Over the last three decades, while insulin replacement in type 1 diabetes in the young remains fundamental, the methods of delivering this therapy have changed dramatically. 'Intensive insulin' therapy offers the best outcome, in terms of glycaemia and long-term health, and a shift to multiple injection therapy and pumps has become the approach promoted early after diagnosis. A recent recognition is the sustained effect of near-normal glycaemia from diagnosis ('metabolic memory'), achieved through strict glucose targets and dose adjustment of insulin for carbohydrate. To use the developing technology of type 1 diabetes requires considerable motivation from patients and their families with a need for a parallel support programme from a multidisciplinary team. The components of successful adherence to the management regimens are a matching of health beliefs, attuned communication and reciprocity between those with diabetes, their families and health professionals. Innovative approaches are required to deliver these components within a health service. For many patients across the world, the context in which they live markedly affects the treatment offered and the acceptance of the condition. With the increasing incidence of type 1 diabetes the difficulties encountered in different environments and social settings are considerable, requiring support and direction from an international 'diabetes family'.