5h twice 1 year (7) attendance rate, T0:
a week for 12 wk (24 sessions) baseline, T1: 12 wk
16 wk exercise intervention: interval 40 children (20 (1) Anxiety, revised,
treatment concurrent resistance aerobic intervention, 20 Children’s Manifest
training with a duration of 60 min control) aged 8 to Anxiety Scale (RCMAS)
performed 3 times a week; 10 min 14 y (mean 11 to (2) QoL, peds QoL (3)
warm-up, 20 min pilates, 20 min 11.2), T1DM for at HbA1c (4) cortisol, T0:
body wt-bearing exercise, 20 min least 1 year baseline, T1: 16 wk
aerobic training (50% to 75% of
max heart rate), 5 min cooldown
12 wk intervention: wears open 78 adolescents (38 (1) Daily step count (2)
and regular pedometer with a goal of at least intervention, 40 physical activity: self-
motivational text 10 000 steps a day 1 receives control), 36 boys report NZPAQ (3.) BMI (4)
messages, C: usual motivational text messages and 42 girls aged blood pressure (5)
care 11 to 18 y (mean HbA1c (6) QoL: subjective
14.4) QoL (7) total daily dose
of insulin: T0: baseline,
T1: 12 wk

SHOREY et al
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TABLE 1 Continued
Author (Year), Study Design and
No. Country Title Aim Conditions Intervention Design Sample Characteristics Outcome Measures
11. Paganus et al Beneficial effects of palatable To evaluates the effects of Randomized crossover Each diet period is 3 wk: all start 22 children, 9 boys and (1) Urinary blood glucose
(1987), guar and guar plus extended, guar and guar study, I1: palatable without supplementation, the 13 girls aged 8 to (2.)HbA1c (%) (3) serum
Finland68 fructose diets 1 fructose diets on the guar, I2: guar with amount of guar in both guar diets 16 y (mean age lipids
in diabetic children metabolic balance of fructose, C: no was equal to 5% of the daily 12.2 y), diagnosis of
children with insulin- supplementation carbohydrate intake >6 mo
dependent diabetes
mellitus
12. Petschnig et al Effect of strength training on To examine the effect of RCT, I: strength training, C: 32 wk of physical training intervention: 21 children (11 (1) Strength tests (bench
(2020), glycemic control and isolated supervised no training 50 mins per session, twice a week, intervention, 10 press, leg press, bench
Austria62 adiponectin in diabetic progressive resistance 10 min warm-up, 20 to 40 min control) aged 8 to pull) (2) HbA1c, T0:
children training with a duration of circuit training 12 y (mean 11 to baseline, T1: 17 wk, T2:
more than 32 wk on 11.3), T1DM for at 32 wk

PEDIATRICS Volume 150, number 3, September 2022

13. Quirk et al A physical activity To explore the feasibility and Randomized feasibility
(2018), UK29 intervention for children
with type 1 diabetes- steps
to active kids with
diabetes (STAK-D): a
feasibility study
muscle strength,
metabolic control, and
adiponectin
acceptability of the
intervention and study
design.
least 6 mo (2.63 to
2.8 y)
6 wk physical activity intervention: 13 children-parent (1) Self-report physical
trial, I: intervention 1 Steps to Active Kids with Diabetes dyads (8 activity: PAQ (2) objective
usual care, C: usual (STAK-D), 6 wk intervention, intervention, 5 physical activity:
care education, behavioral, cognitive control), 7 boys and accelerometer (3) self-
behavioral strategies (healthy eating 6 girls aged 9 to 11 efficacy for physical
but not carbohydrate counting, y (mean 10.1), T1DM activity: CSAPPA scale, T0:
hypoglycemia management, blood for at least 1 year baseline, T1: 6 wk, T2:

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14. Salem et al Is exercise a therapeutic tool To evaluate the impact of 6 RCT, C: no exercise, I1:
(2010), for the improvement of
Egypt23 cardiovascular risk factors
in adolescents with type 1
diabetes mellitus? a
randomized controlled
trial
months of exercise
program on glycemic
control, plasma lipids
values, blood pressure,
severity and frequency of
hypoglycemia,
anthropometric
measurements, and insulin
dose in a sample of
adolescents with T1DM
6 mo exercise program: either once a
exercise once a week,
I2: exercise thrice a
week
glucose monitoring), active diary, (mean 4.3 y) 3 mo
pedometer, dance routine, circuit
training style, goal setting and
motivational interviewing,
educational booklet for parents
196 patients (48 (1) HBA1c (2) blood
week or thrice a week, 5 mins control, I1: 75, I2: pressure (3) frequency
warm-up, 20 mins training, 5 mins 73), 75 boys, 121 of hypoglycemia (4) lipid
cool down, aerobic exercises either girls aged 12 to 18 profile levels, T0:
cycling or treadmill 1 anaerobic y (mean 14.5 to 15), baseline, T1: 6 mo
interval training on treadmill 1 T1DM for at least
progressive resistive exercise (leg 3 y (mean 3.6 to
extension, leg curl) 1 free strength 5.5 y) and
and endurance exercise 1 flexibility glycosylated
exercise 1 neuromuscular exercise; hemoglobin (HbA1c)
C: instructed not to undertake any $7.5% (mean 8.3 to
formal exercise or change their 8.9)
physical activity level during the
study period

7
by guest
8
TABLE 1 Continued
Author (Year), Study Design and
No. Country Title Aim Conditions Intervention Design Sample Characteristics Outcome Measures
15. Schwingshandl Effect of the introduction of To assess the metabolic RCT, I: changed diet, C: Dietary intervention: unspecified 28 participants (14 per (1) HbA1c (2) dietary intake:
et al (1994), dietary sucrose on control of children and usual “sucrose free” duration (mean 77 d of group), 14 boys and food diary, T0: baseline,
Austria63 metabolic control in adolescents with type I diet observation), recommended, the 14 girls, mean 15 to T1: follow up (end of
children and adolescents diabetes in relation to diet included 5% of total kcal as 16 y, T1DM for at observation, mean 77 d)
with type I diabetes sucrose consumption sucrose, sucrose consumption least 6 mo (6.6 to
should not exceed 5% of the total 7.8 y)
calories; C: dietary
recommendations in the control
group were the same for the
respective types of insulin regimen,
but the addition of sucrose was
restricted completely
16. Spiegel et al Randomized nutrition To determine whether a RCT, I: usual care 1 1-d interactive 90min carbohydrate 66 youths (33 control (1) CHO counting accuracy
(2012), USA60 education intervention to nutrition education nutrition education, C: counting class: complete the food 33 intervention), 41 (2) HbA1c levels
improve carbohydrate intervention would usual care record form at 2 wk and 8 wk after boys and 25 girls
counting in adolescents improve CHO counting the class and receive feedback from aged 12 to 18 y
with type 1 diabetes study: accuracy and glycemic dieticians; C: receive handout on (mean 15 y)
is more intensive control. CHO content and counting resources
education needed? with 5 min briefing from dietician, 3
to 4 mo follow up
17. Tomar et al Effect of low to moderate To evaluate the effect of 12 RCT, I: exercise, C: no 12 wk exercise program: 3 times a 24 adolescents (12 (1) HbA1c (2) low-density
(2014), Saudi intensity walking and wk exercise program on treatment week on alternate days, treadmill intervention 12 lipoprotein (3) high-
Arabia58 cycling on glycemic and glycemic and metabolic and bicycle ergometer, first 4 wk control) aged 12 to density lipoprotein (4)

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metabolic control in type 1 control in T1DM 40% to 50% of maximum heart rate, 16 y (mean 14.27), triglycerides (5) insulin
diabetes mellitus adolescents week 5 to 8 50% to 60%, week 9 to all boys, T1DM for dose (6) total
adolescent boys: a 12 60% to 70% at least 6 mo (4.36 cholesterol, T0: baseline,
randomized controlled to 4.63 y) T1: 12 wk
trial
18. Tunar et al The effects of pilates on To investigate the effects of RCT, I: pilates class, C: no 3 mo intervention: single center, 3 31 children (17 (1) HbA1c (2) daily insulin
(2012), metabolic control and pilates exercises on treatment days a week for 12 wk (45 mins per intervention 14 dose (3) total cholesterol
Turkey65 physical performance in metabolic control and session), mat based pilates class, 8 control) 15 boys (4) HDL (5) LDL (6.)
adolescents with type 1 physical performance in pilates exercises, 3 sets of 6 to 10 and 16 girls, mean triglyceride levels (7)
diabetes mellitus patients with type 1 repetitions with 30s active rest age 14 y physical fitness (power,
diabetes mellitus (stretching) for each pilates flexibility, vertical jump)
exercise, 5 min cool down
BMI, body mass index; C, control; CHO, carbohydrates; CSAPPA, Children’s Self-Perceptions of Adequacy in and Predilection for Physical Activity; HDL, high-density lipoprotein; I, intervention; HFS, Hypoglycemia Fear Survey; LDL, low-density
lipoprotein; PAQ, Physical Activity Questionnaire; QoL, quality of life; STAK-D, Steps to Active Kids with Diabetes; T, time point; TC, total cholesterol; TG, triglycerides. .

SHOREY et al

FIGURE 1
PRISMA flow diagram.
the use of a pedometer, goal setting,
and motivational interviewing.29,69
Another study adopted a similar
intervention (ActivPals) that included
the use of a pedometer, physical
activity consultation based on
social cognitive theory, goal
setting, and a motivational video.55
The last physical activity
intervention study involved the use
of an open pedometer with daily
steps goal and regular motivational
text messages.66
Nutrition-based interventions
involved 1-day or 2-week
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carbohydrate counting nutrition
education programs60,64 and
dietary interventions (ie, honey,
sucrose diet, guar, guar, and
fructose diet)61,63,68 spanning 3
weeks to 4 months.
The only physical activity and
nutrition-based hybrid intervention
was 12 weeks long and comprised
of two 90-minute recreational
football sessions a week and a daily
caloric control regimen.56 Detailed
description of each intervention is
available in Table 1.
Risk of Bias
The main sources of risk of bias
were performance and detection
bias for subjective outcomes as
blinding of participants was not
possible for self-reported outcomes.
Interrater agreement between both
reviewers was approximately 98%.
The risk of bias summary and graph
are available in Supplemental Fig 4.
Certainty of evidence as assessed
using the GRADE approach was
generally very low to moderate.
Inconsistency was mainly caused by
the high heterogeneity of data
among studies. Most of the studies
had high imprecision because of the
small sample size and wide
confidence interval. The GRADE
summary of evidence is presented in
Supplemental Figs 5 and 6 and
Supplemental Tables 3 and 4.
Effects of Intervention
Physical Activity Interventions
HbA1c Level
Ten out of the 13 included physical
intervention studies reported HbA1c
level as an outcome,18,23,56–59,62,65,66,69
from which data from 8 studies were
meta-analyzed and 2 were summarized
narratively. Comparing the
intervention with the no treatment
group revealed a lack of evidence of
effect (MD 5 0.58%, 95% CI 1.20
to 0.05; z score 5 1.81, P value 5 .07).
Significant heterogeneity between
studies was detected (v2 5 48.57, P
value <.001; I2 5 84%). Sensitivity
analysis was conducted by removing
the Campaigne59 study and the
resulting pooled effect was 0.38
( 0.83 to 0.06); z score 5 1.69 (P
value 5 .09) for which the conclusion
was still the same as the original
pooled effect of 0.58 ( 1.20 to 0.05, P
value 5 .07). Therefore, the authors
have decided to retain the study in the
meta-analysis. Estimates for each study
are displayed in a forest plot (Fig 2)
9
 FIGURE 2
Forest plot of effect estimates of physical activity intervention on HbA1c level.
In Tomar and colleagues' study,58 no
significant within and between-
group effects for median HbA1c
values were observed after 12
weeks. Similarly, in Newton and
colleagues' study,66 no significant
difference in change in median
values was observed within and
between groups postintervention at
12 weeks.
Health-Related Quality of Life
Four studies18,55,57,66 reported on
general health-related quality of life
in relation to physical activity.
Nazari and colleagues discovered
that 16 weeks of concurrent
resistance-aerobic exercise
significantly increased the quality of
life (P value 5 .003) among 8- to
14-year-olds with T1DM, whereas
no significance was reported in the
no-exercise group.57 In Mitchell and
colleagues’ study,55 both exercise,
and nonexercise groups reported
fewer “lifestyle problems” (F) after
4 weeks (F [1 to 16] 5 7.39; P value
5 .015), but there was no significant
difference in scores between groups.
FIGURE 3
Forest plot of effect estimates of nutrition-based intervention on HbA1c level.
10
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However, Newton and colleagues66
found no significant median score
difference for general quality of life
from pre to postintervention
(12 weeks) for both control and
intervention groups and between
groups. In D’hooge and colleagues'
study,18 the comparison of pre and
postintervention median (IQR)
scores for all domains of the
general quality of life (physical
functioning, social functioning,
physical role, emotional role,
mental functioning, pain, general
health, vitality, and change in
health) was not significant within
each group and between groups at
20 weeks.
Conversely, in terms of diabetes-
related quality of life, 2 studies
found improved scores for the
intervention group from
baseline to postintervention at
4 weeks55 and 6 months,67
respectively.
Adverse Events
Out of the 9 physical intervention
studies that mentioned adverse events,
4 reported no occurrence of adverse
events (ie, hypoglycemia).55,58,62,69 A
study by Quirk and colleagues
reported 2 episodes of hypoglycemia
in the intervention group,29 whereas a
study by Mohammed and colleagues
reported 27 hypoglycemic episodes
in the intervention groups and 8
hypoglycemic episodes in the
control group.56 In Campaigne and
colleagues' study,59 only 1
participant in the intervention group
had at least 1 hypoglycemic episode.
In a study by D'Hooge and
colleagues,18 87.5% of participants
in the intervention group
experienced at least 1 hypoglycemic
episode, with a median of 3 episodes
and an overall range of 1 to 6
episodes per participant. In Salem
and colleagues' study,23 there was
no difference in the mean frequency
of hypoglycemic episodes between
the intervention (baseline: 4.4 times
a month; 6 months: 4.82 times a
month) and the control group
(baseline: 4.5 times a month;
6 months: 4.7 times a month) at
baseline and after 6 months of
exercise.
SHOREY et al
 Nutrition-Based Interventions
HbA1c Level
All 6 nutrition-based interventions
reported HbA1c outcome.56,60,61,63,64,68
The meta-analysis reported a MD of
0.61% (95% CI 1.48 to 0.26; z score
5 1.37, P value 5 .17) when comparing
the intervention with the no treatment
control group, indicating a lack of
effect. Significant heterogeneity
between studies was detected (v2 5
74.28, P value <.001;
I2 5 92%). The forest plot is available
in Fig 3.
Adverse Events
One study56 reported a total of
19 hypoglycemic episodes in the
intervention group and 8
hypoglycemic episodes in the no
treatment control group, with a
mean of 2 episodes and 1 episode
per participant in each group,
respectively. In Abdulrhman et al’s
study,61 3 out of 20 participants
developed diabetic ketoacidosis and
were hospitalized for 2 to
4 days.
Physical Activity and Nutrition-Based
Intervention
Only 1 study had an intervention that
combined physical activity (football
training) and caloric control.56 The
study reported a significant decrease
in HbA1c level in the intervention
group from baseline to
postintervention at 3 months,
whereas a significant increase in
HbA1c level was observed in the no
treatment control group.56
Comparing the intervention with the
control, there was a significant mean
difference in HbA1c levels
postintervention. Additionally, 49
hypoglycemic episodes were
reported, with 41 episodes occurring
in the intervention group and 8
episodes in the control group.
Participants’ adherence to
intervention for each intervention
type is summarized in Table 2.
DISCUSSION
This review examined the effects of
physical activity interventions and
nutrition-based interventions for
children and adolescents with T1DM
by pooling data on HbA1c levels and
health-related quality of life, while
consolidating evidence on adverse
events and adherence to the
intervention.
Overall, our review did not find
evidence that adverse events (ie,
hypoglycemia) among children and
adolescents with T1DM were not
increased by physical activity
intervention. However, physical

TABLE 2 Summary of Adherence to Intervention

Duration of
Author (Year) Description of Intervention Intervention Measure of Adherence Participants’ Adherence
Physical activity interventions (n 5 7)
D’Hooge et al In-person physical training 20 wk Number of training sessions Out of 38 sessions, the median number of session
(2011)18 attended participations was 24, with a range of 20 to 32
sessions attended
Heyman et al In-person and home-based 6 mo When participants’ heart rates Supervised face-to-face sessions: 62% to 100%
(2007)67 physical training were 80% to 90% of heart attendance, unsupervised home sessions: 52% to
rate reserve 89% adherence
Knox et al Online web intervention 6 mo (1) Number of visits to the web (1) Mean number of visits per week to the
(2019)31 site (2) number of intervention webpage decreased from 4.31 at
downloads of online 2 months to 0.55 at 6 months (2) mean number
materials (3) number of of downloads per week of the goal sheet and
watch synchronizations goal certificate decreased from 0.01 and 0.00 at
2 months to 0.00 and 0.00 at 6 months,
respectively (3) participants only synchronized
their watches 33.3% of the required occasions
Mitchell et al In-person physical training 4 wk Physical attendance rate Mean attendance rate of 90%
(2018)55
Mohammed In-person physical training 12 wk Physical attendance rate Mean attendance rate of 95.8%
et al (2021)56
Newton et al Open pedometer and text 12 wk Steps count measured by 63% wore the pedometer throughout, 37% stopped
(2009)66 messaging pedometer wearing the pedometer halfway
Quirk et al In-person training 6 wk Number of sessions attended Mean rate of attendance was 55%, with a range of
(2018)29 40% to 80%
Nutrition-based intervention (n 5 1)
Mohammed et al Caloric control regimen: 12 wk Physical attendance rate Mean adherence rate of 91.6% with a range of 75%
(2021)56 12 sessions to 100%
Physical activity and nutrition-based intervention (n 5 1)
Mohammed Caloric control regimen and 12 wk Physical attendance rate Mean adherence rate of 95.8% with a range of
(2021)56 football training: 87.5% to 100%
24 sessions
Nutrition 5 2; Nutrition and physical 5 1; Physical activity 5 13.

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 activity was found to lower HbA1c
levels. This corresponds with
findings from previous reviews
where physical activity had a
moderate impact on HbA1c level32
and reduced HbA1c level was
beneficial for children and
adolescents with T1DM.19 Unlike
our review, both reviews had broad
inclusion criteria for interventions
and accepted any study with an
intervention that was not acute and
one-off.19,32 However, the review by
Quirk and colleagues'32 included
nonrandomized studies, which may
have compromised the quality of
included studies, and examined a
range of physiologic, psychological,
behavioral, and social outcomes of
interest. Additionally, reviewed
evidence suggests that a longer
duration (6 months) and a higher
frequency of exercise each week (at
least three times a week with a total
of 240 minutes) is more effective in
reducing HbA1c levels. Therefore,
we recommend further evaluation
on the optimal combination of
duration, frequency, and type of
physical activities for children and
adolescents with T1DM to reduce
HbA1c levels.
In this review, there was mixed
evidence on the effect of physical
activity interventions in improving
health-related quality of life. Although
existing studies compared the quality
of life scores using the mean, median,
or IQR, the majority of the evidence
did not find a significant difference in
the quality of life scores within and
between exercise and nonexercise
groups. However, in a previous
review examining physical activity
interventions for children and
adolescents with chronic disease and
the general population,70 small to
marginal effects were found for the
parent-proxy report and child-report
health-related quality of life. This
suggests that more T1DM-specific
studies with standardized means of
score comparisons are required to
12
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ascertain the effect of physical activity
interventions.
Our findings also suggest a higher
rate of adherence to face-to-face
physical interventions than online
interventions. A recent review
examining online physical activity
interventions for the general
population of children and
adolescents discovered
overwhelming evidence in favor of
online physical activities, especially
when they are gamified using
exergames or consoles.71 Better
engagement, increased physical
activity, and enhanced self-efficacy
were few of the positive outcomes
reported.71 As the online
intervention included in this review
was more on personalization and
informational content, future
research should consider gamifying
online physical activity interventions
to engage children and adolescents
with T1DM.
To the authors’ knowledge, this is
the first meta-analysis examining
the effects of nutrition-based
interventions among children and
adolescents with T1DM; therefore,
there is no other review to compare
our findings. Although our review
found that nutrition-based
interventions generally lower HbA1c
levels among children and
adolescents with T1DM, this effect
was not significant. Previous
reviews on the effects of nutrition-
based interventions had found
decreased HbA1c levels and fewer
episodes of hypoglycemia after
receiving low-carbohydrate or low
glycemic index diets among mixed
samples of adults and children with
T1DM and/or type 2 diabetes
mellitus.40–42 However, given the
broad inclusion of participants in
previous reviews, the results are not
directly comparable with the
current review.
Our review only identified 1 study
that reported a physical activity-
nutrition-based intervention and
currently, no review examines this
combination of interventions for
children and adolescents with
T1DM. The promising results in
terms of reduction in HbA1c from
this study warrant further research.
LIMITATIONS
Given the stringent eligibility criteria
of this review, many potentially
relevant studies were excluded. For
instance, this review only included
studies with samples aged 18 years
and below, resulting in the exclusion
of a few studies with a sample age
range up to 19 years. Additionally,
the authors were unable to address
the heterogeneity between studies as
there were too few studies (<10) for
sensitivity analyses and subgroup
analyses based on predefined
subgroups in the protocol (ie, types
of intervention, method of delivery
for intervention, providers of
interventions, target audience, age
groups, and different intensities of
interventions). Nevertheless, by using
the random-effects model for all the
analyses instead of the fixed-effects
model, the results obtained better
generalizability. Lastly, there is a low
quality of evidence because of high
performance and detection bias for
subjective outcomes.
Implications for Future Research
and Practice
Our review has highlighted research
gaps in the literature, particularly in
low- and middle-income countries,
including Africa and Asia. Our findings
suggest a need for more physical
activity interventions and nutrition-
based interventions for children and
adolescents with T1DM in these
regions. Given that there are possible
sex differences in physical activity
levels and reporting of health-related
quality of life, we recommend
stratification of data based on sex in
future primary studies. Additionally,
unlike childhood, adolescence is a key
time in which hormonal and
SHOREY et al
 psychosocial change occurs, therefore
future primary studies should
perform data stratification based on
age groups to provide insights that
are more accurate. Apart from the
reporting of HbA1c level and other
physiologic and physical outcomes,
future studies for T1DM should
include a range of outcome measures
such as morbidity, all-cause mortality,
quality of life, self-efficacy,
acceptability, adherence, and attitudes
toward intervention to identify
contributors to the impact of the
intervention and examine the
interplay among these factors. In
addition, existing studies rarely report
on the randomization procedure, the
blinding of participants and
personnel, and the method of
addressing attrition, which affects the
quality of assessment of current
evidence to a large extent. Therefore,
we suggest future trials provide more
detailed and transparent reporting of
intervention methods to improve the
rigor of the study. For countries
experiencing 4 seasons, we strongly
suggest tailoring physical activity
interventions and nutrition-based
interventions according to the
seasons to cater to the lifestyle and
physiologic changes of children and
adolescents with T1DM during the
different seasons. Future trials should
Address correspondence to Shefaly Shorey, PhD, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2,
Clinical Research Centre, Block MD11, 10 Medical Dr, Singapore 117597. E-mail: nurssh@nus.edu.sg
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2022 by the American Academy of Pediatrics
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest to disclose.
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MD: mean difference
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RR: risk ratio
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