13995448, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pedi.13449 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [25/12/2022].

See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Accepted: 2 November 2022
DOI: 10.1111/pedi.13449

REVIEWS AND COMMENTARIES

ISPAD Annual Conference 2022 highlights

Sze May Ng 1,2,3 | Helen Day 1 | Jody B. Grundman 4 | Peerzada Ovais Ahmad 5 |
Maja Raicevic 6 | Tinotenda Dzikiti 7 | Nancy Katkat 8 | Anju Jacob 9 |
Marisa Ferreira Clemente 10 | Hussain Alsaffar 11,12 | Yasmine Ibrahim Elhenawy 13 |
Yasmine Abdelmeguid 14 | Klemen Dovc 15
1
Paediatric Department, Southport and Ormskirk NHS Trust, Ormskirk, UK
2
Faculty of Health, Social Care & Medicine, Edge Hill University, UK
3
Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
4
Children's National Hospital, Washington, DC, USA
5
Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
6
Institute for Children's Diseases, Clinical Centre of Montenegro, Podgorica, Montenegro
7
#dedoc and Zimbabwe Diabetes Association, Harare, Zimbabwe
8
Paediatric Department, Blackpool Teaching Hospital, UK
9
Al Jalila Childrens Specialty Hospital, Dubai, UAE
10
Department of Paediatric Diabetes, Alder Hey Children's Hospital, UK
11
Child Health Department, Pediatric Endocrine and Diabetes Unit, Sultan Qaboos University Hospital, Muscat, Oman
12
College of Medicine, Wasit University, Wasit, Iraq
13
Pediatric and Adolescent Diabetes Unit, Faculty of Medicine, Ain Shams University, Cairo, Egypt
14
Pediatrics Endocrinology and Diabetology, Alexandria University, Egypt
15
Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC – University Children's Hospital, and Faculty of Medicine, University of Ljubljana,
Ljubljana, Slovenia

Correspondence
Sze May Ng, Paediatric Department, Southport and Ormskirk NHS Trust, Ormskirk L39 2AZ, UK.
Email: [email protected]

K E Y W O R D S : diabetes, ISPAD, Ispad highlights, pediatric

1 | PLENARY—ADVANCES IN DIABETES genome by a polymerase chain reaction and of enterovirus proteins

TREATMENT by immunohistochemistry in pancreatic sections. The evidence from
the DiViD study could provide evidence that an enterovirus vaccine
Clinical trials performed in the last three decades have shown that may potentially be effective for the primary and secondary preven-
restoration of beta-cell function via transplantation of isolated islet tion of T1D. A prospective, randomized controlled DiVid interven-
cells allowed the achievement of a more physiological release of tional study is now in progress, using antiviral treatment (pleconaril
endocrine hormones. The future of insulin-producing cells is and ribavirin) for 6 months in newly diagnosed individuals with
expected to progress to implantation without requiring immunosup- T1D. Novel immunotherapies for different T1D endotypes are
pression by using gene editing, allowing the production of immune- currently underway, using bionics, chimeric antigen receptor
evasive cells. Viral infections have long been considered possible (CAR)-engineered regulatory T cells (Tregs) and vaccination with tol-
candidates for environmental triggers in genetically susceptible indi- erogenic dendritic cells. Currently, five immunotherapies have been
viduals with type 1 diabetes (T1D). Epidemiological studies have shown to preserve insulin secretion in patients with newly diag-
demonstrated that enterovirus infections are associated with the nosed T1D: teplizumab, otelixizumab, rituximab, abatacept, low-
development of islet autoimmunity and T1D. The Diabetes Virus dose anti-thymocyte globulin and alefacept, most of them having
Detection (DiViD) study reported the presence of enterovirus an acceptable safety profile and side effect. The expected approval

Pediatr Diabetes. 2022;23:1151–1156. wileyonlinelibrary.com/journal/pedi © 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd. 1151
 13995448, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pedi.13449 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [25/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1152 NG ET AL.

of teplizumab by the FDA and EMA will force the treatment para- 4 | P L E N A R Y —D I G I T A L I Z A T I O N I N
digm of T1D to shift by placing a greater emphasis on screening DI A B E T E S E D U C A T I O N A N D C A R E
for T1D and by driving the market revolving around individuals
with T1D toward precision medicine. The advances in diabetes technology have identified health inequal-
ities within areas such as deprivation and ethnicity. Healthcare profes-
sionals are challenged to integrate technology and digitalization of
2 | S Y M P O SI U M — N U T R I T I O N diabetes education and care into routine diabetes management, but
MANAGEMENT IN DIABETES ensuring that underserved populations do not miss out is a key prior-
ity. “Big Data” collection helps to identify metabolic models for stag-
Continuous glucose monitoring (CGM) has become a routine part of ing T1D and to identify therapeutic outcomes. It also allows
clinical practice as it provides glucose metrics that healthcare profes- healthcare professionals to identify individual outcomes and support
sionals can analyze with families and provide valuable information those living with diabetes. “Voice bio marker identification” is being
regarding glucose control, moving from HbA1c outcomes to CGM met- currently researched to identify vocal biomarkers for screening diabe-
rics outcomes. Some of the key features to discuss with the families tes and monitoring the health of those living with the condition. The
about CGM metrics include time in range, time above and below range “Colive Voice Study” have recognized that those living with diabetes
and the visualization of the graphs allowing them to have a better com- have distinct vocal signatures compared to the general population.
prehension of the impact of nutrition choices on glucose behavior. Fami- The study aims to look at this research data being integrated into arti-
lies reported that CGM had increased their awareness of the different ficial intelligence delivery algorithms, using vocal assistance to support
impacts of foods and snacks. The prevalence of celiac disease in T1D patient management and monitoring in the future.
ranges from 1 to 16% worldwide. The greatest risk is associated with
children diagnosed with T1D before 5 years of age and with longer dia-
betes duration. ISPAD and ADA recommend screening for celiac disease 5 | SYM P OSIU M—M E N T A L H E A L T H
should be performed soon after diagnosis of T1D, and at 2 to 5 years IN DIABETES
intervals (sooner if symptomatic or having a first-degree relative with
celiac disease). Literature indicates that the normalization time of celiac Diabetes burnout may be a result of the relentless daily tasks of living
titers depends on the degree of serology elevation and severity of intes- with T1D. Health professionals must recognize the difference
tinal damage. In practice, it might take as long as 4 years, despite a strict between distress and depression. Depression is a psychiatric condi-
gluten-free diet. Long-standing celiac disease in individuals with T1D tion that is more than burnout or distress, and the symptoms interfere
increases the risk of retinopathy and nephropathy, higher bone fracture with day-to-day functions. Distress in teenagers is linked to worsen-
risk and higher rates of concomitant autoimmune thyroid disease. These ing self-care behaviors and sub-optimal glycemic management. Diabe-
individuals are at greater risk for depression and eating disorders. tes distress is recognized to be higher within lower social economic
groups and those with racial and ethnic minority backgrounds. How-
ever, teenagers with strong peer support have shown that they are
3 | S Y M P O SI U M — R E G I S T R I E S : WH Y A R E less likely to experience diabetes distress. The statistics show that the
THEY IMPORTANT? prevalence of a clinically diagnosed eating disorder is greater in
women with Type 1 diabetes and this is twice greater in adolescents
Registries are a systematic and organized way of data collection that helps with T1D. The physical and psychological impact of an eating disorder
in evaluating specific outcomes, as well as contributing to quality improve- increases the risk of diabetic ketoacidosis, long-term complications
ment, surveillance, and benchmarking. Registries play an important role in associated with diabetes and strong negative emotions resulting in
improving patients' care and serve as a reliable guide for health authorities, increased depression and suicidal thoughts. As health professionals, it
insurance companies and other health organizations. Collaborative com- is important to develop knowledge about eating disorders in those liv-
parisons between international pediatric diabetes registries and the blend- ing with diabetes and to establish appropriate treatment pathways.
ing of their data may pave the way for the development of more relevant
international guidelines. There are multiple T1D registries globally. In
2016, the T1D Exchange Quality Improvement Collaborative (T1DX-QI) 6 | SYM P OSIU M—U P D A T E S ON CO V I D
registry, included data from more than 50 centers in the United States of A ND D I A B ET E S I N CH I L D R E N
America. The Kuwaiti experience CODeR (Childhood Onset Diabetes
Electronic Registry) was also developed in the Middle East. Registries are During the COVID-19 pandemic, new approaches in clinical follow-up
important tools and provide an important source of information that could were developed using telemedicine consultations and remote educa-
help in monitoring the progression of the disease and the course of its tional sessions. Studies focusing on the doctor-patient relationship in
complication, identify risk factors, estimate costs and direct resources, synchronous real-time video consultations compared to in-person
design prevention programs, and improve the standard of care locally and visits concluded that patient-care satisfaction and perception of the
globally. doctor-patient relationship, along with patients' perception of
 13995448, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pedi.13449 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [25/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
NG ET AL. 1153

physician empathy did not substantially differ between the two forms Primary prevention trials are currently investigating rituximab, teplizu-
of consultation. Adults with T1D registered worsening of metabolic mab, abatacept, and autoantigen-specific therapy. Secondary preven-
control associated with a significant reduction of physical activity dur- tion trials are investigating the use of anti-CD3, teplizumab,
ing lockdown due to COVID-19 pandemic, which disagreed with data abatacept, hydroxychloroquine, golimumab, and liraglutide. Teplizu-
from pediatric participants. This difference may relate to the normal mab treatment for 14 days was the first drug shown to be able to
activity in children that can compensate for the lack of structured slow the disease process leading to T1D in high-risk individuals. Other
physical exercise. CoVidentary, an innovative online exercise training developments have shown a rapid decline in gut microbiota diversity
program created during the pandemic in Italy used social media to in those with T1D. Fecal transplantation can potentially improve
reduce sedentary behaviors in children with T1D during the pandemic diversity, rearrange gut metabolites with immunomodulatory effects,
and a virtual camp to monitor glycemic management. Exercise and restore gut permeability, and incite changes in the immune system. In
nutrition advice and management were some of the initiatives devel- a study where individuals were randomized to receive stool from a
oped to compensate lockdown restrictions and improve glycemic healthy young donor or autologous feces from self, there was stabili-
management. zation in fasting and stimulated c-peptide in both groups but not for
all participants.

7 | J O I N T SY M P O S I U M —J D R F - I S P A D :
ACCESS TO CARE CHALLENGES AND 9 | P L E N A R Y —O B E S I T Y A N D I T S
SOLUTIONS MANAGEMENT

The challenges of living with T1D are greater in low-middle-income The prevalence of childhood obesity is increasing worldwide. Obesity
countries (LMICs). These include limited health coverage for insulin, in childhood is a multi-faceted disease with genetic, metabolic, envi-
skilled multidisciplinary teams, and comprehensive diabetes education ronmental and behavioral factors that interact with each other.
programs. Something unique to developing countries is that there is a Greater severity of obesity is associated with a greater risk of low
large out-of-pocket expense that puts a disproportional burden for HDL cholesterol, high systolic and diastolic blood pressure, and high
healthcare on those in low-income households. There are also issues triglyceride and HbA1c. The ENDO Society recommends the use of
related to the public health system which is overburdened and com- drugs only after failure of lifestyle changes and pharmacotherapy
monly provides varying standards of care in primary or tertiary set- options for children are limited. Orlistat reduces fat absorption by
tings, with a lack of regular follow-up or established registry to inhibiting pancreatic lipases but the safety/efficacy profile for children
adequately track outcome data. Barriers to access to insulin in LMICs <12 years has not been established. Phentermine demonstrated
are related to regulation, production costs and complex regulatory enhanced weight loss in many, but there are several adverse events in
assessment. Prescription issues include a lack of clinical guidelines, a adolescents, and it is currently only approved for >16 years. Liraglu-
lack of sustainable training for healthcare providers and a limited tide leads to a significantly greater reduction in BMI SD score with
understanding of healthcare providers about biosimilars. Novel inno- lifestyle changes compared to placebo, with greater improvements in
vations in insulin and glucose testing need to meaningfully involve BMI and body weight. Phentermine/topiramate offered statistically
people with T1D and their caregivers from low-income settings Addi- significant reductions in BMI and favorably impacted triglyceride and
tional strategies to address challenges include removing barriers that HDL-C levels in adolescents with obesity. The meta-analysis con-
hinder competition, ensuring that products on the market are quality cluded that liraglutide had a higher probability of achieving clinically
assured by a regulatory authority, pooling procurement at the national significant weight loss compared with other drugs, while topiramate
level, ensuring price transparency in the supply chain and developing was superior in safety. There are ongoing combination therapies being
clinical guidelines within the health systems. studied in adults and children that show combination therapy achieves
higher weight loss, and patients prescribed >3 medications lost signifi-
cantly more weight than those prescribed 2 or no anti-obesity medi-
8 | S Y M P O SI U M — PREDICTI ON AND cations at 12 months. Currently, the need to select therapy is based
P R E V E NT I O N O F T Y P E 1 D I A B E T E S on affordability and insurance coverage. Bariatric surgery in adoles-
cents have also demonstrated a higher likelihood of having remission
The vast majority of individuals that have two or more antibodies pro- of type 2 diabetes and hypertension compared to adults.
gress to T1D diagnosis. Progression differs by age, as those identified
under the age of 9 progress faster, and those over the age of 20 pro-
gress more slowly. The concept of endotypes in T1D is based on the 10 | S YM P OSI U M —U P D A T E S ON
first autoantibody specificity and age at diagnosis (<7 years, 7– TECHNOLOGY IN DIABETES CARE
12 years, >12 years). Current investigations looking at the role of
enterovirus in developing T1D found that IAA first endotype risk was The iLet Bionic Pancreas could be the preferred option for patients
associated with coxsackie B1, and no risk was seen with GADA. with T1D in the future who want less interaction and a simpler
 13995448, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pedi.13449 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [25/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1154 NG ET AL.

interface with the insulin delivery system as it requires no adjustments labor. If a person with T1D wishes to fast, a risk assessment is impor-
of basal rates and bolus settings, no carb counting or manual correc- tant. A New DaR-IDF Risk score is available to help in making this deci-
tion boluses, This investigational insulin delivery system is a closed sion. Interventions should also be planned ahead to ensure safe fasting,
loop system which uses a mono- (insulin) or bi- hormonal (insulin and and these include pre-fast counselling, pre-fast glycemic optimization,
glucagon) therapy. The glucose target is the only setting to adjust, and frequent blood glucose monitoring, insulin modifications, nutrition and
the device adapts continuously to the individual insulin needs and activity. Blood glucose monitoring is an essential element to risk quanti-
carbohydrate counting is not needed. In the pediatric cohort of fication for people wishing to fast. Pre-fasting nutritional education is
165 participants, HbA1c were 0.5% lower in patients with the crucial for safe fasting and an individualized dietary plan is needed to
bionic pancreas compared to those on standard care. Despite the maintain a healthy body weight, avoid excessive weight changes and
increasing availability of licensed closed loops, open-source auto- minimize complication risk. Necessary dietary modifications should be
mated insulin delivery systems are still in the game. Arguments for made such as type of food, time of meals, insulin regimen and ensuring
open-source automated insulin delivery systems include technologi- knowledge about carbohydrate counting. Advancing technologies such
cal advantages such as customizable personal profile, remote control as CGM have also made it possible to fast safely, as it provides an accu-
of profile, unavailability of hybrid closed loop system in some coun- rate and reliable understanding of blood glucose changes, duration of
tries, unachieved therapy goals and less frequent interaction with hyperglycemia as well as time in target.
diabetes technology.

13 | J O I N T SY M P O S I U M E S P E - I S P A D :
1 1 | JOINT S YM POSIU M —A T T D - I S P A D : M O N O G E N I C A N D O T H E R F O RM S O F
A D V A N C E D TE C H N O L O G Y I N DI A B E T E S DI A B E T E S

Artificial intelligence is often used to describe machines that mimic Monogenic diabetes is a heterogenous condition, caused by one or
human cognitive functions. Clinical Decision Support System (CDSS) more defects in a single gene or chromosomal locus. Combined, mono-
provides clinicians, staff and individuals with knowledge and person- genic diabetes accounts for approximately 2.5%–6.5% of pediatric dia-
specific information to enhance their health care. A wide range of betes. The list of genes causing monogenic diabetes is growing fast
CDSS is available to cover all aspects of diabetes care and could be (more than 50 genes have been identified so far, associated with either
classified into the following groups: (1) tools for people with diabetes T-cell dysfunction (T1DB-like), insulin receptor defect (T2D-like), or
self-management (personalized nutrition support and physical activ- monogenic autoimmunity) and this underscores the need for compre-
ity), (2) screening and prevention for diabetes-related complications, hensive next-generation sequencing (NGS) as the best diagnostic
(3) prediction tools for identification of people more likely to develop approach. Early and accurate diagnosis can guide treatment, rather than
diabetes, and (4) clinical management support. The idea is to improve phenotype-based targeted testing, particularly for neonatal diabetes
clinical outcomes, increase access to care, enhance the utilization of (NDM). Glibenclamide, which stimulates insulin release from pancreatic
healthcare resources and provide precision medicine, allocating beta-cells by inhibiting ATP-sensitive potassium channels, could be
always the decision comparable to the one that an experienced physi- used as a specific treatment of NDM due to KATP channel mutations.
cian would provide. Open-source automated insulin-delivery systems Glibenclamide is also a neuroprotective drug and has been shown to
have been extensively studied, and are safe, effective and have the improve neurological features in NDM such as epilepsy, motor func-
potential to help a wide population of individuals with T1D alongside tion, global neurological improvement, and hypotonia. Glibenclamide
commercial systems. Every healthcare professional is responsible to oral suspension (Amglidia) has been designed for premature, neonates,
learn about all treatment options, including open-source systems toddlers and children and is as efficient as tablets. Monogenic diabetes
while these systems should fully disclose how they operate to enable in Arab regions has a different spectrum and is mostly associated with a
healthcare professionals and patients to understand the benefits and rare familial recessive syndrome. Neonatal diabetes is more common in
limits of these systems. Arabs and has a different genetic etiology compared to other popula-
tions, associated also with a higher rate of consanguinity. The most fre-
quent etiology reported in this region is Wolcott-Rallison syndrome
12 | JOINT SYMPOSIUM ASPED-ISPAD: due to EIF2AK3 mutations. On the other hand, data on MODY in Arabs
DIABETES & FASTING are limited, which might be due to unknown genetic mechanisms con-
tributing to the pathogenesis of MODY in Arabs.
Fasting is a part of many religions, and the best example of this is Ram-
adan fasting. Advancing technology has made it possible to fast safely.
The challenges of fasting with diabetes include the risk of hypoglyce- 14 | S YM P OSI U M —I M P A C T O F D I A B E T E S
mia, hyperglycemia, ketoacidosis, dehydration and thrombosis. There ON BEHAVIOR
are some exemptions from religious fasting such as very young age,
women who are pregnant or breastfeeding, persons with intellectual Sleep is vitally important in the early years of life, and it is fundamen-
disabilities and individuals who are travelling or doing heavy physical tal for brain development. Humans spent a third of their lives asleep.
 13995448, 2022, 8, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/pedi.13449 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [25/12/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
NG ET AL. 1155

Out of six main categories of sleep disorders, diabetes mellitus con- 16 | S YM P OSI U M —D I A B E T E S
tributes to two of them; “parasomnias” resulting from enuresis, and PUBLICATIONS SPECIAL HIGHLIGHTS
“sleep-related movement disorder,” especially in people living with
T1DM for a long time. Sleep disturbance could increase the vulnera- Numerous studies were published in the last year describing clinical
bility to some psychological disorders including depression. A investigations of type 1 or type 2 diabetes care, including recent find-
chronic condition such as T1D that requires constant monitoring ings in the understanding of diabetes etiology and possible prevention
results in sleep disturbance due to several factors such as staying strategies, novel (adjunctive) pharmacological molecules and state-of-
awake late to deal with hypoglycemia, waking during the night to the-art technological approaches. Based on a growing body of evi-
correct for hyperglycemia, or struggling to fall asleep due to a late dence that supports the technological advantages, the management
sweet snack. Sleep has to be kept high on the research agenda to of type 1 diabetes is changing substantially almost in real-time. Auto-
learn how best to support families to find the balance between mated insulin delivery (AID) consists of a CGM that measures the glu-
waking to manage diabetes and sleeping for health. Evidence-based cose concentration, an insulin pump, and an algorithm that uses
intervention strategies include behavioral parent training in improv- glucose concentration and prior insulin delivery data to control insulin
ing communication, encouraging behavior management, promoting delivery in a glucose-responsive manner is becoming the standard of
structure within the family, and planning ahead. Digital interventions care and is recommended for youth with diabetes were available in
to improve self-care and mental health in young people such as the the latest ISPAD clinical guidelines. Recent randomized controlled tri-
self-compassion chatbot “COMPASS” were found to be helpful in als have demonstrated the efficacy and safety of different control
improving the well-being of adolescents living with T1DM. Future algorithms and have included different populations, including very
directions recommended include developing digital tools that incor- young children with T1D and children with newly diagnosed T1D.
porate evidence-based psychological theories, use of digital tools to These data were complemented with data from large multinational
augment face-to-face therapy, involving young people in the devel- registries. Clinical outcomes in diabetes are unfortunately determined
opment and including parents and families in the delivery are by disparities in socioeconomic status and consequently in inequities
needed. in diabetes care. Data from underserved countries and communities
are critical in understanding barriers to technology use, including lim-
ited accessibility and reimbursement policies, and thus could help us
15 | JOINT SYMPOSIUM ISPAE-ISPAD: develop targeted interventions to address these disparate outcomes.
DIABETES CARE SYSTEMS SET-UP

Task shifting and sharing involve the redistribution or delegation of 17 | J O I N T SY M P O S I U M I D F – I S P A D : H O W

healthcare tasks within the task workforce and communities. Task T O I M P RO V E T H E L O N G - T E R M D I A B E T E S
shifting occurs when a task is transferred or delegated while task OUTCOME?
sharing occurs when tasks are completed collaboratively between
providers with different levels of training. The purpose of task shar- Life for a Child in collaboration with ISPAD, JDRF and IDF, has devel-
ing or shifting is to reduce morbidity, mortality and burden of the oped the T1D Index data simulation tool mapping the impact of T1D.
disease among the populations where a shortage or inaccessibility The T1D index measures the human, public health, and economic impact
of highly skilled professional health workers limits access to effec- of T1D throughout the world and at the country level. Incidence, preva-
tive care so that shifting or sharing achieves this purpose by posi- lence and mortality are used to model estimates of new cases of T1D in
tioning providers with less training to deliver effective interventions a year by country, age group and risk of mortality and complications.
thereby improving access to and coverage of those interventions There are approximately 9 million individuals estimated living with T1D
without compromising standards of care. In LMICs, patient access to globally. The global average for a person diagnosed with T1D at 10 years
multidisciplinary teams is limited. LFAC ISPAD-Task shifting survey old will live 42 unburdened years but will have 32 healthy years lost due
reported on gaps in access to skilled medical, nursing and AHPs for to early mortality, disability and complications. Timely diagnosis, access
young people with T1D in LMICs. The responsibility of T1D care in to insulin, test strips and new preventative therapies are strategies that
Uganda lies primarily at the primary healthcare centers and not at could lead to 4 million fewer lives lost by 2040. Vascular complications
the tertiary hospitals. Care in Uganda is mainly provided by nurses and mortality rates remain a real challenge for young people with T1D
working in isolated clinics with limited drugs and equipment. In requiring early prevention and detection for better outcomes. Data from
Uganda, internet penetration is only about 26.2% of the total 47 mil- the Adolescent Type 1 Diabetes Cardio-Renal Intervention Trial (AdDIT)
lion population, while only half the population has mobile phone showed that subclinical increases in albumin creatinine ratio (ACR) may
connections. PEN-Plus is part of an ecosystem where care and provide a valuable tool to identify adolescents at higher risk of vascular
treatment are provided at first-level district hospitals. Decentralizing complications. The keys to preventing complications during adolescence
of T1D care through the PEN-Plus was achieved by mid-level pro- include good glycemic management, lifestyle interventions, angiotensin-
viders who are trained in T1D to facilitate follow-up and manage- converting enzymes (ACE) inhibitors, statins, and psychological and moti-
ment of T1D. vational interventions.