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DAFNE programme yields flexible diabetes management

Peter Jennings
BSN BAPsychol
Diabetes Specialist Nurse
Jenny O'Neill Diabetes Unit
Derbyshire Royal Infirmary Derby

E:Peter.Jennings@sdah-tr.trent. nhs.uk

Dose Adjustment For Normal Eating (DAFNE) is a training programme for adults with type 1 diabetes recently introduced into the UK. DAFNE was adapted from a university hospital diabetes centre in Dusseldorf, Germany, where this approach to intensive diabetes management has been used successfully for over 20 years.(1) The DAFNE motto - "Eat what you like, like what you eat" - clearly differentiates itself from the conventional approaches used to manage type 1 diabetes in the UK. By teaching diabetes self-management skills, DAFNE trains individuals to adjust insulin according to their lifestyle instead of planning their lives around diabetes. Its aim is to maintain optimal blood glucose control and lessen the risk of developing diabetes-related complications.

Overview of DAFNE
Initially, DAFNE was tested in three UK hospital diabetes clinics as part of a randomised controlled trial.(2) The results showed that, by following DAFNE, average HbA(1c) levels fell significantly. Overall weight gain, incidence of severe hypoglycaemia and blood lipid levels remained stable. Quality of life and dietary freedom measurements improved significantly. With the support of the Department of Health and Diabetes UK, DAFNE has since been expanded to seven more centres, which are:

  • Sheffield Teaching Hospitals NHS Trust.
  • Northumbria Healthcare Trust.
  • King's College Hospital, London.
  • Addenbrooke's NHS Trust, Cambridge.
  • Central Middlesex Hospital.
  • Derbyshire Royal Infirmary.
  • University of Leicester NHS Trust.
  • Northampton General Hospital.
  • Nottingham Queen's Medical Centre.
  • Scarborough and Bridlington Hospitals.

What is DAFNE?
Each DAFNE course lasts for one week and runs over five consecutive days. A typical team of certified DAFNE educators consists of a dietician, nurse and physician. They facilitate a group of six to eight adults with type 1 diabetes. Individuals are chosen based on specific selection criteria, as listed in Table 1. DAFNE topics relate to aspects of insulin action, diet and lifestyle. A basal-bolus insulin regimen is initiated at the beginning of the course. Basal insulin usually involves two injections of intermediate-acting isophane insulin (morning and evening). However, one injection of insulin glargine (Lantus(®); Aventis), the new long-acting insulin analogue, can be used as an alternative. The basal insulin is meant to provide enough insulin to maintain stable glucose values over 24 hours. When this is correctly matched to an ­individual's requirements, flexibility is gained relating to the timing of the meal bolus. This is the injection of short-acting soluble insulin or rapid-acting analogue insulin taken before each meal. Participants practise identifying foods that contain carbohydrates and estimating the amount of carbohydrate portions (CPs) in these foods. When determining mealtime insulin boluses, individuals consider CPs along with ­current blood glucose readings and anticipated activity.

[[NIP10_table1_35]]

A typical day during a DAFNE week begins with individuals presenting their glucose diaries to the group. Information includes glucose values, steps used to determine CPs, and dosages of basal/bolus insulin. The group discusses ways of adjusting insulin or calculating CPs based on methods learned during the course. Individuals gain valuable feedback and experience analysing other participants' diaries. The approach is supportive, not critical. Glucose values are interpreted not as being "good" or "bad" but in relation to defined target glucose values. Elevated readings may simply require more insulin and should not reflect poorly on the individual.

Achieving target glucose values is not the sole aim. Other factors that contribute to "optimal control" include:

  • HbA(1c) between 6.0% and 7.0%.
  • Flexible lifestyle.
  • High quality of life.
  • Stable weight.
  • Avoidance of severe hypoglycaemia.
  • Avoidance of diabetic ketoacidosis.

Following the insulin dose adjustment, the group may take part in a nutrition session. The approaches used to accurately measure and estimate CPs resemble those used in the past when "carbohydrate counting" was standard practice. The key difference with DAFNE relates to flexibility. Individuals can eat as much or as little as they choose. The emphasis is to correctly match the mealtime insulin to CPs eaten. Lunch provides an excellent opportunity to practise this. The afternoons cover a variety of topics, including managing exercise, hyper­glycaemia, hypoglycaemia and illness. The day ends with individuals again sharing diaries and formulating personal management plans to be used until the next day.

Benefits
Following the completion of a DAFNE course, participants should have begun to acquire the skills, experience and confidence to autonomously adjust their insulin based on blood glucose values, diet and exercise. Individuals should feel empowered to "eat what you like, like what you eat", and be able to match insulin to CPs. By using glucose values to determine the required insulin dose, patients understand the reasoning behind glucose monitoring and recording. By improving blood glucose levels, individuals are more likely to reduce the risk of diabetes-related complications as reported in the diabetes control and complications trial.(3)

Habits developed over many years will be challenged during the course. Five days provides time for patients to learn new skills, to practise dose adjustment, and to receive feedback from the group. DAFNE may be the first opportunity participants have to meet others with type 1 diabetes. By sharing experiences, they gain knowledge and support from other group members. Individual or structured group follow-up sessions are available as needed.

Limitations
DAFNE is not a cure for diabetes. Limitations exist for both individuals and the health service. It is an intensive approach that may not be suitable for those unwilling or unable to assume responsibility for managing their diabetes. The 40-hour time commitment may restrict those caring for family members or unable to leave work. Letters can be sent to employers explaining the importance of DAFNE training and requesting paid leave for the course.

As DAFNE is currently  available in only 10 centres within the UK, access is restricted. Efforts to expand the programme could falter as diabetes centres may struggle to fund staff or resources needed to start and maintain a DAFNE programme. The National Institute for Clinical Excellence (NICE) has recognised DAFNE as a cost-effective approach to managing type 1 diabetes.(4) However, more data assessing patient satisfaction, long-term adherence and metabolic control are needed to secure funding.

Conclusion
DAFNE encompasses the aim of the NSF for Diabetes:

"… to ensure that people with diabetes are ­empowered to live with their condition and to take ­responsibility for day-to-day management of their diabetes in a way which enables them to experience the best quality of life".(5)

DAFNE is a fun and effective way to educate and empower adults with type 1 diabetes. It may be extended throughout the NHS. Hence it is useful for practice nurses to understand the relevance of DAFNE to support those patients who have participated in courses and to encourage those who have yet to attend.

References

  1. Muhlhauser I, Jorgens V, Berger M, et al. Bicentric evaluation of a teaching and treatment programme for type 1 (insulin dependent) diabetic patients: improvement of metabolic control and other measures of diabetes care for up to 22 months. Diabetologia 1983;25:476.
  2. DAFNE Study Group. 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;325:746-51.
  3. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:683-9.
  4. National Institute for Clinical Excellence. Patient-education models for diabetes. The clinical effectiveness and cost effectiveness of patient education models for diabetes (Appraisal ­consultation document). London: NICE; 2002. Available from URL: http://www.nice.org.uk
  5. Department of Health. National Service Framework for Diabetes Standard 3. Empowering people with diabetes. London: DoH; 2003.

Resources
To learn more about DAFNE, please visit the Diabetes UK website W:www.diabetes.org.uk/dafne
Or contact:
Gillian Thompson
Central DAFNE Administration Office
Diabetes Resource Centre
North Tyneside General Hospital
Rake Lane
North Shields
Tyne & Wear
NE29 8NH
E:Gillian.
Thompson@northumbria-healthcare.nhs.uk

National Institute for Clinical Excellence (NICE)
W:www.nice.org.uk