World Diabetes Day 14 November (4) The Lancet: Global progress and challenges for type 1 diabetes among children and adolescents in low-income and middle-income countries

12 November, 2021

CITATION: The Lancet Volume 398, Issue 10313, 13 November 2021, Pages 1837-1850

A century past the discovery of insulin: global progress and challenges for type 1 diabetes among children and adolescents in low-income and middle-income countries

Zulfiqar A Bhutta et al.


Type 1 diabetes is on the rise globally; however, the burden of mortality remains disproportionate in low-income and middle-income countries (LMICs). As 2021 marks 100 years since the discovery of insulin, we revisit progress, global burden of type 1 diabetes trends, and understanding of the pathogenesis and management practices related to the disease. Despite much progress, inequities in access and availability of insulin formulations persist and are reflected in differences in survival and morbidity patterns related to the disease. Some of these inequities have also been exacerbated by health-system challenges during the COVID-19 pandemic. There is a clear opportunity to improve access to insulin and related essential technologies for improved management of type 1 diabetes in LMICs, especially as a part of universal health coverage. These improvements will require concerted action and investments in human resources, community engagement, and education for the timely diagnosis and management of type 1 diabetes, as well as adequate health-care financing. Further research in LMICs, especially those in Africa, is needed to improve our understanding of the burden, risk factors, and implementation strategies for managing type 1 diabetes.


'Evidence suggests that incorporating shared-decision making, life-skills training, diabetes self- management education and integrating continuous subcutaneous insulin infusion (CSII) over multiple daily injections (MDI) has significant positive effects [among children with type 1 diabetes]

'Evidence suggests that increased awareness campaigns and education interventions are effective in reducing diabetic ketoacidosis among children and adolescents with type 1 diabetes.'

[Looking at systematic reviews, the vast majority of available evidence is from high-income countries.]

'Human resources, especially trained paediatric endocrinologists and diabetologists are a rarity in most LMICs, and hence a strategy to train existing physicians in the management of type 1 diabetes is important alongside strong public education strategies. There is considerable potential for task sharing by training and deploying community health workers (CHWs) to increase awareness of diabetes, for referrals, and for assisting in the management of type 1 diabetes in marginalised communities and special populations at risk...'

Neil Pakenham-Walsh, HIFA Coordinator,