Episode 34 — Building High-Performance Type 1 Diabetes Care

In this episode

Many clinics now have access to CGM and automated insulin delivery (AID), yet outcomes vary widely between centres, regions, and countries. That gap is not just about the technology — it is about 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. The discussion also explores what comes after insulin-only AID: smarter data-driven care pathways and adjunct therapies such as GLP-1 receptor agonists.

What this episode explores

• How Sweden used a national diabetes registry to create accountability and rapid learning between clinics
• Why early structured follow-up after starting CGM or AID tends to be an investment, not an optional extra
• How targets shape behaviour: changing what you measure changes what you achieve
• Why people with the highest HbA1c are often among those who benefit most from 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-1 receptor agonists

Key themes

1. Start technology with a structure, not a handout

Peter’s model: educate the person using the device, bring them back quickly (often within one to two weeks), then iterate with a clear target and a plan. Early follow-up is the part that tends to convert “having technology” into “getting results from technology”.

2. Invest up front, or don’t start

If a clinic cannot support early and frequent follow-up after technology initiation, outcomes tend to plateau and frustration rises. The early investment phase is where the opportunity to improve is greatest.

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 small number of enthusiasts to carry the knowledge burden for everyone.

4. Accountability drives improvement

Sweden’s national registry started with anonymised clinic comparisons, then moved to named clinic transparency. Once performance is visible and comparable, behaviour tends to change: clinics learn from the best-performing centres and compete to improve.

5. Aim high early, then individualise

In the first zero to two years after diagnosis, residual insulin can make tight targets more achievable, and early gains tend to pay off long-term. Later, targets still matter, but the burden and impact on daily life must be balanced so people do not burn out.

6. The high HbA1c group should not be left behind

Peter argues against the “prove yourself first” mindset. People who find bolusing, carb counting, or daily maths difficult are often among those who benefit most from AID — and withholding technology can deepen inequality.

7. 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.

8. Care should follow need, not calendar appointments

With 288 CGM readings per day, one recurring question is why to wait three months to act. Peter describes a future where platforms flag deterioration early and clinics contact the right patients in the right week — while those doing well might attend less often.

9. Diabetes “2.0” may involve mixed therapy and smarter systems

Beyond insulin-only AID, Peter anticipates more personalised add-ons — including GLP-1 receptor agonists in selected cases — especially for those with high total daily doses and weight-related challenges. The goal is not only glycaemia but reducing insulin burden and supporting long-term health.

Practical exploration checklist

For clinics starting or scaling CGM and AID programmes:

• Build a standard onboarding pathway: education session, review at one to two weeks, then planned optimisation reviews
• Define what success looks like — range targets, hypoglycaemia thresholds, and 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 technology, 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 best-performing centres

For people with type 1 diabetes and families using CGM and 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
• 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, explore the full conversation with your team

About the 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.

Related episodes

• Episode 18 — Exercise without fear (Othmar Moser)
• Episode 7 — Fundamentals of The GNL
• Episode 8 — Activity snacking and time in range