Comment on ‘Risk Predictors of Glycaemic Control in Children and Adolescents With Type 1 Diabetes: A Systematic Review and Meta‐Analysis’

The incidence of diabetes mellitus (especially type 1 diabetes mellitus, T1DM) continues to rise in children and adolescents, making it a global public health challenge. Early onset of T1DM and chronic high blood glucose levels can lead to multiple organ damage and serious complications such as diabetic nephropathy and retinopathy. Although effective glycaemic control has been shown to reduce the risk of these complications, glycaemic control in children and adolescents is currently suboptimal (Habteyohans et al. 2023). Many studies have examined the risk factors that influence glycaemic control (Alassaf et al. 2022); however, the results of existing studies are often inconsistent due to differences in region, study size and study design. Therefore, it is important to systematically evaluate these risk factors to inform the development of interventions. A recent systematic review published in the Journal of Clinical Nursing provided a comprehensive examination of risk predictors of glycaemic control in children and adolescents with T1DM (Gangqiang, Hua, and Hongyu 2024). Although this study provides valuable insights into the factors that influence glycaemic control, a number of methodological and interpretive limitations may affect the strength and generalizability of its findings. First, the authors chose the Newcastle–Ottawa Scale to assess the quality of the included studies. However, this tool has limited control over selection bias, particularly with respect to the diversity and representativeness of the included population. Meanwhile, the scale has only one item to assess whether studies adequately control for confounders and does not explicitly require or refine control for specific confounders. In addition, different raters may interpret the 'comparability' item differently, which may lead to less consistent scoring. Therefore, we recommend the use of more disaggregated scoring systems, such as the Downs and Black tool, to assess the methodological quality of nonrandomised trials (Downs and Black 1998). Second, the pooled results in this paper are highly heterogeneous due to the variability between studies and the high risk of bias in some of the included studies. Although the authors explain some of the possible sources of heterogeneity at the end, the conclusions drawn from the highly heterogeneous results may still be difficult to convince the general reader. Although some of the pooled results in the paper show positive results, the random effects model they use relies on the number of instantaneous estimates to represent the degree of deviation between the true values of the study to obtain conservative pooled results (Stang 2010). Therefore, we suggest replacing the random effects model with a model more appropriate for highly heterogeneous results—the inverse variance heterogeneity model—to validate the true effect sizes. Third, the study failed to provide an assessment of the level of evidence for the outcome indicators, which is a significant shortcoming. Although the study analysed several important outcome indicators, such as glycated haemoglobin levels, hypoglycaemic events and diabetic ketoacidosis, it failed to provide a hierarchical assessment of the strength of evidence for these outcomes. This lack of hierarchical classification of evidence may make it impossible for readers to accurately assess the credibility of the conclusions, which in turn affects the reliability of the clinical application. For clinicians whose decisions are based on high-quality evidence, this deficiency may result in some conclusions based on weak evidence being inappropriately applied to actual treatment. Despite these shortcomings, the authors provide a comprehensive summary and analysis of the existing literature through a systematic review approach, especially in the Chinese child and adolescent T1DM population, making the findings more regionally representative. The study not only validated the internationally known influences on glycaemic control but also highlighted many specific risk factors associated with glycaemic management, such as family structure and economic status. Meanwhile, the study calls for more high-quality randomised controlled trials targeting these risk factors in future, as well as the optimization of existing intervention models to provide more precise and robust evidence to support clinical practice. The authors have nothing to report. The authors declare no conflicts of interest. The data sets used and/or analysed during this study are available from the corresponding author upon reasonable request.