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
Open accessAbstract
Objectives: To evaluate whether a course teaching flexible intensive insulin treatment combining dietary freedom and insulin adjustment can improve both glycaemic control and quality of life in type 1 diabetes. Design: Randomised design with participants either attending training immediately (immediate DAFNE) or acting as waiting list controls and attending “delayed DAFNE” training 6 months later. Setting: Secondary care diabetes clinics in three English health districts. Participants: 169 adults with type 1 diabetes and moderate or poor glycaemic control. Main outcome measures: Glycated haemoglobin (HbA 1c ), severe hypoglycaemia, impact of diabetes on quality of life (ADDQoL). Results: At 6 months, HbA 1c was significantly better in immediate DAFNE patients (mean 8.4%) than in delayed DAFNE patients (9.4%) ( t =6.1, P<0.0001). The impact of diabetes on dietary freedom was significantly improved in immediate DAFNE patients compared with delayed DAFNE patients ( t =−5.4, P<0.0001), as was the impact of diabetes on overall quality of life ( t =2.9, P<0.01). General wellbeing and treatment satisfaction were also significantly improved, but severe hypoglycaemia, weight, and lipids remained unchanged. Improvements in “present quality of life” did not reach significance at 6 months but were significant by 1 year. Conclusion: Skills training promoting dietary freedom improved quality of life and glycaemic control in people with type 1 diabetes without worsening severe hypoglycaemia or cardiovascular risk. This approach has the potential to enable more people to adopt intensive insulin treatment and is worthy of further investigation.
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There is convincing evidence that formal training programs that teach patients to replace insulin "physiologically" by giving background and mealtime/correction doses of insulin can reduce the risk of severe hypoglycemia.
“There is convincing evidence that formal training programs that teach patients to replace insulin “physiologically” by giving background and mealtime/correction doses of insulin can reduce the risk of severe hypoglycemia.”
From Hypoglycemia and Diabetes: A Report of a Workgroup of the American Diabetes Association and The Endocrine Society (2013) · cites this paper as [103]
The skills course section describes training patients to adjust insulin to their meals. But the paper reports that severe hypoglycaemia remained unchanged; the Discussion says there was no significant increase, not a reduction in risk. The claimed risk reduction is therefore contrary to the reported finding. (LLM, conf=0.88)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredThese programs have been successfully delivered in other settings with comparable reductions in hypoglycemic risk.
“These programs have been successfully delivered in other settings (103,104) with comparable reductions in hypoglycemic risk (105).”
From Hypoglycemia and Diabetes: A Report of a Workgroup of the American Diabetes Association and The Endocrine Society (2013) · cites this paper as [103]
Inhaled insulin has a faster peak and shorter duration and is available as prandial insulin, but it requires repeated inhaled correction doses one to two hours after meals.
“Inhaled insulin with a faster peak of action and shorter duration is also available as prandial insulin, with the requirement of using repeated inhaled correctional insulin doses after 1 to 2 hours postmeal.1158,1159”
From American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. (2022) · cites this paper as [1158]
The Skills course section describes matching insulin doses to meals, and Secondary outcomes reports the number of injections per day; neither addresses inhaled insulin. Searches for inhaled insulin and postmeal correction doses found no passage about its action profile, availability, or dosing schedule. No page numbers are available in our copy. (LLM, conf=0.76)
Experimental — accuracy not yet measuredThese programs have been successfully delivered in other settings with comparable reductions in hypoglycemic risk.
“These programs have been successfully delivered in other settings (103,104) with comparable reductions in hypoglycemic risk (105).”
From Hypoglycemia and Diabetes: A Report of a Workgroup of the American Diabetes Association and The Endocrine Society (2013) · cites this paper as [103]
Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive.
“Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose management (156,157).”
From 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes:<i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [156]
Monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose management.
“Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose management (156,157).”
From 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes:<i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [156]
Education on using insulin-to-carbohydrate ratios for meal planning can assist individuals with effectively modifying insulin dosing from meal to meal to improve glycemic management.
“In addition, education on using insulin-to-carbohydrate ratios for meal planning can assist individuals with effectively modifying insulin dosing from meal to meal to improve glycemic management (97,156,(180)(181)(182)(183).”
From 5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes:<i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [156]
Multiple studies have demonstrated sustained improvements in A1C at 12 months and longer when a registered dietitian provided follow-up visits ranging from monthly to three sessions per year.
“Multiple studies have demonstrated sustained improvements in A1C at 12 months and longer when a registered dietician provided follow-up visits ranging from monthly to three sessions per year (69–76).”
From Standards of Medical Care in Diabetes—2009 (2009) · cites this paper as [69]
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Hissa, M. N. (2016) · Diabetology & Metabolic Syndrome · doi:10.1186/s13098-016-0180-2 · Cited by 1 · see citing works
- Venue
- BMJ
- Publisher
- BMJ
- Published
- 2002-10-05
- Volume
- 325
- Issue
- 7367
- Pages
- 746
- ISSN
- 0007-1447 (ISSN-L)
- 0959-8138
- 1468-5833
- PMC
- PMC128375
- OpenAlex
- W4243162779
- Cited by
- 916
- References
- 13
- Citations by year
- 2026: 18 · 2025: 25 · 2024: 30 · 2023: 26 · 2022: 38 · 2021: 46 · 2020: 43 · 2019: 39 · 2018: 51 · 2017: 50 · 2016: 43 · 2015: 54 · 2014: 52 · 2013: 50 · 2012: 54
- FWCI
- 13.16
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- www.bmj.com/company/legal-information/terms-conditions/legal-information/tdm-licencepolicy (tdm)
- Locations
- BMJ (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Own your potential (DEAKIN) (submittedVersion)
- Durham Research Online (Durham University) (submittedVersion, cc-by)
- Funders
- Diabetes UK
- King's College London
- Novo Nordisk
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Keywords
- type 1 diabetes, DAΦNE, insulin dose adjustment, glycemic control, HbA1c, severe hypoglycemia, quality of life, diabetes self-management education, treatment satisfaction
- MeSH terms
- Adult, Aged, Diabetes Mellitus, Type 1, Diet, Female, Humans, Hypoglycemic Agents, Insulin, Male, Middle Aged, Patient Education as Topic, Quality of Life, Patient Satisfaction
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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