Dose Adjustment For Normal Eating and Exercise (DAFNE)

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 to exercise, and ability to cope with variability in insulin requirements caused by, for example, illness. One of the catchphrases of the course illustrates this theme:

• 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

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.

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

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.

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).