What is DAFNE?
Since the 1980’s, the diabetes team at the Diabetes Centre in Düsseldorf, led by the late Michael Berger, has developed a five-day structured training programme in intensive insulin therapy and self-management.[1-3]
The main principles of the DAFNE course are:
• Skills based training to teach flexible insulin adjustment to match carbohydrate in a free diet on a meal-by-meal basis.
• Emphasis on self-management and independence from the diabetes care team.
The carbohydrate portion
Good diabetic control involves eating the amount of carbohydrate you would like, and learning how to match this with an appropriate dose on insulin. Carbohydrate portions (CPs) are a way of judging the amount of carbohydrate in food.
One carbohydrate portions (CP) contains about 10g of carbohydrate.
- 10g carbohydrate portions = 1 CP
- 15g carbohydrate portions = 1.5 CP
- 20g carbohydrate portions = 2 CPs
By using the carbohydrate portion list as here you will be able to add up the carbohydrate value of the foods you would like to eat. You can then inject the right amount of quick-acting insulin to match this. On the DAFNE training program, you will begin to learn how many units of quick-acting insulin you need for each 1 CP. Carbohydrate in both meals and snakes will need insulin.
Principles of insulin dose adjustment
At the beginning of the week, basal insulin requirements are supplied by isophane insulin divided into 2 equal doses given at breakfast and before bed with a starting dose of around 1 unit/h, ie 12 units bd. The total split dose is usually adjusted during the week and over subsequent months, with the evening dose determined by the fasting glucose level on the following morning. The morning NPH dose is adjusted according to blood glucose measurements of the previous two days, particularly the pre-evening meal value, roughly aiming for a 50:50 basal/quick acting split.
Glucose targets are:
Fasting 5.5 – 7.7mmol/l
Pre-meal 4.5 – 7.7mmol/l
Bedtime 6.5 – 8.0mmol/l
Participants are advised to give a standard proportion of quick acting insulin per carbohydrate portion which varies at different times of the day: Ratios of quick-acting to CP usually vary between:
Breakfast 2 – 3 units per CP
Lunch 1 – 2 units per CP
Evening meal 1 – 2 units per CP
Patients are free to miss meals if they choose, although a dose of quick-acting insulin may be needed at breakfast even if no carbohydrate is eaten due to the slow onset of basal insulin and the effect of the “Dawn Phenomenon”. These suggested values are, ofcourse, only starting guidelines and individuals gradually work out what proportions ofinsulin to carbohydrate intake suit them. Carbohydrate content at any given meal is oftenhigher in the UK than Germany (more chips, pasta and bread!). If pre-meal solubleinsul in doses are regularly above 15 units these large doses can have an extended duration of action. If this leads to problems with hypoglycaemia, we advise the substitution of quick-acting insulin analogues which have a shorter duration of action at higher doses.
High and low results can be corrected by extra quick-acting insulin or carbohydrate and participants are encouraged to use these to keep blood glucose values within the target range.
They begin by working on the principle that:
• 1 unit of quick acting insulin lowers blood glucose by 2-3mmol/l.
• 1-2 CPs raise blood glucose by 2-3mmol/l.
Participants are encouraged to accept mild hypoglycaemia as an inevitable and normal consequences of life with diabetes. Standard guidance is provided for treating hypoglycaemic symptoms, (equivalent to 100-120ml Lucozade or 5 glucose tablets) followed by an additional 1-2 CPs of slower acting CHO depending upon when the next meal is due.
There is a clear set of instructions to deal with illness which include testing urine for ketones and using quite large corrective doses of quick-acting insulin. If ketonuria is present and blood glucose above 13mmol/l, patients are taught to take 20% of the previous day’s total daily insulin dose at each mealtime until their glucose falls to normal.
Other sessions during the week are devoted to additional aspects of life with diabetes and are comparable to many other diabetes training programmes. They take up about a quarter of the course. These include sessions on the risk and consequence of diabetic complications, pregnancy and contraception and hypoglycaemia and gender make-up of the group and their own needs will dictate the exact content to some extent.