Preclinical Noninvasive Markers of Atherosclerosis in Children and

Adolescents with Type 1 Diabetes Are Influenced by Physical Activity

Beatrice Trigona, MOM, Yacine Aggoun, MD, Albane Maggio, MD, Xavier E. Martin, MS, Laetitia M. Marchand, MS,
Maurice Beghetti, PD, and Nathalie J. Farpour-Lambert, MD
Objectives To measure preclinical noninvasive markers of atherosclerosis in youth with type 1 diabetes (T1DM),
and to determine their associations between physical activity level and cardiorespiratory fitness (maximal oxygen
consumption [VO2max]).
Study design This was a cross-sectional study including 32 patients with T1DM and 42 healthy subjects aged 6 to
17 years. Main outcome measures included arterial flow-mediated dilation (FMD) and intima-media thickness with
high-resolution ultrasonography; physical activity by accelerometer (valid 26 patients with T1DM, 35 healthy subjects) and VO2max.
Results Compared with healthy control subjects, patients with T1DM had higher intima-media thickness (mean
0.50 mm [0.48-0.52, 95% CI] vs 0.48 [0.47-0.49], P = .02) and reduced FMD (4.9% [4.1%-5.7%] vs 7.3 [6.4-8.1],
P = .001), VO2max (45.5 mL/kg/min [43.0-48.0] vs 48.7 [46.7-50.6], P # .001), total (567.1 [458.6-675.6] vs 694.9
[606.6-883.2] counts per minute, P = .001) and moderate-to-vigorous physical activity. Patients with T1DM who
did more than 60 min/day 1 of moderate-to-vigorous physical activity had similar FMD compared with relatively inactive healthy subjects, but not as high as active control subjects.
Conclusion Youth with T1DM present early signs of atherosclerosis, as well as low physical activity level and cardiorespiratory fitness. Endothelial function is enhanced in patients who practice more than 60 min/day 1 of
moderate-to-vigorous physical activity. (J Pediatr 2010;157:533-9).
See editorial, p 523 and related
articles, p 540, and p 547

t is well known that atherosclerotic process begins in childhood1 and is accelerated in patients with type 1 diabetes (T1DM),
with cardiovascular diseases (CVD) being the major cause of morbidity and death in this population.2,3 Impaired endothelial function is now considered an early sign of atherosclerosis in children, which precedes the atherosclerotic plaque formation and has therefore become an important noninvasive marker of cardiovascular risk,4,5 particularly in those with
T1DM.6,7
The structure and function of large arteries can be studied by noninvasive high-resolution ultrasonograhy. The increase of
the intima-media thickness (IMT) is measured at the right common carotid artery and is considered an early sign of arterial wall
remodeling. The flow-mediated dilation (FMD) of the brachial artery, a marker of endothelial cell function, is assessed by measuring the arterial diameter response to increased flow. Arterial dilation occurs mainly as the result of endothelial release of
nitric oxide (NO).8 In youth with T1DM, previous studies have demonstrated a premature thickening of the arterial IMT
and impaired endothelial function after a disease duration as short as 6 months.6,7,9-12
The benefits of physical activity in the prevention and treatment of CVD have been very well described in adults.13 In children, physical activity improves blood pressure, lipid profile, and body fatness,14 which are important determinants of atherosclerosis. Enhanced blood flow in arteries induces a vascular stress that results in liberation of NO during but also after
exercise.15 This mechanism lowers vascular resistance and improves FMD. In adult patients with T1DM, a recent study has
showed improvement in endothelial function after a bicycle training program; however, changes disappeared 8 months after
training cessation.16

BP
CVD
FMD
IMT
NO
NTGMD
SLPA
T1DM
VO2max

Blood pressure
Cardiovascular diseases
Flow-mediated dilation
Intima-media thickness
Nitric oxide
Nitroglycerin-mediated dilation
Sedentary-to-light physical activity
Type 1 diabetes mellitus
Maximal oxygen consumption

From the Pediatric Cardiology Unit, Department of Child

and Adolescent, University Hospitals of Geneva and
University of Geneva , Geneva, Switzerland
Supported by the Mimosa Fellowship of the Pediatric
Department, University of Geneva. The authors declare
no conflicts of interest.
0022-3476/$ - see front matter. Copyright 2010 Mosby Inc.
All rights reserved. 10.1016/j.jpeds.2010.04.023

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The first aim of this study was to assess preclinical noninvasive markers of atherosclerosis in children and adolescents
with T1DM, compared with healthy subjects. The second aim
was to determine which volume and intensity of physical activity is beneficial for cardiovascular health in this population. Finally, we aimed to evaluate the relationship between
cardiorespiratory fitness and markers of atherosclerosis.

Methods
This was a cross-sectional study including 32 children and
adolescents with T1DM (World Health Organization criteria) and 42 healthy subjects aged 6 to 17 years old. Physical
activity data by accelerometer were obtained in 26 patients
with T1DM and 35 healthy subjects.
Patients with T1DM were recruited in the Pediatric Endocrinology and Diabetology Unit of the University Hospitals
of Geneva and eligible subjects (32 of 45 patients) were invited to participate in the study. The disease duration was
at least 1 year. Subjects with T1DM were excluded from the
study if they (1) had no known kidney and clinical cardiovascular complication; or another chronic disease; (2) had an orthopedic disease or injury limiting physical activity; (3) took
any medications, which may influence cardiovascular function or lipid metabolism.
Healthy subjects were recruited from peers of children
with T1DM or from local schools. Subjects were asked to participate in the study if they met each of the following eligibility criteria: (1) good health and no recent (previous 2 years)
systemic illness; (2) no known history of chronic disease; (3)
no orthopedic disease or injury limiting physical activity; (4)
no medications, which might influence cardiovascular function, lipid, or glucose metabolism. The study protocol was
approved by the Mother and Child Ethics Committee of
the University Hospitals of Geneva, and a written informed
consent was obtained from both parents and child.
At baseline, participants visited the Childrens Hospital
from 8 to 12 A.M. The personal and medical history was assessed before testing, and the dose of insulin was calculated
in children with T1DM (U/kg/d). Subjects with diabetes
and healthy subjects underwent identical testing. Observers
were blinded to subject grouping.
We measured body mass with light clothes at the nearest 0.1
kg with an electronic scale (Seca 701; Seca GmbH, Hamburg,
Germany) and stature to the nearest 0.1 cm with a Harpenden
stadiometer. We calculated body mass index as body mass/
stature squared (kg/m 2). The pubertal stage (Tanner) was
assessed by use of a validated self-assessment questionnaire.17
The brachial resting blood pressure (BP) was measured 3
times at a 2-minute interval after 10 minutes of rest with
the patient in the supine position with the back supported,
by use of a validated automated device (Colin Press-Mate
BP 8800C; Colin Medical Instruments Corporation, San Antonio, Texas). The cuff covered at least two thirds of the
length of the upper arm, with the length of the bladder wrapping the arm circumference.
534

Vol. 157, No. 4

Noninvasive measurements of arterial geometry and function were performed with a real-time B-mode ultrasound imager (VingMed CFM800C system; VingMed Sound A/S,
Horten, Norway) with a 10-MHz linear high-resolution vascular probe as previously described.18 Imaging of the intimamedia thickness (IMT) was performed in the far wall of the
right common carotid artery 2 to 3 cm proximal to the bifurcation. The 2 parallel echogenic lines (double-line pattern),
corresponding to the lumen-intima and media-adventitia interfaces defining the IMT, were obtained in the right carotid
artery in all subjects. The correct IMT image was frozen in
end-diastole by electrocardiography R-triggering, transferred
to a computer, digitized into 640  580 peak cells with 256
grey levels, and stored for offline analysis. All offline measurements of IMT were performed by the same reader
(Y.A) without knowing subject group assignment and using
an automated computerized program (Iotec System; Iodata
Processing, Paris, France).18 Average IMT was calculated as
the mean value of a great number of local IMT measurements
performed every 100 mm along at least 1 cm of longitudinal
length of the artery. The measurement field included specifically the far wall IMT and drew automatically a rectangle of
at least 1 cm in length in the longitudinal axis of the vessel
and of at least 0.3 cm in width, perpendicular to the wall.
The computerized program of measurement located the 2 interfaces (lumen-intima and media-adventitia) by discriminating changes in gray levels inside the rectangle.
Noninvasive assessment of endothelium-dependent
dilation (flow-mediated dilation [FMD]) and endotheliumindependent dilation (in response to 300 mg sublingual
nitroglycerin [NTGMD]) of the right brachial artery were
performed by the same echocardiographic vascular linear
probe as previously described.19 After baseline measure, we
assessed the dilation of the right brachial artery in response
to increased flow and nitroglycerin, and FMD and NTGMD
were calculated as absolute and percentage maximum increase in vessel size from baseline.
Physical fitness was measured as maximal oxygen consumption (VO2 max) assessed by direct gas analysis (Vmax
Spectra; Viasys Healthcare, Hong Kong, Republic of China)
during a multistage treadmill test (Marquette 2000; GE
Healthcare, Milwaukee, Wisconsin).20 After a sufficient
warm-up, the subject ran on the treadmill at a constant
speed, which varied by age and physical capacity (from 5 to
9 km/h). The grade of the treadmill was increased by 2.5% every 2 minutes until the subject was exhausted and reached the
pediatric VO2 max criteria: clinical signs of exhaustion and:
heart rate >95% predicted maximal heart rate for age, or respiratory exchange ratio > 1.0, or oxygen plateau < 2 mL/kg/
min increase in VO2 with increasing work rate.21 Because this
test can provoke hypoglycemia, we measured capillary glucose concentration 20 minutes before and 30 minutes after
testing. A supplement of glucose 15 to 30 g was given if the
value was below 10 mmol/L. If the value was above 15
mmol/L 1, a urinary test was done to exclude the presence
of ketones, which is a contraindication to exercise. None of
the patients had ketones.
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Objective measure of physical activity level was obtained
using a uniaxial accelerometer (ActiGraph MT 6471; ActiGraph, Pensacola, Florida). The monitor was set on a 1-minute cycle, at the end of which the sum was stored in the
memory. The monitor was attached at the right hip with an
elastic belt and was worn all day long except during bathing
or swimming. This device has demonstrated good reliability
in the pediatric population.22 The Excel software was used for
data reduction and further analysis. Only periods from awakening to sleep time were analyzed. For this study, zero activity periods of 20 minutes or longer were interpreted as being
due to unworn accelerometers and were removed from the
total activity count. Data were expressed as total activity
counts per registered time (counts/min). We used cut-offs
of different intensity levels for children as described by Ekelund et al,23 where sedentary-to-light physical activity (SLPA)
was defined as counts per minute below 1999 and moderateto-vigorous physical activity above 2000. Subjects data were
taken into account if total counts per minute were under
4000 to exclude artifacts, and if the monitor was worn during
at least 4 days, including at least 2 week days and 1 weekend
day. In this study, 26 of 32 subjects with T1DM and 35 of 42
healthy children fulfilled the above criteria. The monitor was
worn for a mean of 7.4  1.4 days, the days being similar
among groups.
Blood samples were collected at 8 A.M. via venipuncture after a 10-hour overnight fast, before insulin injection in children with T1DM. They were analyzed in our laboratory
within 2 hours after venipuncture. Total cholesterol (TC),
high-density lipoprotein cholesterol (HDL-C), and triglyceride levels (mmol/L 1) were determined by standard automated techniques (Synchron LX20). Low-density
lipoprotein cholesterol (LDL-C) was calculated with the Friedewalds formula. The intraassay and interassay coefficients
of variation were 1.1% to 3.6% for TC, 2.0% to 6.8% for
HDL-C, and 2.3% to 4.6% for triglycerides, respectively. Calibration was performed every 14 days for TC and triglycerides
and every 30 days for HDL-C with the Multi Synchron (Synchron, Republic of Singapore).
Glycosylated hemoglobin (HbA1c,%) was determined
with a quantitative automotative technique (Synchron
LX20; Synchron). The intraassay and interassay coefficients
of variation were 2.8% to 2.7%, respectively. Calibration
was performed every 30 days with the HbA1c Synchron. Because patients visit the diabetes clinic every 3 months, we also
calculated the mean past 12 months HbA1c level (DCA 2000;
Bayer AG, Zurich, Switzerland). Calibration was done once
a month with a specific DCA calibration set.
Statistical analyses were performed with the statistical software program SPSS version 15.0 (SPSS, Inc., Chicago, Illinois). Data were screened initially for normal distribution.
Flow-mediated dilation was transformed and successfully
normalized with the square root of the value. Results are expressed as means and 95% confidence intervals. Statistical
differences between groups were determined with independent Student t test, c2 test, or analysis of covariance when
needed: mean blood pressure was adjusted for sex and stat-

ure, physical activity variables were adjusted for age, and aerobic fitness was adjusted for age and sex. To compare the
percentage of moderate-to-vigorous physical activity among
groups, we used a non-parametric test (Mann-Whitney) as
the distribution was not normal. The associations between
vascular variables (IMT and FMD) and physical activity variables, cardiovascular fitness, age, sex, and pubertal stage were
assessed with univariate and multivariate linear regression
analysis. Differences were considered significant if P < .05.

Results
Physical characteristics and lipid concentrations of subjects are
reported in Table I. Groups were not intentionally matched,
but there were no differences among groups for age, sex,
pubertal stage, body mass index, and stature. The body mass
index was significantly higher in patients with T1DM; 4
patients with diabetes were overweight, but none were
obese.24 Lipid concentrations were not significantly different
among groups and, as expected, patients with diabetes had
significantly higher HbA1c level than control subjects. Mean
disease duration was 5.1 years (4.0-6.1, CI 95%), daily
insulin dose was 0.8 U/kg/d (0.7-0.9), and the previous 12month HbA1c level was 8.5% (8.0%-8.9%). Children with
T1DM had significantly lower VO2max (6 7%), total
physical activity count (6 18%), and moderate-tovigorous physical activity (6 31%), whereas they had
higher SLPA (6 +17%) compared with healthy subjects.

Table I. Physical characteristics and blood lipid

concentrations in children with T1DM and healthy
control subjects
Variables
Age (y)
Sex (no. of female)
Pubertal stage (no. of cases
per stage, from 1 to 5)
Body mass (kg)
Stature (m)
BMI (kg/m)
VO2 max (mL/kg/min)
Physical activity count
(count/min)*
Time spent in MVPA
(% of total physical activity)*
Time spent in MVPA
(min/day)*
N of subjects with
MVPA >60 min/day 1 (%)*
Time spent in SLPA
(min/day)*
Total Cholesterol (mmol/L)
HDL-Cholesterol (mmol/L)
LDL-Cholesterol (mmol/L)
Triglycerides (mmol/L)
HbA1c (%)

P
T1DM (n = 32) Healthy (n = 42) value
11.5 (10.2-12.8) 10.7 (9.6-11.8)
15 (47%)
25 (60%)
16/3/3/5/5
29/0/3/7/3
43.1 (36.9-49.2)
1.46 (1.40-1.53)
19.2 (17.9-20.4)
45.5 (43.0-48.0)
567.1
(458.6-675.6)
7.6 (5.9-9.3)

.32
.28

38.4 (33.6-43.1) .22

1.45 (1.40-1.51) .76
17.4 (16.5-18.4) .03
48.7 (46.7-50.6) <.001
694.9
<.001
(606.6-783.2)
9.7 (8.3-11.2)
.006

53.3 (32.9-73.7) 77.3 (57.8-96.8) 0.008

9 (35)
618.6
(548.9-688.2)
4.41 (4.11-4.70)
1.46 (1.35-1.57)
2.71 (2.45-2.97)
0.52 (0.37-0.67)
8.20 (7.84-8.56)

20 (57)

.08

514.3
<.001
(425.5-603.2)
4.14 (3.94-4.34) .13
1.38 (1.29-1.48) .28
2.50 (2.32-2.68) .17
0.57 (0.49-0.65) .50
5.02 (4.94-5.11) <.001

N, number; BMI, body mass index; MVPA, moderate-to-vigorous physical activity; LDL, lowdensity protein; HDL, high-density protein; HbA1c, glycated hemoglobin.
Results are means and 95% confidence intervals.
*Twenty-six of 32 subjects with T1DM and 35 of 42 healthy control subjects had valid physical
activity data.

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Table II. Blood pressure, vascular reactivity and intimamedia thickness in children with T1DM and healthy
control subjects
Variables

T1DM
(n = 32)

Healthy
(n = 42)

Systolic BP (mm Hg) 108.3 (104.1-112.5) 109.0 (106.3-111.7)

Diastolic BP (mm Hg)
57.6 (54.7-60.5)
52.8 (50.9-54.8)
Baseline RBA
2.74 (2.57-2.92)
2.74 (2.62-2.87)
diameter (mm)
IMT (mm)
0.50 (0.48-0.52)
0.48 (0.47-0.49)
FMD (%)
4.91 (4.14-5.68)
7.28 (6.44-8.12)
NTGMD (%)
20.10 (16.9-23.3)
24.38 (21.8-26.9)

P value
.36
.003
.99
.02
<.001
.04

RBA, Right brachial artery.

Results are means and 95% confidence intervals

The right brachial artery baseline diameter was not significantly different between groups (Table II). Children with
T1DM had higher diastolic BP and IMT, whereas they had
lower FMD and NTGMD than control subjects.
Prepubertal children (Tanner stage 1) with T1DM had also
significantly reduced FMD (mean 5.2% [4.0%-6.6%, CI
95%] vs 8.2% [7.4%-9.0%]), P < .001.
We divided the diabetic and healthy subjects (separately)
into 2 groups, respectively: (1) equal or more than 60 minutes per day of moderate-to-vigorous physical activity; and
(2) less than 60 minutes per day of moderate-to-vigorous
physical activity (Figure). In children with T1DM, we
found a significantly lower FMD in the inactive compared
with the active group (4.2% [3.4%-5.0%] vs 6.2% [3.9%8.4%]; P = .02). Interestingly, similar differences were
found among inactive and active healthy subjects (5.3%
[4.3%-6.3%] vs 8.9% [7.8%-10.0%], P # .001). In
addition, FMD was not significantly different between
active patients with T1DM and inactive healthy children
(P = .44), but it remained significantly lower compared
with active healthy subjects (P = .02).
We performed the same analysis after excluding the 4 overweight subjects with T1DM and obtained similar results for
physical characteristics, physical activity level, VO2max,
blood pressure and vascular measures. Triglyceride concentrations were significantly higher in healthy controls than
T1DM (P = .007); however, all values were within the normal
range.
We investigated the within-group relationships between
vascular variables (IMT and FMD, as dependent variables)
and physical activity or cardiorespiratory fitness (as independent variables) with univariate and multivariate analysis, adjusting for age, pubertal stage, and sex. In children with
T1DM, there were no associations between FMD or IMT
and physical activity variables, VO2max, duration of disease
or glycemic control. In healthy subjects, total physical activity
accounted for 49% (beta coefficient = 0.7, P # .001),
moderate-to-vigorous physical activity for 34.3% (beta coefficient = 0.6, P =.001), and SLPA for 41.2% (beta coefficient =
0.4, P = .005) of the variance of FMD, respectively; however, we did not observe similar findings for IMT. The beta
coefficient represents the estimated average change in standard deviation (SD) unit.
536

Figure. Comparison of arterial flow-mediated dilation among

subjects meeting the international recommendations of 60
minutes per day of moderate-to-vigorous physical activity.
The square represents the mean, and the error bar represents
the 95% confidence interval. *Significantly lower than active
subjects with T1DM and active healthy subjects (> 60 minutes
of moderate-to-vigorous physical activity), P < .05.

In all subjects (n = 61 with valid accelerometer data), we

performed multivariate linear regression analysis including
FMD or IMT as dependent variables, and disease, age, pubertal stage, and physical activity variables (total count,
moderate-to-vigorous physical activity, or SLPA). We found
that T1DM (beta coefficient = -0.3, P = .004) and physical activity count (beta coefficient = 0.4, P = .001) were independently associated with FMD. We observed a similar
relationship for moderate-to-vigorous physical activity
(beta coefficient = 0.3, P = .006) or SLPA (beta coefficient
= 0.3, P = .011), but pubertal stage was also a significant determinant (beta coefficient = 0.3, P = .03) of FMD. We then
repeated the analysis including VO2max instead of physical
activity, adjusting for age and sex, and did not find any relationship with in all subjects (n = 61 with valid accelerometer
data), we performed multivariate linear regression analysis
including FMD or IMT as dependent variables, and disease,
age, pubertal stage, and physical activity variables (total
count, moderate-to-vigorous physical activity, or SLPA).
We found that T1DM (beta coefficient = 0.3, P = .004)
and physical activity count (beta coefficient = 0.4, P =
.001) were independently associated with FMD. We observed
a similar relationship for moderate-to-vigorous physical activity (beta coefficient = 0.3, P = .006) or SLPA (beta coefficient = 0.3, P = .011), but pubertal stage was also
a significant determinant (beta coefficient = 0.3, P = .03)
Trigona et al

ORIGINAL ARTICLES

October 2010
of FMD. We then repeated the analysis including VO2max instead of physical activity, adjusting for age and sex, and did
not find any relationship with FMD or IMT. Only T1DM
(beta coefficient = 0.3, P = .011) was independently associated with IMT.

Discussion
Endothelial variables were impaired even before puberty in
youth with T1DM, with no evidence of clinical cardiovascular complications or dyslipidemia (annual screening), and an
HbA1c level of 8.5%  1.0% (target value 5% to 8%). Previous studies have demonstrated early modifications of endothelial function, which is considered the first sign of
atherosclerosis.6,7 Singh et al6 reported reduced FMD in 31
adolescents with diabetes (mean age 15 years) with a duration
of disease of 6 years and no known complications. Others
confirmed these findings in a cohort of 45 patients (mean
age 11 years).7 Endothelial dysfunction in T1DM appears
to be due to reduced local NO concentrations caused by
superoxide-mediated NO destruction.25
In this study, we also found increased IMT (between group
difference +0.02 mm), even in absence of dyslipidemia, suggesting that the arterial wall remodeling may be a consequence of hemodynamic stress, as previously described.26,27
In adults, increased IMT and impaired FMD are associated
with cardiovascular risk factors and coronary atherosclerosis.28,29 A meta-analysis of 8 trials showed that a carotid
IMT increment of 0.1 mm increases the risk of myocardial infarction by 10% to 15% and the risk of stroke by 13% to 18%,
after adjusting for age and sex.30 We may therefore hypothesize that an augmentation of IMT by 0.02 mm (20% of 0.1
mm) in youth with T1DM, compared with healthy control
subjects, may result in a higher risk of cardiovascular disease
later in life. These results highlight the importance to optimize the management of T1DM during growth, particularly
by motivating and supporting patients to practice regular
physical exercise.
Reduced physical activity during childhood is an important risk factor for CVD. International recommendations indicate that school-aged children should do at least 60 minutes
of moderate-to-vigorous physical activity per day to improve
their cardiovascular health, reduce adiposity, and increase
bone mineral density and well-being.14 In The European
Youth Heart Study including 1732 children and adolescents,
Andersen et al31 demonstrated that the first to the third quintile of physical activity had a raised CVD risk (odds ratio
from 3.3 to 2.5) compared with the most active quintile
(mean time spent in moderate-to-vigorous physical activity
116 min/day 1 in 9-year-olds and 88 minutes in 15-yearolds in the forth quintile).31 The mean difference between
the third (high CVD risk) and the forth quintile (low CVD
risk) was 24 minutes in 9-year-olds and 18 minutes in 15year-olds. In patients with T1DM, physical activity level
may be reduced because of fear of hypoglycemic events, frequent capillary glucose measurements, or difficulty of adjust-

ing insulin doses.32 In our study, total physical activity count

and the time spent in moderate-to-vigorous physical activity
were significantly lower in subjects with T1DM than healthy
children (mean difference 24 minutes). Moreover, almost
two third of patients with diabetes were below the minimal
time of moderate-to-vigorous physical activity recommended (<60 min/day). Finally, the time spent in SLPA was significantly higher in subjects with T1DM compared with
control subjects, suggesting a sedentary lifestyle (television
watching, computer use, electronic games).
In healthy children, endothelial function is positively associated with physical activity level, when a validated stable isotope technique is used.33 Exercise may indeed reduce NO
destruction via the production of antioxidative enzymes, as
previously reported in animal models.34 In our study, patients
with T1DM who met the international criteria of 60 minutes
per day of moderate-to-vigorous physical activity had a higher
FMD than inactive patients with diabetes and a FMD of same
magnitude compared with inactive healthy subjects. However, it remained impaired compared with active healthy subjects. These findings indicate that physical activity may
influence FMD through the active mobilization of vasodilation reserve. However, another study including 29 children
and adolescents with T1DM reported no correlation between
physical activity level and microvascular reactivity.35 We hypothesize that a high intensity or volume of physical activity
might be needed to offset the negative impact of T1DM.
With multiple regression analysis, we showed that T1DM,
physical activity count (volume), or time spent in moderateto-vigorous physical activity (intensity) were independently
associated with FMD. Furthermore, sedentary activities
(time spent in SLPA), such as television watching or computer use, had a negative influence on FMD. It is therefore
important to inform parents and patients about the benefits
of regular physical activity and to target at least 60 minutes
per day of moderate-to-vigorous physical activity. They
may need some support for adjusting insulin doses and carbohydrate intake when practicing activities.
In both healthy children and those with T1DM, we did not
observe any relationship between IMT and physical activity.
There is, to our knowledge, no information about the effects
of exercise on IMT in children. In adults with coronary heart
disease, Sato and al36 showed a significant improvement of
IMT in patients walking 4 km/day 1.
Cardiorespiratory fitness was significantly reduced in patients with diabetes compared with healthy subjects. A recent
study has demonstrated a positive and independent association between aerobic fitness (VO2max) and skin microvascular reactivity in youth with T1DM.35 On the contrary, we did
not observe any relationship between FMD or IMT and aerobic fitness, in both T1DM and healthy children. These findings may be due to the different techniques used. Further
research is needed to investigate the effects of an aerobic exercise training program on IMT and endothelial function in
both populations.
Our study has some limitations. First, patients with T1DM
had slightly higher Tanner stages than controls, and this may

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have overestimated the between-group differences for vascular variables, physical activity level, and aerobic fitness. However, when adjusted for pubertal stage, T1DM remained an
independent determinant of FMD and IMT. Second, this
was a cross-sectional study, which does not allow establishing
causality between exercise and arterial measures. A randomized controlled trial including a structured exercise training
program would be required. Third, we measured physical activity during 1 week, and this may not reflect the annual
physical activity pattern. Finally, the low proportion of active
subjects with T1DM (35%), the small sample size, and the
homogeneity with regard to physical activity level in the diabetic group may also have underestimated associations between physical activity or fitness and arterial measures.
Children and adolescents with T1DM who do more than
60 minutes per day of moderate-to-vigorous physical activity
have higher FMD than inactive patients with diabetes, but
not as high as active healthy subjects. We recommend that
pediatricians encourage children and adolescents with
T1DM to practice regular physical activity, including at least
1 hour per day of moderate-to-vigorous physical activity, and
to reduce sedentary lifestyle to enhance cardiovascular
health. n
We thank the Mimosa Fellowship of the Pediatric Department, University of Geneva, which supported financially this project. We also thank
the subjects for volunteering for the study, as well as Valerie Schwitzgebel, Emmanuelle Golay, Francois Herrmann, and the nurses of the pediatric policlinic for their assistance.
Submitted for publication Sep 22, 2009; last revision received Mar 16, 2010;
accepted Apr 13, 2010.
Reprint requests: Nathalie Farpour-Lambert, MD, Pediatric Cardiology Unit,
Department of Child and Adolescent, University Hospitals of Geneva, 6, rue
Willy-Donze, 1211 Geneva 14, Switzerland. E-mail: nathalie.farpourlambert@
hcuge.ch.

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50 Years Ago in THE JOURNAL OF PEDIATRICS

The Feeding of Prematurely Born Infants

A Critique of Current Status

Davidson M. J Pediatr 1960;57:604-10.

.J. Davidson reviewed the evidence supporting enteral nutrition for premature infants. Although there were still
significant areas of debate that needed clarification and further research, this report provided a review of more
than two decades of direct clinical experience in nutritional support for the smallest infants of their times. They used
empiric trials to identify the best formula composition for prematurely born infants. Importantly, they defined thinking in terms of free water, protein, carbohydrate, and fats. Perhaps one of Davidsons most important points was identifying the need to define the terms adequate and optimal before we can proceed with research testing them.
Today, most agree that optimal nutrition of the preterm infant should achieve a postnatal growth rate and composition of weight gain approximating that of the normal fetus of the same gestational age. We have gained insight into
the composition of enteral feedings required to achieve this goal. We recognize the benefits of human milk, albeit
needing some discrete supplementation. We have developed humanized formulas with respect to protein content
and composition, such as whey-to-casein ratios. Protein intake between 3.5 to 4 g/kg/d is now recommended to promote weight gain and is well tolerated. Fat requirements have been shown to be 5 to 7 g/kg/d. Preterm infants have no
problems absorbing the saturated fats of human milk or the medium-chain triglycerides and polyunsaturated longchain triglycerides of formula. The carbohydrate recommendation is 10 to 14 g/kg/d.
As the field of neonatology continues to make significant advances that are allowing smaller and earlier infants to
survive, the need to answer Davidsons challenges is more important than ever. Although we have succeeded in
defining a goal for optimal nutrition, we still have room for improvement. Despite increased understanding of the
required composition of feedings, many preterm infants experience postnatal growth restriction during the hospitalization after birth. We also now know that both intrauterine and postnatal growth restriction of the preterm infant can
result in long-term cardiovascular and metabolic disorders, as well as impaired behavioral, motor, and cognitive outcomes. Current studies are focusing on new fortifiers, the role of the fatty acids DHA and ARA, alternative fat sources,
prebiotics, probiotics, and long-term neurodevelopmental outcomes. We look forward to continued progress.
Sailaja Ghanta, MD
James F. Padbury, MD
Department of Pediatrics
Women & Infants Hospital of Rhode Island
Warren Alpert Medical School at Brown University
Providence, Rhode Island
10.1016/j.jpeds.2010.04.014

Preclinical Noninvasive Markers of Atherosclerosis in Children and Adolescents with Type 1 Diabetes Are Influenced by
Physical Activity

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