dafne course workbook

DAFNE is a comprehensive diabetes education program for adults with type 1 diabetes. In Australia, we call it OzDAFNE. People attend the program in groups of 6 to 8, and together you learn the skills to calculate how much insulin you need for the amount of carbohydrate in the food you want to eat. The program covers carbohydrate counting and adjusting insulin doses, as well as how to manage exercise, illness and hypoglycaemia. This allows more freedom in your lifestyle at the same time as improving your diabetes control.

The OzDAFNE program covers three main areas:

This section teaches you how to estimate the amount of carbohydrate in the food you want to eat and then match this with an appropriate insulin dose. There are practical exercises using real food, photographs of food, food models and food packets that allow you to practice what you have learned. The nutrition topics also include snacks, recipes, eating out, alcohol and sweeteners.

OzDAFNE teaches you how to check if your basal insulin dose is correct, and how to adjust your bolus insulin dose to match the amount of carbohydrate in the food you want to eat at each meal. 

You will be asked to check your glucose levels before each main meal and before bed. 

If you have impaired awareness of hypoglycaemia or retinopathy, we may ask you to use the upper end of these targets initially.

3. Other topics

The program also covers other topics like managing hypoglycaemia, exercise, illness, diabetes complications and goal setting. This makes it a truly comprehensive type 1 diabetes self-management program.

To see what the program involves in action, check out the videos below.

1. Diabetes Victoria OzDAFNE participants

2. Diabetes UK DAFNE participants

What is involved?

Program formats.

OzDAFNE offers separate programs for people using insulin pens and insulin pumps. (Please note, not all formats may be available at all OzDAFNE centres ).  OzDAFNE Pens programs

• 1 week program (in person) - runs Monday to Friday for one week, from 9 am to 5 pm each day.
• 5x1 program (in person) - runs one day a week for 5 consecutive weeks, from 9 am to 5 pm each day. 
• OzDAFNE@home - runs over 6 weeks with online lessons and weekly half day Zoom group meetings. 

OzDAFNE Pump programs

About the program

To get the most out of the OzDAFNE program, you will need to attend all sessions. You may need to take time off work, study or other commitments. We can give you a letter for your employer that explains the OzDAFNE program and its benefits for your health. This may help you get time off work to attend the program. The cost to attend an OzDAFNE program varies between locations. This is because there are different funding levels and running costs at each OzDAFNE centre. Please contact your local  OzDAFNE centre  directly to find out how much their programs cost.

Before the program

Before the program starts, you will need to attend a 1.5 hour appointment with the OzDAFNE Facilitator running the program. At the appointment, we will give you more information and talk about any changes you may need to make before the program begins. You will need to have some blood and urine tests done, fill in a few questionnaires, and answer some questions about your diabetes management and your general health. All information that is collected about you will be kept confidential and securely filed to meet legal requirements. It will only be passed on to your endocrinologist, doctor or other members of your diabetes care team if you give us permission to do so.  

Before the program starts, we will ask your endocrinologist or treating doctor to complete a form giving their approval for you to attend the program. Therefore, it is important that you have talked to them about your interest in OzDAFNE. Your doctor can contact their local  OzDAFNE centre  or the  OzDAFNE Project Officer  for more information about the program.   

After the program

There are also review sessions for your group after you have finished the OzDAFNE program. Review sessions last for about 3 to 4 hours and are a good way to catch up with your group members. You can talk about any improvements or issues that you have had since the program finished. Review sessions are held at 6 weeks, 6 months and 12 months after your program. We will look at your diabetes management and general health again at the 12 month review session. By looking at your pre-program and 12 month information, we will be able to see the difference that OzDAFNE has made to your diabetes management. 

Is OzDAFNE for me?

The OzDAFNE program may not be right for all people with type 1 diabetes. Below is a list of criteria that may help you decide if OzDAFNE is right for you. We also suggest that you talk to your endocrinologist or treating doctor about your interest in the program. 

To attend OzDAFNE, you need to:

• Have type 1 diabetes
• Be 18 years or older
• Be using multiple daily injections of insulin or an insulin pump
• Be willing to check and record your glucose levels at least four or five times a day
• Be prepared to adjust your own insulin according to what you eat, your glucose levels, and other factors (for example, exercise)
• Be able to attend the complete program
• Be able to speak, understand and read English

We will need some information about your current diabetes management and your general health, including:

• Your latest HbA1c result, and other blood and urine test results
• Any complications you have as a result of your diabetes
• Whether you are pregnant or trying to become pregnant
• The contact details for your endocrinologist or treating doctor. We will ask them for your medical history, and their consent for you to attend the program.

If you have any questions about whether the OzDAFNE program would be suitable for you or would like to book into a program, please contact your local  OzDAFNE centre  or the  OzDAFNE Project Officer .

Feedback from participants 

Over 4000 people have completed an OzDAFNE program in Australia, New Zealand and Singapore. We collect feedback from all of our participants, as we love to hear what they have to say.

Read some comments from people who have completed the program.

We asked Tony some more detailed questions about his experience with OzDAFNE.

People express their thoughts about OzDAFNE in many different ways.

Do you have something to share?

If you are an OzDAFNE graduate who would like to submit your feedback, please contact the  OzDAFNE Project Officer  with your comments, poems, songs, whatever!  

Frequently Asked Questions

Below are the answers to some frequently asked questions about OzDAFNE. If you have a question that is not answered here, please contact your nearest  OzDAFNE centre  or the OzDAFNE Project Officer .

A short history of OzDAFNE

Beginnings in germany.

A five day structured training program was created in Germany in the 1980s. It was designed by the diabetes team at the Diabetes Centre in Dusseldorf, led by the late Michael Berger. This inpatient program focused on intensive insulin therapy and the self-management of type 1 diabetes (references 1 - 3).

The educational approach is based on the Assal model of "therapeutic education" (4). People learn to match their insulin dose to their food on a meal-by-meal basis. The aim is that they can keep healthy blood glucose control without a higher risk of severe hypoglycaemia. They can then continue this with minimal support from their diabetes team.

Across to the UK

In 1998, the Dose Adjustment For Normal Eating (DAFNE) Project in the UK looked at creating a course based on the Dusseldorf model. The main change was that people would attend the course on an outpatient basis (5). A similar outpatient course was developed in Graz, Austria, led by Thomas Pieber (6). The Austrian course produced equally successful 12-year outcomes to those shown by the Dusseldorf model in Germany (7). This approach has now been widely adapted and developed across Europe.

The UK-based DAFNE Study Group translated the curriculum and carried out a randomised controlled trial of the Dusseldorf approach. The results showed significant improvement in glycaemic control, without increased risk of severe hypoglycaemia. Participants' quality of life and treatment satisfaction were also significantly improved (5). Over 15,000 people with type 1 in the UK have now done a DAFNE course.

Down under to Australia

Diabetes teams from Victoria, Queensland and Western Australia visited the UK for DAFNE Educator training in November 2004. These teams started to run DAFNE courses in Australia for people with type 1 diabetes in 2005. Over 2000 people have now completed the course in Australia.

In Australia, we call the program OzDAFNE. There are now OzDAFNE courses in most Australian states. OzDAFNE has also spread to nearby countries like New Zealand and Singapore. Click the link to find your nearest OzDAFNE centre .

Reference List

• 1. Mühlhauser, I., Jörgens, V., Berger, M., Graninger, W., Gürtler, W., Hornke, L., Kunz, A., Schernthaner, G., Scholz, V., & Voss, H.E. (1983) 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 25:470-476.
• 2. Mühlhauser, I., Bruckner, I., Berger, M., Cheta, D., Jörgens, V., Ionescu-Tîrgoviste, C., Scholz, V., & Mincu, I. (1987) Evaluation of an intensified insulin treatment and teaching programme as routine management of type 1 (insulin-dependent) diabetes. The Bucharest-Düsseldorf Study. Diabetologia 30:681-690.
• 3. Bott, S., Bott, U., Berger, M., & Mühlhauser, I. (1997) Intensified insulin therapy and the risk of severe hypoglycaemia. Diabetologia 40:926-932.
• 4. Assal, J.P., Mühlhauser, I., Pernet, A., Gfeller, R., Jörgens, V., & Berger, M. (1985) Patient education as the basis for diabetes care in clinical practice and research. Diabetologia 28:602-613.
• 5. The DAFNE Study Group. (2002) Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: the dose adjustment for normal eating (DAFNE) randomised control trial. BMJ 325:746.
• 6. Pieber, T.R., Brunner, G.A., Schnedl, W.J., Schattenberg, S., Kaufmann, P., & Krejs, G.J. (1995) Evaluation of a structured outpatient group education program for intensive insulin therapy. Diabetes Care 18:625-630.
• 7. Plank, J., Köhler, G., Rakovac, I., Semlitsch, B.M., Horvath, K., Bock, G., Kraly, B., & Pieber, T.R. (2004) Long-term evaluation of a structured outpatient education programme for intensified insulin therapy in patients with type 1 diabetes: a 12 year follow-up. Diabetologia 47:1370-1375.
• 8. Howorka, K. (1996) Functional insulin treatment. Berlin: Springer.

Does OzDAFNE work?

The DAFNE program has now been evaluated in a number of countries. Participants have seen improvements in a variety of key diabetes management areas. The following benefits have been shown in both Australia and the United Kingdom:

• Improved HbA1c (blood glucose control)
• Reduced diabetes distress, depression and anxiety symptoms
• Increased dietary freedom
• No weight gain
• No increase in blood fats
• No increase in severe hypoglycaemia (In Australian studies of OzDAFNE we have found that severe hypoglycaemia has been reduced).

Below is a brief summary of the findings of some key DAFNE research papers.

DAFNE Study Group. (2002) 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; 325:746.

The DAFNE Study Group set up a randomised controlled trial to evaluate the DAFNE program in the UK. The program was based on the Dusseldorf model of intensive insulin therapy ( read more ). It was translated to English and run as an outpatient course in three clinics across the UK during the trial.

The trial demonstrated that DAFNE was effective over a short-term (12 month) period. Specifically, the HbA1c of participants significantly decreased from baseline to the 12 month mark (a mean difference of 0.5%). This improvement occurred without a significant increase in severe hypoglycaemia. Cardiovascular risk factors did not worsen despite the increased dietary freedom reported by participants. The trial results also showed significant improvements for participants’ psychological well-being, quality of life, and satisfaction with treatment.

Speight J, Amiel SA, Bradley C, Heller S, Oliver L, Roberts S, Rogers H, Taylor C, Thompson G. (2010) Long-term biomedical and psychosocial outcomes following DAFNE (Dose Adjustment For Normal Eating) structured education to promote intensive insulin therapy in adults with sub-optimally controlled Type 1 diabetes. Diabetes Research & Clinical Practice; 89:22–29.

This research aimed to assess the long-term outcomes for participants in the original DAFNE trial. Participants provided follow-up data at an average of 44 months after their DAFNE course. The results showed that the improvement in HbA1c reported at 12 months (0.5%) had deteriorated slightly to 0.32% at 44 months but this was still statistically significant.

On the other hand, the positive psychological outcomes reported at the 12 month point were fully sustained at 44 months. These improvements were maintained in areas such as the impact of diabetes on dietary freedom, the impact of diabetes on quality of life, and present quality of life.

The authors concluded that DAFNE “offers major long-term benefits for quality of life outcomes and treatment satisfaction and more modest long-term benefits for glycaemic control”.

McIntyre HD, Knight BA, Harvey DM, Noud MN, Hagger VL, Gilshenan KS. (2010) Dose Adjustment for Normal Eating (DAFNE) – an audit of outcomes in Australia. Medical Journal of Australia; 192(11):637–640.

The aim of this research was to assess the short-term outcomes for participants in the DAFNE program in Australia. At 12 months post-course, the mean HbA1c of participants had fallen from 8.2% to 7.8% (a decrease of 0.4%). Overall, the decrease in HbA1c was found to be greater for those participants whose baseline HbA1c was the highest pre-course. The incidence of severe hypoglycaemic episodes decreased in Australian DAFNE participants. This is different to the earlier UK DAFNE studies, which showed no change in severe hypoglycaemia post-course. The Australian DAFNE audit also showed improvements in diabetes-related distress, and anxiety and depression symptoms.

DAFNE research

The DAFNE Collaborative is strongly committed to research and development to improve the DAFNE program. The DAFNE Research Group is currently working on a number of studies and research programs. Some of these are listed below. You can read more about further studies by visiting the UK DAFNE website .

Australian research & projects

Team t1 – teens empowered to actively manage type 1 diabetes.

TEAM T1 is a five-day group education program designed for teenagers aged 14 to 18 years with type 1 diabetes. It has been adapted for adolescents from the DAFNE program for adults with type 1 diabetes.

A pilot version of the TEAM T1 program was run at three Australian locations in 2009 and 2010, with 19 teenagers. Results showed that the program was acceptable and helpful for teenagers and their parents. Most participants had improved HbA1c levels 3 months after the program. They also reported improved confidence to manage their diabetes and less diabetes-related distress.

Another 5 years of funding for TEAM T1 was received from the Australian Government under the Chronic Disease Prevention and Service Improvement Fund. However unfortunately this program funding has now expired and there are currently no centres in Australia running TEAM T1 programs.

UK research & projects

Trial of 5-day vs 5-week dafne format.

Research has shown that delivering DAFNE over a consecutive 5-day period is very effective. However, some people are unable to attend a full week program, and so miss out on doing a DAFNE program altogether. DAFNE in the UK responded to these requests by trialling an “intermittent” delivery format. These programs were delivered one day per week over five weeks (5-week DAFNE).

This research showed that there were no significant differences in outcomes for people who attended the standard 5-day programs compared with the 5-week programs. Both groups had similar improvements across all biomedical and psychosocial areas included in the study. The team concluded that both program formats should be made available.

As a result of these research findings, a number of Australian OzDAFNE centres introduced the 5-week format. Check directly with your preferred centre to see if they are offering this format.

REPOSE: Relative Effectiveness of Pumps Over MDI and Structured Education

Insulin pumps are sometimes seen as the ‘gold star’ method of delivering insulin to people with type 1 diabetes. This research looked at the effectiveness of pumps in comparison to multiple daily injections of insulin. One study group received the standard DAFNE program for people using MDI therapy. The second study group received DAFNE education that was adapted for people using pump therapy.

This study showed that both groups had improvements in their diabetes management, and that pump treatment was not significantly better than multiple daily injections when DAFNE training was used. Read the full article explaining the results here .

Irish research & projects

Ongoing care post-dafne.

Research has shown that ongoing support assists with improving outcomes from education programs. The Irish DAFNE Study Group looked at two different methods of follow-up care after a DAFNE course. Their research also looked at economic concerns and the qualitative experiences of participants in both study groups. For more information about the results and outcomes of this research, please see the list of published articles and abstracts , or contact Professor Sean Dinneen .

OzDAFNE graduates

In this section there is information on:

• The OzDAFNE ketone and illness guidelines
• How to order a replacement OzDAFNE Tracker (Diary) or Carbohydrate Portion List
• Upcoming OzDAFNE graduate events
• Get involved in OzDAFNE!

We are always looking for new ideas. Please let us know if you have any thoughts on topics you would like to see in the OzDAFNE graduate section of this website.

OzDAFNE ketone and illness guidelines

Follow the OzDAFNE ketone and illness guidelines:

• At the first sign of feeling unwell, even if your BGLs are in target
• When your blood ketones are 0.6 mmol/L or more, even if you feel well
• When your BGL is 15.0 mmol/L or more for over 6 hours, even if you feel well

The OzDAFNE ketone and illness guidelines must be used whether it is day or night.

The OzDAFNE ketone and illness guidelines are based on ketone checking. If you are not able to check your ketones, you must get medical help so that ketones can be checked for you and treatment given as needed.

Make sure that you always have in-date blood ketone test strips.

Click the link to download the latest OzDAFNE ketone and illness guidelines (December 2019)(PDF).

You can also download an extended OzDAFNE Tracker page to help you record the extra BGL and ketone checks (PDF).

Need more help?

If you are feeling too unwell to follow these guidelines or you are not sure what to do then contact your doctor or diabetes educator, or call the Emergency Department of your nearest hospital to ask their advice.

Contact your OzDAFNE Facilitators if you would like to talk about the OzDAFNE ketone and illness guidelines, or another aspect of OzDAFNE and your diabetes management. You can contact your local OzDAFNE centre directly or fill in the Contact Us form with your location and we will put you in touch with a Facilitator near you.

The NDSS Helpline (1800 637 700) is also available if you want to talk to a health professional about any aspect of managing your diabetes.

OzDAFNE resource ordering

OzDAFNE provides graduates with extra copies of the OzDAFNE Tracker (Diary) for free. Each Tracker lasts for about 6 months.

There are a number of options to order extra copies of the Tracker.

• Contact your local OzDAFNE centre . They sometimes have copies that they can give to you.
• Click here to place an order.

If you have any questions or problems with ordering, please contact the OzDAFNE Project Officer .

Get involved with OzDAFNE

We are always looking for graduates who are happy to tell us about their OzDAFNE experiences. We want to make the OzDAFNE program as great as it can possibly be. This feedback helps us make changes to improve the course and the experiences of people who attend the program. It gives us the opportunity to promote the OzDAFNE program to people with diabetes and health professionals. It also helps us approach various funding bodies with an aim to make the program available to as many people as possible.

There are a number of ways that you can get involved in helping us. You could:

• Be interviewed about your OzDAFNE experience (either on video or in written format)
• Write a page or paragraph or blog about OzDAFNE that we can use on this website, in newsletters or in funding applications.
• Tell health professionals about your experience at one of our health professional workshops.
• Be a mentor to people who are thinking about doing OzDAFNE, or other graduates who may need some support.
• Be a ‘case study’ – letting our OzDAFNE Facilitators follow your progress and report on this at conferences in Australia and overseas.
• Simply help spread the word. Tell people about your experience with OzDAFNE.

If you are happy to volunteer some time to get involved in the OzDAFNE community, then please let us know! Feel free to contact your  OzDAFNE centre  or contact the OzDAFNE Project Officer for any current opportunities in your area.

TEAM T1 program for teens with T1 diabetes

*please note: there are currently no centres in australia running team t1*, what is team t1.

TEAM T1  stands for T eens E mpowered to A ctively M anage T ype 1 Diabetes.

TEAM T1 was designed for teenagers aged 14 to 18 years old, and was based on the adult DAFNE program. The program was run over 5 days (10am to 3pm) in a small group of 6 to 8 people. It was run by a diabetes educator and dietitian trained in type 1 diabetes management.

TEAM T1 taught young people the skills to work out how much insulin they needed for the amount of carbohydrate in the food they wanted to eat. It also taught them how to manage hypos, how to manage above-target blood glucose levels, and how to adjust food and insulin for exercise.

The emphasis of the program was on self-management, problem-solving, and building confidence to help prepare young people to manage their diabetes as they leave school and move to work, study, and adult diabetes care.

There was also a two day parent support program for parents of young people who were participating in a TEAM T1 program, which was held on the Monday and Friday of the TEAM T1 program. The parent program included information about insulin adjustment, carbohydrate counting, hypoglycaemia, exercise and sick day management and how to support their teenager with diabetes as they transitioned to adulthood. The TEAM T1 program was originally funded by the Australian Government under the Chronic Disease Prevention and Service Improvement Fund. The initial TEAM T1 project funding lasted for 5 years.

Unfortunately the project funding has now expired and there are currently no centres in Australia running the TEAM T1 program.

DAFNE – Dose Adjustment for Normal Eating

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DAFNE is an educational course for managing type 1 diabetes, giving diabetic patients the necessary skills to administer the right amount of insulin for the amount of carbohydrate you choose to eat.

The aim of the DAFNE course is to improve health outcomes for type 1 diabetics, by providing well-structured information and guidance.

The DAFNE programme is continually developing and improving.

What is the DAFNE course?

DAFNE is a method of managing type 1 diabetes for adults. DAFNE stands for Dose Adjustment for Normal Eating

The primary goal of DAFNE is to help diabetics live the most normal life possible, whilst keeping blood glucose levels stable and lowering the risk of diabetes complications.

What does a DAFNE course entail?

There are a number of questions often asked about the DAFNE course which are detailed below.

How long is a DAFNE course?

DAFNE is a 5-day training course, with a follow-up 8 weeks after the course finishes.

How many people are in a DAFNE course?

Groups of 6-8 participants are given guidance by educators trained in DAFNE, allowing patients to learn by experience and practice the key skills of estimating carbohydrate and adjusting insulin dose.

So I won’t do DAFNE alone?

Usually, DAFNE is conducted as part of a group. Patients can share their experiences, but also speak with DAFNE Educators privately about their individual circumstances.

Will I have to change everything?

One of the core goals of DAFNE is to allow people to fit diabetes within their current lifestyle , rather than making huge lifestyle adjustments for their diabetes.

How do I get on a DAFNE course?

DAFNE is offered throughout the UK and ROI, 77 different diabetes centres offer the course. However, DAFNE is currently only offered by diabetes units that have DAFNE trained educators and doctors, and private DAFNE courses are not yet available.

Ask your health team about the opportunities to be booked onto a DAFNE course.

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Dose adjustment for normal eating (DAFNE): doctor programme

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• Peer review
• Jonathan Schofield , specialist trainee year 6, diabetes and endocrinology
• 1 Central Manchester University Hospitals NHS Foundation Trust, UK
• jschofield{at}doctors.org.uk

The dose adjustment for normal eating (DAFNE) course for people with type 1 diabetes is an evidence based, structured education programme that provides them with the skills they need to estimate the carbohydrate content in each meal and inject the right dose of insulin. A total of 3387 DAFNE courses were delivered up to June 2012.

Who is it for?

The DAFNE course is delivered to small groups by trained diabetes specialist nurses and dietitians over five consecutive days. Participants are taught to match their insulin dose to their chosen food intake on a meal by meal basis.

The DAFNE doctor programme enables doctors to provide leadership and clinical support to DAFNE educators in the delivery of DAFNE courses. Doctors who have completed the doctor programme can deliver the introduction and facilitate the question and answer session during the week long DAFNE course. The doctor programme is mainly for consultants and specialty trainees in diabetes, although I would recommend it to any doctor interested in the management of diabetes. To date over 300 doctors have been trained in DAFNE techniques.

When did you do it?

I observed the five day DAFNE course during my specialty training year 4 and completed the one day doctor programme the next year.

Why did you do it?

Structured education enables patients to participate in their own healthcare; guidance from the National Institute for Health and Clinical Excellence (NICE) on the management of type 1 diabetes underlines the importance of this. 1 The DAFNE programme aims to give patients with type 1 diabetes a more flexible lifestyle and to improve outcomes through training in insulin dose adjustment and carbohydrate counting.

An evaluation of the DAFNE approach published in the BMJ in 2002 showed that structured education can improve glycaemic control, quality of life, and satisfaction with treatment in people with type 1 diabetes. 2 Since then, nearly 25 000 people with type 1 diabetes have completed the DAFNE course, and feedback remains overwhelmingly positive.

What did it involve?

The DAFNE doctor programme consists of orientation and background reading (4-6 hours), observation of a five day DAFNE course (37.5 hours), and attendance at a one day training workshop (6.5 hours).

The workshop starts with a review of the DAFNE philosophy, evidence for this approach, and the role of quality assurance in the DAFNE programme. This is followed by revision of the DAFNE dose adjustment principles before a discussion of the issues likely to arise when DAFNE is embedded into services for patients with type 1 diabetes.

How much did it cost?

To become a DAFNE doctor, the five day observation course and one day workshop must be successfully completed. The cost is £285, which includes all training materials. For an additional fee, doctors can attend a one day “doctor as educator workshop” to learn how to deliver more than the introduction and question and answer sessions of the DAFNE courses.

Is there an exam?

Although there is no exam, doctors who want to deliver a DAFNE session from the patient curriculum are assessed to ensure that the quality of any course they deliver is of the expected standard. A certificate is posted on completion of the doctor programme.

Was it worth it?

Yes, this course was worth attending. After taking part in the doctor programme I understood the principles and some of the problems in carbohydrate counting and using dose adjustment algorithms. I can now support DAFNE educators in the incorporation of DAFNE into routine service delivery.

One of the concepts discussed is that clinicians have a responsibility to, but not for, people with diabetes. I strongly agree with this philosophy and believe that the DAFNE doctor programme lays the foundations for understanding the importance to this approach of structured education.

Attending the observation week before the doctor programme is valuable, not just for understanding DAFNE principles but also as an opportunity to listen to patients’ experiences.

Apply early—only four DAFNE doctor programmes are scheduled for 2012.

Further information

For the latest information about DAFNE courses and the doctor programme go to www.DAFNE.uk.com or email dafne{at}northumbria-healthcare.nhs.uk .

Competing interests: None declared.

• ↵ National Institute for Health and Clinical Excellence. Guidance on the use of patient-education models for diabetes. NICE technology appraisal 60. April 2003.
• ↵ 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 . OpenUrl Abstract / FREE Full Text

• Journal of Diabetes Nursing

Vol:16 | No:09

The Dose Adjustment for Normal Eating (DAFNE) education programme

• 14 Nov 2012

DAFNE (Dose Adjustment for Normal Eating) is perhaps the best known of a number of structured education programmes for adults with type 1 diabetes introduced into the UK over the last 12 years. This article is a review of the development of DAFNE, the achievements to date and some of the current limitations. The author also outlines the research which has been fundamental to the development and subsequent evaluation of DAFNE, and which will underpin future clinical development.

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DAFNE (Dose Adjustment for Normal Eating) is a structured education programme that teaches the use of flexible intensive insulin therapy to optimise glycaemic control through independent self-management. The aims of DAFNE and similar programmes are to improve overall glycaemic control, to minimise hypoglycaemia and to improve the quality of life for those living with type 1 diabetes.

The concept of flexible, fast-acting, meal-related insulin dose adjustment dates back to the 1930s and was originally based on urine glucose tests. However, this approach really only became practicable with the advent of home blood glucose monitoring. Modern structured education programmes were first developed in Germany as the Diabetes Teaching and Treatment Programme (DTTP), which is based on a residential 1-week course (Mühlhauser et al, 1983; Assal et al, 1985). Interest in and observation of the DTTP by a multidisciplinary diabetes team from the UK led to a trial in England of structured education for adults with type 1 diabetes. The German programme was translated and modified as a 5-day, non-residential course.

The UK course was then tested using a controlled (delayed entry) three-centre trial (DAFNE Study Group, 2002). This showed an improvement in HbA 1c of 11 mmol/mol (1.0 percentage points) at 6 months, regressing to 5 mmol/mol (0.5 percentage points) at 12 months. There was no change in weight or rates of severe hypoglycaemia but there were considerable improvements in the adverse impact of diabetes on the quality of life, freedom of eating and the Diabetes Treatment Satisfaction questionnaire score.

The success of the initial DAFNE research project led to the programme being rolled out to seven other centres in 2002. DAFNE is now provided by 69 centres in 132 locations across the UK and there are currently approximately 25000 graduates (www.dafne.uk.com) representing around 10% of the UK population with type 1 diabetes, which has an estimated prevalence of 0.4% (NHS Information Centre, 2011). DAFNE education programmes are also now established in Eire, Australia, Kuwait, New Zealand and Singapore.

The DAFNE programme Principles The fundamental principle underlying DAFNE and other structured education programmes teaching flexible intensive insulin therapy is the separation of basal- and meal-related insulins. The basal or background insulin dose is kept relatively constant to maintain the blood glucose level within the given target range in the “fasting state” or after carbohydrate-free meals. The most important skill taught in DAFNE concerns the calculation of the meal-time, fast-acting insulin dose.

The dose required to cover the meal itself is determined by estimating the carbohydrate content of the food to be eaten in terms of the number of 10 g carbohydrate portions (CPs) and multiplying by an individualised ratio of the number of insulin units to each CP (often 1:1). A correction to the insulin dose may be required if the relevant pre-meal blood glucose level is outside of the target range, and further adjustments may be necessary, for example, before exercise. DAFNE diaries are provided so that blood glucose levels can be recorded, along with the CPs of the meals consumed and the insulin doses used, in order to aid reflection and, hence, refine future insulin dose adjustment.

Courses Individual courses are led by two trained educators (usually one DSN and one dietitian) in a group with six to eight people with type 1 diabetes. The courses are run along adult education principles, encouraging inclusivity, and participation and involvement by all. The education sessions outline carbohydrate counting and the adjustment of meal-related, fast-acting insulin doses.

Group feedback sessions on insulin adjustment and achieving target blood glucose levels take place at the beginning and end of each day. During the week-long course, there are additional sessions on:

• Insulin types.
• Duration and action.
• Blood glucose monitoring.
• Hypoglycaemia.
• Diabetes complications.
• The annual review.
• Diabetes in special situations, e.g. illness, alcohol and exercise.

A follow-up is provided in a single session at 6–12 weeks after each course, but is thereafter not specified and left to individual centres. A simple dataset is collected at pre-course assessment and then annually for audit purposes.

Quality control DAFNE educators, specifically trained for their role, are required to teach on at least one course every 6 months to maintain their skills and are intermittently peer-reviewed. Participating centres are audited on a 3-year cycle for the process on delivering the DAFNE programme and on local outcomes, particularly the recorded changes in HbA 1c .

Central organisation The DAFNE programme is coordinated by a central organisation that is funded by annual payments from individual centres. DAFNE Central is responsible for curriculum revision, training and peer review for educators, centre audits, course materials, a centralised database for audit of outcomes and a website (www.dafne.uk.com).

All participating DAFNE centres in the UK are invited to send representatives to the annual collaborative meeting, and regional educator meetings take place biannually. There is a patient support network called the DAFNE User Group, with a sub-group of elected representatives, the DAFNE User Action Group, having input into DAFNE planning and research development (Ward, 2011).

Outcomes One of the principles underlying the DAFNE programme is that this is evidence-based, quality assured and subject to audits. On the premise that there should be ongoing research to refine diabetes education for the ultimate benefit of people with diabetes, DAFNE is not a fixed and unchanging educational package. Research and audits within the DAFNE programme have been facilitated by the programme being standardised, centrally organised and run on a collaborative basis.

HbA 1c In the original DAFNE trial, the baseline HbA 1c of 79 mmol/mol (9.4%) improved by 11 mmol/mol (1.0 percentage point) at 6 months, rising to 74 mmol/mol (8.9%) at 12 months (DAFNE Study Group, 2002). In a subsequent study of as many of the original DAFNE participants who could be contacted, it was demonstrated that the mean HbA 1c remained, on average, 4 mmol/mol (0.36 percentage points) below the baseline nearly 4 years post-education (Speight et al, 2010).

In a single-centre study, participants in the earliest DAFNE courses in Nottingham had a persistent improvement in HbA 1c from baseline of 3 mmol/mol (0.3 percentage points) at 7 years compared with matched controls, with no differences in weight change over time between the groups (Gunn and Mansell, 2012). In a cohort of all the participants undergoing DAFNE education in the UK in 2005, the overall HbA 1c fell from 69 mmol/mol (8.5%) to 66 mmol/mol (8.2%) at a 1-year follow-up (Hopkins et al, 2012).

To date, longer-term improvements in HbA 1c following DAFNE have been moderate and less than that indicated by the original trial. There are, however, differences between more recent audits and the original DAFNE study. In the trial, there was a greater potential scope for improvement in HbA 1c , as the participants were relatively poorly controlled with a baseline HbA 1c of 79 mmol/mol (9.4%), those with an initial HbA 1c below 58 mmol/mol (7.5%) being excluded. It is also likely that a higher proportion of people with type 1 diabetes taking part in a trial over 10 years ago may not have been using a basal–bolus insulin regimen prior to entry compared with later cohorts. However, it is not as yet entirely clear why central European education programmes generally achieve lower outcome HbAlc levels than is the case with DAFNE in the UK (Mühlhauser et al, 1983; Pieber et al, 1995).

Hypoglycaemia Rates of hypoglycaemia were unchanged after structured education in the original DAFNE trial, despite a marked improvement in HbA 1c (DAFNE Study Group, 2002). In contrast, in the intensively treated group in the Diabetes Control and Complications Trial, the improvement in HbA 1c was accompanied by a much higher rate of hypoglycaemia (the Diabetes Control and Complications Trial Research Group, 1993). In the audit of the national DAFNE cohort in 2005, the rate of severe hypoglycaemia fell from 1.7 to 0.6 episodes per person per year between baseline and the 12-month follow-up, and hypoglycaemia recognition improved in 43% of those initially reporting unawareness (Hopkins et al, 2012).

Patient-reported quality of life and outcome measures As discussed previously, there were significant improvements in certain reported outcome measures and the quality of life at 12 months post-DAFNE education in the original trial. These improvements were maintained some 4 years later (Speight et al, 2010). In the UK DAFNE cohort in 2005, psychological distress was evident at baseline with a PAID (Problem Areas in Diabetes) score of 25.2 and HADS (Hospital Anxiety and Depression Scale) scores of 5.3 (“anxiety”) and 4.8 (“depression”).

These scores improved to 16.7 (PAID), 4.6 (HADS anxiety) and 4.2 (HADS depression) 1 year following DAFNE education, with the prevalence of clinically relevant anxiety and depression (HADS score ≥8) falling from 24.4 to 18.0% and 20.9 to 15.5%, respectively (Hopkins et al, 2012).

Limitations A potential threat to DAFNE and, indeed, to all similar programmes in the UK comes from current suggestions that the bulk of type 1 diabetes management should take place in the community rather than in secondary care, as this may make coordination of education more difficult. It has, however, been demonstrated that a “hub-and-spoke” model can be used to provide such education successfully (Rogers et al, 2009).

DAFNE clearly brings benefits to many people with type 1 diabetes, most notably perhaps in terms of the improved quality of life, but there are certain limitations to the programme at present. Firstly, the only modest improvement in overall blood glucose control following DAFNE in the UK means that many will remain above the target HbA 1c of 58 mmol/mol (7.5%) and, hence, at a higher risk of tissue complications.

Secondly, DAFNE is sometimes seen as “exclusive” or expensive, but this may be an unfortunate perception associated with the necessity for a central organisation to maintain standards with a uniform, validated curriculum with common teaching materials, peer review and audit in accordance with nationally agreed standards for structured education (Department of Health and Diabetes UK, 2005). Thirdly, the current education package is not suitable for all – for example, those who do not choose a flexible insulin regimen or who are unable to access the course owing to disability, language issues or simply the inability to free up the time required.

Finally, it is increasingly recognised that a substantial proportion of the adult population does not possess the arithmetical ability necessary to calculate insulin bolus doses as required in flexible intensive insulin therapy (Cavanaugh et al, 2008). This may be related to the observation that numeracy below the equivalent of grade C GCSE Mathematics is independently associated with a higher HbA 1c (Marsden et al, 2012).

DAFNE education has so far been deliberately discussed in terms of course delivery and teaching. However, teaching is not necessarily the same as learning and practice, and until recently there has been little evidence as to the behaviour that people with diabetes adopt following participation in the DAFNE programme or other structured diabetes education programmes, and how this may influence outcomes. This is a major component of current research in DAFNE.

Current research The ethos underlying the DAFNE programme is that it should be evidence-based, and so evolve through the application of audit and research. There is an active research group within DAFNE, which has been in receipt of an NIHR (National Institute for Health Research) programme grant from 2007 to 2012. The research group is multidisciplinary and includes clinicians, DSNs, dietitians, clinical psychologists, sociologists and health economists, and involves representative adults with type 1 diabetes who have undertaken DAFNE education. Research takes place at many DAFNE centres.

The current research programme includes randomised trials of providing DAFNE on 1 day per week over the course of 5 weeks, rather than over 1 week, using DAFNE with an insulin pump rather than multiple subcutaneous injections, and a pilot study of an intervention to assist those who continue to experience severe hypoglycaemia following DAFNE. These projects are either just complete or underway but are not yet published.

A research database study using a self-management questionnaire has shown that the self-care behaviours recommended during a DAFNE course vary considerably 1 year later (Mansell et al, 2012). In-depth interviews have confirmed the following:

• The frequency of blood glucose recording and reflection tends to decrease with time (Lawton et al, 2011; Rankin et al, 2011).
• Individual blood glucose targets tend to shift upwards from those originally set (Rankin et al, 2012b).
• Some people may require more support following DAFNE than that which is currently provided (Rankin et al, 2012a).

Further issues being studied include the rates of hypoglycaemia post-DAFNE education, the use of insulin pumps, outcomes in relation to the duration of diabetes, and an extensive health economics evaluation.

Conclusion DAFNE is a widely available education programme for adults with type 1 diabetes. Following the undertaking of DAFNE education, there are significant improvements in psychosocial outcomes, rates of severe hypoglycaemia and, to a lesser extent, overall glycaemic control. The relatively modest improvement observed in the HbA 1c of participants is a challenge to DAFNE and similar structured education programmes. It is interesting to consider whether glycaemic control following DAFNE could be improved by one or more of the following ways:

• Refining the education programme itself.
• Introducing a more structured follow-up, including the reinforcement of target setting.
• Embracing new technologies, particularly insulin bolus dose calculators, continuous blood glucose monitoring and insulin pump technology.

A further multidisciplinary research programme has been proposed to ensure that DAFNE education remains evidence-based and progressive.

Assal JP, Mühlhauser I, Pernet A et al (1985) Patient education as the basis for diabetes care in clinical practice and research. Diabetologia 28 : 602–13 Cavanaugh K, Huizinga MM, Wallston KA et al (2008) Association of numeracy and diabetes control. Ann Intern Med 148 : 737–46 DAFNE Study Group (2002) 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 325 : 746–9 Diabetes Control and Complications Trial Research Group (1993) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. NEJM 329 : 977–86 Department of Health, Diabetes UK (2005) Structured patient education in diabetes: Report from the Patient Education Working Group . DH, London. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4113197.pdf (accessed 08.10.12) Gunn D, Mansell P (2012) Glycaemic control and weight 7 years after Dose Adjustment For Normal Eating (DAFNE) structured education in type 1 diabetes. Diabet Med 29 : 807–12 Hopkins D, Lawrence I, Mansell P et al (2012) Improved biomedical and psychological outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes: the U.K. DAFNE experience. Diabetes Care 35 : 1638–42 Lawton J, Rankin D, Cooke DD et al (2011) Dose Adjustment for Normal Eating: a qualitative longitudinal exploration of the food and eating practices of type 1 diabetes patients converted to flexible intensive insulin therapy in the UK. Diabetes Res Clin Pract 91 : 87–93 Mansell P, Grant L, Cooke D et al (2012) Diabetes self-management strategies after DAFNE structured education. Diabet Med 29 (Suppl 1): 8 Marsden S, Thomas PW, Sheppard ZA et al (2012) Poor numeracy skills are associated with glycaemic control in type 1 diabetes. Diabet Med 29 : 662–9 Mühlhauser I, Jörgens V, Berger M et al (1983) 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 25 : 470–6 NHS Information Centre (2011) National Diabetes Audit Executive Summary 2009–2010 . The NHS Information Centre for health and social care, Leeds. Available at: http://www.ic.nhs.uk/webfiles/Services/NCASP/Diabetes/200910 annual report documents/National_Diabetes_Audit_Executive_Summary_2009_2010.pdf (accessed 08.10.12) Pieber TR, Brunner GA, Schnedl WJ et al (1995) Evaluation of a structured outpatient group education program for intensive insulin therapy. Diabetes Care 18 : 625–30 Rankin D, Cooke DD, Clark M et al (2011) How and why do patients with type 1 diabetes sustain their use of flexible intensive insulin therapy? A qualitative longitudinal investigation of patients’ self-management practices following attendance at a Dose Adjustment for Normal Eating (DAFNE) course. Diabet Med 28 : 532–8 Rankin D, Cooke DD, Elliott J et al (2012a) Supporting self-management after attending a structured education programme: a qualitative longitudinal investigation of type 1 diabetes patients’ experiences and views. BMC Public Health 12 : 652 Rankin D, Cooke DD, Heller S et al (2012b) Experiences of using blood glucose targets when following an intensive insulin regimen: a qualitative longitudinal investigation involving patients with type 1 diabetes. Diabet Med 29 : 1079–84 Rogers H, Turner E, Thompson G et al (2009) Hub-and-spoke model for a 5-day structured patient education programme for people with type 1 diabetes. Diabet Med 26 : 915–20 Speight J, Amiel SA, Bradley C et al (2010) Long-term biomedical and psychosocial outcomes following DAFNE (Dose Adjustment for Normal Eating) structured education to promote intensive insulin therapy in adults with sub-optimally controlled type 1 diabetes. Diabetes Res Clin Pract 89 : 22–9 Ward E (2011) DAFNE User Action Group (DUAG). Journal of Diabetes Nursing 15 : 318

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Welcome to the  Dose Adjustment For Normal Eating (DAFNE)  collection of courses

DAFNE is a way of managing type 1 diabetes and provides people with the skills necessary to estimate the carbohydrate in each meal and to inject the right dose of insulin.

This collection of courses contains up-to-date information on DAFNE for people living with type 1 diabetes and for healthcare professionals.

Our vision is to improve outcomes for people with type 1 diabetes through high quality structured education which is embedded in the Health Service and create a framework in which to develop this patient centred model of care.

We will continue to improve and develop DAFNE through research and development (R&D) and collaboration with other groups, to understand the determinants of success.

What is DAFNE?

DAFNE is a programme hosted by Northumbria Healthcare NHS Foundation Trust and delivered to adults with type 1 diabetes through a consortium of NHS foundation trusts and NHS health boards across the UK.

DAFNE stands for Dose Adjustment For Normal Eating and is a way of managing type 1 diabetes for adults; it provides the skills necessary to estimate the carbohydrate in each meal and to inject the right dose of insulin.

The aim of DAFNE is to help people with type 1 diabetes to lead as normal a life as possible, while controlling their blood glucose levels, hence reducing the risk of long-term diabetes complications. These courses are about learning from experience and practising the skills of carbohydrate counting and insulin adjustment.

Most of the training is built around group work, sharing and comparing experiences with other participants. However, there are opportunities for each person to speak to DAFNE Educators individually.

DAFNE allows people to fit diabetes into their lifestyle, rather than changing their lifestyle to fit in with their diabetes.

More information about DAFNE and DAFNE training can be found on the website:

www.dafne.nhs.uk

There is information on the DAFNE NHS site about how to access a DAFNE course https://dafne.nhs.uk/do-you-have-type-1-diabetes/how-do-i-access-a-course

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