Diabetes Metab J.  2014 Apr;38(2):87-91. 10.4093/dmj.2014.38.2.87.

Dose Adjustment for Normal Eating: A Role for the Expert Patient?

• McIntyre H

• KMID: 2280698
• DOI: http://doi.org/10.4093/dmj.2014.38.2.87

Abstract

The Dose Adjustment for Normal Eating (DAFNE) programme of intensive insulin therapy for type 1 diabetes provides a structured educational intervention to improve glycemic control, reduce hypoglycemia and improve quality of life. Enhancement of self-management skills is a key element of DAFNE and patients acquire detailed skills in insulin dose adjustment. Following DAFNE training, patients report improved confidence in their ability to manage their own insulin dosing, but generally still seek and require the assistance of health professionals when making substantial changes to their insulin regimens. Some DAFNE trained patients may be able to assist their peers in aspects of diabetes management within a group environment, but widespread introduction of the expert patient/peer educator role in the self-management of type 1 diabetes, in particular related to insulin dose management, would require formal and detailed evaluation, preferably in randomized controlled clinical trials, before being introduced into routine clinical practice.

Keyword

Diabetes mellitus, type 1; Dose Adjustment for Normal Eating; Insulin therapy

MeSH Terms

Diabetes Mellitus, Type 1
Eating*
Health Occupations
Humans
Hypoglycemia
Insulin
Quality of Life
Self Care
Insulin

Reference

1. 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; 329:977–986.

2. The Diabetes Control and Complications Trial Research Group. Hypoglycemia in the Diabetes Control and Complications Trial. Diabetes. 1997; 46:271–286.

3. Egger M, Davey Smith G, Stettler C, Diem P. Risk of adverse effects of intensified treatment in insulin-dependent diabetes mellitus: a meta-analysis. Diabet Med. 1997; 14:919–928.

4. Berger M, Muhlhauser I. Implementation of intensified insulin therapy: a European perspective. Diabet Med. 1995; 12:201–208.

5. Mühlhauser I, Bruckner I, Berger M, Cheta D, Jorgens V, Ionescu-Tirgoviste C, Scholz V, Mincu I. Evaluation of an intensified insulin treatment and teaching programme as routine management of type 1 (insulin-dependent) diabetes: the Bucharest-Dusseldorf Study. Diabetologia. 1987; 30:681–690.

6. Mühlhauser I, Jorgens V, Berger M, Graninger W, Gurtler W, Hornke L, Kunz A, Schernthaner G, Scholz V, Voss HE. 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; 25:470–476.

7. 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.

8. McIntyre HD. DAFNE (Dose Adjustment for Normal Eating): structured education in insulin replacement therapy for type 1 diabetes. Med J Aust. 2006; 184:317–318.

9. McIntyre HD, Knight BA, Harvey DM, Noud MN, Hagger VL, Gilshenan KS. Dose adjustment for normal eating (DAFNE): an audit of outcomes in Australia. Med J Aust. 2010; 192:637–640.

10. Tattersall RL. The expert patient: a new approach to chronic disease management for the twenty-first century. Clin Med. 2002; 2:227–229.

11. Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988; 3:448–457.

12. Andel M, Tattersall R. Authoritarianism in diabetology. Diabet Med. 1989; 6:471.

13. Greenhalgh T. Patient and public involvement in chronic illness: beyond the expert patient. BMJ. 2009; 338:b49.

14. Griffiths C, Foster G, Ramsay J, Eldridge S, Taylor S. How effective are expert patient (lay led) education programmes for chronic disease? BMJ. 2007; 334:1254–1256.

15. Cade JE, Kirk SF, Nelson P, Hollins L, Deakin T, Greenwood DC, Harvey EL. Can peer educators influence healthy eating in people with diabetes? Results of a randomized controlled trial. Diabet Med. 2009; 26:1048–1054.

16. van der Wulp I, de Leeuw JR, Gorter KJ, Rutten GE. Effectiveness of peer-led self-management coaching for patients recently diagnosed with Type 2 diabetes mellitus in primary care: a randomized controlled trial. Diabet Med. 2012; 29:e390–e397.

17. Keen AJ, Duncan E, McKillop-Smith A, Evans ND, Gold AE. Dose Adjustment for Normal Eating (DAFNE) in routine clinical practice: who benefits? Diabet Med. 2012; 29:670–676.

18. Lawton J, Rankin D, Cooke D, Elliott J, Amiel S, Heller S. UK NIHR DAFNE Study Group. Patient's experiences of adjusting insulin doses when implementing flexible intensive insulin therapy: a longitudinal, qualitative investigation. Diabetes Res Clin Pract. 2012; 98:236–242.

19. Marden S, Thomas PW, Sheppard ZA, Knott J, Lueddeke J, Kerr D. Poor numeracy skills are associated with glycaemic control in Type 1 diabetes. Diabet Med. 2012; 29:662–669.

20. Kerr D, Marden S. Numeracy and insulin pump therapy. Diabet Med. 2010; 27:730–731.

21. Cukierman-Yaffe T, Konvalina N, Cohen O. Key elements for successful intensive insulin pump therapy in individuals with type 1 diabetes. Diabetes Res Clin Pract. 2011; 92:69–73.

22. Dinneen SF, O'Hara MC, Byrne M, Smith D, Courtney CH, McGurk C, Heller SR, Newell J, Coffey N, Breen C, O'Scannail M, O'Shea D. Irish DAFNE Study Group. Group follow-up compared to individual clinic visits after structured education for type 1 diabetes: a cluster randomised controlled trial. Diabetes Res Clin Pract. 2013; 100:29–38.

23. Gunn D, Mansell P. Glycaemic control and weight 7 years after Dose Adjustment For Normal Eating (DAFNE) structured education in Type 1 diabetes. Diabet Med. 2012; 29:807–812.

24. Müller N, Kloos C, Samann A, Wolf G, Muller UA. Evaluation of a treatment and teaching refresher programme for the optimization of intensified insulin therapy in type 1 diabetes. Patient Educ Couns. 2013; 93:108–113.

25. National Institute for Clinical Excellence. Guidance on the use of patient-education models for diabetes. updated 2003 Apr 29. Available from: http://www.nice.org.uk/nicemedia/pdf/60Patienteducationmodelsfullguidance.pdf.

26. Shearer A, Bagust A, Sanderson D, Heller S, Roberts S. Cost-effectiveness of flexible intensive insulin management to enable dietary freedom in people with Type 1 diabetes in the UK. Diabet Med. 2004; 21:460–467.

27. Kruger J, Brennan A, Thokala P, Basarir H, Jacques R, Elliott J, Heller S, Speight J. The cost-effectiveness of the Dose Adjustment for Normal Eating (DAFNE) structured education programme: an update using the Sheffield Type 1 Diabetes Policy Model. Diabet Med. 2013; 30:1236–1244.

28. 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) randomized controlled trial. Diabet Med. 2003; 20:Suppl 3. 4–5.

29. Mühlhauser I, Berger M. Patient education: evaluation of a complex intervention. Diabetologia. 2002; 45:1723–1733.

30. Sämann A, Muhlhauser I, Bender R, Kloos Ch, Muller UA. 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; 48:1965–1970.