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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

      Abstract

      Aims

      To explore long-term outcomes of participation in a Dose Adjustment For Normal Eating (DAFNE) training course, which provided one-off exposure to structured education in intensive insulin therapy to people with established Type 1 diabetes.

      Methods

      A cohort design follow-up of original trial participants at a mean of 44 months (range: 37–51 months) in hospital diabetes clinics in three English health districts. 104 (74%) original participants provided biomedical data; 88 (63%) completed questionnaires including the ADDQoL, measuring impact of diabetes on quality of life (QoL).

      Results

      At 44 months, mean improvement in HbA1c from baseline was 0.36% (9.32 ± 1.1% to 8.96 ± 1.2%, p < 0.01) remaining significant but deteriorated from 12 months (p < 0.05). Improvements in QoL seen at 12 months were sustained at 44 (e.g. impact of diabetes on dietary freedom: −1.78 ± 2.33 at 44 months versus −4.27 ± 2.94, baseline, p < 0.0001; versus 1.80 ± 2.32 at 12 months, ns). Similar results were obtained using last observation carried forward for patients not supplying follow-up data.

      Conclusions

      The impact of a single DAFNE course on glycaemic control remains apparent in the long term, although further interventions will be required to achieve recommended HbA1c. In contrast, improvements in QoL and other patient-reported outcomes are well maintained over approximately 4 years.

      Abbreviations:

      ADDQoL (Audit of Diabetes-Dependent Quality of Life), ANOVA (analysis of variance), BMI (body mass index), DAFNE (Dose Adjustment For Normal Eating), DCCT (Diabetes Control and Complications Trial), DTSQ (Diabetes Treatment Satisfaction Questionnaire), HbA1c (haemaglobin A1c), HDL (high-density lipoprotein), QoL (quality of life), STTP (Structured Teaching and Treatment Programme)

      Keywords

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      References

        • Muhlhauser I.
        • Jorgens V.
        • Berger M.
        • Graninger W.
        • Gurtler W.
        • Hornke L.
        • 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: 470-476
        • Muhlhauser I.
        • Bruckner I.
        • Berger M.
        • Cheta D.
        • Jorgens V.
        • Ionescu-Tirgoviste C.
        • et al.
        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
        • Bott U.
        • Jorgens V.
        • Grusser M.
        • Bender R.
        • Muhlhauser I.
        • Berger M.
        Predictors of glycaemic control in type 1 diabetic patients after participation in an intensified treatment and teaching programme.
        Diabet. Med. 1994; 11: 362-371
        • Starostina E.G.
        • Antsiferov M.
        • Galstyan G.R.
        • Trautner Ch
        • Jorgens V.
        • Bott U.
        • et al.
        Effectiveness and cost–benefit analysis of intensive treatment and teaching programmes for type 1 (insulin-dependent) diabetes mellitus in Moscow—blood glucose versus urine glucose self-monitoring.
        Diabetologia. 1994; 37: 170-176
        • Bott S.
        • Bott U.
        • Berger M.
        • Muhlhauser I.
        Intensified insulin therapy and the risk of severe hypoglycaemia.
        Diabetologia. 1997; 40: 926-932
        • Tankova T.
        • Dakovska G.
        • Koev D.
        Education of diabetic patients—a one year experience.
        Patient Educ. Counsel. 2001; 43: 139-145
        • Pieber T.R.
        • Schattenberg S.
        • Brunner G.A.
        • Kauffmann P.
        • Schnedl W.J.
        • Krejs G.J.
        Evaluation of a structured outpatient group education program for intensive insulin therapy.
        Diabetes Care. 1995; 18: 625-630
        • The 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.
        Br. Med. J. 2002; 325: 746-749
        • Muhlhauser I.
        • Berger M.
        Patient education—evaluation of a complex intervention.
        Diabetologia. 2002; 45: 1723-1733
        • Falconnier Bendik C.
        • Keller U.
        • Moriconi N.
        • Gessler A.
        • Schindler C.
        • Zulewski H.
        • et al.
        Training in flexible, intensive insulin therapy improves quality of life, decreases the risk of hypoglycaemia and ameliorates poor metabolic control in patients with type 1 diabetes.
        Diabetes Res. Clin. Pract. 2009; 83: 327-333
      1. Department of Health. National Service Framework for Diabetes: Delivery Strategy. Department of Health, London, 2003.

        • Bradley C.
        • Todd C.
        • Gorton T.
        • Symonds E.
        • Martin A.
        • Plowright R.
        The development of an individualized questionnaire measure of perceived impact of diabetes on quality of life: the ADDQoL.
        Qual. Life Res. 1999; 8: 79-91
        • Bradley C.
        • Speight J.
        Patient perceptions of diabetes and diabetes therapy: assessing quality of life.
        Diabetes Metab. Res. Rev. 2002; 18: S64-S69
        • Bradley C.
        Diabetes Treatment Satisfaction Questionnaire (DTSQ).
        in: Bradley C. Handbook of Psychology and Diabetes: A Guide to Psychological Measurement in Diabetes Research and Practice. Harwood Academic Publishers, Chur, Switzerland1994: 111-132
        • Skinner T.C.
        What does make the difference?.
        Diabet. Med. 2006; 23: 933-934
        • American Diabetes Association
        Standards of medical care in diabetes.
        Diabetes Care. 2005; 28: 4-36
        • European Diabetes Policy Group
        A desktop guide to type 1 (insulin-dependent) diabetes mellitus.
        Diabet. Med. 1999; 16: 253-266
        • Michie S.
        • Abraham C.
        Interventions to change health behaviours: evidence-based or evidence-inspired?.
        Psychol. Health. 2004; 19: 29-49
        • Bott U.
        • Bott S.
        • Hemmann D.
        • Berger M.
        Evaluation of a holistic treatment and teaching programme for patients with type 1 diabetes who failed to achieve their therapeutic goals under intensified insulin therapy.
        Diabet. Med. 2000; 17: 635-643
        • Speight J.
        • The DAFNE Study Group
        Predicting outcomes in the Dose Adjustment For Normal Eating (DAFNE) trial.
        Proc. Br. Psychol. Soc. 2005; 13: 89
        • Martikainen P.T.
        • Marmot M.
        Socioeconomic differences in weight gain and determinants and consequences of coronary risk factors.
        Am. J. Clin. Nutr. 1999; 69: 719-726
        • Howorka K.
        • Pumprla J.
        • Schlusche C.
        • Wagner-Nosiska D.
        • Schabmann A.
        • Bradley C.
        Dealing with ceiling baseline treatment satisfaction level in patients with diabetes under flexible, functional insulin treatment: assessment of improvements in treatment satisfaction with a new insulin analogue.
        Qual. Life Res. 2000; 9: 915-930
        • Bradley C.
        • Plowright R.
        • Stewart J.
        • Valentine J.
        • Witthaus E.
        The Diabetes Treatment Satisfaction Questionnaire change version (DTSQc) evaluated in insulin glargine trials shows greater responsiveness to improvements than the original DTSQ.
        Health Qual. Life Outcomes. 2007; 5: 57
        • DCCT 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
        • Lawrence I.G.
        • Hopkins D.
        • Mansell P.
        • Thompson G.
        • Amiel S.
        • Heller S.
        DAFNE (Dose Adjustment For Normal Eating) training delivered in routine clinical practice is associated with improved glycaemic control and a reduction in severe hypoglycaemia.
        Diabet. Med. 2008; 25: P115-P172
        • Wolpert H.A.
        • Anderson B.J.
        Management of diabetes: are doctors framing the benefits from the wrong perspective?.
        Br. Med. J. 2001; 323: 994-996