- Guest: Dr Peter Adolfsson (ISPAD 2022 Exercise Chapter Lead; Paediatric Diabetologist, Sweden)
- Host: John Pemberton
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Why this episode exists
Many clinics now have access to CGM and automated insulin delivery (AID), yet outcomes vary wildly between centres, regions, and countries. That gap is not just “the technology” — it is how teams educate, follow up, set targets, share best practice, and hold themselves accountable.
In this conversation, Dr Peter Adolfsson explains how Sweden built a system that uses national data, structured technology onboarding, and early investment (especially in the first two years after diagnosis) to improve HbA1c and raise expectations — without ignoring real-world constraints like psychology, social complexity, and inequality of access. We also explore what comes after insulin-only AID: smarter data-driven care pathways and adjunct therapies such as GLP-1 receptor agonists.
What you’ll learn
- How Sweden used a national diabetes registry to create accountability and rapid learning between clinics
- Why early structured follow-up after starting CGM/AID is an investment, not an optional extra
- How targets shape behaviour: changing what you measure changes what you achieve
- Why the people with the highest HbA1c should often be first in line for AID
- How to think about time in tight range (70–140 mg/dL; 3.9–7.8 mmol/L) in a way that is ambitious but humane
- Where diabetes “2.0” may be heading: smarter platforms, more frequent support, and mixed therapies (including GLP-1RA)
Key takeaways
1) Start tech with a structure, not a handout
Peter’s model is simple: educate the person using the device, bring them back quickly (often within 1–2 weeks), then iterate with a clear target and a plan. The early follow-up is not a luxury — it is the part that converts “having technology” into “getting results”.
2) Invest up front, or don’t start
If a clinic cannot support early and frequent follow-up after technology initiation, outcomes will plateau and frustration rises. Peter’s blunt point: if you cannot do the investment phase, you risk doing a poor start that wastes the opportunity.
3) Healthcare professionals need education too
Scaling outcomes requires training teams, not just families. Sweden has run large national pump and advanced technology courses, because a service cannot rely on a couple of “nerdy” staff members to carry the knowledge burden for everyone.
4) Accountability drives improvement
Sweden’s national registry started with anonymised clinic comparisons (the “carrot”), then moved to named clinic transparency (the “stick”). Once performance is visible and comparable, behaviour changes: clinics learn from the best-performing centres and compete to improve.
5) Targets are a nudge, and they work
Peter describes the deliberate move to a tighter CGM range based on healthy glucose distributions, and the reality that once teams and families know what “good” looks like, outcomes often shift. Measuring the right thing changes attention and action.
6) Aim high early, then individualise
In the first 0–2 years after diagnosis, residual insulin can make tight targets more achievable, and early gains pay off long-term. Later, targets still matter, but the “cost” (burden, fear, family capacity) must be balanced so people do not burn out.
7) The high HbA1c group should not be left behind
Peter argues strongly against the “prove yourself first” mindset. People who struggle with bolusing, carb counting, or daily maths are often exactly the people who benefit most from AID — and withholding technology can deepen inequality.
8) Equity needs data, not good intentions
John reflects on discovering unequal AID onboarding by ethnicity despite believing the service was equitable. The fix started with measurement: check your onboarding, compare it to your population, then do the harder work to engage those who have been overlooked.
9) Care should follow need, not calendar appointments
With 288 CGM readings per day, the question becomes: why wait three months to intervene? Peter describes a future where platforms flag deterioration early and clinics contact the right 10 people this week — while those doing well might attend less often.
10) Diabetes “2.0” may be mixed therapy plus smarter systems
Beyond insulin-only AID, Peter expects more personalised add-ons (including GLP-1RA, potentially others in selected cases), especially for those with high total daily doses and weight-related challenges. The goal is not just glycaemia — it is reducing insulin burden and improving long-term health.
Practical checklist
For clinics starting or scaling CGM/AID:
- Build a standard onboarding pathway: education session, then review at 1–2 weeks, then planned optimisation reviews
- Define what success looks like (range targets, hypoglycaemia thresholds, what matters to the person)
- Train the whole team, not just one or two enthusiasts: algorithms, settings logic, and common failure modes
- Use your service data: who is being offered tech, who is not, and why
- Prioritise those at highest risk: persistent high HbA1c, frequent admissions, or those overwhelmed by dosing complexity
- Measure outcomes, share learning, and copy what works from the best-performing centres
For people with type 1 diabetes and families using CGM/AID:
- Ask for early follow-up after starting a new device: small tweaks early can change everything
- Set targets that stretch you, but do not punish you: progress matters even when perfection is unrealistic
- Celebrate wins: not only “excellent control”, but any meaningful improvement
- If you are struggling with boluses or daily maths, say it out loud: that is a reason for more support, not a reason to delay technology
- If weight management is a major issue alongside high insulin doses, discuss the full toolbox with your team (nutrition support, resistance training, and where appropriate adjunct therapies)
Guest
Dr Peter Adolfsson is a paediatric diabetologist in Sweden and a long-standing leader in technology-enabled type 1 diabetes care. He has contributed extensively to diabetes education, CGM use in clinical practice, and international guidelines, including leading the ISPAD 2022 Exercise chapter. His work focuses on turning devices into outcomes: structured onboarding, early follow-up, clear targets, and systems that support both clinicians and families to achieve safer, tighter glucose control.
Disclaimer
The content available in The Glucose Never Lies® guides and podcast is for informational purposes only. Listening to the podcast does not constitute medical advice and is not a substitute for individualised care, and does not create a clinician–patient or therapeutic relationship with The Glucose Never Lies® or any guest. Always discuss changes to your diabetes management with your healthcare team.
