Access to Diabetes Care Should Be a Universal Right for People With Type 1 Diabetes: Lessons Learned From the Norwegian Childhood Diabetes Registry

In a study published in this issue of Diabetes Care, Bratke et al. (1) showed success in glycemic control in children and adolescents with type 1 diabetes in Norway. On the other hand, many people with type 1 diabetes in the U.S. do not meet the American Diabetes Association or the International Society for Pediatric and Adolescent Diabetes HbA_1c goal of <7% despite advances in diabetes technologies and therapeutics (2). The T1D Exchange clinic registry, the largest type 1 diabetes registry for children and adults in the U.S., showed that mean HbA_1c was lower (8.4% vs. 8.7%) and the percentage of people who achieved HbA_1c <7% was higher (26% vs. 20%) in 2022 than they were in 2016 (2). Although there has been an improvement in glycemic control in the U.S. in recent years, many studies have revealed that glycemic outcomes are worse in the U.S. than in European countries (3–5). In addition, disparities exist in access to diabetes technologies and diabetes care (6,7). Nordic countries have a very high incidence of type 1 diabetes; however, their mean HbA_1c is significantly lower than those of the rest of the world (8,9). How do Nordic countries achieve that?

The study by Bratke et al. (1) analyzed 27,214 annual registrations from 6,775 children and adolescents from the Norwegian Childhood Diabetes Registry (NCDR) from 2013 to 2022. The authors investigated how HbA_1c and acute diabetes complications have changed from 2013 to 2022 with the use of diabetes technologies, carbohydrate counting, and participation in a quality improvement (QI) project. From 2013 to 2022, mean HbA_1c decreased from 8.2 to 7.2%, and the percentage of children and adolescents who achieved HbA_1c <7% increased from 13 to 43%. In the same period, the incidence of severe hypoglycemia and diabetic ketoacidosis–related hospital admissions decreased from 4.9 to 2.1% and from 4.8 to 1%, respectively. Use of continuous glucose monitors (CGM) and insulin pumps increased from 34 to 97% (2016 to 2022) and from 65 to 91% (2013 to 2022), respectively. A higher percentage of children and adolescents with HbA_1c <7% was found among the carbohydrate counters compared with the noncounters (33% vs. 18%). Mean HbA_1c was higher in adolescence than in childhood, and boys had lower mean HbA_1c than girls in 2013 and 2022. The children and adolescents who were being followed by the teams that participated in a QI project had significantly lower HbA_1c levels. The QI project included five learning sessions and one follow-up meeting, and it focused on identifying problems to improve glycemic control.

The study by Bratke et al. (1) has several strengths. It has a fairly large data set of children and adolescents with type 1 diabetes followed over 10 years with a high degree of data completeness and participation rate. The study was conducted in a country where diabetes technologies are fully reimbursed with no costs to the users, which minimizes selection bias. HbA_1c measurements were analyzed centrally at a single standardized laboratory for all registrants, with one HbA_1c measurement per registrant per year.

The current study also has limitations. It is based on observational data, and it may have potential bias by indication effect that some of the groups may change over time, such as using diabetes technologies intermittently and checking HbA_1c in different phases of treatment. In addition, there are no data on automated insulin delivery (AID) use in this registry. However, between 2018 and 2022 insulin pump users had significantly lower HbA_1c than users of multiple daily injection, while there was no difference in HbA_1c between these groups from 2013 to 2018. This change can likely be explained by the introduction of AID after 2018, so this study indirectly shows the benefits of AID use in type 1 diabetes. Pump users without CGM had significantly higher HbA_1c than CGM users with pump or multiple daily injections in this study. This finding further strengthens the importance of CGM use in type 1 diabetes management. Even though it was not indicated in this study, it is apparent that early initiation of diabetes technologies may also affect these results positively if we consider the significant improvements in outcomes in more recent years of the registry. Previous studies also showed lower HbA_1c and fewer diabetic ketoacidosis events with the early initiation of diabetes technologies within months from type 1 diabetes diagnosis (10,11).

The results from the study by Bratke et al. (1) support previous longitudinal studies that showed use of diabetes technologies has a significant impact on glycemic control. Alonso et al. (12) showed a significant decrease in HbA_1c (8.9% to 8.6%) with increasing use of CGM and AID in 1,455 children and adolescents with type 1 diabetes from 2016 to 2020. Similarly, Karakus et al. (13) showed that HbA_1c difference between diabetes technology users and nonusers increased over time, from 0.36% in 2014 to 0.93% in 2021 in 4,174 adults with type 1 diabetes. Another study by the T1D Exchange using >22,000 children and adults with type 1 diabetes showed that mean HbA_1c has decreased in the U.S. steadily from 2017 to 2022, and the lowest HbA_1c was achieved by the concomitant use of insulin pump and CGM (14).

There are several lessons we can learn from the NCDR. In Norway, almost all children and adolescents with type 1 diabetes are enlisted in a registry (98%), and almost all of them use diabetes technologies (CGM use 97% and pump use 91% in 2022). The improvement in HbA_1c and decrease in acute diabetes complications by year show the impact of diabetes technologies on diabetes-related outcomes. In addition to the benefits of diabetes technologies, this study showed the positive effect of carbohydrate counting and involvement in QI projects on diabetes care. As we also learned from this study, with structured diabetes education, early initiation and continuous use of diabetes technologies, nutrition counseling with carbohydrate counting, regular follow-ups for assessment of progress, and screening for diabetes-related complications, optimal glycemic control can be achieved (Fig. 1).

Sweden is another Nordic country with a low mean HbA_1c in children with type 1 diabetes, as shown in many studies (3,15). Sweden has full coverage for diabetes care costs for all children and adolescents. Diabetes registries such as the Swedish Pediatric Diabetes Quality Registry (SWEDIABKIDS) and the Swedish National Diabetes Register (NDR) played a significant role in establishing quality improvement projects and tracking participant meters (15).

Diabetes registries can be great sources to identify factors that affect glycemic control over time in the real world and monitor the development of long-term diabetes-related complications. I hope all countries can achieve the success of Norway in diabetes care. Universal access to health care coverage, equal access to diabetes technologies, and structured diabetes education programs strengthened with quality improvement projects are likely the keys to the success of Nordic countries. Access to diabetes care should be a universal right for all people with type 1 diabetes.