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Physical activity and sports participation in

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Nutrition, Metabolism & Cardiovascular Diseases (2007) 17, 376e382

www.elsevier.com/locate/nmcd

Physical activity and sports participation in

children and adolescents with type 1
diabetes mellitus
Giuliana Valerio a,*, Maria Immacolata Spagnuolo b,
Francesca Lombardi b, Raffaella Spadaro b, Maria Siano b,
Adriana Franzese b
a

School of Movement Sciences (DiSISTe), Parthenope University, Via Ammiraglio Acton 38,
80133 Naples, Italy
b
Department of Paediatrics, Federico II University, Naples, Italy
Received 23 June 2005; received in revised form 20 October 2005; accepted 28 October 2005

KEYWORDS
Adolescent;
Glycosylated
haemoglobin;
Physical activity;
Type 1 diabetes

Abstract Background and aim: Regular physical activity is of great importance in

the management of type 1 diabetes mellitus (T1DM). We investigate here the levels
of moderate/vigorous physical activity (MVPA) and participation in sporting activity
in a sample of children and adolescents with T1DM and analyse whether they differed from healthy subjects. The family variables associated with MVPA or sports
participation and the influence of exercise on metabolic parameters are also
explored.
Methods and results: In this cross-sectional case control study, 138 children and
adolescents with T1DM (of which 67 were boys, age 13.6  4.1 years; duration of
diabetes 6.1  3.8 years) and 269 (of which 120 were boys) healthy controls were
studied. Weekly levels of MVPA and sports participation were investigated using
a questionnaire. Body mass index standard deviation score (BMI-SDS) values, plasma
total cholesterol, serum triglycerides and the mean glycated haemoglobin (A1c)
levels over the past year were assessed in T1DM subjects. MVPA scores in T1DM
patients were lower than in controls (p 0.0004). MVPA was higher in boys than
in girls, both in diabetic and control subjects; T1DM girls were less frequently engaged in MVPA than control girls. MVPA scores were significantly and independently
correlated with sex, age and diabetic status. Lower triglyceride levels and fewer
subjects with poor metabolic control were found more among physically active
patients (MVPA > 5 days/week) than in inactive patients (weekly MVPA 0). Sports
participation was lower in T1DM patients than in controls (p 0.002) and was

* Corresponding author. Tel.: 39 081 547 5747; fax: 39 081 545 1278.
E-mail address: giuliana.valerio@uniparthenope.it (G. Valerio).
0939-4753/$ - see front matter 2005 Elsevier B.V. All rights reserved.
doi:10.1016/j.numecd.2005.10.012

Physical activity in type 1 diabetes

377

significantly and independently correlated with sex, fathers education level

and diabetic status. Triglyceride levels and the percentage of subjects with poor
metabolic control were significantly lower in sports participants than in nonparticipants.
Conclusions: Children and adolescents with T1DM appeared to spend less time in
physical activity than their non-diabetic peers. Regular physical activity was associated with better metabolic control and lipid profile. Adolescents, particularly the
girls, tended to be less active. Further efforts should be made to motivate patients
with type 1 diabetes.
2005 Elsevier B.V. All rights reserved.

Introduction
Type 1 diabetes mellitus (T1DM) greatly influences
physical and emotional development. Effective
management requires continuous attention to
food intake, multiple daily injections of insulin,
and glycaemic self-monitoring. Obtaining good
metabolic control, preventing long-term complications and promoting social competence and selfworth are the targets of management in young
patients with diabetes [1]. The importance of
regular physical activity in the management of
children and adolescents with T1DM has been highlighted in recent years [2]. Despite the beneficial
effects of exercise, the level of physical activity
generally undertaken by diabetic patients remains
an issue of concern. Limited information exists
about physical activity and sporting habits of young
patients with T1DM. Several studies have failed to
show an independent effect of exercise on improving glycaemic control in T1DM patients [3], while it
was demonstrated that exercise reduces known
risk factors for atherosclerosis (excess weight, dyslipidemia and hypertension) [4]. In addition, organised activity programmes, including sporting
activities, contribute to improved socialisation,
social integration and self-esteem in subjects
with diabetes, allowing them to take part in
different activities just as their peers do [5].
According to the American Department of
Health and Human Services Healthy People
2010 recommendations, adults should practise
a moderate physical activity for at least 30 min
nearly every day and an intense activity for at
least 20 min three times a week [6]. The guidelines
for young people do not greatly differ from this
and suggest participating in at least 60 min per
day of moderate/intense activity for most of the
week. Levels of physical activity in healthy children, and particularly in adolescents, are surprisingly low [7]. Determinants of childhood levels of
physical activity are complex and vary according
to individual characteristics, parental and environmental influences [8]. A low educational level of

parents has been associated with an unhealthy

lifestyle and increased future risk of cardiovascular disease in their offspring [9]. Important barriers
to physical activity include television viewing and
computer use [10]. The presence of a chronic disease, such as type 1 diabetes, may additionally
interfere with participation in physical activities,
for the risk felt by parents and children of acute
metabolic complications, such as hypoglycaemic
crises [11,12]. Therefore, levels of physical activity may not meet guidelines particularly in
diabetic children.
The aim of this study was to investigate the
levels of moderate/vigorous physical activity
(MVPA) and participation in sporting activities in
a sample of children and adolescents with T1DM.
The influence of parental educational level on
MVPA or sports participation and the influence of
exercise on metabolic parameters were also
explored.

Methods
In this cross-sectional case control study, 138
children and adolescents with type 1 diabetes
mellitus (67 boys, 71 girls) were recruited at the
Diabetes Unit, Department of Paediatrics, Federico II University of Naples, from October 2002 to
January 2003. Mean age was 13.6  4.1 years
(range 5.9e20 years); duration of diabetes was
6.1  3.8 years (range 1e17 years). They were
treated with recombinant human insulin (mean
0.86  0.22 U/kg), divided into 3e4 daily doses,
and performed self-monitoring of glycaemic control; a balanced normocaloric diet was prescribed.
Only patients free of any diabetic complication
were enrolled. Height was measured by Harpenden
stadiometer and weight by SECA scale; body mass
index (BMI) was calculated (weight/height2). Limits for overweight and obesity were represented
by the Italian centiles [13] having at 18 years the
value of 25 and 30 kg/m2, according to the method
proposed by Cole et al. [14]. Thirty-two patients
were overweight (23.2%) and 4 obese (2.9%).

378
Since BMI values are sex- and age-dependent, the
standard deviation scores of BMI (BMI-SDS) were
also calculated by Coles LMS method, using the
Italian standards [13]. Two hundred and sixtynine healthy schoolchildren and adolescents (120
boys, 149 girls), mean age 12.9  3.5 years (range
6e19 years), were the control group. They were
recruited from five classes (grades 1e5) randomly
selected from one elementary school, three classes (grades 1e3) from one middle school and five
classes (grades 1e5) from one high school in the
district of Naples. No anthropometric measurement was taken in the control group. All subjects
and their parents gave their informed consent to
participate in the investigation.
A questionnaire was used to obtain information
about parents educational level. Length of school
attendance was calculated and coded as 0 for no
education, 5 years for primary school, 8 years for
lower secondary education, 13 years for upper secondary education and 17 years and over for post
secondary education. Children and adolescents reported the following information about their own
lifestyle: engagement in moderate/vigorous physical activity (MVPA) in spare time, number and kind
of sports played in the last 12 months and weekly
hours spent training. A score of MVPA was assessed
by calculating the number of days in which subjects had accumulated 60 min of MVPA during the
previous days and for a typical week. This was
achieved using a structured questionnaire, the reliability and validity of which had been previously
assessed [15]. MVPA scores significantly correlated
with the data provided by an accelerometer, an
electronic device that objectively measures frequency and intensity of physical activity. The following two questions were asked: (1) Over the
past 7 days, on how many days were you physically
active for a total of at least 60 min per day (min.
0emax. 7 days)?; (2) Over a typical or usual
week, on how many days are you physically active
for a total of at least 60 min per day (min. 0emax.
7 days)?. The measure defined physical activity
broadly as an activity that increases your heart
rate and makes you get out of breath some of
the time and did not specify intensity; some
examples of physical activity were reported as
running, brisk walking, rollerblading, biking, dancing, skateboarding, swimming, soccer and basketball. A composite average of the two items
yielded a score of the number of days per week
during which the subject accumulated 60 min
of MVPA. Subjects were considered inactive if
they did not report any MVPA over the week,
moderately active if they were participating
in MVPA 1e4 times/week and active if they

G. Valerio et al.
Table 1

Demographic characteristics of participants

T1DM patients Controls

Number
Male/Female
Age (years)
Elementary school, n (%)
Middle school, n (%)
High school, n (%)
Fathers school years
Mothers school years

138
67/71
13.6  4.1
33 (23.9)
36 (26.1)
69 (50.0)
10.3  3.5
9.6  3.8

269
120/149
12.9  3.5
69 (25.6)
66 (24.5)
134 (49.9)
9.8  3.7
9.5  3.9

were participating 5 or more times/week. Demographic characteristics of the participants are

shown in Table 1.

Biochemical assessments
Blood samples were collected in the morning only
from diabetic patients using venipuncture after
a 12-h overnight fast. Total cholesterol and triglycerides were measured by enzymatic assays
(Roche/Hitachi 747). As an indicator of metabolic
control, the mean A1c level of the last 3e4
determinations performed over the past year was
calculated. A1c measurements (immunoassay)
were taken by an Ames DCA-2000 Analyser
(normal range: 4.2e6.5%).

Statistical analyses
Power calculation was done before the study, using
McNemars test of equality of paired proportion
with a 0.05 two-sided significance level. It was
found that a sample size of 115 pairs would have
80% power to detect a difference in proportion of
0.200, while the proportion of discordant pairs was
expected to be 0.600. The following parametric
and non-parametric tests have been used when
appropriate: Students unpaired t-test or the
ManneWhitney test were used to compare the
means between two groups (diabetic patients
versus healthy controls, sports participants versus
non-participants), while ANOVA or KruskalleWallis
tests were used to compare the means among
groups with different MVPA levels. Associations
between MVPA levels or sports participation and
diabetic status were explored using the Fisher exact
test for categorical variables. Multiple and logistic
linear regression analyses were performed to
determine the relationships between individual
and family variables on childrens MVPA or sports
participation. The dependent variables were, respectively, MVPA scores and sports participation,
while the independent variables were gender

Physical activity in type 1 diabetes

(coded as 1 for boys and 2 for girls), age, fathers
and mothers education level and diabetic status
(coded as 0 for absent and 1 for present). Data
are shown as mean  standard deviation (SD). Analysis was performed by SPSS 10.0 release. A p value
of less than 0.05 was considered significant.

Results
Measure of MVPA and associated variables
Scores of MVPA were widely distributed in the
population (range 0e7 days), with a mean of
2.8  2.5 days/week in T1DM patients and 3.6 
1.9 days/week in controls (p 0.0001). Mean
MVPA score was higher for boys than for girls,
either when diabetic subjects (3.5  2.6 vs. 2.1 
2.3, respectively, p 0.001) or controls (3.9 
1.8 vs. 3.3  1.9, respectively, p 0.003) were
considered. Diabetic girls were less frequently
engaged in MVPA than control girls (p 0.0001),
while no significant difference was found between
diabetic and control boys. According to the classification based upon the number of days per week
on which the subject participated in MVPA, 34
patients (24.6%) were inactive, 70 (50.7%) were
moderately active and 34 (24.6%) were active.
This distribution was significantly different from
that found in the control group, where only 21
subjects were inactive (7.8%), 149 (55.4%) were
moderately active and 99 (36.8%) were active
(p < 0.0001).
In order to analyse factors influencing the MVPA
score, multiple regression analysis was performed
in the whole population of patients and controls.
MVPA score was the dependent variable, while
gender, age, fathers and mothers education

379
level, diabetic status and sporting practice were
the independent variables. MVPA was significantly
and independently correlated with sex, age and
diabetic status (Table 2).
BMI-SDS values did not differ among the different groups of MVPA (inactive 0.52  0.67, moderately active 0.49  0.94 and active 0.63  0.92).
Triglyceride serum levels in inactive diabetic
patients were higher than in active patients (inactive 73  28 mg/dl, moderately active 66  23
mg/dl and active 59  21 mg/dl, p 0.035), while
no significant difference was found regarding
total cholesterol levels (inactive 177  33 mg/dl,
moderately active 164  30 mg/dl and active
165  31 mg/dl). Prevalence of patients with
poor metabolic control (A1c > 8.5%) was higher in
inactive patients than in those who were moderately active or active (Fig. 1).

Sports participation and associated

variables
Sports participation was reported by 65 diabetic
patients (of which 34, or 47.1%, were boys) and 170
controls (of which 86, or 63.2%, were boys)
(p 0.002). Weekly time spent in training was similar between groups (2.53  0.6 and 2.51  0.6 h/
week, respectively). Generally, participation in individual sports outnumbered participation in team
sports in the patient group (46 individual sports
versus 19 team sports), while they were evenly distributed in the control group (96 individual sports
versus 74 team sports).
In order to analyse factors influencing sports
participation, a logistic regression analysis was
performed on the whole population of patients
and controls. Sports participation was the dependent variable. Gender, age, fathers and mothers

Table 2 Variables independently associated with MVPA (model 1) or sports participation (model 2) by multiple
and logistic regression analyses in the whole sample of subjects (patients and controls)
Independent variable

Dependent variables

Beta (SE)

Standardised beta

Gender
Age
Fathers education
Mothers education
Diabetic status

0.98
0.19
0.004
0.01
0.74

(0.22)
(0.03)
(0.04)
(0.04)
(0.22)

0.225
0.299
0.065
0.021
0.164

0.0001
0.0001
0.341
0.754
0.001

Gender
Age
Fathers education
Mothers education
Diabetic status

0.18
0.004
0.02
0.003
0.18

(0.06)
(0.01)
(0.01)
(0.01)
(0.06)

0.152
0.023
0.151
0.020
0.154

0.004
0.674
0.035
0.777
0.004

Model 1: MVPA

Model 2: Sports participation

380

G. Valerio et al.
45
38.2

40

chi2 for trend 0.017

35

% cases

30
25
20.0
20
14.7

15
10
5
0
inactive

moderately
active

active

Figure 1 Percentage of subjects with poor glycaemic

control (HbA1c > 8.5%) stratified according to days of
MVPA per week.

education level and diabetic status were the independent variables. Sports participation was
significantly and independently correlated with
sex, fathers educational level and diabetic status
(Table 2).
By comparing sports participants and nonparticipants among the diabetic subjects, no difference was found regarding BMI-SDS (0.58  0.85
vs. 0.49  0.89, p > 0.05), daily insulin dosage
(0.9  0.2 vs. 0.9  0.2 U/kg, p > 0.05), mean
A1c (7.8  0.9 vs. 7.9  1.0%, p > 0.05) and
total cholesterol (168  33 vs. 167  30 mg/dl,
p > 0.05). On the contrary, triglyceride serum
levels were significantly lower in sports participants than in non-participants (61.5  19.9 vs.
70.8  26.9 mg/dl, p 0.037). In agreement with
the above, the percentage of subjects with poor
metabolic control was lower in patients reporting
sports participation (10 of 65 or 15.4%) than that
found in patients who did not report any sports
participation (22 of 73 or 30.1%, p 0.045).

Discussion
Regular physical activity is associated with immediate and long-term health benefits [16]. It therefore represents a critical component of diabetes
management. According to ADA guidelines, all
patients with diabetes should be given the opportunity to benefit from the many effects of exercise [2]. Every kind of physical exercise,
including competitive sports, should be made
available to diabetic children, who should never
feel different from their non-diabetic peers.
Appropriate adjustment of insulin dosage, frequent

glucose self-monitoring, more careful dietary

management before starting physical activity and
programming the right time for exercise are the
indispensable recommendations.
In this survey, weekly time engaged in MVPA and
participation in sports were investigated in a wide
sample of children and adolescents with type 1
diabetes using a structured questionnaire. Scores
of MVPA obtained through this questionnaire have
been proposed as an easy measure for assessing
participation in overall physical activity and for
assessing conformance to current guidelines. This
study has limitations that need to be considered
before interpreting the findings. The measure used
to assess levels of physical activity was brief and
based on self-report, and thus bias may be present
as children and adolescents may tend to respond in
a socially desirable manner by over-reporting their
physical behaviour. Despite health recommendations, many young people in industrialised countries have already adopted a sedentary life-style
by the age of 13 years; girls, furthermore, being
more inactive than boys [17,18]. According to previous reports using the same measure of moderatevigorous physical activity that we used, between
26.8% and 53% U.S. adolescents meet the Healthy
People 2010 recommendations [15,19]. No previous data exist regarding the Italian population. In
our sample, only 25% of patients reached good levels of physical activity compared to 37% of healthy
controls. Scores of MVPA were lower in diabetic
patients than in controls, indicating the influence
that diabetic status has on the levels of physical
activity. In particular, multiple regression analysis
indicated that low levels of MVPA were independently associated not only with diabetic status
but also with female gender and older age, confirming that, as many children develop into adolescence, their physical activity levels decline [20].
Similarly, participation in sports was significantly
lower in patients than in controls (47% vs. 63%).
Again no published data exists for the Italian
population, apart from the survey released by
the Italian Institute of Statistics in 2003, indicating
that about 59% of youth between 6 and 17 years of
age regularly or occasionally engage in one or more
sporting activities. In our sample, multiple regression analysis indicated that male gender and
higher paternal education levels were independently associated with sports participation. Education is often used as an indirect measure of
socioeconomic status in studies aimed at investigating the effect of socioeconomic inequalities in
health research [21]. Higher parental educational
level, and consequently higher socioeconomic status (SES), may provide better support for sporting

Physical activity in type 1 diabetes

activities in children, increasing the availability of
and access to community-based organised sports
programmes at and outside school. A direct relationship between fathers occupation and sporting
activities has been found also among seventh and
eighth grade healthy students [22]. In chronically
ill patients, lower educational levels and lower
degrees of physical activity were associated with
poor metabolic control in adult patients with
T1DM [23]. The findings provided by multiple regression analysis in our sample indicate that, while
individual features (gender, chronic disease) are
important correlates of MVPA levels as well as of
sporting activity, social and cultural factors may
not affect the free-time playdalthough they may
impede participation in organised sports in healthy
and chronically ill children.
The sporting habits of T1DM patients did not
differ from healthy controls in terms of time spent
weekly, while a stronger trend towards individual
sports was found in diabetic patients. This may be
interpreted as difficult socialisation experienced
by patients.
Since physical exercise can reduce blood glucose levels and insulin resistance [24,25], the
hypothesis that regular aerobic exercise can improve metabolic control in T1DM patients has
been analysed by several authors. Two crosssectional studies on the levels of physical activity
evaluated using a questionnaire did not demonstrate any improvement in their long-term glycaemic control in T1DM adults [26,27]. Short-term
trials have been carried out in T1DM children.
While results are unequivocal in demonstrating
an increase in aerobic capacity or fitness after
a programme of physical activity, contrasting
data were reported on the capacity of exercise
to reduce A1c levels [3,28e31]. These contrasting
results can be explained by the fact that several
factors, such as variation in caloric intake or insulin dosage, stress or stricter medical monitoring
can influence glycaemic status. For instance, increased carbohydrate intake to avoid hypoglycaemia may erroneously occur on days of physical
activity, particularly in children, or additional
care and/or attention to diet and insulin may be
given to the training patients, resulting in a bias
in the opposite direction. Our cross-sectional survey precludes the establishment of any causation.
However, it suggests that conforming to the physical activity guidelines (at least 5 days of MVPA
a week) or attending sports activities was associated with a lower percentage of subjects with bad
metabolic control compared to that for inactive
patients. Patients with a more active lifestyle are
also more motivated to participate in various

381
programmes related to diabetes management,
which is not necessarily an effect of training per
se. In fact, according to previous findings, selfreported exercise was associated with both a
better quality of life and better metabolic control
in young T1DM patients [32]. Moreover, sports
participation among high school students has
been associated with multiple positive health
behaviours, including fruit and vegetable consumption and reduced cigarette smoking [33].
Other studies underline the benefit of exercise
on lipid profile and cardiovascular risk factors in
T1DM patients. In 59 T1DM adolescents, fitness
measured by VO2 max during cyclo-ergometry was
negatively correlated with A1c levels, insulin
dose, triglycerides, total and LDL-cholesterol levels [4]. Lehmann et al. [34] reported that at the
end of a 3-month programme of physical exercise
performed by 20 T1DM patients under good metabolic control, physical activity levels and the VO2
max increased, while LDL-cholesterol, systolic and
diastolic blood pressure, weight and abdominal
fat decreased. In agreement with these findings,
our data, too, indicated that T1DM patients who
met physical activity guidelines or attended sporting activity had triglyceride levels lower than those
found in inactive patients. No variation was found
in total cholesterol, which indeed is less susceptible to changes than LDL and HDL fractions; unfortunately, these fractions were not measured in our
patients.
In conclusion, our results indicate that only 25%
of young diabetic patients meet the guidelines for
healthy physical activity and that less than 50% of
them appear to spend time with sporting activity.
Participation in organised sports is largely influenced by cultural factors, both in healthy and
chronically ill adolescents. Regular practice of
moderate to intense physical activity or sports
participation is associated with better metabolic
control and lipid profile. Within our diabetic
adolescent population, particularly the girls are
at risk from the effects of low physical activity and
should therefore be targeted by educational programmes promoting a more active lifestyle.

Acknowledgements
The authors wish to thank Dr Giuseppe Signoriello
for his invaluable statistical advice.

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