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Sometimes you have to give a man a fish

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Top-down and bottom-up approaches are both needed to improve diabetes outcomes worldwide

“The effort of diabetes care is great, but the reward is also great, for the prize is life itself.” Unfortunately, this statement by Elliot Joslin, made in 1928, is still true today. Over 90 years after Banting and Best’s Nobel prize-winning discovery of insulin, a front cover of The Lancet in 2006 posed Edwin Gale’s question “What is the commonest cause of death in a child with diabetes? The answer — from a global perspective — is lack of access to insulin.” This tragedy has particular relevance to people with type 1 diabetes in developing regions. Children and adults who develop this increasingly common, incurable condition, through no action or inaction of their own or their family, are totally dependent on insulin treatment for their survival, and if that is achieved, then for their quality of life. Even in affluent countries that subsidise insulin, blood tests and health care, the demands of balancing insulin doses with food, exercise, hormonal changes, intercurrent illness and stress are challenging.

In disadvantaged countries I have found that the average HbA1c (glycated haemoglobin)…