In 1997, 3 diabetes units (Sheffield Teaching Hospitals, Northumbria Healthcare Trust and King’s College Hospital, London) began to discuss their dissatisfaction with current achievements for people with Type 1 diabetes in the UK and the poor quality of the research and evidence upon which much of the current practice at the time was based. They decided to search for evidence to improve their practice.

The DCCT [1] suggested long-term benefits of improved glycaemic control could be achieved only at the risk of a 3-fold increase in short-term severe hypoglycaemia.

A 5-day structured training programme in intensive insulin therapy (IIT), developed by the late Michael Berger’s team in Düsseldorf [2, 3, 4] based on therapeutic patient education principles [5] , produced a sustained reduction in HbA1c of 1.5% when compared with knowledge transfer alone, but unlike the DCCT reduced rather than increased the incidence of severe hypoglycaemia. The Düsseldorf approach had been widely adopted in Germany and other European countries which have added to the evidence base for the effectiveness of the programme [6].

The sceptical team from the UK made a structured observational visit to Düsseldorf in June 1998, following an invitation from Michael Berger, and observed an entire 5-day training programme. Contrary to their expectations, the team were impressed by the intervention which was highly valued by patients. The cultural differences seemed small and the team decided to evaluate the course in a UK setting.

With Diabetes UK funding and assistance from Berger and colleagues, the newly formed DAFNE group, translated the curriculum and conducted a feasibility, randomised waiting list controlled trial of this approach. This study demonstrated that IIT could be translated to a UK setting with associated improvements in HbA1c and no increase in hypoglycaemia. In addition the study showed improved Quality of Life and treatment satisfaction, also demonstrating that even with a message of freedom to eat cardiovascular risk factors and weight did not deteriorate, at least in the short-term [7].

Using the MRC Framework for Complex Interventions (reference Figure 1) and recognising that a full RCT had previously been conducted by the Düsseldorf group in Rumania [6] the DAFNE group decided the next step was a closely audited rollout of the intervention in routine care.

DAFNE was further evaluated for 12-months in 7 additional UK diabetes services, which reported similar biomedical and psychological benefits as the feasibility study [8]. DAFNE is now delivered as part of routine clinical care in 75 diabetes services in the UK and Southern Ireland. DAFNE has also been exported to Australia, as Oz DAFNE being delivered in 14 centres including New Zealand. Teams from Spain, South Africa, Nigeria and Kuwait have recently travelled to the UK to observe DAFNE and receive training.


References

1. The Diabetes Control and Complication 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; 329:683-9

2. Muhlhauser I, Jorgens V, Berger M, 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; 25:470-6.

3. Muhlhauser I, Bruckner I, Berger M, 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; 30:681-90.

4. Bott S, Bott U, Berger M, Muhlhauser I. Intensified insulin therapy and the risk of severe hypoglycaemia. Diabetologia 1997; 40:926-32.

5. Assal JP, Muhlhauser I, Pernet A, et al. Patient education as the basis for diabetes care in clinical practice and research. Diabetologia 1985; 28: 602-13

6. Pieber TR, Brunner GA, Schnedl WJ, et al. Evaluation of a structured outpatient group education program for intensive insulin therapy. Diabetes Care 1995;18:625-30.

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. Mansell P, Clarke P, Pownall N, et al. Dosae adjustment for normal eating (DAFNE) education programme. Improvements in HbA1c maintained for two years. Diabetic Medicine 2005 ; 22 (Suppl.2) : 7


Last Updated: 01/03/2013