Tuesday, March 17, 2009

Dose Adjustment For Normal Eating and Exercise (DAFNE)

Introduction

See also: DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed); Diabetes and Intercurrent Illness.

The National service Framework for diabetes1 explicitly requires the institution of education programmes for all patients with diabetes mellitus. NICE has issued guidance on the criteria for, and form of, such education programmes, one of which is the DAFNE model.2 DAFNE is a validated, structured, reproducible diabetes education programme that aims to teach those with type 1 diabetes how to manage their insulin dosing in a flexible manner. The aim of the course is to empower type 1 diabetics through understanding of their condition, hopefully enabling them to lead as normal a life as possible in terms of heterogeneity of diet, being able toexercise, and ability to cope with variability in insulin requirements caused by, for example, illness. One of the catchphrases of the course illustrates this theme:

"It is not about dose adjustment for normal eating, it is dose adjustment for normal living!"

Another desired outcome is that type 1 diabetics will achieve better glycaemic control and avoid marked variability in their blood glucose levels by being able to tailor their long-acting and fast-acting insulin doses to their current dietary and physiological requirements. The course gives a working understanding of the key areas listed below.

Main areas covered during a DAFNE course

  • Pathophysiology of diabetes
  • Types of diabetes
  • Metabolic control of diabetes and its monitoring
  • The types, actions and duration of action of insulin preparations
  • Nutritional food groups
  • The concepts of carbohydrate portions and the glycaemic index
  • Adjusting short-acting insulin to the carbohydrate portions and glycaemic index of a meal
  • Avoiding weight gain
  • Sweeteners and sugar substitutes
  • Alcohol, insulin and diabetes
  • Dose adjustment for snacks
  • A step-wise approach to insulin dose adjustment
  • How to deal with episodes of hyperglycaemia
  • Coping with intercurrent illness and adjusting the insulin dose when ill (using supplementary 10% and 20% of total daily insulin dose system with a ready reckoner for ease of use)
  • The origin and symptoms of hypoglycaemia
  • Treating episodes of hypoglycaemia
  • Adjusting insulin dose following hypoglycaemia
  • Insulin adjustment for physical activity and exercise
  • The purpose and content of the annual diabetic review
  • Footcare
  • Travelling with type 1 diabetes
  • Driving and type 1 diabetes
  • Pregnancycontraception and type 1 diabetes

The course was originally conceived and developed in Düsseldorf at the WHO co-ordinating centre under the auspices of the late Michael Berger and his team. The imbalance between UK and continental results for diabetic control and outcomes led 3 UK diabetes centres (Sheffield Teaching Hospitals, Northumbria Healthcare Trust and King's College Hospital, London) to investigate the course's usefulness and suitability for delivery in the UK. They became convinced that the principles and practice of the unit and the published evidence were sound, and that the programme would be suitable for UK patients and should be tested.

The course lasts for 5 days and is highly structured. It requires attendance each day for about 8 hours, with breaks. It is delivered via discussion and teaching of the concepts being learned in as relaxed a manner as possible, although there is a lot to get through so it is relatively busy. The course includes a lunchtime meal which is used as an opportunity to try out the concepts being learned in terms of insulin dose adjustment.

What is the evidence that it works?
  • In the late nineties Diabetes UK funded a trial to assess the effect of attendance at a DAFNE course on diabetic control and quality of life measures. After 6 months, those who had attended the course had a fall in HbA1c of 1% compared to a control group, sustained at around 0.5% at 1 year after the course. Despite an increase in the number of injections and blood tests, those attending a DAFNE course reported an improvement in their quality of life and increased satisfaction with their treatment. Another important finding was that of the many areas in their lives in which they reported improvements, the largest increase was observed in the area of freedom to eat as they liked.3
  • Recent research has shown that this improvement in glycaemic control is not at the expense of more frequent episodes of hypoglycaemia, in fact the opposite was true with those attending the course having fewer episodes.4
  • An analysis of its cost effectiveness has shown that it is better than current standard practice and has modest effects on survival, yields significant improvements in quality of life, and would save the NHS ~£2,200 per patient enrolled, over 10 years.5
  • NICE have performed a technology appraisal on the DAFNE approach and approved it as a useful model to improve diabetes education within the implementation of the National Service Framework for diabetes (which calls for structured education programs for all those with diabetes).2
  • A study of patients undergoing insulin initiation as part of a structured educational program showed that they had a better quality of life compared to patients who were on insulin but had not undergone an educational program.6
  • One study using a single educational intervention within the normal clinical setting showed long-lasting benefits.7
How does it work?

Those who attend the course are taught how to assess the carbohydrate portions (CPs) and glycaemic index of the meals that they eat. A handy pocket book is provided to help with this, covering a wide range of commonly eaten foods, including trademarked brands. The patient's individual response to taking the recommended dose of insulin for the CPs eaten is assessed and the patient self-adjusts the amount of fast acting insulin they take for a given quantity of CPs, and according to their pre-prandial capillary blood glucose. This helps to improve glycaemic control, and encourages the patient to analyse, rather than just record, their capillary blood glucose measurements. The patient is given a step-wise approach on how to adjust both fast-acting and long-acting insulin where glycaemic control can be improved.

Who should go on the course, and where can they do it?

Essentially, all patients with type 1 diabetes. However, the trial data for its effectiveness were based upon patients with HbA1c values in the range 7.5–12% (moderate or poor control of diabetes). Initially, as the programme is rolled out across the UK, it would be sensible to send patients with HbA1c values in this range, as places are still relatively limited in many locations. Personal factors such as motivation, educational level, co-morbidity and associated disability may influence patient selection for the course. In 2006 there were 37 trained and accredited DAFNE centres in the UK. The initiative has now been rolled out so that a centre providing initial training (a hub) or a centre providing follow up ( a spoke) is geographically accessible to virtually all UK residents.8

How do you become involved as a healthcare professional?

The DAFNE website (see further reading section below) has details of how to become a DAFNE centre and train as a DAFNE educator or DAFNE doctor.

Further research

The DAFNE programme is part of an ongoing collaborative research effort to assess its effectiveness and outcomes. Current areas of active research are:

  • Long-term follow-up of the DAFNE feasibility study participants, to assess how sustainable the changes observed in the initial group of patients will be in the long-term (currently being analysed).
  • DAFNE hub-and-spoke programme to enable the efficient roll-out of the availability of the course to as many diabetic patients as possible (currently being analysed).
  • DAFNE for the young, a pilot study looking at providing a DAFNE course for children aged 11–16 (pilot study being analysed, funding for randomised controlled trial awaited).


Document references
  1. Department of Health; Diabetes policy and guidance including NSF; Links to useful resources
  2. Diabetes (types 1 and 2) - patient education models, NICE Technology Appraisal (2003); The clinical effectiveness and cost effectiveness of patient education models for diabetes.
  3. No authors listed; Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. BMJ. 2002 Oct 5;325(7367):746. [abstract]
  4. Samann A, Muhlhauser I, Bender R, et al; Glycaemic control and severe hypoglycaemia following training in flexible, intensive insulin therapy to enable dietary freedom in people with type 1 diabetes: a prospective implementation study. Diabetologia. 2005 Oct;48(10):1965-70. Epub 2005 Aug 18. [abstract]
  5. Shearer A, Bagust A, Sanderson D, et al; Cost-effectiveness of flexible intensive insulin management to enable dietary freedom in people with Type 1 diabetes in the UK. Diabet Med. 2004 May;21(5):460-7. [abstract]
  6. Braun A, Samann A, Kubiak T, et al; Effects of metabolic control, patient education and initiation of insulin therapy on the quality of life of patients with type 2 diabetes mellitus. Patient Educ Couns. 2008 Jun 24;. [abstract]
  7. Lowe J, Linjawi S, Mensch M, et al; Flexible eating and flexible insulin dosing in patients with diabetes: Results of an intensive self-management course. Diabetes Res Clin Pract. 2008 Jun;80(3):439-43. Epub 2008 Mar 18. [abstract]
  8. DAFNE today; Includes list of UK centres that are accredited to run the course.

Internet and further reading

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