Dose Adjustment For Normal Eating

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Dose Adjustment For Normal Eating

• A structured education programme for Type 1
  diabetes
• Dr Karen Tait
• Consultant Diabetologist

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Epidemiology

• Globally up to 20 million people with type 1 DM
• Average reduction in life expectancy
• 20 years
• UK 237000
• West Midlands 20000
• Worcestershire 2000

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Epidemiology

• Incidence has doubled every 20 years since 1945
• Half are diagnosed under 15 years
• 90 by age 30
• Peak age for diagnosis 10-14 years
• Steep rise in under 5s

• New cases per year -
• R B 20 adults 2008

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Complications

• Increase with duration of diabetes
• 20 reach ESRF
• 1000/year people with diabetes start dialysis
• Leading cause of blindness in people of working
  age.
• 15 times higher rates of amputation
• NHS spends 5 of budget on DM and complications

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The importance of good glycaemic control (DCCT
1993)

• Reduction in
• New retinopathy by 76
• Worsening of existing retinopathy by 54
• Early renal disease by 54
• Late nephropathy by 39
• Neuropathy by 60
• Pregnancy outcomes

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Pregnancy

• CEMACH report (Feb 07)
• Preterm delivery 36 vs. 7
• LSCS 67 vs. 22
• Weight gt 4kg 21 vs. 11
• 5 x stillbirth, 2 x foetal anomaly, 3 x perinatal
  mortality.
• Indicators of poor outcome
• Maternal hypoglycaemia
• Pre existing complications
• Suboptimal control pre and during pregnancy

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Barriers to good glycaemic control

• Poor understanding/ education
• Patients
• Healthcare professionals
• Relatives
• Hypoglycaemia
• Psychological
• Lack of peer support
• Empowerment

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Structured education

• Requirement of NSF for diabetes care
• Relevant to most standards
• Standard 3
• HCC survey 2006 11 patients had received
  education
• Need to specific to needs of type 1 diabetes
• QA and evidence based

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Dose Adjustment For Normal Eatingwww.dafne.uk.co
m

• A structured education programme for Type 1
  diabetes

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Important message first

• Type 1 diabetes is a condition caused by insulin
  deficiency
• Treatment is with insulin not diet
• Patients should eat normally and flexibly

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What is DAFNE?

• 5 day structured education programme for type 1
  diabetes
• Adult Learning principles in a group setting
• Autonomy
• Confidence to adjust insulin with dietary freedom
  in safe setting.
• CHO counting

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Other topics covered

• Pathophysiology
• Complications
• Hypos
• Exercise
• Pregnancy
• Alcohol
• Annual review
• Q A
• CHO counting practice sessions

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Background to DAFNE

• Diabetes control poor in UK compared to rest of
  Europe
• Complications
• QoL
• Severe hypos
• HbAic
• DCCT 1993 long term benefits of improved
  glycaemic control only achieved with 3 fold
  increase in severe hypos.

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In the beginning.

• 8 members of MDT from 3 UK centres visited
  Düsseldorf June 1998 to observe 5 day patient
  education programme.
• Convinced by principles, practice and evidence in
  the unit.
• Improved control, less complications, patient
  satisfaction

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DAFNE Study Group. Training in flexible,
intensive insulin management to enable dietary
freedom in people with type 1 diabetes DAFNE
RCT. BMJ 2002 325746

• 169 patients ½ DAFNE immediately, ½ after 6
  months
• Powered to detected reduction in HbAic of 1
• Biomedical and QOL outcomes measured at 0,6 and
  12 months
• At 6 months those attended dropped HbAic by 1,
  at 12 months 0.5
• 2nd group 0.7 drop at 6 months
• Improved QoL, freedom to eat
• No increase in severe hypoglycaemia

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Setting up a DAFNE centre

• 2 educators, 1 doctor per course
• DEP 18-19 days
• Observe course (5)
• Workshop (2)
• Deliver peer supported course (55)
• Follow up workshop (1)
• Accommodation
• 8 patients, 2 educators, 3 observers
• Course material

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Cost
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Cost EffectivenessShearer et al, Diabetic
Medicine 2004, 21, 460-467

• Increased life expectancy 19 days/patient
• Longer periods free from complications
• Life years without retinopathy doubled
• Blindness reduced by 25
• ESRD and foot ulceration/amputation reduced by
  10
• 4 fewer episodes of DKA/ 100 patients over 10
  years

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Cost Effectiveness

• Over 10 years DAFNE as a structured education
  programme saves 2200 per patient
• Breaks even after 4 years
• Savings reduced amputation, dialysis

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Other cost benefits

• Less outpatient visits
• Reduced insulin requirements
• Preconception and pregnancy
• DAFNE in hospital
• Pump use
• Less time off work

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QA

• Peer review
• Outcome measures recorded in central DAFNE
  database
• Patient feedback

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Patient selection

• Type 1 DM for at least 6 months
• Over 17 years old (KICk OFf)
• HbAic lt 12
• Motivated
• Need for flexibility
• Willing to inject and test gt 4 times daily
• Absence of end stage complications
• Availability to attend
• Basal bolus/CSII
• Numeracy skills

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Other benefits

• 5 years on delivering the NSF
• Approved by NICE
• TA60 patient education models
• Facilitate the formation of a clinical network
• Hub and spoke
• Diabetes register
• National collaborative

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Barriers

• Setting up costs
• Educator hours
• Time off work/childcare
• Not suitable for all patients
• Large geographical area
• 68 centres in UK
• 1460 courses delivered
• 10,000 graduates

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Patient satisfaction

• No longer missed work due to hypoglycaemia
  unawareness
• Able to eat with the family
• I have lost weight
• Freedom from a fixed routine
• Am able to miss meals or eat later
• In control of the diabetes rather than the other
  way around
• First holiday abroad in 25 years

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• Thank you

www.dafne.org.au