Our data show that a structured training course (designed to maintain glucose control while enabling dietary freedom) teaching self management skills to patients with type 1 diabetes was effective over the short term in a British healthcare setting. DAFNE training significantly improved glycated haemoglobin, with no significant increase in severe hypoglycaemia. The training also produced sustained positive effects on quality of life, satisfaction with treatment, and psychological wellbeing, despite an increase in the number of insulin injections and encouragement to increase blood glucose monitoring. Despite increased dietary freedom (as shown by responses to the “freedom to eat as I wish” item in the audit of diabetes-dependent quality of life), we observed no deterioration in cardiovascular risk factors. These results are encouraging and suggest that people with established diabetes, when taught appropriate skills, will intensify management of their diabetes and that this can be (and perhaps needs to be) associated with improved quality of life.
As with any randomised controlled trial, a crucial question is how readily the observed effects might be transferred to the wider population of adults with type 1 diabetes. The participants may have been atypical in the impact of diabetes on their quality of life, their dissatisfaction with current treatment, and their willingness to inject insulin five times a day. However, the fact that a third of patients attending routine hospital clinics expressed interest in participating after a single unsolicited advertisement is encouraging. Other studies have shown that current management of diabetes in the United Kingdom leads to negative effects on quality of life comparable to those seen in our participants at baseline, indicating that many patients with type 1 diabetes stand to benefit from a more flexible approach with increased dietary freedom.4,5
The presentation of the course to patients as a trial may have deterred some, but many patients who are reluctant to participate in research might attend training as part of standard treatment, especially once our findings are known.
Many participants had a relatively long duration of diabetes, with well established, albeit imperfect, strategies for coping with the condition. Patients with a shorter duration of diabetes might prove even more receptive to a flexible, intensive approach. DAFNE training, by facilitating a more flexible lifestyle, might also encourage patients with tight glycaemic control (who were excluded from the trial), particularly those experiencing severe hypoglycaemia, to maintain tight glycaemic targets with greater safety and less damage to quality of life.
The fall in HbA1c
at the six month analysis was comparable to that reported in similar interventions. The Dusseldorf group reported a lower HbA1c
(by 1.5%) one year after training, compared with group teaching of diabetes related information alone,11
and similar improvements have been maintained for three and six years.12,13
We did not see this in the immediate DAFNE group at one year; HbA1c
rose slightly from the six month value, although it remained statistically and clinically significantly lower than at baseline. The UK participants had a longer duration of diabetes than those in earlier studies and were discharged to a healthcare system unfamiliar with this approach. We avoided proactive follow up by DAFNE educators in order to evaluate the effects of the course alone. We might have expected some deterioration without specific reinforcement or feedback of HbA1c
As with any complex intervention, it is difficult to know which aspects contributed to its effect. Control participants received only usual care, and it is possible that the benefits were merely the result of patients spending five days intensively focusing on diabetes, receiving attention from enthusiastic educators. However, the diabetes control and complications trial was unable to show any improvements in quality of life,2
and evidence in type 2 diabetes suggests that improvements in audit of diabetes-dependent quality of life scores and HbA1c
cannot be achieved by empowerment alone.14
Not everyone with type 1 diabetes will wish to undertake intensive insulin treatment, even without dietary restrictions; some will prefer a simpler regimen with routine meal timing and fewer injections. Such options will still be needed. Nevertheless, as the only way of reducing microvascular disease currently is by maintaining tight glycaemic control, we need better ways of enabling patients to intensify their insulin treatment. This study builds on earlier work and shows that skills training and unrestricted food choices can be applied successfully across different healthcare systems. The follow up of our patients was, however, relatively short. We now need to establish whether similar results can be achieved in routine care and devise ways of sustaining improvement in glycaemic control.
We have shown, in a group of volunteers, that skills training in insulin adjustment that provides patients with the ability to fit diabetes into their lives rather than their lives into diabetes improves quality of life and glycaemic control in the short term. The DAFNE approach has the potential to reduce the incidence of microvascular complications and thereby protect quality of life in the long term, as well as the short term, and is worthy of further investigation.