Good Enough Got Us Here. But We Need What Is Next.

Gratitude first

Thank you to the researchers who discovered insulin. To the engineers who gave us sensors and pumps. To the clinicians, carers, and families who have fought for better care, day in and day out. And to every single person with type 1 diabetes who has helped move the needle — not just in clinical trials, but in the quiet, relentless work of day-to-day life.

A century ago, a diagnosis was a death sentence. Today, people with type 1 diabetes live longer, fuller lives than ever. That deserves acknowledgement.

But we cannot stop here.

Diabetes made us pioneers

There is a unique kind of wisdom that comes from living with type 1 diabetes. You learn to trial and error your way through every day. You read your body like a scientist. You sense trends before your CGM does. You know when something is off before a number confirms it.

We are data nerds, detectives, analysts, and artists of adaptation.

But that does not mean it is easy.

Despite the advances, type 1 diabetes is still a condition of constant vigilance. It is waking up to alarms in the night. It is adjusting doses on holiday. It is trying to explain to a boss or a teacher or a friend that you are fine, while actually feeling shaky, foggy, and 3.2 mmol/L.

Even now, only one in four people reach recommended glucose targets. Even now, many children are still diagnosed in DKA. Even now, people with type 1 diabetes die too early. Even with a lifetime of HbA1c values at target, the risk of all-cause cardiovascular death is approximately three times higher than in the general population.

This is not a failure. It is a sign we have gone as far as insulin can take us.

We are on the edge of something big

The future is not just about managing diabetes better. It is about changing it entirely.

Researchers now understand that type 1 diabetes develops over time. Before diagnosis, the immune system is already quietly attacking beta cells. That opens a window of opportunity — one where it may be possible to preserve, protect, and possibly restore insulin production.

Proof of concept already exists:

• Teplizumab can delay the clinical onset of diabetes by years in at-risk individuals
• Donislecel is a cell therapy in which some people have become insulin-independent

These are not theoretical possibilities. They are happening now. They mark the beginning of a chapter where the field stops simply firefighting glucose and starts addressing the root cause.

But progress needs permission

The challenge is that our systems have not caught up with our science.

Regulatory rules still centre HbA1c and hypoglycaemia rates as the key endpoints for trial approval. These do not tell the full story. They do not measure the emotional toll, the disrupted sleep, the burnout, or the mental load of 24/7 decision-making.

We need smarter tools to assess benefit. We need to include C-peptide to measure beta-cell function — if you want to understand why, the GNL C-peptide guide explains why every bit of residual insulin production counts.

We need CGM metrics that show real-time progress. But for that, we need standardisation of CGM accuracy assessments. The IFCC Working Group on CGM is driving towards an ISO standard — worth getting behind. For more on why CGM accuracy standardisation matters, the GNL CGM accuracy guide covers the detail, and Episode 35 with Professor Othmar Moser explains how independent researchers are contributing to that standardisation effort — and why CE marking alone is not sufficient evidence for insulin dosing decisions.

And above all, we need patient voices front and centre.

When people with type 1 diabetes say they would accept new trade-offs — such as the risk of immunosuppression for the chance of insulin independence — we must believe them. They have lived with risk their whole lives. They know what is worth it.

The cost of stagnation, seen clearly, is a threefold increase in risk of death. That framing changes the risk-benefit calculation significantly.