type 1 diabetes research uk

Current Research

Find out more about taking part in one of our studies

Find out more about taking part in an intervention treatment trial where you may receive a new treatment being tested for T1D. We also have information on monitoring trials where data is collected but there is no intervention/treatment and also information on screening for T1D. Screening studies are also available which can identify people who may be at risk of developing T1D

Treatment Trials

Paused to recruitment until mid 2025

A 12-month, randomized, single-blind, placebo-controlled exposure- response study of TCD601 (siplizumab) in new onset type 1 diabetes patients (STRIDE)

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Monitoring Studies

Would you like to be involved in studies where you have more monitoring, so that researchers can find out more about type 1 diabetes?

A research project for children and adults aged 1 or older and newly diagnosed with type 1 diabetes (within the last 6 months), to collect information about their diabetes, and inform them about other opportunities to take part in type 1 diabetes research. Siblings can help too.

Type 1 diabetes risk in adults (T1DRA)

Research Study screening for risk of type 1 diabetes in adults aged 18-70 years.

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INNODIA – People at Increased Risk

A study to identify people who are at increased risk of developing T1D and monitor them for two years to see who progresses to T1D.

The ELSA Study is screening children aged from 3-13 years to determine their risk of developing type 1 diabetes.

Closed Trials

Ver-A-T1D Study

Recruitment closed

A randomised, double-blind, placebo controlled, parallel group, multi-centre trial in adult subjects with newly diagnosed type 1 diabetes mellitus investigating the effect of Verapamil SR on preservation of beta-cell function (Ver-A-T1D)

EXTOD-Immune

EXTOD Immune

Can a remotely monitored, home-based exercise intervention for individuals with type-one diabetes reduce immune driven disease activity? (EXTOD-Immune)

MELD-ATG Trial

Trial of a new medication in people with 1 diabetes aged 5-25. Screening visit to be conducted within 9 weeks of diagnosis.

IMPACT Study

Trial of a new medication in people with 1 diabetes aged 18-44. Screening visit to be conducted within 9 weeks of diagnosis.

CFZ533X2207 Trial

Study of safety and efficacy of CFZ533 in children and young adults with new onset type 1 diabetes.

Remote study investigating the progression of Type 1 diabetes in adults (18 years and over) within 120 days of diagnosis and insulin treated.

A project throughout Europe which collects blood samples and data from newly diagnosed patients between 1 and 45 years who have been diagnosed with type 1 diabetes within the previous 6 weeks and their first degree relatives (brothers, sisters, parents or children).

PROTECT Study

The PROTECT Study is testing how well an investigational medicine works in children and adolescents with Type 1 diabetes (T1D).

Interleukin-2 Therapy of Autoimmunity in Diabetes (ITAD)

ITAD is a multicentre, randomised, double-blind, placebo-controlled clinical trial of to see if a drug called aldesleukin, can preserve insulin production in children and young adults recently diagnosed with type 1 diabetes.

Ustekinumab in adolescents with new onset type 1 diabetes

Trial of a new medication in 12-18 year olds with Type 1 diabetes within 100 days of diagnosis

Research study for people with Type 1 Diabetes: EXALT

The main purpose of this study is to assess the safety of three different doses of an investigational drug in patients who have been recently diagnosed with type 1 diabetes.

The Effect of Abatacept on the Immune System in Type 1 Diabetes

This study aims to gain a better understanding of the immune processes that lead to the destruction of insulin producing beta cells.

The Effect of Anti-IL-21 and Liraglutide in Newly Diagnosed Type 1 Diabetes

This study will investigate if a new drug Anti-IL-21 when given together with another drug marketed for type 2 diabetes called liraglutide can preserve the beta cells in subjects diagnosed with type 1 diabetes.

Diabetes research would not be possible without the support of people with diabetes.

Moving towards insulin-free T1D

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King's College London

Type 1 diabetes research group.

We are experimental medicine researchers and clinical academics performing mechanistic and clinical studies, using qualitative, quantitative and neuroimaging techniques, and clinical trials to investigate aspects of diabetes, including mechanisms and treatment of hypoglycaemia, eating disorders and appetite control.

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UCL researchers awarded £1m to investigate new treatment for type 1 diabetes

17 December 2023

Scientists at the UCL Institute of Immunity & Transplantation (IIT) are part of a team to receive £997,000 from the Type 1 Diabetes Grand Challenge, a new partnership involving The Steve Morgan Foundation, Diabetes UK and JDRF.

Previous research led by Professor Lucy Walker (UCL IIT) found that an existing immunotherapy called Abatacept could be made to work better by combining it with low-dose interleukin-2 (IL-2). The combined therapy suppressed disease-causing immune cells, but spared cells with regulatory function and could inhibit autoimmune diabetes in a mouse model.

The new research will study the effects of this combination therapy in people for the first time to assess whether it has the same benefits as it does in mice. The clinical work will be led by Dr Danijela Tatovic at Cardiff University, with the analysis of how the therapy affects the immune system led by Professor Walker. Within the UCL team, Dr Andreas Mayer will use mathematical modelling to understand in detail how different immune cells are impacted by treatment.

People with type 1 diabetes will be recruited from the Royal Free Hospital and University Hospital Wales to participate in the study.

Professor Walker said: “We are thrilled to have the opportunity to take our research findings to the next stage and explore how this therapy works in people. Our aim is to alter the immune response so that it no longer damages the insulin-producing cells in the pancreas. This could be used to inhibit type 1 diabetes in those recently diagnosed, by tackling the root cause of the disease rather than just treating the symptoms.”

If the results of the research are positive, this could pave the way for a clinical trial to test this approach in people with type 1 diabetes. The therapy has the potential to prevent the disease occurring or reverse the onset in people recently diagnosed who still have some insulin-producing beta cells.

Dr Elizabeth Robertson, Director of Research at Diabetes UK, said: “We’re in a hugely exciting period for the Type 1 Diabetes Grand Challenge, as today we welcome six exceptional scientists who will lead exciting multi-disciplinary teams to drive forward this pioneering initiative and build momentum towards our ambitious goal.

“This announcement brings with it fresh hope of a cure for everyone living with type 1 diabetes, and we look forward to seeing how these projects will break new ground in our search for life-changing beta cell therapies and treatments to overcome the type 1 immune system attack.”

More information on the six new research projects selected for the Type 1 Diabetes Grand Challenge is available here .

• Professor Lucy Walker's academic profile
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E: m.midgley [at] ucl.ac.uk

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New advances in type 1 diabetes

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This article has a correction. Please see:

• New advances in type 1 diabetes - June 03, 2024
• Savitha Subramanian , professor of medicine ,
• Farah Khan , clinical associate professor of medicine ,
• Irl B Hirsch , professor of medicine
• University of Washington Diabetes Institute, Division of Metabolism, Endocrinology and Nutrition, University of Washington, Seattle, WA, USA
• Correspondence to: I B Hirsch ihirsch{at}uw.edu

Type 1 diabetes is an autoimmune condition resulting in insulin deficiency and eventual loss of pancreatic β cell function requiring lifelong insulin therapy. Since the discovery of insulin more than 100 years ago, vast advances in treatments have improved care for many people with type 1 diabetes. Ongoing research on the genetics and immunology of type 1 diabetes and on interventions to modify disease course and preserve β cell function have expanded our broad understanding of this condition. Biomarkers of type 1 diabetes are detectable months to years before development of overt disease, and three stages of diabetes are now recognized. The advent of continuous glucose monitoring and the newer automated insulin delivery systems have changed the landscape of type 1 diabetes management and are associated with improved glycated hemoglobin and decreased hypoglycemia. Adjunctive therapies such as sodium glucose cotransporter-1 inhibitors and glucagon-like peptide 1 receptor agonists may find use in management in the future. Despite these rapid advances in the field, people living in under-resourced parts of the world struggle to obtain necessities such as insulin, syringes, and blood glucose monitoring essential for managing this condition. This review covers recent developments in diagnosis and treatment and future directions in the broad field of type 1 diabetes.

Introduction

Type 1 diabetes is an autoimmune condition that occurs as a result of destruction of the insulin producing β cells of the pancreatic islets, usually leading to severe endogenous insulin deficiency. 1 Without treatment, diabetic ketoacidosis will develop and eventually death will follow; thus, lifelong insulin therapy is needed for survival. Type 1 diabetes represents 5-10% of all diabetes, and diagnosis classically occurs in children but can also occur in adulthood. The burden of type 1 diabetes is expansive; it can result in long term complications, decreased life expectancy, and reduced quality of life and can add significant financial burden. Despite vast improvements in insulin, insulin delivery, and glucose monitoring technology, a large proportion of people with type 1 diabetes do not achieve glycemic goals. The massive burden of type 1 diabetes for patients and their families needs to be appreciated. The calculation and timing of prandial insulin dosing, often from food with unknown carbohydrate content, appropriate food and insulin dosing when exercising, and cost of therapy are all major challenges. The psychological realities of both acute management and the prospect of chronic complications add to the burden. Education programs and consistent surveillance for “diabetes burnout” are ideally available to everyone with type 1 diabetes.

In this review, we discuss recent developments in the rapidly changing landscape of type 1 diabetes and highlight aspects of current epidemiology and advances in diagnosis, technology, and management. We do not cover the breadth of complications of diabetes or certain unique scenarios including psychosocial aspects of type 1 diabetes management, management aspects specific to older adults, and β cell replacement therapies. Our review is intended for the clinical reader, including general internists, family practitioners, and endocrinologists, but we acknowledge the critical role that people living with type 1 diabetes and their families play in the ongoing efforts to understand this lifelong condition.

Sources and selection criteria

We did individual searches for studies on PubMed by using terms relevant to the specific topics covered in this review pertaining to type 1 diabetes. Search terms used included “type 1 diabetes” and each individual topic—diagnosis, autoantibodies, adjuvant therapies, continuous glucose monitoring, automated insulin delivery, immunotherapies, diabetic ketoacidosis, hypoglycemia, and under-resourced settings. We considered all studies published in the English language between 1 January 2001 and 31 January 2023. We selected publications outside of this timeline on the basis of relevance to each topic. We also supplemented our search strategy by a hand search of the references of key articles. We prioritized studies on each highlighted topic according to the level of evidence (randomized controlled trials (RCTs), systematic reviews and meta-analyses, consensus statements, and high quality observational studies), study size (we prioritized studies with at least 50 participants when available), and time of publication (we prioritized studies published since 2003 except for the landmark Diabetes Control and Complications Trial and a historical paper by Tuomi on diabetes autoantibodies, both from 1993). For topics on which evidence from RCTs was unavailable, we included other study types of the highest level of evidence available. To cover all important clinical aspects of the broad array of topics covered in this review, we included additional publications such as clinical reviews as appropriate on the basis of clinical relevance to both patients and clinicians in our opinion.

Epidemiology

The incidence of type 1 diabetes is rising worldwide, possibly owing to epigenetic and environmental factors. Globally in 2020 an estimated 8.7 million people were living with type 1 diabetes, of whom approximately 1.5 million were under 20 years of age. 2 This number is expected to rise to more than 17 million by 2040 ( https://www.t1dindex.org/#global ). The International Diabetes Federation estimates the global prevalence of type 1 diabetes at 0.1%, and this is likely an underestimation as diagnoses of type 1 diabetes in adults are often not accounted for. The incidence of adult onset type 1 diabetes is higher in Europe, especially in Nordic countries, and lowest in Asian countries. 3 Adult onset type 1 diabetes is also more prevalent in men than in women. An increase in prevalence in people under 20 years of age has been observed in several western cohorts including the US, 4 5 Netherlands, 6 Canada, 7 Hungary, 8 and Germany. 9

Classically, type 1 diabetes presents over the course of days or weeks in children and adolescents with polyuria, polydipsia, and weight loss due to glycosuria. The diagnosis is usually straightforward, with profound hyperglycemia (often >300 mg/dL) usually with ketonuria with or without ketoacidemia. Usually, more than one autoantibody is present at diagnosis ( table 1 ). 10 The number of islet autoantibodies combined with parameters of glucose tolerance now forms the basis of risk prediction for type 1 diabetes, with stage 3 being clinical disease ( fig 1 ). 11 The originally discovered autoantibody, islet cell antibody, is no longer used clinically owing to variability of the assay despite standardisation. 12

Autoantibody characteristics associated with increased risk of type 1 diabetes 10

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Natural history of type 1 diabetes. Adapted with permission from Insel RA, et al. Diabetes Care 2015;38:1964-74 11

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Half of all new cases of type 1 diabetes are now recognized as occurring in adults. 13 Misclassification due to misdiagnosis (commonly as type 2 diabetes) occurs in nearly 40% of people. 14 As opposed to typical childhood onset type 1 diabetes, progression to severe insulin deficiency, and therefore its clinical presentation in adults, is variable. The term latent autoimmune diabetes of adults (LADA) was introduced 30 years ago to identify adults who developed immune mediated diabetes. 15 An international consensus defined the diagnostic criteria for LADA as age >30 years, lack of need for insulin use for at least six months, and presence of islet cell autoantibodies. 16 However, debate as to whether the term LADA should even be used as a diagnostic term persists. The American Diabetes Association (ADA) Standards of Care note that for the purpose of classification, all forms of diabetes mediated by autoimmune β cell destruction are included in the classification of type 1 diabetes. 17 Nevertheless, they note that use of the term LADA is acceptable owing to the practical effect of heightening awareness of adults likely to have progressive autoimmune β cell destruction and thereby accelerating insulin initiation by clinicians to prevent diabetic ketoacidosis.

The investigation of adults with suspected type 1 diabetes is not always straightforward ( fig 2 ). 18 Islet cell autoantibodies such as glutamic acid decarboxylase antibody (GADA), tyrosine phosphatase IA2 antibody, and zinc transporter isoform 8 autoantibody act as markers of immune activity and can be detected in the blood with standardized assays ( table 1 ). The presence of one or more antibodies in adults with diabetes could mark the progression to severe insulin deficiency; these individuals should be considered to have type 1 diabetes. 1 Autoantibodies, especially GADA, should be measured only in people with clinically suspected type 1 diabetes, as low concentrations of GADA can be seen in type 2 diabetes and thus false positive measurements are a concern. 19 That 5-10% of cases of type 1 diabetes may occur without diabetes autoantibodies is also now clear, 20 and that the diabetes autoantibodies disappear over time is also well appreciated. 21

Flowchart for investigation of suspected type 1 diabetes in adults, based on data from white European populations. No single clinical feature in isolation confirms type 1 diabetes. The most discriminative feature is younger age at diagnosis (<35 years), with lower body mass index (<25), unintentional weight loss, ketoacidosis, and glucose >360 mg/dL at presentation. Adapted with permission from Holt RIG, et al. Diabetes Care 2021;44:2589-625 1

Genetic risk scoring (GRS) for type 1 diabetes has received attention to differentiate people whose classification is unclear. 22 23 24 Developed in 2019, the T1D-GRS2 uses 67 single nucleotide polymorphisms from known autoimmune loci and can predict type 1 diabetes in children of European and African ancestry. Although GRS is not available for routine clinical use, it may allow prediction of future cases of type 1 diabetes to allow prevention strategies with immune intervention (see below).

A major change in the type 1 diabetes phenotype has occurred over the past few decades, with an increase in obesity; the reasons for this are complex. In the general population, including people with type 1 diabetes, an epidemic of sedentary lifestyles and the “westernized diet” consisting of increased processed foods, refined sugars, and saturated fat is occurring. In people with type 1 diabetes, the overall improvement in glycemic control since the report of the Diabetes Control and Complications Trial (DCCT) in 1993 (when one or two insulin injections a day was standard therapy) has resulted in less glycosuria so that the typical patient with lower body weight is uncommon in high income countries. In the US T1D Exchange, more than two thirds of the adult population were overweight or obese. 25

Similarly, obesity in young people with type 1 diabetes has also increased over the decades. 26 The combination of autoimmune insulin deficiency with obesity and insulin resistance has received several descriptive names over the years, with this phenotype being described as double diabetes and hybrid diabetes, among others, 26 27 but no formal nomenclature in the diabetes classification exists. Many of these patients have family members with type 2 diabetes, and some patients probably do have both types of diabetes. Clinically, minimal research has been done into how this specific population responds to certain antihyperglycemic oral agents, such as glucagon-like peptide 1 (GLP-1) receptor agonists, given the glycemic, weight loss, and cardiovascular benefits seen with these agents. 28 These patients are common in most adult diabetes practices, and weight management in the presence of insulin resistance and insulin deficiency remains unclear.

Advances in monitoring

The introduction of home blood glucose monitoring (BGM) more than 45 years ago was met with much skepticism until the report of the DCCT. 29 Since then, home BGM has improved in accuracy, precision, and ease of use. 30 Today, in many parts of the world, home BGM, a static measurement of blood glucose, has been replaced by continuous glucose monitoring (CGM), a dynamic view of glycemia. CGM is superior to home BGM for glycemic control, as confirmed in a meta-analysis of 21 studies and 2149 participants with type 1 diabetes in which CGM use significantly decreased glycated hemoglobin (HbA 1c ) concentrations compared with BGM (mean difference −0.23%, 95% confidence interval −3.83 to −1.08; P<0.001), with a greater benefit if baseline HbA 1c was >8% (mean difference −0.43%, −6.04 to −3.30; P<0.001). 31 This newer technology has also evolved into a critical component of automated insulin delivery. 32

CGM is the standard for glucose monitoring for most adults with type 1 diabetes. 1 This technology uses interstitial fluid glucose concentrations to estimate blood glucose. Two types of CGM are available. The first type, called “real time CGM”, provides a continuous stream of glucose data to a receiver, mobile application, smartwatch, or pump. The second type, “intermittently scanned CGM,” needs to be scanned by a reader device or smartphone. Both of these technologies have shown improvements in HbA 1c and amount of time spent in the hypoglycemic range compared with home BGM when used in conjunction with multiple daily injections or “open loop” insulin pump therapy. 33 34 Real time CGM has also been shown to reduce hypoglycemic burden in older adults with type 1 diabetes ( table 2 ). 36 Alerts that predict or alarm with both hypoglycemia and hyperglycemia can be customized for the patient’s situation (for example, a person with unawareness of hypoglycemia would have an alert at a higher glucose concentration). Family members can also remotely monitor glycemia and be alerted when appropriate. The accuracy of these devices has improved since their introduction in 2006, so that currently available sensors can be used without a confirmation glucose concentration to make a treatment decision with insulin. However, some situations require home BGM, especially when concerns exist that the CGM does not match symptoms of hypoglycemia.

Summary of trials for each topic covered

Analysis of CGM reports retrospectively can assist therapeutic decision making both for the provider and the patient. Importantly, assessing the retrospective reports and watching the CGM in real time together offer insight to the patient with regard to insulin dosing, food choices, and exercise. Patients should be encouraged to assess their data on a regular basis to better understand their diabetes self-management. Table 3 shows standard metrics and targets for CGM data. 52 Figure 3 shows an ambulatory glucose profile.

Standardized continuous glucose monitoring metrics for adults with diabetes 52

Example of ambulatory glucose profile of 52 year old woman with type 1 diabetes and fear of hypoglycemia. CGM=continuous glucose monitoring; GMI=glucose management indicator

Improvements in technology and evidence for CGM resulting in international recommendations for its widespread use have resulted in greater uptake by people with type 1 diabetes across the globe where available and accessible. Despite this, not everyone wishes to use it; some people find wearing any device too intrusive, and for many the cost is prohibitive. These people need at the very least before meal and bedtime home BGM.

A next generation implantable CGM device (Sensionics), with an improved calibration algorithm that lasts 180 days after insertion by a healthcare professional, is available in both the EU and US. Although fingerstick glucose calibration is needed, the accuracy is comparable to that of other available devices. 53

Advances in treatments

The discovery of insulin in 1921, resulting in a Nobel Prize, was considered one of the greatest scientific achievements of the 20th century. The development of purified animal insulins in the late 1970s, followed by human insulin in the early 1980s, resulted in dramatic reductions in allergic reactions and lipoatrophy. Introduction of the first generation of insulin analogs, insulin lispro in the mid-1990s followed by insulin glargine in the early 2000s, was an important advance for the treatment of type 1 diabetes. 54 We review the next generation of insulin analogs here. Table 4 provides details on available insulins.

Pharmacokinetics of commonly used insulin preparations

Ultra-long acting basal insulins

Insulin degludec was developed with the intention of improving the duration of action and achieving a flatter profile compared with the original long acting insulin analogs, insulin glargine and insulin detemir. Its duration of action of 42 hours at steady state means that the profile is generally flat without significant day-to-day variability, resulting in less hypoglycemia compared with U-100 glargine. 39 55

When U-100 insulin glargine is concentrated threefold, its action is prolonged. 56 U-300 glargine has a different kinetic profile and is delivered in one third of the volume of U-100 glargine, with longer and flatter effects. The smaller volume of U-300 glargine results in slower and more gradual release of insulin monomers owing to reduced surface area in the subcutaneous space. 57 U-300 glargine also results in lesser hypoglycemia compared with U-100 glargine. 58

Ultra-rapid acting prandial insulins

Rapid acting insulin analogs include insulin lispro, aspart, and glulisine. With availability of insulin lispro, the hope was for a prandial insulin that better matched food absorption. However, these newer insulins are too slow to control the glucose spike seen with ingestion of a high carbohydrate load, leading to the development of insulins with even faster onset of action.

The first available ultra-rapid prandial insulin was fast acting insulin aspart. This insulin has an onset of appearance approximately twice as fast (~5 min earlier) as insulin aspart, whereas dose-concentration and dose-response relations are comparable between the two insulins ( table 4 ). 59 In adults with type 1 diabetes, mealtime and post-meal fast acting aspart led to non-inferior glycemic control compared with mealtime aspart, in combination with basal insulin. 60 Mean HbA 1c was 7.3%, 7.3%, and 7.4% in the mealtime faster aspart, mealtime aspart, and post‐meal faster aspart arms, respectively (P<0.001 for non-inferiority).

Insulin lispro-aabc is the second ultra-rapid prandial insulin. In early kinetic studies, insulin lispro-aabc appeared in the serum five minutes faster with 6.4-fold greater exposure in the first 15 minutes compared with insulin lispro. 61 The duration of exposure of the insulin concentrations in this study was 51 minutes faster with lispro-aabc. Overall insulin exposure was similar between the two groups. Clinically, lispro-aabc is non-inferior to insulin lispro, but postprandial hyperglycemia is lower with the faster acting analog. 62 Lispro-aabc given at mealtime resulted in greater improvement in post-prandial glucose (two hour post-prandial glucose −31.1 mg/dL, 95% confidence interval −41.0 to −21.2; P<0.001).

Both ultra-rapid acting insulins can be used in insulin pumps. Lispro-aabc tends to have more insertion site reactions than insulin lispro. 63 A meta-analysis including nine studies and 1156 participants reported increased infusion set changes on rapid acting insulin analogs (odds ratio 1.60, 95% confidence interval 1.26 to 2.03). 64

Pulmonary inhaled insulin

The quickest acting insulin is pulmonary inhaled insulin, with an onset of action of 12 minutes and a duration of 1.5-3 hours. 65 When used with postprandial supplemental dosing, glucose control is improved without an increase in hypoglycemia. 66

Insulin delivery systems

Approved automated insulin delivery systems.

CGM systems and insulin pumps have shown improvement in glycemic control and decreased risk of severe hypoglycemia compared with use of self-monitoring of blood glucose and multiple daily insulin injections in type 1 diabetes. 67 68 69 Using CGM and insulin pump together (referred to as sensor augmented pump therapy) only modestly improves HbA 1c in patients who have high sensor wear time, 70 71 but the management burden of diabetes does not decrease as frequent user input is necessary. Thus emerged the concept of glucose responsive automated insulin delivery (AID), in which data from CGM can inform and allow adjustment of insulin delivery.

In the past decade, exponential improvements in CGM technologies and refined insulin dosing pump algorithms have led to the development of AID systems that allow for minimization of insulin delivery burden. The early AID systems reduced hypoglycemia risk by automatically suspending insulin delivery when glucose concentrations dropped to below a pre-specified threshold but did not account for high glucose concentrations. More complex algorithms adjusting insulin delivery up and down automatically in response to real time sensor glucose concentrations now allow close replication of normal endocrine pancreatic physiology.

AID systems (also called closed loop or artificial pancreas systems) include three components—an insulin pump that continuously delivers rapid acting insulin, a continuous glucose sensor that measures interstitial fluid glucose at frequent intervals, and a control algorithm that continuously adjusts insulin delivery that resides in the insulin pump or a smartphone application or handheld device ( fig 4 ). All AID systems that are available today are referred to as “hybrid” closed loop (HCL) systems, as users are required to manually enter prandial insulin boluses and signal exercise, but insulin delivery is automated at night time and between meals. AID systems, regardless of the type used, have shown benefit in glycemic control and cost effectiveness, improve quality of life by improving sleep quality, and decrease anxiety and diabetes burden in adults and children. 72 73 74 Limitations to today’s HCL systems are primarily related to pharmacokinetics and pharmacodynamics of available analog insulins and accuracy of CGM in extremes of blood glucose values. The iLet bionic pancreas, cleared by the US Food and Drug Administration (FDA) in May 2023, is an AID system that determines all therapeutic insulin doses for an individual on the basis of body weight, eliminating the need for calculation of basal rates, insulin to carbohydrate ratios, blood glucose corrections, and bolus dose. The control algorithms adapt continuously and autonomously to the individual’s insulin needs. 38 Table 5 lists available AID systems.

Schematic of closed loop insulin pump technology. The continuous glucose monitor senses interstitial glucose concentrations and sends the information via Bluetooth to a control algorithm hosted on an insulin pump (or smartphone). The algorithm calculates the amount of insulin required, and the insulin pump delivers rapid acting insulin subcutaneously

Comparison of commercially available hybrid closed loop systems 75

Unapproved systems

Do-it-yourself (DIY) closed loop systems—DIY open artificial pancreas systems—have been developed by people with type 1 diabetes with the goal of self-adjusting insulin by modifying their individually owned devices. 76 These systems are built by the individual using an open source code widely available to anyone with compatible medical devices who is willing and able to build their own system. DIY systems are used by several thousand people across the globe but are not approved by regulatory bodies; they are patient-driven and considered “off-label” use of technology with the patient assuming full responsibility for their use. Clinicians caring for these patients should ensure basic diabetes skills, including pump site maintenance, a knowledge of how the chosen system works, and knowing when to switch to “manual mode” for patients using an artificial pancreas system of any kind. 76 The small body of studies on DIY looping suggests improvement in HbA 1c , increased time in range, decreased hypoglycemia and glucose variability, improvement in night time blood glucose concentrations, and reduced mental burden of diabetes management. 77 78 79 Although actively prescribing or initiating these options is not recommended, these patients should be supported by clinical teams; insulin prescription should not be withheld, and, if initiated by the patient, unregulated DIY options should be openly discussed to ensure open and transparent relationships. 78

In January 2023, the US FDA cleared the Tidepool Loop app, a DIY AID system. This software will connect the CGM, insulin pump, and Loop algorithm, but no RCTs using this method are available.

β cell replacement therapies

For patients with type 1 diabetes who meet specific clinical criteria, β cell replacement therapy using whole pancreas or pancreatic islet transplantation can be considered. Benefits of transplantation include immediate cessation of insulin therapy, attainment of euglycemia, and avoidance of hypoglycemia. Additional benefits include improved quality of life and stabilization of complications. 80 Chronic immunosuppression is needed to prevent graft rejection after transplantation.

Pancreas transplantation

Whole pancreas transplantation, first performed in 1966, involves complex abdominal surgery and lifelong immunosuppressive therapy and is limited by organ donor availability. Today, pancreas transplants are usually performed simultaneously using two organs from the same donor (simultaneous pancreas-kidney transplant (SPKT)), sequentially if the candidate has a living donor for renal transplantation (pancreas after kidney transplant (PAKT)) or on its own (pancreas transplantation alone). Most whole pancreas transplants are performed with kidney transplantation for end stage diabetic kidney disease. Pancreas graft survival at five years after SPKT is 80% and is superior to that with pancreas transplants alone (62%) or PAKT (67%). 81 Studies from large centers where SPKT is performed show that recipients can expect metabolic improvements including amelioration of problematic hypoglycemia for at least five years. 81 The number of pancreas transplantations has steadily decreased in the past two decades.

Islet transplantation

Islet transplantation can be pursued in selected patients with type 1 diabetes marked by unawareness of hypoglycemia and severe hypoglycemic episodes, to help restore the α cell response critical for responding to hypoglycemia. 82 83 Islet transplantation involves donor pancreas procurement with subsequent steps to isolate, purify, culture, and infuse the islets. Multiple donors are needed to provide enough islet cells to overcome islet cell loss during transplantation. Survival of the islet grafts, limited donor supply, and lifelong need for immunosuppressant therapy remain some of the biggest challenges. 84 Islet transplantation remains experimental in the US and is offered in a few specialized centers in North America, some parts of Europe, and Australia. 85

Disease modifying treatments for β cell preservation

Therapies targeting T cells, B cells, and cytokines that find use in a variety of autoimmune diseases have also been applied to type 1 diabetes. The overarching goal of immune therapies in type 1 diabetes is to prevent or delay the loss of functional β cell mass. Studies thus far in early type 1 diabetes have not yet successfully shown reversal of loss of C peptide or maintenance of concentrations after diagnosis, although some have shown preservation or slowing of loss of β cells. This suggests that a critical time window of opportunity exists for starting treatment depending on the stage of type 1 diabetes ( fig 1 ).

Teplizumab is a humanized monoclonal antibody against the CD3 molecule on T cells; it is thought to modify CD8 positive T lymphocytes, key effector cells that mediate β cell death and preserves regulatory T cells. 86 Teplizumab, when administered to patients with new onset of type 1 diabetes, was unable to restore glycemia despite C peptide preservation. 87 However, in its phase II prevention study of early intervention in susceptible individuals (at least two positive autoantibodies and an abnormal oral glucose tolerance test at trial entry), a single course of teplizumab delayed progression to clinical type 1 diabetes by about two years ( table 2 ). 43 On the basis of these results, teplizumab received approval in the US for people at high risk of type 1 diabetes in November 2022. 88 A phase III trial (PROTECT; NCT03875729 ) to evaluate the efficacy and safety of teplizumab versus placebo in children and adolescents with new diagnosis of type 1 diabetes (within six weeks) is ongoing. 89

Thus far, targeting various components of the immune response has been attempted in early type 1 diabetes without any long term beneficial effects on C peptide preservation. Co-stimulation blockade using CTLA4-Ig abatacept, a fusion protein that interferes with co-stimulation needed in the early phases of T cell activation that occurs in type 1 diabetes, is being tested for efficacy in prevention of type 1 diabetes ( NCT01773707 ). 90 Similarly, several cytokine directed anti-inflammatory targets (interleukin 6 receptor, interleukin 1β, tumor necrosis factor ɑ) have not shown any benefit.

Non-immunomodulatory adjunctive therapies

Adjunctive therapies for type 1 diabetes have been long entertained owing to problems surrounding insulin delivery, adequacy of glycemic management, and side effects associated with insulin, especially weight gain and hypoglycemia. At least 50% of adults with type 1 diabetes are overweight or obese, presenting an unmet need for weight management in these people. Increased cardiovascular risk in these people despite good glycemic management presents additional challenges. Thus, use of adjuvant therapies may tackle these problems.

Metformin, by decreasing hepatic glucose production, could potentially decrease fasting glucose concentrations. 91 It has shown benefit in reducing insulin doses and possibly improving metabolic control in obese/overweight people with type 1 diabetes. A meta-analysis of 19 RCTs suggests short term improvement in HbA 1c that is not sustained after three months and is associated with higher incidence of gastrointestinal side effects. 92 No evidence shows that metformin decreases cardiovascular morbidity in type 1 diabetes. Therefore, owing to lack of conclusive benefit, addition of metformin to treatment regimens is not recommended in consensus guidelines.

Glucagon-like peptide receptor agonists

Endogenous GLP-1 is an incretin hormone secreted from intestinal L cells in response to nutrient ingestion and enhances glucose induced insulin secretion, suppresses glucagon secretion, delays gastric emptying, and induces satiety. 93 GLP-1 promotes β cell proliferation and inhibits apoptosis, leading to expansion of β cell mass. GLP-1 secretion in patients with type 1 diabetes is similar to that seen in people without diabetes. Early RCTs of liraglutide in type 1 diabetes resulted in weight loss and modest lowering of HbA 1c ( table 2 ). 49 50 Liraglutide 1.8 mg in people with type 1 diabetes and higher body mass index decreased HbA 1c , weight, and insulin requirements with no increased hypoglycemia risk. 94 However, on the basis of results from a study of weekly exenatide that showed similar results, these effects may not be sustained. 51 A meta-analysis of 24 studies including 3377 participants showed that the average HbA 1c decrease from GLP-1 receptor agonists compared with placebo was highest for liraglutide 1.8 mg daily (−0.28%, 95% confidence interval −0.38% to−0.19%) and exenatide (−0.17%, −0.28% to 0.02%). The estimated weight loss from GLP-1 receptor agonists compared with placebo was −4.89 (−5.33 to−4.45)  kg for liraglutide 1.8 mg and −4.06  (−5.33 to−2.79) kg for exenatide. 95 No increase in severe hypoglycemia was seen (odds ratio 0.67, 0.43 to 1.04) but therapy was associated with higher levels of nausea. GLP-1 receptor agonist use may be beneficial for weight loss and reducing insulin doses in a subset of patients with type 1 diabetes. GLP-1 receptor agonists are not a recommended treatment option in type 1 diabetes. Semaglutide is being studied in type 1 diabetes in two clinical trials ( NCT05819138 ; NCT05822609 ).

Sodium-glucose cotransporter inhibitors

Sodium-glucose cotransporter 2 (SGLT-2), a protein expressed in the proximal convoluted tubule of the kidney, reabsorbs filtered glucose; its inhibition prevents glucose reabsorption in the tubule and increases glucose excretion by the kidney. Notably, the action of these agents is independent of insulin, so this class of drugs has potential as adjunctive therapy for type 1 diabetes. Clinical trials have shown significant benefit in cardiovascular and renal outcomes in type 2 diabetes; therefore, significant interest exists for use in type 1 diabetes. Several available SGLT-2 inhibitors have been studied in type 1 diabetes and have shown promising results with evidence of decreased total daily insulin dosage, improvement in HbA 1c , lower rates of hypoglycemia, and decrease in body weight; however, these effects do not seem to be sustained at one year in clinical trials and seem to wane with time. Despite beneficial effects, increased incidence of diabetic ketoacidosis has been observed in all trials, is a major concern, and is persistent despite educational efforts. 96 97 98 Low dose empagliflozin (2.5 mg) has shown lower rates of diabetic ketoacidosis in clinical trials ( table 2 ). 47 Favorable risk profiles have been noted in Japan, the only market where SGLT-2 inhibitors are approved for adjunctive use in type 1 diabetes. 99 In the US, SGLT-2 inhibitors are approved for use in type 2 diabetes only. In Europe, although dapagliflozin was approved for use as adjunct therapy to insulin in adults with type 1 diabetes, the manufacturer voluntarily withdrew the indication for the drug in 2021. 100 Sotagliflozin is a dual SGLT-1 and SGLT-2 inhibitor that decreases renal glucose reabsorption through systemic inhibition of SGLT-2 and decreases glucose absorption in the proximal intestine by SGLT-1 inhibition, blunting and delaying postprandial hyperglycemia. 101 Studies of sotagliflozin in type 1 diabetes have shown sustained HbA 1c reduction, weight loss, lower insulin requirements, lesser hypoglycemia, and more diabetic ketoacidosis relative to placebo. 102 103 104 The drug received authorization in the EU for use in type 1 diabetes, but it is not marketed there. Although SGLT inhibitors are efficacious in type 1 diabetes management, the risk of diabetic ketoacidosis is a major limitation to widespread use of these agents.

Updates in acute complications of type 1 diabetes

Diabetic ketoacidosis.

Diabetic ketoacidosis is a serious and potentially fatal hyperglycemic emergency accompanied by significant rates of mortality and morbidity as well as high financial burden for healthcare systems and societies. In the past decade, increasing rates of diabetic ketoacidosis in adults have been observed in the US and Europe. 105 106 This may be related to changes in the definition of diabetic ketoacidosis, use of medications associated with higher risk, and admission of patients at lower risk. 107 In a US report of hospital admissions with diabetic ketoacidosis, 53% of those admitted were between the ages of 18 and 44, with higher rates in men than in women. 108 Overall, although mortality from diabetic ketoacidosis in developed countries remains low, rates have risen in people aged >60 and in those with coexisting life threatening illnesses. 109 110 Recurrent diabetic ketoacidosis is associated with a substantial mortality rate. 111 Frequency of diabetic ketoacidosis increases with higher HbA 1c concentrations and with lower socioeconomic status. 112 Common precipitating factors include newly diagnosed type 1 diabetes, infection, poor adherence to insulin, and an acute cardiovascular event. 109

Euglycemic diabetic ketoacidosis refers to the clinical picture of an increased anion gap metabolic acidosis, ketonemia, or significant ketonuria in a person with diabetes without significant glucose elevation. This can be seen with concomitant use of SGLT-2 inhibitors (currently not indicated in type 1 diabetes), heavy alcohol use, cocaine use, pancreatitis, sepsis, and chronic liver disease and in pregnancy 113 Treatment is similar to that for hyperglycemic diabetic ketoacidosis but can require earlier use and greater concentrations of a dextrose containing fluid for the insulin infusion in addition to 0.9% normal saline resuscitation fluid. 114

The diagnosis of diabetic ketoacidosis has evolved from a gluco-centric diagnosis to one requiring hyperketonemia. By definition, independent of blood glucose, a β-hydroxybutyrate concentration >3 mmol/L is required for diagnosis. 115 However, the use of this ketone for assessment of the severity of the diabetic ketoacidosis is controversial. 116 Bedside β-hydroxybutyrate testing during treatment is standard of care in many parts of the world (such as the UK) but not others (such as the US). Concerns have been raised about accuracy of bedside β-hydroxybutyrate meters, but this is related to concentrations above the threshold for diabetic ketoacidosis. 116

Goals for management of diabetic ketoacidosis include restoration of circulatory volume, correction of electrolyte imbalances, and treatment of hyperglycemia. Intravenous regular insulin infusion is the standard of care for treatment worldwide owing to rapidity of onset of action and rapid resolution of ketonemia and hyperglycemia. As hypoglycemia and hypokalemia are more common during treatment, insulin doses are now recommended to be reduced from 0.1 u/kg/h to 0.05 u/kg/h when glucose concentrations drop below 250 mg/dL or 14 mM. 115 Subcutaneous rapid acting insulin protocols have emerged as alternative treatments for mild to moderate diabetic ketoacidosis. 117 Such regimens seem to be safe and have the advantages of not requiring admission to intensive care, having lower rates of complications related to intravenous therapy, and requiring fewer resources. 117 118 Ketonemia and acidosis resolve within 24 hours in most people. 115 To prevent rebound hyperglycemia, the transition off an intravenous insulin drip must overlap subcutaneous insulin by at least two to four hours. 115

Hypoglycemia

Hypoglycemia, a common occurrence in people with type 1 diabetes, is a well appreciated effect of insulin treatment and occurs when blood glucose falls below the normal range. Increased susceptibility to hypoglycemia from exogenous insulin use in people with type 1 diabetes results from multiple factors, including imperfect subcutaneous insulin delivery tools, loss of glucagon within a few years of diagnosis, progressive impairment of the sympatho-adrenal response with repeated hypoglycemic episodes, and eventual development of impaired awareness. In 2017 the International Hypoglycemia Study Group developed guidance for definitions of hypoglycemia; on the basis of this, a glucose concentration of 3.0-3.9 mmol/L (54-70 mg/dL) was designated as level 1 hypoglycemia, signifying impending development of level 2 hypoglycemia—a glucose concentration <3 mmol/L (54 mg/dL). 119 120 At approximately 54 mg/dL, neuroglycopenic hypoglycemia symptoms, including vision and behavior changes, seizures, and loss of consciousness, begin to occur as a result of glucose deprivation of neurons in the central nervous system. This can eventually lead to cerebral dysfunction at concentrations <50 mg/dL. 121 Severe hypoglycemia (level 3), denoting severe cognitive and/or physical impairment and needing external assistance for recovery, is a common reason for emergency department visits and is more likely to occur in people with lower socioeconomic status and with the longest duration of diabetes. 112 Prevalence of self-reported severe hypoglycemia is very high according to a global population study that included more than 8000 people with type 1 diabetes. 122 Severe hypoglycemia occurred commonly in younger people with suboptimal glycemia according to a large electronic health record database study in the US. 123 Self- reported severe hypoglycemia is associated with a 3.4-fold increase in mortality. 124 125

Acute consequences of hypoglycemia include impaired cognitive function, temporary focal deficits including stroke-like symptoms, and memory deficits. 126 Cardiovascular effects including tachycardia, arrhythmias, QT prolongation, and bradycardia can occur. 127 Hypoglycemia can impair many activities of daily living, including motor vehicle safety. 128 In a survey of adults with type 1 diabetes who drive a vehicle at least once a week, 72% of respondents reported having hypoglycemia while driving, with around 5% reporting a motor vehicle accident due to hypoglycemia in the previous two years. 129 This contributes to the stress and fear that many patients face while grappling with the difficulties of ongoing hypoglycemia. 130

Glucagon is highly efficacious for the primary treatment of severe hypoglycemia when a patient is unable to ingest carbohydrate safely, but it is unfortunately under-prescribed and underused. 131 132 Availability of nasal, ready to inject, and shelf-stable liquid glucagon formulations have superseded the need for reconstituting older injectable glucagon preparations before administration and are now preferred. 133 134 Real time CGM studies have shown a decreased hypoglycemic exposure in people with impaired awareness without a change in HbA 1c . 34 135 136 137 138 CGM has shown benefit in decreasing hypoglycemia across the lifespan, including in teens, young adults, and older people. 36 139 Although CGM reduces the burden of hypoglycemia including severe hypoglycemia, it does not eliminate it; overall, such severe level 3 hypoglycemia rates in clinical trials are very low and hard to decipher in the real world. HCL insulin delivery systems integrated with CGM have been shown to decrease hypoglycemia. Among available rapid acting insulins, ultra-rapid acting lispro (lispro-aabc) seems to be associated with less frequent hypoglycemia in type 1 diabetes. 140 141

As prevention of hypoglycemia is a crucial aspect of diabetes management, formal training programs to increase awareness and education on avoidance of hypoglycemia, such as the UK’s Dose Adjustment for Normal Eating (DAFNE), have been developed. 142 143 This program has shown fewer severe hypoglycemia (mean 1.7 (standard deviation 8.5) episodes per person per year before training to 0.6 (3.7) episodes one year after training) and restoration of recognition of hypoglycemia in 43% of people reporting unawareness. Clinically relevant anxiety and depression fell from 24.4% to 18.0% and from 20.9% to 15.5%, respectively. A structured education program with cognitive and psychotherapeutic aspects for changing hypoglycemia related behaviors, called the Hypoglycemia Awareness Restoration Program despite optimized self-care (HARPdoc), showed a positive effect on changing unhelpful beliefs around hypoglycemia and improved diabetes related and general distress and anxiety scores. 144

Management in under-resourced settings

According to a recent estimate from the International Diabetes Federation, 1.8 million people with type 1 diabetes live in low and middle income countries (LMICs). 2 In many LMICs, the actual burden of type 1 diabetes remains unknown and material resources needed to manage type 1 diabetes are lacking. 145 146 Health systems in these settings are underequipped to tackle the complex chronic disease that is type 1 diabetes. Few diabetes and endocrinology specialist physicians are available owing to lack of specific postgraduate training programs in many LMICs; general practitioners with little to no clinical experience in managing type 1 diabetes care for these patients. 146 This, along with poor availability and affordability of insulin and lack of access to technology, results in high mortality rates. 147 148 149 In developed nations, low socioeconomic status is associated with higher levels of mortality and morbidity for adults with type 1 diabetes despite access to a universal healthcare system. 150 Although global governments have committed to universal health coverage and therefore widespread availability of insulin, it remains very far from realization in most LMICs. 151

Access to technology is patchy and varies globally. In the UST1DX, CGM use was least in the lowest fifth of socioeconomic status. 152 Even where technology is available, successful engagement does not always occur. 153 In a US cohort, lower CGM use was seen in non-Hispanic Black children owing to lower rates of device initiation and higher rates of discontinuation. 154 In many LMICs, blood glucose testing strips are not readily available and cost more than insulin. 151 In resource limited settings, where even diagnosis, basic treatments including insulin, syringes, and diabetes education are limited, use of CGM adds additional burden to patients. Need for support services and the time/resources needed to download and interpret data are limiting factors from a clinician’s perspective. Current rates of CGM use in many LMICs are unknown.

Inequities in the availability of and access to certain insulin formulations continue to plague diabetes care. 155 In developed countries such as the US, rising costs have led to insulin rationing by around 25% of people with type 1 diabetes. 156 LMICs have similar trends while also remaining burdened by disproportionate mortality and complications from type 1 diabetes. 155 157 With the inclusion of long acting insulin analogs in the World Health Organization’s Model List of Essential Medicines in 2021, hope has arisen that these will be included as standard of care across the world. 158 In the past, the pricing of long acting analogs has limited their use in resource poor settings 159 ; however, their inclusion in WHO’s list was a major step in improving their affordability. 158 With the introduction of lower cost long acting insulin biosimilars, improved access to these worldwide in the future can be anticipated. 160

Making insulin available is not enough on its own to improve the prognosis for patients with diabetes in resource poor settings. 161 Improved healthcare infrastructure, better availability of diabetes supplies, and trained personnel are all critical to improving type 1 diabetes care in LMICs. 161 Despite awareness of limitations and barriers, a clear understanding of how to implement management strategies in these settings is still lacking. The Global Diabetes Compact was launched in 2021 with the goal of increasing access to treatment and improving outcomes for people with diabetes across the globe. 162

Emerging technologies and treatments

Monitoring systems.

The ability to measure urinary or more recently blood ketone concentrations is an integral part of self-management of type 1 diabetes, especially during acute illness, intermittent fasting, and religious fasts to prevent diabetic ketoacidosis. 163 Many people with type 1 diabetes do not adhere to urine or blood ketone testing, which likely results in unnecessary episodes of diabetic ketoacidosis. 164 Noting that blood and urine ketone testing is not widely available in all countries and settings is important. 1 Regular assessment of patients’ access to ketone testing (blood or urine) is critical for all clinicians. Euglycemic diabetic ketoacidosis in type 1 diabetes is a particular problem with concomitant use of SGLT-2 inhibitors; for this reason, these agents are not approved for use in these patients. For sick day management (and possibly for the future use of SGLT-2 inhibitors in people with type 1 diabetes), it is hoped that continuous ketone monitoring (CKM) can mitigate the risks of diabetic ketoacidosis. 165 Like CGM, the initial CKM device measures interstitial fluid β-hydroxybutyrate instead of glucose. CKM use becomes important in conjunction with a hybrid closed loop insulin pump system and added SGLT-2 inhibitor therapy, where insulin interruptions are common and hyperketonemia is frequent. 166

Perhaps the greatest technological challenge to date has been the development of non-invasive glucose monitoring. Numerous attempts have been made using strategies including optics, microwave, and electrochemistry. 167 Lack of success to date has resulted in healthy skepticism from the medical community. 168 However, active interest in the development of non-invasive technology with either interstitial or blood glucose remains.

Insulin and delivery systems

In the immediate future, two weekly basal insulins, insulin icodec and basal insulin Fc, may become available. 169 Studies of insulin icodec in type 1 diabetes are ongoing (ONWARDS 6; NCT04848480 ). How these insulins will be incorporated in management of type 1 diabetes is not yet clear.

Currently available AID systems use only a single hormone, insulin. Dual hormone AID systems incorporating glucagon are in development. 170 171 Barriers to the use of dual hormone systems include the need for a second chamber in the pump, a lack of stable glucagon formulations approved for long term subcutaneous delivery, lack of demonstrated long term safety, and gastrointestinal side effects from glucagon use. 74 Similarly, co-formulations of insulin and amylin (a hormone co-secreted with insulin and deficient in people with type 1 diabetes) are in development. 172

Immunotherapy for type 1 diabetes

As our understanding of the immunology of type 1 diabetes expands, development of the next generation of immunotherapies is under active pursuit. Antigen specific therapies, peptide immunotherapy, immune tolerance using DNA vaccination, and regulatory T cell based adoptive transfer targeting β cell senescence are all future opportunities for drug development. Combining immunotherapies with metabolic therapies such as GLP-1 receptor agonists to help to improve β cell mass is being actively investigated.

The quest for β cell replacement methods is ongoing. Transplantation of stem cell derived islets offers promise for personalized regenerative therapies as a potentially curative method that does away with the need for donor tissue. Since the first in vivo model of glucose responsive β cells derived from human embryonic stem cells, 173 different approaches have been attempted. Mesenchymal stromal cell treatment and autologous hematopoietic stem cells in newly diagnosed type 1 diabetes may preserve β cell function without any safety signals. 174 175 176 Stem cell transplantation for type 1 diabetes remains investigational. Encapsulation, in which β cells are protected using a physical barrier to prevent immune attack and avoid lifelong immunosuppression, and gene therapy techniques using CRISPR technology also remain in early stages of investigation.

Until recently, no specific guidelines for management of type 1 diabetes existed and management guidance was combined with consensus statements developed for type 2 diabetes. Table 6 summarizes available guidance and statements from various societies. A consensus report for management of type 1 diabetes in adults by the ADA and European Association for the Study of Diabetes became available in 2021; it covers several topics of diagnosis and management of type 1 diabetes, including glucose monitoring, insulin therapy, and acute complications. Similarly, the National Institute for Health and Care Excellence also offers guidance on management of various aspects of type 1 diabetes. Consensus statements for use of CGM, insulin pump, and AID systems are also available.

Guidelines in type 1 diabetes

Conclusions

Type 1 diabetes is a complex chronic condition with increasing worldwide prevalence affecting several million people. Several successes in management of type 1 diabetes have occurred over the years from the serendipitous discovery of insulin in 1921 to blood glucose monitoring, insulin pumps, transplantation, and immunomodulation. The past two decades have seen advancements in diagnosis, treatment, and technology including development of analog insulins, CGM, and advanced insulin delivery systems. Although we have gained a broad understanding on many important aspects of type 1 diabetes, gaps still exist. Pivotal research continues targeting immune targets to prevent or delay onset of type 1 diabetes. Although insulin is likely the oldest of existing modern drugs, no low priced generic supply of insulin exists anywhere in the world. Management of type 1 diabetes in under resourced areas continues to be a multifaceted problem with social, cultural, and political barriers.

Glossary of abbreviations

ADA—American Diabetes Association

AID—automated insulin delivery

BGM—blood glucose monitoring

CGM—continuous glucose monitoring

CKM—continuous ketone monitoring

DCCT—Diabetes Control and Complications Trial

DIY—do-it-yourself

FDA—Food and Drug Administration

GADA—glutamic acid decarboxylase antibody

GLP-1—glucagon-like peptide 1

GRS—genetic risk scoring

HbA1c—glycated hemoglobin

HCL—hybrid closed loop

LADA—latent autoimmune diabetes of adults

LMIC—low and middle income country

PAKT—pancreas after kidney transplant

RCT—randomized controlled trial

SGLT-2—sodium-glucose cotransporter 2

SPKT—simultaneous pancreas-kidney transplant

Questions for future research

What future new technologies can be helpful in management of type 1 diabetes?

How can newer insulin delivery methods benefit people with type 1 diabetes?

What is the role of disease modifying treatments in prevention and delay of type 1 diabetes?

Is there a role for sodium-glucose co-transporter inhibitors or glucagon-like peptide 1 receptor angonists in the management of type 1 diabetes?

As the population with type 1 diabetes ages, how should management of these people be tailored?

How can we better serve people with type 1 diabetes who live in under-resourced settings with limited access to medications and technology?

How patients were involved in the creation of this manuscript

A person with lived experience of type 1 diabetes reviewed a draft of the manuscript and offered input on important aspects of their experience that should be included. This person is involved in large scale education and activism around type 1 diabetes. They offered their views on various aspects of type 1 diabetes, especially the use of adjuvant therapies and the burden of living with diabetes. This person also raised the importance of education of general practitioners on the various stages of type 1 diabetes and the management aspects. On the basis of this feedback, we have highlighted the burden of living with diabetes on a daily basis.

Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

Contributors: SS and IBH contributed to the planning, drafting, and critical review of this manuscript. FNK contributed to the drafting of portions of the manuscript. All three authors are responsible for the overall content as guarantors.

Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: SS has received an honorarium from Abbott Diabetes Care; IBH has received honorariums from Abbott Diabetes Care, Lifescan, embecta, and Hagar and research support from Dexcom and Insulet.

Provenance and peer review: Commissioned; externally peer reviewed.

• DeVries JH ,
• Hess-Fischl A ,
• Gregory GA ,
• Robinson TIG ,
• Linklater SE ,
• International Diabetes Federation Diabetes Atlas Type 1 Diabetes in Adults Special Interest Group
• Harding JL ,
• Wander PL ,
• Dabelea D ,
• Mayer-Davis EJ ,
• SEARCH for Diabetes in Youth Study
• Lawrence JM ,
• SEARCH for Diabetes in Youth Study Group
• Fazeli Farsani S ,
• Souverein PC ,
• van der Vorst MM ,
• Sutherland J ,
• Rokszin G ,
• Stahl-Pehe A ,
• Kamrath C ,
• Atkinson MA ,
• Bingley PJ ,
• Bonifacio E ,
• Leslie RD ,
• Evans-Molina C ,
• Freund-Brown J ,
• Thomas NJ ,
• Zimmet PZ ,
• Rowley MJ ,
• Knowles W ,
• Fourlanos S ,
• Greenbaum CJ ,
• ElSayed NA ,
• American Diabetes Association
• Miller RG ,
• Secrest AM ,
• Sharma RK ,
• Songer TJ ,
• McDonald T ,
• Greenfield JR
• Tridgell DM ,
• Spiekerman C ,
• Greenbaum CJ
• Glessner J ,
• Foster NC ,
• Miller KM ,
• Becker DJ ,
• Khawandanah J
• Pedrosa MR ,
• Franco DR ,
• Gieremek HW ,
• Nathan DM ,
• Diabetes Control and Complications Trial Research Group
• Klonoff DC ,
• Parkes JL ,
• Kovatchev BP ,
• Raghinaru D ,
• iDCL Trial Research Group
• Riddlesworth T ,
• DIAMOND Study Group
• Leelarathna L ,
• Neupane S ,
• FLASH-UK Trial Study Group
• Polonsky W ,
• Hirsch IB ,
• Pratley RE ,
• Kanapka LG ,
• Rickels MR ,
• Wireless Innovation for Seniors With Diabetes Mellitus (WISDM) Study Group
• Tauschmann M ,
• APCam11 Consortium
• Russell SJ ,
• Damiano ER ,
• Bionic Pancreas Research Group
• Bailey TS ,
• Group Information ,
• Bergenstal RM ,
• Dellva MA ,
• Mathieu C ,
• Herold KC ,
• Type 1 Diabetes TrialNet Study Group
• Libman IM ,
• DiMeglio LA ,
• T1D Exchange Clinic Network Metformin RCT Study Group
• Petrie JR ,
• Chaturvedi N ,
• REMOVAL Study Group
• Dandona P ,
• Phillip M ,
• DEPICT-1 Investigators
• Rosenstock J ,
• Marquard J ,
• Laffel LM ,
• Hemmingsson JU ,
• ADJUNCT ONE Investigators
• Pieber TR ,
• ADJUNCT TWO Investigators
• Reynolds J ,
• Battelino T ,
• Liljenquist D ,
• Becker RH ,
• Bergmann K ,
• Lehmann A ,
• Cheng AYY ,
• Stender-Petersen K ,
• Hövelmann U ,
• Carlson AL ,
• Komatsu M ,
• Coutant DE ,
• Stamati A ,
• Karagiannis T ,
• Christoforidis A
• Heinemann L ,
• Baughman R ,
• Akturk HK ,
• Snell-Bergeon JK ,
• Prabhu JN ,
• Seyed Ahmadi S ,
• Westman K ,
• Pivodic A ,
• Hermann JM ,
• Freiberg C ,
• DPV Initiative
• Dicembrini I ,
• Cosentino C ,
• Mannucci E ,
• Abelseth J ,
• Karageorgiou V ,
• Papaioannou TG ,
• Weisman A ,
• Cardinez M ,
• Kramer CK ,
• Asarani NAM ,
• Reynolds AN ,
• Elbalshy M ,
• Jennings P ,
• Burnside MJ ,
• Williman JA ,
• Fridell JA ,
• Stratta RJ ,
• Gruessner AC
• Robertson RP
• Shapiro AM ,
• Pepper AR ,
• Shapiro AMJ
• Walker JT ,
• Saunders DC ,
• Brissova M ,
• Gitelman SE ,
• Bluestone JA
• Hagopian W ,
• Ferry RJ Jr . ,
• Protégé Trial Investigators
• von Scholten BJ ,
• Kreiner FF ,
• Gough SCL ,
• von Herrath M
• Type 1 Diabetes TrialNet Abatacept Study Group
• Hardie DG ,
• Dejgaard TF ,
• Christiansen E ,
• ADJUNCT ONE and ADJUNCT TWO Investigators
• Yunasan E ,
• Peters AL ,
• Palanca A ,
• van Nes F ,
• Ampudia Blasco FJ ,
• Dobbins RL ,
• Greenway FL ,
• Zambrowicz BP ,
• Brodovicz K ,
• Soleymanlou N ,
• Wissinger E ,
• Juhaeri J ,
• Mayer-Davis EJ
• Dhatariya KK ,
• Glaser NS ,
• Umpierrez GE
• Ramphul K ,
• Umpierrez G ,
• Korytkowski M
• Weinstock RS ,
• T1D Exchange Clinic Network
• Eshkoli T ,
• Brandstaetter E ,
• Jotkowitz A
• Dhatariya KK
• Joint British Diabetes Societies for Inpatient Care
• Kilpatrick ES ,
• Butler AE ,
• Ostlundh L ,
• Koufakis T ,
• Agiostratidou G ,
• International Hypoglycaemia Study Group
• van de Ven KC ,
• Heerschap A ,
• van der Graaf M ,
• de Galan BE
• Alsifri S ,
• Aronson R ,
• HAT Investigator Group
• Pettus JH ,
• Shepherd L ,
• Van Houten HK ,
• Ziegenfuss JY ,
• Wermers RA ,
• Schernthaner G ,
• Anderson J ,
• Saunders AL ,
• Snell-Bergeon J ,
• Forlenza GP ,
• Bispham J ,
• Gabbay RA ,
• Pontiroli AE ,
• Tagliabue E
• T1D Exchange Intranasal Glucagon Investigators
• Freckmann G ,
• Ehrmann D ,
• El Laboudi A ,
• Spanudakis E ,
• Anantharaja S ,
• Peleckis AJ ,
• Dalton-Bakes C ,
• van Beers CA ,
• Kleijer SJ ,
• CGM Intervention in Teens and Young Adults with T1D (CITY) Study Group ,
• Piras de Oliveira C ,
• Ribeiro A ,
• Chigutsa F ,
• Malecki MT ,
• Hopkins D ,
• Lawrence I ,
• Mansell P ,
• Stanton-Fay SH ,
• Hamilton K ,
• Chadwick PM ,
• DAFNEplus study group
• Goldsmith K ,
• Yudkin JS ,
• Buntinx F ,
• Mapatano MA ,
• De Clerck M ,
• Truyers C ,
• Chambers D ,
• O’Cathain A
• Klatman EL ,
• Auzanneau M ,
• Tanenbaum ML ,
• Iturralde E ,
• Lipman TH ,
• Bhutta ZA ,
• Pfiester E ,
• Thieffry A ,
• Ballhausen H ,
• Gajewska KA ,
• O’Donnell S
• Wareham NJ ,
• Joosse HJ ,
• Raposo JF ,
• de Courten M
• Hemmingsen B ,
• Abouhassan T ,
• Albanese-O’Neill A ,
• Jacobsen L ,
• Haller MJ ,
• Castorino K ,
• Lovblom LE ,
• Cardinez N ,
• Nguyen KT ,
• Andersen G ,
• Meiffren G ,
• Famulla S ,
• Castellanos LE ,
• Balliro CA ,
• Sherwood JS ,
• Tsoukas MA ,
• Bernier-Twardy S ,
• Martinson LA ,
• Carlsson PO ,
• Schwarcz E ,
• Korsgren O ,
• Oliveira MC ,
• Stracieri AB ,
• Buzzetti R ,
• Mauricio D ,
• McGibbon A ,
• Ingersoll K ,
• Tugwell B ,
• Diabetes Canada Clinical Practice Guidelines Expert Committee
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Your top priorities for research into type 1 diabetes revealed

Hundreds of people with type 1 diabetes, their families and healthcare professionals have chosen their most pressing research priorities for type 1 diabetes. The top ten priorities will help to guide future type 1 diabetes research in the UK and Ireland to make sure it has the greatest possible benefit for people with the condition. 

As the UK’s largest charitable funder of diabetes research, it’s critical that our research funds address the specific challenges and needs of people with diabetes and those who care for them.

It’s also critical that we make sure others - academics, healthcare professionals and other research funders – hear these views loud and clear and act upon them.  

We work with the Priority Setting Partnership (PSP) initiative, run by the  James Lind Alliance (JLA) and supported by the National Institute for Health Research (NIHR) , to help bring the views of people with real-life experience of diabetes into research.

Through surveys and workshops, this initiative finds and prioritises their most pressing concerns and questions that can be answered through research. Diabetes UK contributed to the first Type 1 Diabetes PSP in 2011, the Diabetes and Pregnancy PSP in 2020 , and led the Type 2 Diabetes PSP in 2017. 

Your new top ten priorities  

Since the last Type 1 Diabetes PSP in 2011 there's been  some big changes in type 1 treatment and care , so the priorities were due an update. The latest Type 1 PSP – which condensed and whittled down nearly 3000 questions submitted by people affected by type 1 to a shortlist of the top ten – has just been published . And here they are: 

1. Can the use of artificial intelligence or faster acting insulins help achieve fully closed loop insulin delivery?

2. Is time in range a better predictor of diabetes management and complications compared to HbA1c (an average reading of blood sugar over a 3-month period)?

3. What impact do hormonal phases such as the perimenstrual period and menopause play in glycaemic management and what treatments are most effective for managing glucose levels around these times?

4. What interventions are the most effective for reducing diabetes related distress and burnout?

5. What are the long-term implications of frequent hypoglycaemia on physical and mental health?

6. What impact does type 1 diabetes (including frequent low blood sugar) have on memory and cognition in older adults?

7. How can health care professionals better take into account the physical, psychological and social aspects of type 1 diabetes in clinics?

8. How can access to potential therapies like stem cell therapy, transplants and medications that modify the immune systems be improved so that everyone with type 1 diabetes can be guaranteed access?

9. Why do some people with type 1 diabetes become insulin resistant and does resistance increase with the number of years a person has diabetes and if so, why?

10. Can technology assist to accurately count carbohydrates without having to weigh or measure all foods and drink? 

Dr Christine Newman, Lead Clinical Researcher at the  Health Research Board Diabetes Collaborative Clinical Trial Network  in Ireland who funded the PSP, emphasised the importance of these findings:

“This study is a powerful example of how Public and Patient Involvement can shape the future of healthcare. This work highlights the real-world challenges and unmet needs of adults living with Type 1 diabetes. By focusing on these top ten priorities, we can ensure that future research and healthcare services are aligned with what truly matters to those affected by the condition.”

We will use these top 10 research priorities in the decisions it makes about how research is funded, and they will inform the work of the Diabetes Research Steering Groups .

We will also publicise these priorities widely to researchers and organisations that fund diabetes research. The priorities could influence those who work in universities and academic institutions, government agencies or in industry.  

Dr Elizabeth Robertson, Director of Research at Diabetes UK, explains: 

“We need to make sure research that we fund has the greatest possible benefit for people with diabetes. Knowing the most important priorities of people living with or treating type 1 diabetes will help us direct funding to where it’s needed most.”

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Ten-year review of trends in children with type 1 diabetes in England and Wales

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Author contributions: Ng SM conceived the paper; Ng SM and Soni A wrote the draft and finalised the paper.

Corresponding author: Sze M Ng, OBE, PhD, MBA, LLM, MSc, MBBS, FRCPCH, Professor, Department of Paediatrics, Mersey and West Lancashire Teaching Hospitals NHS Trust, Ormskirk District General Hospital, Ormskirk L39 2AZ, United Kingdom. [email protected]

Received 2023 Feb 3; Revised 2023 Mar 9; Accepted 2023 Jun 21; Issue date 2023 Aug 15.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.

This review describes the prevalence, incidence, and demographics of children and young people (CYP) with type 1 diabetes in England and Wales using data from the United Kingdom National Paediatric Diabetes Audit (NPDA) and has almost 100% submission from all paediatric diabetes centres annually. It is a powerful benchmarking tool and is an essential part of a long-term quality improvement programme for CYP with diabetes. Clinical characteristics of this population by age, insulin regimen, complication rates, health inequalities, access to diabetes technology, socioeconomic deprivation and glycaemic outcomes over the past decade is described in the review. The NPDA for England and Wales is commissioned by the United Kingdom Healthcare Quality Improvement Partnership as part of the National Clinical Audit for the United Kingdom National Service Framework for Diabetes. The rising incidence of Type 1 diabetes is evidenced in the past decade. Reduction in national median glycated hemoglobin for CYP with diabetes is observed over the last 10 years and the improvement sustained by various initiatives and quality improvement pro-grammes implemented with universal health coverage.

Keywords: Paediatric, Type 1, Trends, Outcomes, Glycated hemoglobin

Core Tip: This review describes the prevalence, incidence and demographics of children and young people (CYP) with type 1 diabetes in England and Wales using data from the United Kingdom National Paediatric Diabetes Audit. Reduction in national median glycated hemoglobin for CYP with diabetes is seen over the last 10 years and sustained by various initiatives and quality improvement programmes implemented with universal health coverage.

INTRODUCTION

Type 1 diabetes is a chronic condition and represent the most common type of diabetes in children and young people (CYP). International epidemiology reported that there has been a significant rise in the diagnosis of type 1 diabetes in CYP in the past decade with an estimated incidence of approximately 1 in every 1000 children[ 1 ]. Globally, diabetes is reported to affect 1.5 million deaths due to short and long term complications. However, there is currently no accurate epidemiological data on the prevalence or incidence of Type 1 diabetes in many countries worldwide, particularly lacking in low-middle-income countries[ 2 ]. The United Kingdom has one of the highest prevalence of CYP with type 1 diabetes in Western Europe and it has an estimated incidence rate of 193.8 per 100000[ 3 ].

In the United Kingdom, there are approximately 400000 people diagnosed with type 1 diabetes, with 30000 CYP from 0 to of 18 years living with Type 1 diabetes[ 1 ]. The International Diabetes Federation Diabetes Atlas 9 th edition reported that an estimated 600000 CYP with Type 1 diabetes are under 15 years of age worldwide[ 4 - 6 ]. A recent paper based on the discrete-time cohort-level Markov illness–death model, estimates that worldwide prevalence of type 1 diabetes is substantial and is growing[ 2 ].

Prevalence and incidence

The United Kingdom National Paediatric Diabetes Audit (NPDA) 2020/2021 in England and Wales reported approximately 30000 CYP with Type 1 diabetes and 600 CYP with type 2 Diabetes[ 7 ]. The reported prevalence rate of Type 1 diabetes in England and Wales was 204.5 per 100000 population in the United Kingdom. The NPDA 2019/2020 audit reported an incidence of 2900 CYP diagnosed with Type 1 diabetes, of whom almost 3000 CYP (95.3%) were aged between 0 and 15 years. In 2020/2021, there was an increase in number of both girls and boys diagnosed with Type 1 diabetes (27.4% and 12.6% increase in boys and girls respectively). The seasonal pattern of new diagnoses of type 1 diabetes mellitus (T1DM) was also disrupted in 2020/2021. Previously there had been a consistent pattern of new diagnoses of Type 1 amongst CYP with a spike in new diagnoses during winter months and fall in the summer. This is a well-known phenomenon in other countries with high incidence of diabetes[ 8 ]. The reason for this is unclear but it has been suggested that this could be due to increase in viral illnesses during winter months[ 7 ]. This pattern of new diagnoses was disrupted in 2020/2021 and reason for this is not known. One could attribute this to coronavirus disease 2019 (COVID-19) pandemic. Efforts to control COVID-19 such as lockdowns, social isolation led to reduction in common childhood viral illnesses[ 9 - 11 ].

Glycated hemoglobin outcomes and complication rates

Glycated hemoglobin (HbA1c) is a marker for glycaemic control over preceding 2-3 mo. The Diabetes and Complications Trial (DCCT) trial has shown that intensive diabetes management and good glycaemic control lower the risk of developing microvascular complications and early mortality in the future[ 12 ]. Data from NPDA have shown consistent year on year improvements in HbA1c[ 5 ]. Median HbA1c in England has fallen from 73 mmol/mol in 2009/2010 to 61 mmol/mol 2020/2021. Similar trend has been noticed in Wales where HbA1c fell from 72 mmol/mol to 62 mmol/mol over the same period (Figure 1 ).

Median glycated hemoglobin of all types of diabetes in England and Wales from 2009/2010 to 2020/2021 for children and young people under the age of 18 years (permission to reproduce from National Paediatric Diabetes Audit Royal College of Paediatrics and Child Health and Healthcare Quality Improvement Partnership). Citation: National Paediatric Diabetes Audit Annual Report 2021-22: Care Processes and Outcomes. London: Royal College of Paediatrics and Child Health, 2023. Copyright © 2023 Healthcare Quality Improvement Partnership ( Supplementary material ).

In 2015, the National Institute for Health and Care Excellence (NICE) recommended a target HbA1c of 48 mmol/mol or less to improve the diabetes management[ 13 ]. This led to updated diabetes delivery plan in Wales[ 14 ]. Prior to that best practice tariff (BPT) was introduced in England in 2012. Peer review (Quality assurance) was introduced at the back of BPT to support the paediatric diabetes units in fulfilling the criteria as set out in BPT. Other national initiatives such as the Royal College of Paediatrics and Child Health Quality improvement programme have been introduced to help achieve the target HbA1c [15 . This QI collaborative supported diabetes teams with tools to identify and deliver their own initiatives that are relevant to the needs of the CYP and their families that they care for locally. Although the overall HbA1c trend has been downwards amongst the CYP with T1DM, there have been consistent differences in outcomes between different ethnic backgrounds. Those from white ethnicity achieve lower average HbA1c compared to those from black ethnicity and this trend is apparent year on year[ 7 ] (Figure 2 ). The NPDA showed a significant relationship between HbA1c and deprivation. Those living in deprived areas tend to have a higher HbA1c (Figure 3 ). However, this trend has not been noticed in CYP of black ethnicity. Average HbA1c for CYP from black ethnicity living in least deprived areas is similar to those from white ethnicity in the most deprived.

Mean glycated hemoglobin for children and young people with Type 1 diabetes in England and Wales by ethnic group from 2003/2004 to 2020/2021 (permission to reproduce from National Paediatric Diabetes Audit Royal College of Paediatrics and Child Health and Healthcare Quality Improvement Partnership). Citation: National Paediatric Diabetes Audit Annual Report 2021-22: Care Processes and Outcomes. London: Royal College of Paediatrics and Child Health, 2023. Copyright © 2023 Healthcare Quality Improvement Partnership ( Supplementary material ).

Mean glycated hemoglobin for children and young people with Type 1 diabetes by deprivation quintile, 2013/2014 to 2020/2021 (permission to reproduce from National Paediatric Diabetes Audit Royal College of Paediatrics and Child Health and Healthcare Quality Improvement Partnership). Citation: National Paediatric Diabetes Audit Annual Report 2021-22: Care Processes and Outcomes. London: Royal College of Paediatrics and Child Health, 2023. Copyright © 2023 Healthcare Quality Improvement Partnership ( Supplementary material ).

CYP with diabetes are at increased risk of diabetic nephropathy and retinopathy. All CYP with Type 1 diabetes are screened for albuminuria after 12 years of age since NICE made that recommendation in 2015[ 13 ]. 10.3% of CYP were recorded as having micro or macroalbuminuria. This number has been static since 2015/2016[ 7 , 14 ]. Across the audit year, there has been no significant changes in the presence of albuminuria associated with duration of diabetes. CYP above 12 years of age get retinopathy screening annually. But the interval for screening changed for many in 2020/2021. Many screening services were advised to screen biennially unless an abnormal result was identified previously. Almost 25% of CYP with T1DM who were eligible for eye screening were screened in 2020/2021 compared to 75% in 2019/2020. The NPDA records eye screening as abnormal or normal. It does not differentiate between the grade of retinopathy. In 2020/2021, 16.9% of those who were screened had an abnormal result, this number has varied between 12%-15% since 2015/2016. CYP with T1DM are more likely to develop other autoimmune conditions. They are annually screened for thyroid and coeliac disease. Two-point-seven percent of screened children had thyroid disease and 5.2% were positive for coeliac in 2020/2. Figure 4 shows the longitudinal trend of% of children with thyroid and coeliac disease from 2015/2016- 2020/2021.

Percentage of children and young people with Type 1 diabetes with thyroid or coeliac disease in England and Wales, 2014/2015 to 2020/2021. Prevalence of coeliac disease was highest among the white children and young people (CYP) and thyroid disease was commonest among the Asian CYP in 2020/2021. Citation: National Paediatric Diabetes Audit Annual Report 2021-22: Care Processes and Outcomes. London: Royal College of Paediatrics and Child Health, 2023. Copyright © 2023 Healthcare Quality Improvement Partnership ( Supplementary material ).

Key care processes performed annually

NICE recommends 7 key health check that should be performed annually[ 13 ]. HbA1c (4 readings a year), height and weight for all CYP with T1DM. Thyroid function tests to be undertaken every year for all CYP. After 12 years of age, CYP with T1DM should get urinary albumin, blood pressure, retinopathy screen and foot examination. However, there were disruptions to retinopathy screening in 2020/2021[ 7 ]. Retinopathy screening was reduced from annually to biennially unless there was a previous abnormal result. There have been an improvement in completion of key health checks over the last 10 years. The completion rates for 2020/2021 reduced due to cessation of face to face clinic due the COVID-19 pandemic. Figure 5 shows the trend improvement in completion of all key processes over the years. There was a large difference amongst various diabetes units’ ability in completing key health check in 2020/2021. Similar trends have been noticed in previous audit years.

Percentage of children and young people who completed a full year of care recorded as receiving individual health checks, 2004/2005 to 2020/2021. Citation: National Paediatric Diabetes Audit Annual Report 2021-22: Care Processes and Outcomes. London: Royal College of Paediatrics and Child Health, 2023. Copyright © 2023 Healthcare Quality Improvement Partnership ( Supplementary material ).

Insulin regimens

In 2020/2021, 38.5% of CYP with T1DM in England and Wales were using an insulin pump to manage their diabetes[ 7 ]. This has increased from 28.1% in 2015/2016. In 2020/2021, 59.1% were on multiple daily injection and only 2.4% were on one-three injections a day. The number of CYP using pump therapy have steadily increased over the years. But this trend has reversed amongst 0-9 years old since 2018/2019 (Figure 6 ). CYP are more likely to be on insulin injections in the first year of their diagnosis compared to those who were 5-9 years in to diagnosis in 2020/2021. The percentage of those using insulin pumps in 1 st year of their diagnosis reduced in 2020/2021 to 13.9% from 4.8% in the previous year. It could be a reflection of changes in care provision due to pandemic as this number has been steadily increasing since 2016/2017. There remains a larger gap in insulin pump usage and insulin injections amongst those CYP living in most deprived areas. In 2020/2021 the gap in number of CYP on insulin pump therapy in those living in the most and least deprived areas was 32.5% compared to 44.0%, respectively (a difference of 11.5 percentage points), which had widened from 2014/2015, when it was 18.4% vs 26.3% (a difference of 7.9 percentage points).

Percentage of children and young people either on daily insulin injections or pump therapy by age group, 2014/15 to 2020 /21. Citation: National Paediatric Diabetes Audit Annual Report 2021-2022: Care Processes and Outcomes. London: Royal College of Paediatrics and Child Health, 2023. Copyright © 2023 Healthcare Quality Improvement Partnership ( Supplementary material ).

Similar differences in the use of real time continuous glucose monitor (rtCGM) have been identified. Over last few years, increased use of rtCGM has been noticed but the gap in its usage for most and least deprived has widened with time. CYP from least deprived quintiles are more likely to use rtCGM. This is true across most ethnic groups but black CYP typically have lower use of rtCGM which was irrespective of their deprivation status[ 16 ]. NPDA data[ 7 ] has also reported that CYP who were using rtCGM technology were more likely to attain target HbA1c levels compared to those who were not on trCGM. Similarly, pump users were more likely to be using rtCGM compared to those on insulin injections.

Universal health coverage and national quality initiatives

In England and Wales, the existence of universal health coverage and national quality initiatives as well as the formation of 10 Diabetes Regional Networks geographically situated in former Strategic Regional Health Authorities has resulted in improved diabetes health outcomes and diabetes units’ increasing participation in the NPDA[ 7 ]. As a result, the NPDA has allowed a country-wide data monitoring and benchmarking of diabetes outcomes and its services within and between regions. The ultimate aim of such national quality initiatives is to improve diabetes care and quality, and to remove health inequalities of service provision within and between regions. The past decade have seen a move towards intensification of insulin therapy, and increasing use of diabetes technologies such as continuous subcutaneous insulin infusions and rtCGM. The BPT was introduced in England to increase the funding provisions per year of care for paediatric diabetes services, with the aim to enhance the quality of diabetes care and improve the health outcomes for CYP with diabetes[ 17 ]. Participation in the NPDA is one of the key requirements for obtaining the BPT and data for individual centres are further tracked and utilized as part of a ‘peer review’ quality assurance programme.

Health inequalities and social deprivation

The NPDA report[ 7 ] has shown that while there is an increasing trend in insulin pump usage compared to injections in all areas of deprivation, the gap between insulin pump usage and rtCGM usage amongst CYP living in the most and least deprived areas, and between CYP of White ethnicity and Black ethnicity has further widened year-on-year over the past 6 years. Table 1 shows the graphs of CYP with Type 1 diabetes by deprivation areas which are derived by postcode-matching to the English (IMD, 2016) and Welsh (WIMD, 2015) indices of multiple deprivation data. The proportion of CYP with Type 1 diabetes living in the most deprived quintile was slightly higher, and this has been a trend across the years.

Percentage and number of children and young people with Type 1 diabetes by deprivation quintile, 2020/2021 permission to reproduce from National Paediatric Diabetes Audit Royal College of Paediatrics and Child Health and Healthcare Quality Improvement Partnership

Percentage of general population aged 0 to 19 years old in England and Wales. Calculations made using the "Lower layer Super Output Area population estimates" from the Office for National Statistics, mid-year 2020. Citation: National Paediatric Diabetes Audit Annual Report 2021-22: Care Processes and Outcomes. London: Royal College of Paediatrics and Child Health, 2023. Copyright © 2023 Healthcare Quality Improvement Partnership ( Supplementary material ).

There remains a persistent difference in HbA1c health outcomes achieved by Paediatric Diabetes centres across England and Wales even after patient characteristics have been accounted for in the last decade. In addition, there is clear evidence that there are inequalities on access to use of diabetes technologies such as insulin pump and rtCGM which has been shown to have the potential to impact positively on of glycaemic control, fear of hypoglycemia and quality of life[ 16 ].

Research has shown that healthcare professionals can hold strong and sometimes incorrect views about the kinds of individuals who will be the ‘best candidates’ for, and make the best use of, diabetes technologies. Such views may influence who healthcare professionals offer technologies to and/or how they present the benefits/burdens of the technology. Studies have also shown that other factors, such as lack of availability of funding and staff with relevant clinical training, can also influence who does/does not get given opportunities to use new diabetes technologies[ 18 , 19 ].

Similar trends of health inequalities and racial-ethnic disparities in diabetes outcomes and management are reported from the United States Type 1 Diabetes Exchange National Registry which reported that ethnic minority young people had significantly worse diabetes health outcomes and were also prescribed less advanced diabetes technologies, while carers’ perceptions of cost and healthcare providers’ perception bias of family competence cited as reasons to such variations[ 20 - 22 ].

ACKNOWLEDGEMENTS

We thank Holly Robinson and the National Paediatric Diabetes United Kingdom NPDA, Royal College of Paediatrics and Child Health and Healthcare Quality Improvement Partnership for the reporting data and the figures.

Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.

Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Corresponding Author's Membership in Professional Societies: Professor Sze May Ng, OBE is Chair of the UK Association of Children’s Diabetes Clinicians; Chair of the UK NIHR Clinical research Group and Diabetes Research Steering Group for Children and Young People; Officer for Research for the Royal College of Paediatrics; Chair of the European Society of Paediatric Endocrinology (ESPE) E-learning and on the International Society of Pediatric and Adolescent Diabetes (ISPAD) advisory council.

Peer-review started: February 3, 2023

First decision: March 1, 2023

Article in press: June 21, 2023

Specialty type: Endocrinology and metabolism

Country/Territory of origin: United Kingdom

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): B

Grade C (Good): C, C

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Belosludtseva NV, Russia; Islam MS, South Africa; Ng HY, China S-Editor: Li L L-Editor: A P-Editor: Cai YX

Contributor Information

Sze M Ng, Department of Paediatrics, Mersey and West Lancashire Teaching Hospitals NHS Trust, Ormskirk L39 2AZ, United Kingdom; Department of Women's and Children's Health, University of Liverpool, Liverpool L693BX, Merseyside, United Kingdom; Faculty of Health, Social Care & Medicine, Edge Hill University, Ormskirk L39 4QP, Lancashire, United Kingdom. [email protected].

Astha Soni, Department of Paediatrics, Sheffield Children's Hospital, Sheffield S10 2TH, United Kingdom.

• 1. Chan JCN, Lim LL, Wareham NJ, Shaw JE, Orchard TJ, Zhang P, Lau ESH, Eliasson B, Kong APS, Ezzati M, Aguilar-Salinas CA, McGill M, Levitt NS, Ning G, So WY, Adams J, Bracco P, Forouhi NG, Gregory GA, Guo J, Hua X, Klatman EL, Magliano DJ, Ng BP, Ogilvie D, Panter J, Pavkov M, Shao H, Unwin N, White M, Wou C, Ma RCW, Schmidt MI, Ramachandran A, Seino Y, Bennett PH, Oldenburg B, Gagliardino JJ, Luk AOY, Clarke PM, Ogle GD, Davies MJ, Holman RR, Gregg EW. The Lancet Commission on diabetes: using data to transform diabetes care and patient lives. Lancet. 2021;396:2019–2082. doi: 10.1016/S0140-6736(20)32374-6. [ DOI ] [ PubMed ] [ Google Scholar ]
• 2. Gregory GA, Robinson TIG, Linklater SE, Wang F, Colagiuri S, de Beaufort C, Donaghue KC International Diabetes Federation Diabetes Atlas Type 1 Diabetes in Adults Special Interest Group, Magliano DJ, Maniam J, Orchard TJ, Rai P, Ogle GD. Global incidence, prevalence, and mortality of type 1 diabetes in 2021 with projection to 2040: a modelling study. Lancet Diabetes Endocrinol. 2022;10:741–760. doi: 10.1016/S2213-8587(22)00218-2. [ DOI ] [ PubMed ] [ Google Scholar ]
• 3. Iacobucci G. UK has fifth highest rate of type 1 diabetes in children, new figures show. BMJ. 2013;346:f22. doi: 10.1136/bmj.f22. [ DOI ] [ PubMed ] [ Google Scholar ]
• 4. International Diabetes Federation. International Diabetes Federation. [cited 23 May 2023]. Available from: https://idf.org/
• 5. IDF Diabetes Atlas Group. Update of mortality attributable to diabetes for the IDF Diabetes Atlas: Estimates for the year 2013. Diabetes Res Clin Pract. 2015;109:461–465. doi: 10.1016/j.diabres.2015.05.037. [ DOI ] [ PubMed ] [ Google Scholar ]
• 6. IDF Diabetes Atlas. IDF Diabetes Atlas 10th Ed 2021. 2020. [cited 23 May 2023]. Available from: https://diabetesatlas.org/atlas/tenth-edition/
• 7. Royal College of Paediatrics and Child Health. NPDA National report 2020/21: Care processes and outcomes Appendix 1: Full audit analysis. In: health RCoPac. 2022. [cited 23 May 2023]. Available from: https://www.rcpch.ac.uk/sites/default/files/2022-04/NPDA%20report%202020-21%20Appendix%201%20Full%20audit%20analysis_0.pdf . [ Google Scholar ]
• 8. Turtinen M, Härkönen T, Ilonen J, Parkkola A, Knip M Finnish Pediatric Diabetes Register. Seasonality in the manifestation of type 1 diabetes varies according to age at diagnosis in Finnish children. Acta Paediatr. 2022;111:1061–1069. doi: 10.1111/apa.16282. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 9. Principi N, Berioli MG, Bianchini S, Esposito S. Type 1 diabetes and viral infections: What is the relationship? J Clin Virol. 2017;96:26–31. doi: 10.1016/j.jcv.2017.09.003. [ DOI ] [ PubMed ] [ Google Scholar ]
• 10. Kruizinga MD, Peeters D, van Veen M, van Houten M, Wieringa J, Noordzij JG, Bekhof J, Tramper-Stranders G, Vet NJ, Driessen GJA. The impact of lockdown on pediatric ED visits and hospital admissions during the COVID19 pandemic: a multicenter analysis and review of the literature. Eur J Pediatr. 2021;180:2271–2279. doi: 10.1007/s00431-021-04015-0. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 11. Kuitunen I, Artama M, Mäkelä L, Backman K, Heiskanen-Kosma T, Renko M. Effect of Social Distancing Due to the COVID-19 Pandemic on the Incidence of Viral Respiratory Tract Infections in Children in Finland During Early 2020. Pediatr Infect Dis J. 2020;39:e423–e427. doi: 10.1097/INF.0000000000002845. [ DOI ] [ PubMed ] [ Google Scholar ]
• 12. Nathan DM, Genuth S, Lachin J, Cleary P, Crofford O, Davis M, Rand L, Siebert C Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–986. doi: 10.1056/NEJM199309303291401. [ DOI ] [ PubMed ] [ Google Scholar ]
• 13. National Collaborating Centre for Women's and Children's Health (UK) Diabetes (Type 1 and Type 2) in Children and Young People: Diagnosis and Management. London: National Institute for Health and Care Excellence (UK); 2015 Aug. [ PubMed ] [ Google Scholar ]
• 14. Llywodraeth Cymru Welsh Government. Diabetes Delivery Plan for Wales 2016-2020. Welsh: Government W. Dec 2016. [cited 23 May 2023]. Available from: https://www.gov.wales/sites/default/files/publications/2018-12/diabetes-delivery-plan-2016-to-2020.pdf .
• 15. National Diabetes Quality Programme. Secondary National Diabetes Quality Programme. [cited 23 May 2023]. Available from: https://www.rcpch.ac.uk/work-we-do/QI-patient-safety/diabetes-quality-programme .
• 16. Ng SM, Evans ML. Widening health inequalities related to type 1 diabetes care in children and young people in the UK: A time to act now. Diabet Med . 2021;38:e14620.. doi: 10.1111/dme.14620. [ DOI ] [ PubMed ] [ Google Scholar ]
• 17. Randell T. Developing a Best Practice Tariff in paediatric diabetes. Practical Diabetes . 2012;29:176–177a. [ Google Scholar ]
• 18. Ng SM, Moore HS, Clemente MF, Pintus D, Soni A. Continuous Glucose Monitoring in Children with Type 1 Diabetes Improves Well-Being, Alleviates Worry and Fear of Hypoglycemia. Diabetes Technol Ther. 2019;21:133–137. doi: 10.1089/dia.2018.0347. [ DOI ] [ PubMed ] [ Google Scholar ]
• 19. Lawton J, Kirkham J, Rankin D, White DA, Elliott J, Jaap A, Smithson WH, Heller S REPOSE Group. Who gains clinical benefit from using insulin pump therapy? A qualitative study of the perceptions and views of health professionals involved in the Relative Effectiveness of Pumps over MDI and Structured Education (REPOSE) trial. Diabet Med. 2016;33:243–251. doi: 10.1111/dme.12879. [ DOI ] [ PubMed ] [ Google Scholar ]
• 20. Lawton J, Kimbell B, Rankin D, Ashcroft NL, Varghese L, Allen JM, Boughton CK, Campbell F, Randell T, Besser REJ, Trevelyan N, Hovorka R CLOuD Consortium. Health professionals' views about who would benefit from using a closed-loop system: a qualitative study. Diabet Med. 2020;37:1030–1037. doi: 10.1111/dme.14252. [ DOI ] [ PubMed ] [ Google Scholar ]
• 21. Willi SM, Miller KM, DiMeglio LA, Klingensmith GJ, Simmons JH, Tamborlane WV, Nadeau KJ, Kittelsrud JM, Huckfeldt P, Beck RW, Lipman TH T1D Exchange Clinic Network. Racial-ethnic disparities in management and outcomes among children with type 1 diabetes. Pediatrics. 2015;135:424–434. doi: 10.1542/peds.2014-1774. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ]
• 22. Valenzuela JM, La Greca AM, Hsin O, Taylor C, Delamater AM. Prescribed regimen intensity in diverse youth with type 1 diabetes: role of family and provider perceptions. Pediatr Diabetes. 2011;12:696–703. doi: 10.1111/j.1399-5448.2011.00766.x. [ DOI ] [ PubMed ] [ Google Scholar ]
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Home > Knowledge & support > About type 1 diabetes

About type 1 diabetes

Type 1 diabetes is a serious autoimmune condition that occurs when your immune system mistakenly attacks beta cells within the pancreas, which then stop producing insulin. As a result, glucose levels in your blood start to rise, and your body can’t function unless you replace the insulin.

In this section

What is type 1 diabetes?

Find out what type 1 diabetes is and how the condition is treated.

Signs and symptoms of type 1 diabetes

Knowing the signs and symptoms of type 1 diabetes can save someone’s life. Find out what they are and what to do if you spot them.

Causes of type 1 diabetes

There are many myths and misconceptions about the causes of type 1 diabetes. Get the facts from us.

What is the difference between type 1 and type 2 diabetes

Type 1 and type 2 diabetes are two different types of diabetes, which have different causes, symptoms and approaches to treatment.

Treating type 1 diabetes

Type 1 is treated by putting insulin into your body and measuring blood glucose. We take you through the different ways of doing this, how they work and what’s available on the NHS.

The honeymoon phase in type 1 diabetes

Type 1 diabetes can be easier to manage in the first few months after diagnosis. This is known as the honeymoon period. Find out what happens during this phase.

Have you been recently diagnosed?

Our guides can help provide you with information and support in your journey to living well with type 1 diabetes.

Shared stories

Diabetes made me much more open with people

“I was in my first term at university when I first experienced symptoms. I didn’t know it at the time, but they were the classic symptoms of diabetes.”

We are perfectly imperfect

“Surfing reminds me a lot of my journey with diabetes. I often miss waves and fall off my board, but I never stop paddling.”

The dog weighed more than me

Yasmin tells us how hybrid close loop has changed her life.

He thrives at school, has plenty of friends, and takes every day in his stride

Lawrence Newton talks about his son Oliver’s type 1 diagnosis and finding support through family, friends, and other parents of children with type 1.

Further reading

Managing type 1 diabetes

Our guide to managing type 1 diabetes gives you information and support on how to manage your blood glucose levels, count carbs and deal with hypos and hypers.

Everyday life

Just because you have type 1 diabetes, it doesn’t mean you need to stop doing the things you love. Find out more about living well with type 1.

Type 1 diabetes research

We focus on investing in research that will transform the lives of people with type 1 diabetes.

Type 1 diabetes and other autoimmune conditions

Find out why people who have one autoimmune condition are at greater risk of developing other types of autoimmune disease.

More resources

Explore our Type 1 Diabetes Discovery events and browse our resource hub for more type 1 lifestyle information.

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