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In my last posting about my diabetes I said that my improvements came from three main areas:

  • My use of the DAFNE system for managing insulin;
  • Modified eating; and
  • Tons of Testing

In this posting I'm going to describe DAFNE in more detail.

DAFNE stands for Dose Adjustment for Normal Eating. The slogan that goes with the program is "Like what you eat. Eat what you like."

How DAFNE works

DAFNE is a five day (!) training course for people with type one diabetes teaching a method of managing food and insulin doses.

When I first got diabetes, the goal was to eat exactly the same amount of carbohydrates every day and to give exactly the same insulin every day. Over time I loosened this up a bit: I'd eat a bit more or less at each meal and give a bit more or less insulin. Hypos and high blood readings told me that I didn't always judge this correctly. But two thirds of the times that I visited my specialist he'd tell me that I had an HbA1c reading below 7%, so my control was 'excellent'. And the other third of the time he'd tell me I was over 7%, so I was only 'good'. Despite these rules of thumb, my dosing was actually up the creek and I was fluctuating wildly (and often not realising it). It was only my average that was good. (My specialist once commented that my individual glucose results were 'always' very variable, and we assumed this was just a fact of life (like the weather) that we couldn't change (and shouldn't change if the HbA1c readings were OK.))

The DAFNE approach first sets your long acting insulin to an absolutely steady level. If you don't have a bite to eat all day, your insulin level shouldn't vary at all. (OK: exercise, stress and illness might change things. But all things being equal, you'd stay steady.) During the five day course everybody works out what their background doses should be. Interestingly, most of the people on my course substantially dropped their long acting insulin doses. Mine dropped from 50 units per day to 20 units per day (taken in two doses of 10 units).

Then you work out how much insulin you need for your meals. This is calculated with ratios. 1:1 means that for every carbohydrate portion (10 grams of carbohydrates) you have one unit of insulin. 1.5:1 means that for every carbohydrate portion you need 1.5 units of insulin. Through experimentation everybody determines what ratios they need. But the important thing to remember here is that at different times of the day you are likely to need different ratios. So I need 2 units for every carbohydrate portion in the morning, but only 1.5 at other times. Ratios can vary from 0.5:1 to 3:1.

Once you've worked out your ratios, you can vary your meals much or as little as you want. You can change the size of a meal and when you have it. You can skip a meal entirely. Your insulin goes up and down with your meals. As an ongoing process you'll need to keep tracking to make sure you are using the correct ratios. Things will change from time to time as your state of health or the amount of exercise you do varies. But as a general principle you'll be able to eat and select doses with enormous confidence and flexibility.

DAFNE in the real world

People who have been trained in DAFNE have improved control, reduced hypos and improved quality of life. The 25% of participants with the highest HbA1c readings see the biggest improvements (in Australia an average dropped from 9.9 to 9.1%). The 25% of participants with the best HbA1c readings actually increased their HbA1c readings slightly (from 6.8% to 6.9%). But their frequency of severe hypos dropped significantly, indicating that although their average control remained the same, the amount of variation (which wasn't measured in the Australian study) probably dropped.

What did DAFNE do for me?

I was in the 'good' quarter of people taking DAFNE. On average it shouldn't have changed my HbA1c much. Had I known this at the time, I wouldn't have spent five days attending the course. But it turns out that doing DAFNE was especially important for me.

For six months I was doing nothing except follow DAFNE. My HbA1c dropped a couple of percent. Its biggest benefit was the way it reduced my variations in blood glucose readings.

On its own, doing the DAFNE course:
  1. Allowed me to fix my old dosing rules which were entirely wrong (too much background, too much yo-yoing with my quick acting doses)
  2. Has given me confidence that I can avoid 'out of control' hypos: the ones that needed someone to come to my aid. (I haven't had one of these for a couple of years now)

I highly recommend doing DAFNE no matter what your control is currently like. The stability it gives you is well worth the time it takes to do the course.


More information

UK DAFNE Web site
OZ DAFNE web site (for the Australian program)
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 British Medical Journal: 2002; 325: 746
Taking the Guess Work out of Type 1 Diabetes; Dianne Harvey; Diabetes Management Journal, Volume 26, March 2009, page 16 (not available online). Editor dmj@goodhealthpublications.com, Suite 207, 2nd floor, 69 Christie Street, St Leonards New South Wales 2065, Australia.

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Anthony Holmes May 25th, 2009 05:30:27 PM

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