Skip Navigation
Skip to contents

Diabetes Metab J : Diabetes & Metabolism Journal



Page Path
HOME > Diabetes Metab J > Volume 38(2); 2014 > Article
Clinical Care/Education Dose Adjustment for Normal Eating: A Role for the Expert Patient?
Harold David McIntyre
Diabetes & Metabolism Journal 2014;38(2):87-91.
Published online: April 18, 2014
  • 49 Download
  • 8 Web of Science
  • 5 Crossref
  • 7 Scopus

Department of Medicine, Mater Clinical School, The University of Queensland and Mater Health Services, South Brisbane, Australia.

Corresponding author: Harold David McIntyre. Department of Medicine, Mater Clinical School, The University of Queensland and Mater Health Services, Raymond Terrace, South Brisbane QLD 4101, Australia.

Copyright © 2014 Korean Diabetes Association

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • The Dose Adjustment for Normal Eating (DAFNE) programme of intensive insulin therapy for type 1 diabetes provides a structured educational intervention to improve glycemic control, reduce hypoglycemia and improve quality of life. Enhancement of self-management skills is a key element of DAFNE and patients acquire detailed skills in insulin dose adjustment. Following DAFNE training, patients report improved confidence in their ability to manage their own insulin dosing, but generally still seek and require the assistance of health professionals when making substantial changes to their insulin regimens. Some DAFNE trained patients may be able to assist their peers in aspects of diabetes management within a group environment, but widespread introduction of the expert patient/peer educator role in the self-management of type 1 diabetes, in particular related to insulin dose management, would require formal and detailed evaluation, preferably in randomized controlled clinical trials, before being introduced into routine clinical practice.
Problems in type 1 diabetes management
Many people with type 1 diabetes mellitus (T1DM) experience difficulties with the everyday challenges of managing their diabetic condition. In particular, many find it difficult to intensively manage their insulin therapy and achieve near normal blood glucose levels and optimal levels of glycosylated hemoglobin whilst avoiding hypoglycaemia and weight gain.
The landmark Diabetes Control and Complications Study (DCCT) [1], conducted in North America, offered the first clear evidence that intensive glycaemic control in T1DM definitely improves clinical (in particular microvascular) outcomes, but both the DCCT [2] and a subsequent meta-analysis [3] suggested that improved glycaemia as measured by hemoglobin A1c (HbA1c) reduction must inevitably be accompanied by an increased risk of severe hypoglycaemia. This, in addition to the weight gain associated with intensive therapy have served to discourage many people with diabetes and their treating doctors from attempting more intensive glycaemic control [1].
In contrast to the DCCT, clinicians in Germany, led by the late professor Michael Burger, developed the Diabetes Training and Treatment Programme (DTTP) [4,5,6], a structured education programme for people with type 1 diabetes which promoted self-management and demonstrated improved glycemic control without worsening of hypoglycemia.
The Dose Adjustment for Normal Eating (DAFNE) programme of structured education for people with T1DM was developed in the United Kingdom as a modification of the German DTTP and assessed in a randomized controlled trial [7]. Reported benefits of DAFNE training include improved overall glycaemic control, reduced hypoglycaemia, and improved quality of life [7].
Australian clinicians undertook DAFNE training in the United Kingdom in late 2004 and DAFNE courses have been offered in Australia since January 2005 [8]. These involve a 5-day (Monday to Friday over 1 week, 7 to 8 hours/day) outpatient programme of structured education in diabetes self-management for 6 to 8 people with T1DM, with an emphasis on insulin dose adjustment using a flexible dietary intake, detailed estimation of dietary carbohydrate intake and the use of insulin/carbohydrate ratios (units of rapid acting insulin/10 g carbohydrate portion or CP) as the basis for prandial insulin dosing.
Specifically, DAFNE divides insulin doses into 1) background insulin or BI, which generally consists of twice daily isophane insulin or twice daily long acting insulin analogue and 2) quick acting (QA) insulin at mealtimes, consisting of either soluble insulin or a short acting insulin analogue.
The mealtime insulin doses also include a corrective component, used when the premeal glucose level is outside prespecified parameters. Over the course of the DAFNE training week, patients learn the skills of carbohydrate estimation or counting and receive formal instruction regarding many aspects of diabetes care, including the management of insulin adjustments for exercise or alcohol ingestion, the treatment of hypoglycemia, sick day management, the detection and management of chronic diabetes complications and specific areas such as pregnancy management if relevant to the particular group. Twice daily during the 5-day course, group members present their individual glucose monitoring results and learn skills related to insulin adjustment in an experiential approach, seeing the results of insulin adjustments made both by themselves and by other members of the group.
DAFNE courses are generally facilitated by a dietitian and diabetes nurse educator, who together lead the group through a variety of learning experiences. The dietary elements of the programme have been specifically adapted to Australian food choices, but the core curriculum is entirely consistent with resources developed and used in the United Kingdom. The Oz DAFNE programme has shown results similar to those reported in Germany and the United Kingdom, with reduction in HbA1c, reduced severe hypoglycemia, improved quality of life and minor weight reduction [9].
In the early years of the 21 century, coincident with the development of the DAFNE programme in the United Kingdom, the concept of peer involvement in chronic disease management, commonly termed the expert patient approach, was emerging [10]. Although diabetes was frequently included in the list of chronic diseases for which an expert patient approach might prove useful, definite evidence of its utility, especially in the care of T1DM was scant, with conditions such as arthritis and asthma providing more substantial data demonstrating benefits [10]. Although there was some evidence at this time that active patient involvement in diabetes care through structured active participation in clinic visits might improve metabolic control [11], it was also suggested that diabetologists, whilst promoting self-management and patient autonomy in theory, practiced in a much more didactic fashion within their clinic environments [12]. Subsequent publications from the United Kingdom questioned the value of the expert patient approach, or called for a broader framework for consideration of patient/consumer integration into health care delivery [13,14].
No randomized controlled trials exist evaluating the use of expert patients in T1DM management. Two randomized controlled trials have examined the potential role of expert patients in the management of T2DM, with varying results. Cade et al. [15] reported no significant benefits from the use of and expert patient programme in improving dietetic or metabolic parameters in T2DM. In contrast, van der Wulp et al. [16], reported that a peer led self-management approach improved psychological well-being and self-efficacy in T2DM, though these benefits were primarily seen in patients with poor psychological status at baseline.
Although the desirability of self-adjustment of insulin doses as compared to clinician-directed dose adjustment is frequently debated, diabetes self-management is an inescapable everyday reality for people with T1DM. It has been estimated that people with diabetes spend on average only 2.6 hours (or 0.03% of their life) per year with health professionals [17]. Since many must make decisions regarding insulin doses four to five times daily, a degree of autonomy in diabetes management is clearly essential. What is less clear is whether they undertake self-management in a well or poorly informed manner.
The DAFNE programme provides a sound basis for self-adjustment of prandial and basal insulin therapy. Lawton et al. [18] have recently provided useful qualitative data as to how this translates into the real world experiences of patients following DAFNE training. They report that virtually all patients felt confident, motivated and able to adjust their insulin doses immediately after completing the DAFNE course. However, they noted that with longer term (6 to 12 month) follow-up, only a minority of patients described themselves as confident in making independent adjustment to basal insulin doses and prandial insulin/glucose ratios. Many patients felt the need for health professional review and endorsement of their decisions, even when they clearly understood the DAFNE based principles for dose adjustment. Patients described a long history of seeking health professional advice regarding insulin dose adjustments and clearly this ingrained deferential pattern of behaviour did not change substantially after DAFNE instruction. By contrast, patients rapidly adapted to the use of corrective doses of insulin to rapidly and effectively bring their self-monitored glucose readings back towards the normal range. It was reported that patients used corrective dosing as a safety net to control glycemia, rather than making more soundly based long adjustment to prandial insulin/glucose ratios or soliciting health professional input.
Although, the principles of DAFNE insulin dose adjustment are clearly outlined during the one week training course and supported by written handbooks and patient diaries, effective participation in the programme presumes reasonable literacy and numeracy. It has previously been noted that numeracy and glycemic control are inversely related in people with T1DM [19,20] and adequate numeracy has been suggested as a key requirement for successful insulin pump therapy [21].
Optimal patient follow-up after initial structured education courses such as DAFNE remains poorly defined. The Irish DAFNE group have suggested that group follow-up, which clearly includes a high degree of peer interaction, provides equal benefits to one-on-one clinic visits following DAFNE training [22] and some patients have suggested development of a dedicated glycemia support service [18]. As with many patient education programmes, the effects of DAFNE tend to wane over time [23] and optimal patient follow-up is clearly important. The German groups with long standing experience of the DTTP programme have demonstrated the value of refresher courses for patients failing to meet metabolic goals after initial education in intensified insulin therapy [24].
The use of structured patient education as a routine part of diabetes management has been endorsed by the National Institute of Clinical Excellence in the United Kingdom [25], with DAFNE being recognised as one programme which provides a suitable option for people with T1DM. Further, cost modelling in the United Kingdom context has suggested that DAFNE is cost saving [26] or cost effective [27], depending on the assumptions used, due to improved glycemic control and reduced diabetic complications.
The results of the DAFNE programme and its predecessors over many years clearly demonstrate consistent benefits in terms of improvements in glycemic control, reduction in severe hypoglycemia, improved quality of life and the potential for appropriate dietary adjustments to control weight gain [5,6,9,23,28,29,30]. DAFNE definitely promotes patient autonomy in appropriate adjustment of insulin dosing on a day-to-day basis.
These results contrast with those using primarily models of externally driven diabetes management, such as the DCCT [1]. Whilst the DCCT programme was largely doctor, dietician and nurse driven, with prescription of dietary regimens and clinician adjustment of insulin doses, DAFNE promotes dietary flexibility and self-titration of insulin doses using insulin/carbohydrate ratios.
However, as noted previously, improved knowledge in self-titration of insulin may not necessarily translate into the degree of confidence in self-management needed for patients to take over complete responsibility for their insulin therapy. Given this reticence for patients to entirely assume responsibility for their own insulin dosing, it seems unlikely that the majority of DAFNE graduates would be well equipped to act as peer educators or expert patients in the care of other people with T1DM. Further, because of the risks of severe hypoglycemia and its potentially catastrophic consequences such as motor vehicle accidents, the legal implications of promotion of a formal expert patient role in T1DM would need to be carefully considered.
The DAFNE programme offers a well-validated means of improving self-management of insulin therapy in people with T1DM. However, although people who complete the course improve their individual skills in managing their diabetic condition on a day-to-day basis, it appears that few individuals achieve the level of confidence and competence required to act as peer educators or "expert patients" in this area. Nonetheless, peer support has other potentially important roles in the overall promotion of effective diabetes care. It is particularly valuable in encouraging long-term implementation of this programme and in advocating for appropriate funding allocations for diabetes self-management.

No potential conflict of interest relevant to this article was reported.

  • 1. The Diabetes Control and Complications 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;329:977-986. ArticlePubMed
  • 2. The Diabetes Control and Complications Trial Research Group. Hypoglycemia in the Diabetes Control and Complications Trial. Diabetes 1997;46:271-286. ArticlePubMed
  • 3. Egger M, Davey Smith G, Stettler C, Diem P. Risk of adverse effects of intensified treatment in insulin-dependent diabetes mellitus: a meta-analysis. Diabet Med 1997;14:919-928. ArticlePubMed
  • 4. Berger M, Muhlhauser I. Implementation of intensified insulin therapy: a European perspective. Diabet Med 1995;12:201-208. ArticlePubMed
  • 5. Mühlhauser I, Bruckner I, Berger M, Cheta D, Jorgens V, Ionescu-Tirgoviste C, Scholz V, Mincu I. 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. ArticlePubMedPDF
  • 6. Mühlhauser I, Jorgens V, Berger M, Graninger W, Gurtler W, Hornke L, Kunz A, Schernthaner G, Scholz V, Voss HE. 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. PubMed
  • 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;325:746ArticlePubMedPMC
  • 8. McIntyre HD. DAFNE (Dose Adjustment for Normal Eating): structured education in insulin replacement therapy for type 1 diabetes. Med J Aust 2006;184:317-318. ArticlePubMedPDF
  • 9. McIntyre HD, Knight BA, Harvey DM, Noud MN, Hagger VL, Gilshenan KS. Dose adjustment for normal eating (DAFNE): an audit of outcomes in Australia. Med J Aust 2010;192:637-640. ArticlePubMedPDF
  • 10. Tattersall RL. The expert patient: a new approach to chronic disease management for the twenty-first century. Clin Med 2002;2:227-229. Article
  • 11. Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med 1988;3:448-457. ArticlePubMedPDF
  • 12. Andel M, Tattersall R. Authoritarianism in diabetology. Diabet Med 1989;6:471ArticlePubMed
  • 13. Greenhalgh T. Patient and public involvement in chronic illness: beyond the expert patient. BMJ 2009;338:b49ArticlePubMed
  • 14. Griffiths C, Foster G, Ramsay J, Eldridge S, Taylor S. How effective are expert patient (lay led) education programmes for chronic disease? BMJ 2007;334:1254-1256. ArticlePubMedPMC
  • 15. Cade JE, Kirk SF, Nelson P, Hollins L, Deakin T, Greenwood DC, Harvey EL. Can peer educators influence healthy eating in people with diabetes? Results of a randomized controlled trial. Diabet Med 2009;26:1048-1054. ArticlePubMed
  • 16. van der Wulp I, de Leeuw JR, Gorter KJ, Rutten GE. Effectiveness of peer-led self-management coaching for patients recently diagnosed with Type 2 diabetes mellitus in primary care: a randomized controlled trial. Diabet Med 2012;29:e390-e397. ArticlePubMed
  • 17. Keen AJ, Duncan E, McKillop-Smith A, Evans ND, Gold AE. Dose Adjustment for Normal Eating (DAFNE) in routine clinical practice: who benefits? Diabet Med 2012;29:670-676. ArticlePubMed
  • 18. Lawton J, Rankin D, Cooke D, Elliott J, Amiel S, Heller S. UK NIHR DAFNE Study Group. Patient's experiences of adjusting insulin doses when implementing flexible intensive insulin therapy: a longitudinal, qualitative investigation. Diabetes Res Clin Pract 2012;98:236-242. ArticlePubMed
  • 19. Marden S, Thomas PW, Sheppard ZA, Knott J, Lueddeke J, Kerr D. Poor numeracy skills are associated with glycaemic control in Type 1 diabetes. Diabet Med 2012;29:662-669. ArticlePubMed
  • 20. Kerr D, Marden S. Numeracy and insulin pump therapy. Diabet Med 2010;27:730-731. ArticlePubMed
  • 21. Cukierman-Yaffe T, Konvalina N, Cohen O. Key elements for successful intensive insulin pump therapy in individuals with type 1 diabetes. Diabetes Res Clin Pract 2011;92:69-73. ArticlePubMed
  • 22. Dinneen SF, O'Hara MC, Byrne M, Smith D, Courtney CH, McGurk C, Heller SR, Newell J, Coffey N, Breen C, O'Scannail M, O'Shea D. Irish DAFNE Study Group. Group follow-up compared to individual clinic visits after structured education for type 1 diabetes: a cluster randomised controlled trial. Diabetes Res Clin Pract 2013;100:29-38. ArticlePubMed
  • 23. Gunn D, Mansell P. Glycaemic control and weight 7 years after Dose Adjustment For Normal Eating (DAFNE) structured education in Type 1 diabetes. Diabet Med 2012;29:807-812. ArticlePubMed
  • 24. Müller N, Kloos C, Samann A, Wolf G, Muller UA. Evaluation of a treatment and teaching refresher programme for the optimization of intensified insulin therapy in type 1 diabetes. Patient Educ Couns 2013;93:108-113. ArticlePubMed
  • 25. National Institute for Clinical Excellence. Guidance on the use of patient-education models for diabetes updated 2003 Apr 29. Available from:
  • 26. Shearer A, Bagust A, Sanderson D, Heller S, Roberts S. Cost-effectiveness of flexible intensive insulin management to enable dietary freedom in people with Type 1 diabetes in the UK. Diabet Med 2004;21:460-467. ArticlePubMed
  • 27. Kruger J, Brennan A, Thokala P, Basarir H, Jacques R, Elliott J, Heller S, Speight J. The cost-effectiveness of the Dose Adjustment for Normal Eating (DAFNE) structured education programme: an update using the Sheffield Type 1 Diabetes Policy Model. Diabet Med 2013;30:1236-1244. ArticlePubMed
  • 28. 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) randomized controlled trial. Diabet Med 2003;20(Suppl 3):4-5.ArticlePDF
  • 29. Mühlhauser I, Berger M. Patient education: evaluation of a complex intervention. Diabetologia 2002;45:1723-1733. ArticlePubMedPDF
  • 30. Sämann A, Muhlhauser I, Bender R, Kloos Ch, Muller UA. Glycaemic control and severe hypoglycaemia following training in flexible, intensive insulin therapy to enable dietary freedom in people with type 1 diabetes: a prospective implementation study. Diabetologia 2005;48:1965-1970. ArticlePubMedPDF

Figure & Data



    Citations to this article as recorded by  
    • Factors Associated With Resilience During Long-Term Hemodialysis
      Pedro García-Martínez, Rafa Ballester-Arnal, Kavita Gandhi-Morar, María D. Temprado-Albalat, Eladio Collado-Boira, Carlos Saus-Ortega, Jesús Castro-Calvo
      Nursing Research.2023; 72(1): 58.     CrossRef
    • Association Between Management of Continuous Subcutaneous Basal Insulin Administration and HbA1C
      Harry Rubin-Falcone, Ian Fox, Emily Hirschfeld, Lynn Ang, Rodica Pop-Busui, Joyce M. Lee, Jenna Wiens
      Journal of Diabetes Science and Technology.2022; 16(5): 1120.     CrossRef
    • Perceived Stress in Relation to Quality of Life and Resilience in Patients with Advanced Chronic Kidney Disease Undergoing Hemodialysis
      Pedro García-Martínez, Rafael Ballester-Arnal, Kavita Gandhi-Morar, Jesús Castro-Calvo, Vicente Gea-Caballero, Raúl Juárez-Vela, Carlos Saus-Ortega, Raimunda Montejano-Lozoya, Eva María Sosa-Palanca, María del Rosario Gómez-Romero, Eladio Collado-Boira
      International Journal of Environmental Research and Public Health.2021; 18(2): 536.     CrossRef
    • Determinants of blood glucose control among people with Type 2 diabetes in a regional hospital in Ghana
      Sampson Kafui Djonor, Ignatius Terence Ako-Nnubeng, Ewurama Ampadu Owusu, Kwadwo Owusu Akuffo, Pricillia Nortey, Eldad Agyei-Manu, Anthony Danso-Appiah, Lakshmi Pulakat
      PLOS ONE.2021; 16(12): e0261455.     CrossRef
    • Recent advances in type 1 diabetes
      Mervyn Kyi, John M Wentworth, Alison J Nankervis, Spiros Fourlanos, Peter G Colman
      Medical Journal of Australia.2015; 203(7): 290.     CrossRef

    • PubReader PubReader
    • Cite this Article
      Cite this Article
      export Copy Download
      Download Citation
      Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.

      • RIS — For EndNote, ProCite, RefWorks, and most other reference management software
      • BibTeX — For JabRef, BibDesk, and other BibTeX-specific software
      • Citation for the content below
      Dose Adjustment for Normal Eating: A Role for the Expert Patient?
      Diabetes Metab J. 2014;38(2):87-91.   Published online April 18, 2014
    • XML DownloadXML Download
    McIntyre HD. Dose Adjustment for Normal Eating: A Role for the Expert Patient?. Diabetes Metab J. 2014;38(2):87-91.

    Diabetes Metab J : Diabetes & Metabolism Journal
    Close layer