Whose Standards Are We Chasing? Rethinking Diabetes Targets in Low-Resource Settings

Let’s talk about a brutal truth: the global diabetes care playbook was not written with the Global South in mind. It was written in boardrooms, clinics, and conference halls in cities equipped with continuous glucose monitors (CGMs), insulin pumps, closed-loop systems, and endocrinology specialists on speed dial. And then—without pause—it was handed down to us as the gold standard.

But here’s the kicker: while the benchmarks are aspirational, the tools to achieve them remain locked behind the towering walls of inequality. For people living with diabetes in Africa and across many low- and middle-income countries (LMICs), the standard of care set by high-income countries (HICs) is not just unreachable—it’s stigmatizing.

Take “Time in Range” (TIR), for instance. It’s a concept that makes perfect sense when you’re wearing a CGM and adjusting basal rates on an insulin pump. But when you’re injecting premixed insulin twice a day without a glucometer or test strips, it becomes an abstract metric at best—and at worst, a source of shame. We are being measured by rulers we were never given the chance to hold.

Let’s be clear: HbA1c targets of 6.5% are beautiful goals on paper. But in practice, they are often unattainable for people using outdated insulins like NPH (Protaphane), with little-to-no diabetes education, monitoring tools, or support. It's not just an unfair game—it’s rigged.

I say this not as an outsider but as someone deep in the trenches. I live with type 1 diabetes. I am a certified diabetes educator. I am an advocate who has sat with the global experts, many of whom are stunned when I explain the day-to-day realities faced by people in LMICs. Realities where GPs fill in for endocrinologists, where analog insulins are a distant dream, and where most people can only access care when it’s already too late.

The painful irony? More than 90% of the human insulin produced by one of the largest pharma companies goes to LMICs. Meanwhile, we remain without national registries, without sufficient healthcare provider training, and without access to essential technology. This isn’t just a data gap—it’s a humanitarian gap.

I’ve heard of children in rural clinics being prescribed the same dose of NPH for both morning and evening. I’ve heard of hospitalisations spiking—not because of non-compliance, but because the care being offered is non-compatible with life. In what world is this acceptable?

We need to tear up the script and rewrite it in our own language.

A Call to Reality-Based Standards

Diabetes care should not be an exam. A person’s HbA1c is not a moral report card. We must move away from the toxic notion that if you’re not hitting the same targets as someone in London or New York, then you’re “failing.” That’s not medicine—that’s discrimination.

We need to advocate for tiered, realistic, and resource-sensitive standards. Let’s encourage improvement without condemnation. Everyone deserves the dignity of a care plan that starts from their reality—not someone else’s utopia.

Healthcare professionals (HCPs) in LMICs must be empowered to adapt guidelines rather than blindly adopt them. It’s time to drop the judgmental language—"non-compliant," "non-adherent," "uncontrolled"—and replace it with empathy and context. Sometimes, the issue isn’t education or attitude. It’s access.

Let’s replace shame with support. A young woman using twice-daily NPH without test strips should not be told her 8.5% HbA1c is a failure. She should be celebrated for her resilience and supported to aim for 8.0%. Then 7.5%. One step at a time.

And let’s be honest: complications happen. They don’t mean you’ve failed at diabetes. They mean you’ve lived with a condition that—without adequate support—can hurt you. But the good news? Better management reduces the risk. And that’s the true goal: not perfection, but progress toward a better quality of life.

Why Representation and Equity in Knowledge Sharing Matter

I’m eternally grateful for programmes like the #dedoc° voices scholarship that gave me a front-row seat at some of the most extraordinary diabetes conferences. I’ve been privileged to be part of global conversations that often don’t reach the clinic back home. Thanks to Life for a Child (LFAC), I’ve also seen health professionals from LMICs attend ISPAD conferences, participate in mentorships, and gain the knowledge they need to bring meaningful change.

But these opportunities must become the norm—not the exception.

Until all HCPs in LMICs can join international networks, share knowledge, access updated guidelines, and work within diabetes teams (not in silos), we are simply hoping for miracles without the machinery.

What Needs to Change—Now

1. Set resource-appropriate targets – National diabetes programs must define context-specific goals based on available treatments, technology, and workforce.

2. End the insulin apartheid – Everyone should have access to analog insulins and MDIs. Twice-daily NPH is not a 21st-century solution.

3. Train the workforce – We need more than GPs. We need diabetologists, CDEs, dietitians, mental health experts, and social workers working together.

4. Language matters – Let’s banish the blame game. No more “non-compliance.” Let’s talk about “barriers to access.”

5. Invest in registries – We can’t improve what we don’t measure. Data isn’t a luxury; it’s a necessity.

6. Support real-world innovation – Mobile health, peer mentoring, community-led monitoring, pharmacy-based care—we need solutions that work here, not just there.

A Final Word

We often say, “Nothing about us, without us.” But it’s time to go further.

Nothing for us, without understanding us.

The end goal should never be to meet arbitrary numbers on a chart. It should be to ensure that every person living with diabetes—whether in Harare, Hanoi, or Hamburg—can live with dignity, safety, and joy.

Yes, joy. Because diabetes isn’t just about insulin and glucose—it’s about life.

And that life deserves to be legendary.