**4. Glycaemic index and dietetic management in diabetic children and adolescents**

At present, nutritional interventions, physical activity and weight control remain the main pillars of effective diabetes management. Despite modern approaches to intensive insulin therapy and other drugs for the management of diabetes, dietary management remains as the main important action of diabetes treatment [48]. There is not an ideal nutritional intervention for the management of diabetes. A poor GC in subjects with T1DM and T2DM has been related with the onset of diabetes complications. Therefore, it is vital to develop new strategies in order to maintain a good GC. Current standards for diabetes management reflect the need to lower glucose as safely as possible, without increasing the risk or hypoglycaemic episodes. It should receive special consideration the risk of hypoglycaemia in young children (aged <6 years or EOD), because usually they are unable to recognise and/or manage the symptoms. This is called *'hypoglycaemia unawareness'* [6].

There are different dietetic approaches aimed at the improvement of the GC in children and adolescents with T1DM and T2DM, among them it is worth noting low GI diets, diets rich in antioxidants, carbohydrate exchange diets, high-cereal fibre diet, traditional Mediterraneanstyle dietary pattern, low carbohydrate Mediterranean style diet, low carbohydrate diets and low fat diets.

Although there are no long-term intervention studies looking at the effects of a low GI diet on diabetes prevention, there is a large body of evidence from animal models, clinical trials and epidemiologic studies that demonstrates the benefits of a low GI diet in the prevention and management of diabetes. Low GI diets in subjects with T1DM and T2DM improve blood glucose control to a similar extent as medications, improving GC and reducing the risk of hypoglycaemic events [14].

The effect is sufficiently strong that may benefit diabetic patients by reducing or even avoid-

Influence of Glycaemic Control on Cognitive Function in Diabetic Children and Adolescents

http://dx.doi.org/10.5772/intechopen.75562

133

It is important to keep in mind that medications that improve blood glucose levels usually are associated with high risk of hypoglycaemia, which is the greatest barrier to achieve an optimal GC, particularly in T1DM. In people with T2DM a reduction in HbA1c levels after the consumption of low GI diets has been observed, whereas in children with T1DM, with both intensive multiple daily injection of insulin or insulin pump therapy, a reduction in postprandial glucose excursions, as well as improvements in insulin sensitivity after 3 to 4 weeks was demonstrated. However, a high GI diet worsens insulin resistance in individuals with and without diabetes and rises blood glucose levels and the need to medication in T2DM and the insulin requirements in T1DM. Therefore, the reduction of the risk of diabetes-related complications with low GI diets is similar to or greater than the diets including a high intake of

A low GI diets favours slower and more gradual absorption of glucose from the gastrointestinal tract, avoiding hypoglycaemic episodes; moreover, it produces fewer stimuli for insulin release,

According to the Canadian Diabetes Association, interventions replacing high GI carbohydrates with low GI carbohydrates in mixed meals have shown clinically significant improvements in GC over 2 weeks to 6 months in people with T1DM or T2DM; improvements were observed in cardiovascular risk factors, postprandial glycaemia and high sensitivity C-reactive protein over 1 year in people with T2DM, whereas adults and children with T1DM showed lower hypoglycaemic events over 24 to 52 weeks [20]. In addition, it has been shown that low GI diets sustain improved GC and HDL cholesterol compared with a high-cereal fibre diet over 6 months, and improved β-cell function in comparison with a low carbohydrate, high monounsaturated fat diet over 1 year in people with T2DM [20]. As it has been already mentioned, diets with lower GI result in improvements in HbA1c in the order of 0.5%. [19].

In contrast, a review carried out by Madsbad [49] in subjects with T1DM and T2DM showed different results. Dietary carbohydrate restriction as early therapy in T2DM, and as an adjunct to therapy in T1DM, effectively reduces blood glucose levels. However, longer-term studies (≥6 months) have variable results regarding the relative efficacy of low carbohydrate diets compared to low in fat or low GI diets on weight and HbA1c reductions. While recent metaanalyses suggest that low carbohydrate diets may be no more effective over the longer term

It has been observed a reduction in the risk of diabetes with the consumption of low GI diet, whereas high dietary GI and/or glycaemic load increase the risk of T2DM [18]. Observational data suggest that replacing high GI with low GI carbohydrate reduces the risk of metabolic disturbances and T2DM. Nevertheless, some studies show inconclusive results that may be due to methodological differences and confounding parameters that can dramatically modify the post-meal metabolic response, such as the type of carbohydrate and its digestibility, quantity of carbohydrates as compared with other macronutrients, lipids, proteins and fibres [18].

than low fat or Low GI diets, in terms of weight and HbA1c changes [49].

reduces free fatty acids levels and oxidative stress, and increases insulin sensitivity [17].

ing their requirement for medication [10].

fibre and whole grains [14].

Derdemezis and Loveg [4], reported in by a systematic review that low GI diets effectively improve GC. They observed that subjects with T2DM presented significant beneficial effects after the consumption of low GI diets; however, in some cases, a low GI diet was associated with significant weight reduction, which makes difficult to establish firm conclusions, because it is not clear if the effect on the improvement of GC is for the low GI diet per se or derived from the weight loss itself. On the other hand, in subjects with T1DM there is insufficient evidence for the beneficial effects of GI control due to different confounding factors (differences in dietary fibre intake and the values used for calculation of dietary GI and weight loss), suggesting that total carbohydrate content adjusting pre-meal insulin infusion might be more important than GI in controlling postprandial glucose levels. However, low GI diets might be used as a treatment in T1DM in order to reduce the insulin infusions. The potential of a low GI diet in preventing diabetes has not been studied to date, but low GI diet may improve GC and reduce the risk of diabetes and its complications [4].

In another study, T1DM subjects (7–17 years old) were provided with four premade test meals, which were consumed at breakfast after a minimum 10 h overnight fast [16]. The low GI test meal had a GI of 48, meanwhile the one with high-GI test meal had a GI of 84. For the measurement of blood glucose, they used a continuous glucose monitoring system. The low GI meal produced significantly lower postprandial glucose excursion (PPGE) for 30–180 minutes, lower area under the blood glucose response curve (AUC), a smaller peak blood glucose excursion, and reduced time to reach baseline blood glucose levels compared with the high GI meal when preprandial ultra-short-acting insulin was administered. Nevertheless, the effect of GI on the postprandial glucose response requires further exploration in children receiving intensive insulin therapy [16].

A systematic review performed by Thomas and Elliott [2] in T1DM and T2DM children and adults, showed that GC in people with diabetes improved significantly with a low GI diet, by decreasing hypoglycaemic episodes, compared to those on higher GI diets or measured carbohydrate exchange diets. It was observed that a low GI diet produces a decrease of 0.5% HbA1c, clinically significant, similar to the reductions produce by the medications given to newly diagnosed T2DM subjects; as a result, it has been confirmed that a low GI diet is associated with a significant reduction in the risk of microvascular complications [2].

In 2010, these authors performed a meta-analysis with evidence that low GI diets significantly improve GC, by lowering HbA1c without any increase in the rate of hypoglycaemic episodes, when compared with a measured carbohydrate exchange diet and a high-cereal fibre diet. In other studies, low GI diet improved HbA1c levels in T1DM children; in contrast, T2DM low GI group presented a significant increase in insulin sensitivity compared to the high GI group. The effect is sufficiently strong that may benefit diabetic patients by reducing or even avoiding their requirement for medication [10].

Although there are no long-term intervention studies looking at the effects of a low GI diet on diabetes prevention, there is a large body of evidence from animal models, clinical trials and epidemiologic studies that demonstrates the benefits of a low GI diet in the prevention and management of diabetes. Low GI diets in subjects with T1DM and T2DM improve blood glucose control to a similar extent as medications, improving GC and reducing the risk of

Derdemezis and Loveg [4], reported in by a systematic review that low GI diets effectively improve GC. They observed that subjects with T2DM presented significant beneficial effects after the consumption of low GI diets; however, in some cases, a low GI diet was associated with significant weight reduction, which makes difficult to establish firm conclusions, because it is not clear if the effect on the improvement of GC is for the low GI diet per se or derived from the weight loss itself. On the other hand, in subjects with T1DM there is insufficient evidence for the beneficial effects of GI control due to different confounding factors (differences in dietary fibre intake and the values used for calculation of dietary GI and weight loss), suggesting that total carbohydrate content adjusting pre-meal insulin infusion might be more important than GI in controlling postprandial glucose levels. However, low GI diets might be used as a treatment in T1DM in order to reduce the insulin infusions. The potential of a low GI diet in preventing diabetes has not been studied to date, but low GI diet may improve GC

In another study, T1DM subjects (7–17 years old) were provided with four premade test meals, which were consumed at breakfast after a minimum 10 h overnight fast [16]. The low GI test meal had a GI of 48, meanwhile the one with high-GI test meal had a GI of 84. For the measurement of blood glucose, they used a continuous glucose monitoring system. The low GI meal produced significantly lower postprandial glucose excursion (PPGE) for 30–180 minutes, lower area under the blood glucose response curve (AUC), a smaller peak blood glucose excursion, and reduced time to reach baseline blood glucose levels compared with the high GI meal when preprandial ultra-short-acting insulin was administered. Nevertheless, the effect of GI on the postprandial glucose response requires further exploration in children receiving

A systematic review performed by Thomas and Elliott [2] in T1DM and T2DM children and adults, showed that GC in people with diabetes improved significantly with a low GI diet, by decreasing hypoglycaemic episodes, compared to those on higher GI diets or measured carbohydrate exchange diets. It was observed that a low GI diet produces a decrease of 0.5% HbA1c, clinically significant, similar to the reductions produce by the medications given to newly diagnosed T2DM subjects; as a result, it has been confirmed that a low GI diet is associ-

In 2010, these authors performed a meta-analysis with evidence that low GI diets significantly improve GC, by lowering HbA1c without any increase in the rate of hypoglycaemic episodes, when compared with a measured carbohydrate exchange diet and a high-cereal fibre diet. In other studies, low GI diet improved HbA1c levels in T1DM children; in contrast, T2DM low GI group presented a significant increase in insulin sensitivity compared to the high GI group.

ated with a significant reduction in the risk of microvascular complications [2].

hypoglycaemic events [14].

132 Diabetes Food Plan

intensive insulin therapy [16].

and reduce the risk of diabetes and its complications [4].

It is important to keep in mind that medications that improve blood glucose levels usually are associated with high risk of hypoglycaemia, which is the greatest barrier to achieve an optimal GC, particularly in T1DM. In people with T2DM a reduction in HbA1c levels after the consumption of low GI diets has been observed, whereas in children with T1DM, with both intensive multiple daily injection of insulin or insulin pump therapy, a reduction in postprandial glucose excursions, as well as improvements in insulin sensitivity after 3 to 4 weeks was demonstrated. However, a high GI diet worsens insulin resistance in individuals with and without diabetes and rises blood glucose levels and the need to medication in T2DM and the insulin requirements in T1DM. Therefore, the reduction of the risk of diabetes-related complications with low GI diets is similar to or greater than the diets including a high intake of fibre and whole grains [14].

A low GI diets favours slower and more gradual absorption of glucose from the gastrointestinal tract, avoiding hypoglycaemic episodes; moreover, it produces fewer stimuli for insulin release, reduces free fatty acids levels and oxidative stress, and increases insulin sensitivity [17].

According to the Canadian Diabetes Association, interventions replacing high GI carbohydrates with low GI carbohydrates in mixed meals have shown clinically significant improvements in GC over 2 weeks to 6 months in people with T1DM or T2DM; improvements were observed in cardiovascular risk factors, postprandial glycaemia and high sensitivity C-reactive protein over 1 year in people with T2DM, whereas adults and children with T1DM showed lower hypoglycaemic events over 24 to 52 weeks [20]. In addition, it has been shown that low GI diets sustain improved GC and HDL cholesterol compared with a high-cereal fibre diet over 6 months, and improved β-cell function in comparison with a low carbohydrate, high monounsaturated fat diet over 1 year in people with T2DM [20]. As it has been already mentioned, diets with lower GI result in improvements in HbA1c in the order of 0.5%. [19].

In contrast, a review carried out by Madsbad [49] in subjects with T1DM and T2DM showed different results. Dietary carbohydrate restriction as early therapy in T2DM, and as an adjunct to therapy in T1DM, effectively reduces blood glucose levels. However, longer-term studies (≥6 months) have variable results regarding the relative efficacy of low carbohydrate diets compared to low in fat or low GI diets on weight and HbA1c reductions. While recent metaanalyses suggest that low carbohydrate diets may be no more effective over the longer term than low fat or Low GI diets, in terms of weight and HbA1c changes [49].

It has been observed a reduction in the risk of diabetes with the consumption of low GI diet, whereas high dietary GI and/or glycaemic load increase the risk of T2DM [18]. Observational data suggest that replacing high GI with low GI carbohydrate reduces the risk of metabolic disturbances and T2DM. Nevertheless, some studies show inconclusive results that may be due to methodological differences and confounding parameters that can dramatically modify the post-meal metabolic response, such as the type of carbohydrate and its digestibility, quantity of carbohydrates as compared with other macronutrients, lipids, proteins and fibres [18].

Recent criticisms of the GI claim that GI methodology is not valid, and GI values are inaccurate and imprecise, and GI does not predict what foods are healthy and that whole grain and fibre are better markers of carbohydrate quality than GI. Eating a food as part of a mixed meal affects the glycaemic response, but does not alter the food's GI, because is an intrinsic characteristic of food. However, the glycaemic response of a food or a meal is altered in the presence of other foods depending on the amount and source (GI) of carbohydrate and the amounts and types of fat and protein added. Moreover, it is important to take into account that the relative glycaemic response of a meal is determined by its calculated meal GI and the amounts of available carbohydrates, fat and protein. Therefore, GI is a valid marker of carbohydrate quality because GI methodology is accurate and precise and GI is a property of the food, and is biologically meaningful and influences outcomes in health and disease, especially in the nutritional management of diabetes. Despite the fact that the results are inconclusive, there is no evidence to suggest any negative effect of following low GI diets, which are consistent with healthy eating recommendations aimed at weight control and reducing the risk of diabetesrelated complications by improving the GC in people with diabetes (**Table 2**) [14, 15, 17, 49].

**References Low GI diet T1DM** Rahelić, et al. [17] • Lower fasting glucose

Ryan, et al. [16] • Lower PPGE

Derdemezis, et al [4]; Dworatzek

Thomas, et al. [2]; Marsh et al. [14];

**References Low GI diet T2DM** Rahelić et al. [17] Lower fasting glucose

Thomas, et al. [10]; Marsh et al. [14] Increased insulin sensitivity

Dworatzek et al. [20] • Improvement in CV risk factors

Marsh et al. [14] Reduced postprandial hyperglycaemia

et al. [20]

Dworatzek et al. [20]

Thomas et al. [2]; IDF\*

[2]; Dworatzek et al. [20]

Dworatzek et al. [20]

Derdemezis, et al. [4]; Thomas, et al. [10]

Thomas, et al. [2]; Derdemezis, et al.

Thomas, et al. [10]; Marsh et al. [14];

• Reduction of oxidative stress

Improved glycaemic control

Lower hypoglycaemic events

• Increased insulin requirements • Increased postprandial glycaemia • Higher hypoglycaemic episodes

Reduction of oxidative stress

Improved glycaemic control

*levels)* and C-reactive protein

• Improved postprandial glycaemia

Significant weight loss in overweight/obese people

• Significant reduction in BMI, total fat mass and body mass

Improvement in lipid profiles *(total cholesterol, LDL-c and HDL-c* 

[19] Decrease of 0.5% in HbA1c levels

Thomas, et al. [10] • Reduction or avoidance of diabetic medication

• Lower peak blood glucose excursion

Influence of Glycaemic Control on Cognitive Function in Diabetic Children and Adolescents

http://dx.doi.org/10.5772/intechopen.75562

135

• Reduced time to reach baseline blood glucose levels

• Lower AUC

Thomas, et al. [2, 10] Acceptable/ Improved HbA1c levels

Marsh et al. [14]; Blaak et al. [18] Reduced postprandial hyperglycaemia

**High GI diet** Marsh et al. [14] • Rapid rise in blood glucose and insulin levels

It should be noted that a traditional Mediterranean-style dietary pattern improves GC and cardiovascular risk factors, including systolic blood pressure, total cholesterol, HDL cholesterol, the total cholesterol/HDL cholesterol ratio and triglycerides in T2DM. On the other hand, a low carbohydrate Mediterranean-style diet has shown reductions in HbA1c and delays on the need for antihyperglycaemic drug therapy at 4 years of diagnosis, compared with low fat diet in overweight individuals with newly diagnosed T2DM. To sum up, traditional and low carbohydrate Mediterranean-style diets are shown to reduce HbA1c and triglycerides, whereas only the low carbohydrate Mediterranean-style diet improves LDL cholesterol and HDL cholesterol at 1 year of diagnosis in overweight subjects with T2DM [14, 20].

It has been shown that a disrupted balance between oxidative stress and antioxidant cascades contributes to neuroplasticity deficits in experimental models of diabetes; therefore, antioxidants treatments may provide excellent adjunct treatments to traditional approaches to reduce the neurological complications of diabetes. In a review carried out by Reagan, the neuroplasticity deficits were attenuated or eliminated by antioxidants, including melatonin and vitamin E, lycopene, resveratrol, dehydroepiandrosterone (DHEA) and essential fatty acids. T2DM patients supplemented with vitamin E and with increasing serum lycopene levels showed reductions in oxidative stress parameters, whereas DHEA administration showed reductions in plasma oxidative stress measures and lipid peroxidation products and increased antioxidants in T2DM subjects [12].

It is essential to take into account that the nutritional management in children and adolescents is more complex than in adults, because they do not have autonomy or the necessary knowledge to maintain a good GC. In a recent study carried out in 282 T1DM children and adolescents, a greater nutrition knowledge of parents and patients, measured by a type 1 diabetes Nutrition Knowledge Survey (NKS), was associated with both better GC and higher diet quality in their children. Therefore, it is vital an early nutritional education and the role of parents in order to achieve good nutritional management and GC during childhood [48].


Recent criticisms of the GI claim that GI methodology is not valid, and GI values are inaccurate and imprecise, and GI does not predict what foods are healthy and that whole grain and fibre are better markers of carbohydrate quality than GI. Eating a food as part of a mixed meal affects the glycaemic response, but does not alter the food's GI, because is an intrinsic characteristic of food. However, the glycaemic response of a food or a meal is altered in the presence of other foods depending on the amount and source (GI) of carbohydrate and the amounts and types of fat and protein added. Moreover, it is important to take into account that the relative glycaemic response of a meal is determined by its calculated meal GI and the amounts of available carbohydrates, fat and protein. Therefore, GI is a valid marker of carbohydrate quality because GI methodology is accurate and precise and GI is a property of the food, and is biologically meaningful and influences outcomes in health and disease, especially in the nutritional management of diabetes. Despite the fact that the results are inconclusive, there is no evidence to suggest any negative effect of following low GI diets, which are consistent with healthy eating recommendations aimed at weight control and reducing the risk of diabetesrelated complications by improving the GC in people with diabetes (**Table 2**) [14, 15, 17, 49]. It should be noted that a traditional Mediterranean-style dietary pattern improves GC and cardiovascular risk factors, including systolic blood pressure, total cholesterol, HDL cholesterol, the total cholesterol/HDL cholesterol ratio and triglycerides in T2DM. On the other hand, a low carbohydrate Mediterranean-style diet has shown reductions in HbA1c and delays on the need for antihyperglycaemic drug therapy at 4 years of diagnosis, compared with low fat diet in overweight individuals with newly diagnosed T2DM. To sum up, traditional and low carbohydrate Mediterranean-style diets are shown to reduce HbA1c and triglycerides, whereas only the low carbohydrate Mediterranean-style diet improves LDL cholesterol and

HDL cholesterol at 1 year of diagnosis in overweight subjects with T2DM [14, 20].

antioxidants in T2DM subjects [12].

134 Diabetes Food Plan

It has been shown that a disrupted balance between oxidative stress and antioxidant cascades contributes to neuroplasticity deficits in experimental models of diabetes; therefore, antioxidants treatments may provide excellent adjunct treatments to traditional approaches to reduce the neurological complications of diabetes. In a review carried out by Reagan, the neuroplasticity deficits were attenuated or eliminated by antioxidants, including melatonin and vitamin E, lycopene, resveratrol, dehydroepiandrosterone (DHEA) and essential fatty acids. T2DM patients supplemented with vitamin E and with increasing serum lycopene levels showed reductions in oxidative stress parameters, whereas DHEA administration showed reductions in plasma oxidative stress measures and lipid peroxidation products and increased

It is essential to take into account that the nutritional management in children and adolescents is more complex than in adults, because they do not have autonomy or the necessary knowledge to maintain a good GC. In a recent study carried out in 282 T1DM children and adolescents, a greater nutrition knowledge of parents and patients, measured by a type 1 diabetes Nutrition Knowledge Survey (NKS), was associated with both better GC and higher diet quality in their children. Therefore, it is vital an early nutritional education and the role of parents in order to achieve good nutritional management and GC during childhood [48].


strategy for GC, low GI diets are high in fibre and whole-grain products, rich in legumes, fruits and vegetables with balanced fat profile, low saturated fats and high monounsaturated fatty acids (MUFAs) and polyunsaturated fatty acids (PUFAs). Therefore, this nutritional intervention may have beneficial effects in diabetics and populations at risk, such as children with T1DM [4, 14]. Antioxidant treatments or diets rich in antioxidants may reduce the diabetes-related neurological complications, when they are used together with traditional treatments [12]. Given that there is no optimal diet for the management of GC in subjects with T1DM and T2DM, it would be interesting to study the effects of a low GI diet based in a traditional Mediterraneandiet pattern (rich in vegetables and fruits, high content in antioxidants and fibre), that had demonstrated to improve the GC in these subjects, to evaluate the power for preventing cog-

Influence of Glycaemic Control on Cognitive Function in Diabetic Children and Adolescents

http://dx.doi.org/10.5772/intechopen.75562

137

nitive dysfunctions and to optimise the neurodevelopment in children and youth.

hyperglycaemic episodes [44].

disorders and mental health.

**6. Conclusions**

It is vital to perform more long-term studies in children and adolescents, especially in those with T2DM, due to the increased prevalence in this population, considering the scarce evidence for optimal management of children with T2DM [43]. On the other hand, it is essential to develop lifestyle interventions in population at risk during childhood and adolescence (individualised nutritional and exercise programmes), focused on investigating how to prevent the development of glucose tolerance impairment, and diabetes. These interventions could protect against cognitive decline, because they help to achieve GC, reducing hypo and

Furthermore, the clinical follow-up of T1DM children must include also a survey of neuro-

Further research is needed in diabetic children and adolescents, especially well-designed long-term randomised controlled trials with larger sample size to determine the true value of low GI diets on overall quality of life, long-term GC and the prevention or management of diabetes-related complications. The results obtained up to the present moment are inconclusive due to discrepancies between the methods of analysis and the diversity in the methodology employed. Therefore, it is difficult to generalise results. It is necessary the use of validated questionnaires for the dietary assessment and standardised the GI databases in order to make the data comparable between different studies. One limitation of all observational studies published to date is that none of the food frequency questionnaires have been specifically designed to assess the GI and until recently, few were validated against another method of dietary assessment, such as 24 h recalls or diet records. Therefore, these questionnaires have poor ability to estimate carbohydrate intake, calling into question the accuracy of any GI or glycaemic load estimation [14]. On the other hand, the studies use different cognitive tests to assess cognitive domains. Therefore, it is difficult to compare results between studies. Brain imaging is becoming essential to clarify the effects of diabetes on brain development, and it will offer us new perspectives for the prevention of neurological

psychological and brain development to prevent long-lasting consequences.

Area under the blood glucose response curve, AUC; body mass index, BMI; cardiovascular, CV; glycated haemoglobin A1c, HbA1c; high density lipoprotein cholesterol, HDL-c; low density lipoprotein cholesterol, LDL-c; postprandial glucose excursion, PPGE; type 1 diabetes mellitus, T1DM; type 2 diabetes mellitus, T2DM\* International Diabetes Federation.

**Table 2.** Main effects of low and high glycaemic index diets on the nutritional management of diabetes in children and adolescents.

The previous nutritional recommendations are aimed to achieve a good GC and nutritional management in the long-term; nonetheless, it is necessary to address the acute dietary complications, meaning the management of hypoglycaemia, because it is the most common acute complication of the treatment of T1DM. In case of hypoglycaemia (<60–70 mg/dl) it is necessary an immediate oral, rapidly absorbed, simple carbohydrate to raise blood glucose up to 100 mg/dl [39].

Finally, the exercise is indispensable in the management of diabetes, especially in T2DM children and adolescents, due to this pathology is commonly associated with obesity. The American Academy of Paediatrics recommends that health care professionals encourage children and adolescents with T2DM to practice moderate to vigorous exercise for at least 60 minutes daily and to limit non-academic '*screen time*', such as watching television or playing computer games, to less than 2 hours per day for the reduction of BMI and the improvement of GC. Physical activity is an integral part of weight management for the prevention and treatment of T2DM. Although there is scarce available data from children and adolescents with T2DM, several well-controlled studies performed in obese children and adolescents at risk of metabolic syndrome and T2DM provide guidelines for physical activity [43].
