The Revolution Will Be Equitable: What ISPAD 2025 Proved — and Exposed

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Introduction

It was a profound honor and privilege to be part of the 51st ISPAD Scientific Conference 2025, held under the remarkable leadership of Dr. Mélanie Henderson and Dr. Julia von Oettingen, the distinguished convening co-presidents. This year’s conference stood as a beacon of innovation, equity, and collaboration — uniting the brightest minds in pediatric diabetes to reimagine the future of care. To witness the exchange of groundbreaking science, lived experiences, and global perspectives within such a visionary space was both humbling and electrifying — a testament to how far we have come, and how boldly we must continue to move forward.

My Role & Contributions

I am deeply grateful to have served not only as a member of the Scientific Conference Committee, but also as an invited speaker and co-chair in pivotal sessions shaping the global diabetes discourse. My contributions spanned across multiple platforms — from my presentation on “Co-creating solutions to bridge gaps in care and technology access” in the session Advocacy in Action: Policy & Funding Innovations for Achieving High-Quality Diabetes Care in LMICs, to sharing our research on “Global research inequity in type 1 diabetes: a scoping bibliometric analysis by country income”. I also participated in critical conversations through the Diabetes in Africa and Limited Resources Settings meeting, the thought-provoking session “Are we ready to introduce DIY to a broader audience?”, and the Poster Corner on Outcomes and Care Models.  

Speaking & Co-chairing

To stand among global experts and advocates in these dialogues was not merely participation — it was purpose in motion. As the sessions unfolded, several themes deeply resonated with me — lessons that will continue to shape how we advance diabetes care globally.

ISPAD 2025 Reflections Through My Lens

Joseph Wolfsdorf’s story: a clinician shaped by personal history — father with insulin-dependent diabetes and early, resource-poor DKA care in Johannesburg — reminded us that medicine is human first. 

His fascination with fuel metabolism and glucose regulation is why endocrine care marries physiology with compassion.

DCCT → EDIC: the science-and-soul pivot. The trials proved control matters: intensive therapy (≥3 injections/day or pump, 4–5 BG checks/day, frequent contact) reduced micro- and macrovascular complications and improved 30-year mortality. 

The takeaway: aim HbA1c as close to normal as safely possible, start early, and then build the systems to implement it — teamwork is mandatory.

Diabetes education = survival skill, not optional extras. Four clinic visits/year (120–240 minutes total) is a sliver of lived time; patients do the other 99.95%. 

Every visit must increase knowledge and self-efficacy. Teach practical skills, not just numbers.

Team-based care is non-negotiable: nurse educators, dietitians, mental-health pros, endocrinologists, school staff, coaches, pharmacists and family form the safety web. Where teams and registries/benchmarking exist (eg, Sweden/Norway/Germany/Austria) glycemic outcomes improve — standardize messaging and targets across the team.

Psychosocial care must be integral. Validate emotions after IAb positivity, use age-appropriate language, ask how families are coping, screen with validated tools, refer early to diabetes-trained mental health specialists, and normalize support — anxiety is a barrier to follow-up.

Screening for Type 1 diabetes is maturing into evidence-based public health: the consensus favors a three-age IAb screen (≈2–4y, 6–8y, 10–15y).

Targeted screening (relatives, autoimmune disease, HLA risk) is pragmatic, but to catch the majority we need general-population approaches. Early detection = less DKA, fewer admissions, lower HbA1c at diagnosis.

Practical screening nuance: young children who are IAb-positive often progress faster to Stage-3; repeat monitoring is essential. Screening windows at 2 and 5–7 years (and again at 10–14) are practical ties-in with well child visits and school health points.

Communication matters as intervention: explain staging, risks, and plan clearly (no false reassurance).

Use two-way conversations, pause for feedback, introduce skills gradually, and give concrete, accessible monitoring options.

DKA remains deadly and costly. DKA at diagnosis increased in many regions, is rising (~2%/yr), present in ~30% of new T1D (SEARCH) and portends brain changes, neurocognitive deficits, recurrent DKA, worse glycemia and increased morbidity/mortality. 

Preventing DKA is a public-health imperative.

Ketone testing is broken — urine strips are delayed and measure the wrong ketone. 

Blood ketone meters help, but continuous glucose + continuous ketone sensing (dual sensors) could detect metabolic decompensation earlier, prevent DKA, detect infusion failures, and improve AID safety.

Technology progress since DCCT is profound: rapid/ultra-rapid & long-acting analogs, improved BG meters, blood ketone meters, CGM, and automated insulin delivery (AID/hybrid closed-loop). These tools make safer targets achievable — but access determines who benefits.

How are we doing? Tech use and quality of life improved; severe hypoglycemia down. Yet ~60% of children still miss ISPAD glycemic targets. CGM access is a key driver — more automation could help, but equity and specialized care access remain the bottlenecks.

MiniMed™ 780G & Real-world AID: when optimized (recommended optimal settings) kids in Brazil and LATAM achieved comparable — often superior — TIRs vs global averages.

Bolusing behavior still matters; automation compensates but doesn’t absolve proper meal handling.

AID realities: hybrid closed-loop works best with meal announcements; fully closed-loop (no meal input) is the future but limited by insulin pharmacokinetics — current insulins act too slowly to fully prevent post-prandial spikes.

Personal Glucose Targets (PGT) are powerful clinical tools: adjustable PGT range (≈4.4–11 mmol/L) gives flexibility across ages. 

Meaningful changes need >1 mmol/L shifts. Start conservative in toddlers, personalize for exercise/hypo-fear, and use PGTs to bridge algorithmic automation with clinical individuality.

AID at diagnosis in toddlers is feasible: early Dexcom/G6 + diluted insulin + loop/autonomy can be safe. Honeymoon phases are shorter; settings need time to stabilize; let the system work — fewer micro-interventions often wins. 

AI, digital twins & multi-metabolite sensing: AI denoising, anomaly detection, context-aware targets, and digital twins will personalize dosing. Multi-metabolite sensors (ketone, lactate) could predict DKA/hypo risk and augment AID decision-making. Guardrails: explainability, pediatric datasets, and bias checks with man-in-the-loop oversight are mandatory.

Interoperability is foundational: 4 lenses — foundational (data flow), structural (FHIR), semantic (meaning/time/units), organizational (consent/governance). SMART on FHIR, FDA iCGM, Bluetooth SIG and ACE pumps are milestones enabling modular innovation and safer device ecosystems.

Radio & delivery integrity: practical engineering matters — 2.4 GHz congestion, device placement (same side, avoid metal), secure OS permissions, battery/reservoir monitoring, and site/adhesive care are everyday clinical safety workstreams.

Evaluation frameworks must capture safety and burden: 14-day TIR/TBR/CV metrics, daily alert burden, missed boluses, and an easy one-page AI rationale + scorecard for clinicians and families.

Vendor & policy action: engage vendors on FHIR read/write, use information-blocking rights, and push for standardized flowsheets for better clinical workflows. Advocate for reimbursement policies that close technology gaps rather than widen them.

LATAM & Brazil lessons: when children get access to tech (pump + CGM + ROS), glycemic goals become achievable across SES groups. Real equity is possible with policy, reimbursement, and programmatic support.

Indigenous & global equity: structural disadvantages — colonization, historical trauma, policy blind spots — drive diabetes disparities in Indigenous populations. Targeted funding (eg, SGLT2i/GLP-1 RA) and universal CGM/AID funding in AoNZ are examples where policy closed gaps and reduced mortality. Cultural competence, Indigenous leadership, data sovereignty and community-driven models are prerequisites, not nice-to-haves. 

Racial differences & biomarkers: HbA1c can overestimate mean glucose in Black youth and adults (0.45–0.92% differences). Glycation phenotypes (high/low glycators), Hemoglobin Glycation Index (HGI), and skin AGE/SIF link to complications — but most HbA1c disparities are explained by modifiable social and care factors (SES, tech access, distress, care setting). Treat-to-HbA1c targets can raise hypo risk in some groups — individualize targets and interpret HbA1c with CGM context.

Complications snapshot: Non-Hispanic Black youth have higher diabetic retinopathy and CKD burdens; CKD prevalence in a US T1D cohort was 27.1% with higher odds among females, older age, Asian and non-Hispanic Black patients. Equity-first interventions are necessary to close these gaps.

Monogenic diabetes — rethink the label: clinical criteria miss many cases. Antibody-negative cohorts yield high diagnostic returns for genetic testing. Recessive forms may be under-recognized in consanguineous populations (eg SLC19A2 — thiamine-responsive megaloblastic anemia). Test broadly: GCK, HNF1A/4A, HNF1B, KCNJ11, ABCC8, INS, PDX1, NEUROD1, RFX6 and more; consider exomes in high-consanguinity studies. Clinical-feature-independent screening (eg every child in a region, or all IAb-negative cases) reveals true prevalence and changes therapy.

C-peptide & islet function matter: residual C-peptide predicts better outcomes; even long-standing T1D can have detectable C-peptide (Joslin Medalists). Use C-peptide strategically (on insulin, not within 2 weeks of hyperglycemic emergency) and repeat if low with low glucose. New PIF (3D) score (PIF-S, PIF-L, PIF-A) offers richer beta-cell profiling and may stratify MODY phenotypes — promising, but needs pediatric validation.

Syndromic diabetes (WFS1/Wolfram): multidisciplinary care is essential — insulin-dependent non-autoimmune diabetes, progressive optic atrophy, deafness, neurogenic bladder, DI, neurodegeneration. Trials (sodium valproate, AMX0035) show safety signals and some beta-cell effects; clinical care must be adaptive, supportive, and anticipatory.

Transition into adult care is an ethical imperative, not an administrative box. Structured readiness assessment, joint pediatric-adult clinics, peer support (Sweet Mind), tele-follow up, and culturally tailored programs reduce loss to follow-up, lower HbA1c, and restore hope. Transition is empowerment, not a cold hand-off.

Real human stories matter: from Cameroon CDiC beneficiaries to adolescent voices who reclaimed care via peer support — social programs, vocational training, and continuous insulin access save lives and livelihoods. Programs must be context-sensitive and scalable.

DIY/Open-source AID: community-driven innovation filled a need — accessibility, customization, rapid algorithm progress, remote features, and improved sleep/quality of life. Over 10,000 users globally. HCPs must discuss DIY alongside commercial options, avoid gatekeeping, connect patients with peer support, and where appropriate, support safe adoption (build parties, mentorship).

Regulatory and HCP realities: official guidance (e.g., Diabetes Canada) supports discussing DIY AID; clinicians should balance legal/ethical duty of care with patient autonomy and shared decision-making. Physician comfort and community support are keys to safe integration.

Practical DIY caveats: initial setup + Nightscout integration is the hardest step; rebuild every 365 days; settings precision is critical; no official help desk — community support fills the gap. Tech access and socioeconomic resources still shape who can adopt DIY.

Final tech vision: the future is modular, interoperable, and patient-centric — FHIR + iCGM + standardized Bluetooth + explainable AI + multi-metabolite sensing + digital twins. But the tech will only transform outcomes when combined with policy, reimbursement, workforce training, and community engagement.

Call to action (not a tagline): invest in universal access to CGM/AID, embed psychosocial care in routine visits, fund population screening for early T1D detection, scale culturally competent policies for Indigenous & marginalized groups, broaden genetic testing strategies in diverse populations, and support community-led tech adoption — because science without equity amplifies injustice.

Personal ledger: the conference was a reminder that breakthroughs are technical and human. From Wolfdorf’s childhood to grassroots DIY builders and Indigenous policy victories — the message is stark: we can save lives, prevent DKA, and close equity gaps — but only if we pair innovation with relentless commitment to access, context, and care.

Conclusion

ISPAD 2025 left me both inspired and unsettled in the best way — a reminder that progress in diabetes care is never just about smarter algorithms or sleeker devices, but about whether every child, everywhere, can actually benefit from them. Being in the rooms where innovation, equity, lived experience, and hard truths collided made it impossible to ignore the gaps that still define global outcomes, yet equally impossible to leave without a sense of fierce optimism. What I carry forward is a renewed urgency: to push for systems that don’t just admire the science but implement it, scale it, and democratize it; to amplify the voices of families and communities who have always been the real drivers of change; and to keep demanding that equity is not an aspiration but a standard. This conference didn’t just advance knowledge — it sharpened my purpose.

Disclaimer:

My participation in the 51st ISPAD Scientific Conference was made possible through support facilitated by ISPAD, which graciously covered my conference attendance, full access to all scientific sessions, flights and accommodation during the event. I am also grateful to #dedoc° for their collaboration and support on the final night of the conference. The reflections and viewpoints expressed in this report are entirely my own and do not represent the official positions of ISPAD or #dedoc°.