DAFNE stands for Dose Adjustment For Normal Eating
DAFNE is a comprehensive outpatient group education program for adults with type 1 diabetes. In Australia, it is known as OzDAFNE. The program equips participants with the tools to self-manage their insulin doses. During the OzDAFNE program, participants will learn how to:
- Count carbohydrate and calculate bolus insulin doses according to their carbohydrate intake
- Correct glucose levels if needed
- Adjust basal insulin to approximate basal insulin requirements
- Evaluate their glucose patterns and adjust both basal and bolus insulin doses (on separate occasions, not at the same time) to attain glucose levels in the target range
We collect biochemical, anthropometric and quality of life data in order to assess the effectiveness of the program for each participant. This data is collected before the OzDAFNE program begins, and twelve months after it finishes. Read more about the potential benefits of the OzDAFNE program by visiting the Evidence and Data section
OzDAFNE offers separate programs for people using insulin pens and insulin pumps. (Please note, not all formats may be available at all OzDAFNE centres).
OzDAFNE Pens programs
- 1 week program (in person) - runs Monday to Friday for one week, from 9 am to 5 pm each day.
- 5x1 program (in person) - runs one day a week for 5 consecutive weeks, from 9 am to 5 pm each day.
- OzDAFNE@home - runs over 7 weeks with online lessons and weekly half day Zoom group meetings.
OzDAFNE Pump programs
- 1 week program (in person) - runs Monday to Friday for one week, from 9 am to 5 pm each day.
Who can attend?
- Have type 1 diabetes
- Be 18 years or older
- Be using multiple daily injections of insulin or an insulin pump
- Be willing to check and record glucose levels at least four or five times a day
- Be prepared to adjust their own insulin according to what they eat, their glucose levels, and other factors (for example, exercise)
- Be able to attend the complete program
- Be able to speak, understand and read English
Please note: There are times when we may need more information before deciding if a person can attend an OzDAFNE program. Some examples are if a person has an HbA1c of greater than 12%, is pregnant, or has severe complications from their diabetes.
To see what the program involves in action, check out the UK participant video (put together by Diabetes UK) of participants doing the UK DAFNE course in South-East London.
The OzDAFNE principles
The main principles of the OzDAFNE program are:
- Skills-based training to teach flexible insulin adjustment to match carbohydrate intake on a meal-by-meal basis
- Emphasis on self-management and independence from the diabetes care team
- The use of adult education principles to facilitate new learning in a group setting
The program consists of three main areas:
1. Carbohydrate estimation
The OzDAFNE program teaches participants to estimate the carbohydrate content of the food they wish to eat. They then match this with the appropriate bolus insulin dose. The nutrition topics are designed to teach participants how to estimate the carbohydrate content of meals using practical exercises. These include exercises with real food, photographs of food, food models and food packets. The benefits of healthy eating are also discussed in one of the sessions.
Topics covered within the nutrition section of the course include:
- The Carbohydrate Portion (CP)
- Estimating carbohydrates in recipes and nutritional information panels
- Eating out
The Carbohydrate Portion is one of the central principles of OzDAFNE. The program works on the basis that 1 CP equals 10 g of carbohydrate. Insulin doses are then adjusted to match the number of CPs eaten on a ratio basis.
2. Insulin dose adjustment
The OzDAFNE insulin regimen is based on a basal/bolus regimen, with food covered by bolus insulin. Glucose monitoring is performed before each main meal and before bed. Using standard algorithms as a starting point, the following items are considered when calculating the appropriate insulin dose:
- Current glucose result
- The results of previous glucose measurements
- Individual insulin-to-CP ratios at that meal time
- The quantity of the proposed intake of carbohydrate (number of CPs)
The standard target OzDAFNE glucose levels are:
At 3 am
4.0 to 8.0 mmol/L
6.0 to 8.0 mmol/L
5.0 mmol/L or more
7.0 to 10.0 mmol/L
5.0 mmol/L or more
Participants who have retinopathy or impaired awareness of hypoglycaemia may be advised to use the higher end of these targets initially.
Participants are encouraged to keep their glucose values within the target range at the specified times. High pre-meal and pre-bed glucose levels can be corrected by taking extra bolus insulin. Low pre-meal and pre-bed glucose levels can be corrected by taking less bolus insulin or eating extra carbohydrate.
The emphasis of the program is on active participation amongst the participants. The meal times of all the participants, at lunchtime while at the program for in person sessions, and at home, are used as exercises to work through using the OzDAFNE Stepwise Approach. The aim is that participants learn from their own and others’ experiences of dose adjustment during the program.
3. Other topics
The OzDAFNE program also covers various other aspects of daily diabetes management. Participants are given advice on how to best manage hypoglycaemia. Participants are provided with sick day guidelines to enable them to manage illness safely and effectively. There are also discussions regarding how to handle exercise, pregnancy, and future complications.
Health Professional Workshops
The OzDAFNE Health Professional Workshop gives you the confidence to support your clients as they continue using OzDAFNE guidelines and principles after they complete an OzDAFNE program.
One recent workshop attendee said they now have "more confidence in helping clients with insulin adjustment in relation to carbohydrates and blood glucose levels."
The workshop is aimed at health professionals involved in the direct care and support of people with type 1 diabetes. Expert OzDAFNE Facilitators will explain the OzDAFNE approach to:
- Insulin adjustment
- Carbohydrate counting
- Hypoglycaemia management
- Ketone and illness management
The workshop also includes an opportunity to hear from an OzDAFNE program participant, and to learn about the accreditation and training process for OzDAFNE facilitators.*
*Please note: this workshop does not provide accreditation for running OzDAFNE programs. If you wish to deliver OzDAFNE programs, please see the DAFNE Health Professional Training section for more information.
Format: This workshop is delivered as a pre-recorded presentation with additional activities to help practise the guidelines you learn during the Workshop.
As the Workshop is pre-recorded, you will be able to view the presentation and participate in the activities at your own pace and in your own time. Please allow 5 to 7 hours to complete the full Workshop.
You can register at any time. Once you register, you will be sent the video link and supporting handouts via email within 2 business days.
CPD Points: The OzDAFNE Health Professional Workshop is an ADEA Endorsed Educational Program. Successful completion of the workshop provides you with 7 CPD points.
To register, click on the date below to go to the registration page.
Cost: $160 per person inc. GST
Workshop flyer: Download the OzDAFNE HP Workshop flyer.
Enquiries: Contact the OzDAFNE team via email or phone 03 9667 1719.
Health Professional training process
Becoming an OzDAFNE Facilitator
Health professionals must complete training to become an accredited OzDAFNE Facilitator. This training is known as the OzDAFNE Accreditation Training (OAT). To be eligible for OAT, you must:
- Be a Registered Nurse and Credentialled Diabetes Educator (RN-CDE) or an Accredited Practising Dietitian (APD)
- Have clinical experience working with people with type 1 diabetes
- Be committed to the philosophy of self-management and freedom to eat
- Be committed to the principles of OzDAFNE
- Be an effective communicator
- Preferably have had experience in facilitating group programs
- Work at an existing OzDAFNE centre or work in a diabetes service that meets the criteria for becoming a new OzDAFNE Centre
Becoming an OzDAFNE Centre
In order to become and to remain an accredited OzDAFNE Centre, your diabetes service must:
- Have strong management support to introduce and run OzDAFNE. This includes assigning sufficient staff time, resources and funding for:
- The 5-day DAFNE courses
- Pre-course appointments for participants
- Half-day follow-up sessions
- Identify at least one Credentialled Diabetes Nurse Educator to complete the DEP
- Identify at least one Accredited Practising Dietitian to complete the DEP
- Ideally, you will also have a diabetes specialist or doctor who supports OzDAFNE in your service
- Pay the fee for initial training and resources
- Pay the yearly OzDAFNE Collaborative membership fee ($200 in 2022)
- Abide by the OzDAFNE Collaborative guidelines regarding ownership of intellectual property and the use of OzDAFNE resources
- Ensure that your OzDAFNE Facilitators complete the OzDAFNE Quality Assurance Program requirements. This includes:
- Delivering the curriculum to a high standard
- Completing a yearly internal peer review
- Running the minimum number of courses per year as required
The training process – the OzDAFNE Accreditation Training (OAT)
The OAT is a three-part structured training course. It enables trainees to become accredited OzDAFNE Facilitators. A short description of each part of the OAT is below.
STEP 1 – Observation of a 5-day in-person OzDAFNE program
Trainees observe a full 5-day OzDAFNE program in person. Experienced OzDAFNE Facilitators deliver the course. Trainees complete a number of exercises during the week.
STEP 2 – Two-day workshop
Trainees attend a 2-day workshop. The workshop covers the OzDAFNE principles, how to deliver the OzDAFNE curriculum, and how to run the program in a diabetes service. Workshops are held in Melbourne or via Zoom as needed.
STEP 3a – Delivery of a 5-day in-person OzDAFNE program
Trainees deliver their first 5-day OzDAFNE program at their service. They receive peer support from an experienced OzDAFNE Facilitator.
STEP 3b – Peer review
The competency of the trainees is assessed by an experienced OzDAFNE Facilitator during delivery of their first program.
The trainee is accredited as an OzDAFNE Facilitator once they finish the OAT. Each OzDAFNE Facilitator must then complete all quality assurance requirements each year to remain accredited.
Please contact the OzDAFNE Project Officer if you or your diabetes service is interested in training. We can give you more information about becoming an OzDAFNE Facilitator or OzDAFNE centre. Otherwise, you can come along to one of our OzDAFNE Health Professional Workshops. These workshops provide details about the training process and OzDAFNE in general.
A short history of DAFNE
Beginnings in Germany
A five day structured training program was created in Germany in the 1980s. It was designed by the diabetes team at the Diabetes Centre in Dusseldorf, led by the late Michael Berger. This inpatient program focused on intensive insulin therapy and the self-management of type 1 diabetes (references 1 - 3).
The educational approach is based on the Assal model of "therapeutic education" (4). People learn to match their insulin dose to their food on a meal-by-meal basis. The aim is that they can keep healthy blood glucose control without a higher risk of severe hypoglycaemia. They can then continue this with minimal support from their diabetes team.
Across to the UK
In 1998, the Dose Adjustment For Normal Eating (DAFNE) Project in the UK looked at creating a course based on the Dusseldorf model. The main change was that people would attend the course on an outpatient basis (5). A similar outpatient course was developed in Graz, Austria, led by Thomas Pieber (6). The Austrian course produced equally successful 12-year outcomes to those shown by the Dusseldorf model in Germany (7). This approach has now been widely adapted and developed across Europe.
The UK-based DAFNE Study Group translated the curriculum and carried out a randomised controlled trial of the Dusseldorf approach. The results showed significant improvement in glycaemic control, without increased risk of severe hypoglycaemia. Participants' quality of life and treatment satisfaction were also significantly improved (5). Over 15,000 people with type 1 in the UK have now done a DAFNE course.
Down under to Australia
Diabetes teams from Victoria, Queensland and Western Australia visited the UK for DAFNE Educator training in November 2004. These teams started to run DAFNE courses in Australia for people with type 1 diabetes in 2005. Over 2000 people have now completed the course in Australia.
In Australia, we call the program "OzDAFNE". There are now OzDAFNE courses in most Australian states. DAFNE has also spread to nearby countries like New Zealand and Singapore. You can find your nearest centre here.
- 1. Mühlhauser, I., Jörgens, V., Berger, M., Graninger, W., Gürtler, W., Hornke, L., Kunz, A., Schernthaner, G., Scholz, V., & Voss, H.E. (1983) 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 25:470-476.
- 2. Mühlhauser, I., Bruckner, I., Berger, M., Cheta, D., Jörgens, V., Ionescu-Tîrgoviste, C., Scholz, V., & Mincu, I. (1987) Evaluation of an intensified insulin treatment and teaching programme as routine management of type 1 (insulin-dependent) diabetes. The Bucharest-Düsseldorf Study. Diabetologia 30:681-690.
- 3. Bott, S., Bott, U., Berger, M., & Mühlhauser, I. (1997) Intensified insulin therapy and the risk of severe hypoglycaemia. Diabetologia 40:926-932.
- 4. Assal, J.P., Mühlhauser, I., Pernet, A., Gfeller, R., Jörgens, V., & Berger, M. (1985) Patient education as the basis for diabetes care in clinical practice and research. Diabetologia 28:602-613.
- 5. The DAFNE Study Group. (2002) Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: the dose adjustment for normal eating (DAFNE) randomised control trial. BMJ 325:746.
- 6. Pieber, T.R., Brunner, G.A., Schnedl, W.J., Schattenberg, S., Kaufmann, P., & Krejs, G.J. (1995) Evaluation of a structured outpatient group education program for intensive insulin therapy. Diabetes Care 18:625-630.
- 7. Plank, J., Köhler, G., Rakovac, I., Semlitsch, B.M., Horvath, K., Bock, G., Kraly, B., & Pieber, T.R. (2004) Long-term evaluation of a structured outpatient education programme for intensified insulin therapy in patients with type 1 diabetes: a 12 year follow-up. Diabetologia 47:1370-1375.
- 8. Howorka, K. (1996) Functional insulin treatment. Berlin: Springer.
Does OzDAFNE work?
The OzDAFNE program has now been evaluated in a number of countries. Participants have seen improvements in a variety of key diabetes management areas. The following benefits have been shown in both Australia and the United Kingdom:
- Improved HbA1c (blood glucose control)
- Reduced diabetes distress, depression and anxiety symptoms
- Increased dietary freedom
- No weight gain
- No increase in blood fats
- No increase in severe hypoglycaemia (In Australian studies of OzDAFNE we have found that severe hypoglycaemia has been reduced).
Below is a brief summary of the findings of some key DAFNE research papers.
DAFNE Study Group.
(2002) 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; 325:746.
The DAFNE Study Group set up a randomised controlled trial to evaluate the DAFNE program in the UK. The program was based on the Dusseldorf model of intensive insulin therapy (read more). It was translated to English and run as an outpatient course in three clinics across the UK during the trial.
The trial demonstrated that DAFNE was effective over a short-term (12 month) period. Specifically, the HbA1c of participants significantly decreased from baseline to the 12 month mark (a mean difference of 0.5%). This improvement occurred without a significant increase in severe hypoglycaemia. Cardiovascular risk factors did not worsen despite the increased dietary freedom reported by participants. The trial results also showed significant improvements for participants’ psychological well-being, quality of life, and satisfaction with treatment.
Speight J, Amiel SA, Bradley C, Heller S, Oliver L, Roberts S, Rogers H, Taylor C, Thompson G.
(2010) Long-term biomedical and psychosocial outcomes following DAFNE (Dose Adjustment For Normal Eating) structured education to promote intensive insulin therapy in adults with sub-optimally controlled Type 1 diabetes. Diabetes Research & Clinical Practice; 89:22–29.
This research aimed to assess the long-term outcomes for participants in the original DAFNE trial. Participants provided follow-up data at an average of 44 months after their DAFNE course. The results showed that the improvement in HbA1c reported at 12 months (0.5%) had deteriorated slightly to 0.32% at 44 months but this was still statistically significant.
On the other hand, the positive psychological outcomes reported at the 12 month point were fully sustained at 44 months. These improvements were maintained in areas such as the impact of diabetes on dietary freedom, the impact of diabetes on quality of life, and present quality of life.
The authors concluded that DAFNE “offers major long-term benefits for quality of life outcomes and treatment satisfaction and more modest long-term benefits for glycaemic control”.
McIntyre HD, Knight BA, Harvey DM, Noud MN, Hagger VL, Gilshenan KS.
(2010) Dose Adjustment for Normal Eating (DAFNE) – an audit of outcomes in Australia. Medical Journal of Australia; 192(11):637–640.
The aim of this research was to assess the short-term outcomes for participants in the DAFNE program in Australia. At 12 months post-course, the mean HbA1c of participants had fallen from 8.2% to 7.8% (a decrease of 0.4%). Overall, the decrease in HbA1c was found to be greater for those participants whose baseline HbA1c was the highest pre-course. The incidence of severe hypoglycaemic episodes decreased in Australian DAFNE participants. This is different to the earlier UK DAFNE studies, which showed no change in severe hypoglycaemia post-course. The Australian DAFNE audit also showed improvements in diabetes-related distress, and anxiety and depression symptoms.
Current DAFNE research
The DAFNE Collaborative is strongly committed to research and development to improve the DAFNE program. The DAFNE Research Group is currently working on a number of studies and research programs. Some of these are listed below. You can read more about further studies by visiting the UK DAFNE website.
Australian research & projects
TEAM T1 – Teens Empowered to Actively Manage Type 1 Diabetes
TEAM T1 is a five-day group education program designed for teenagers aged 14 to 18 years with type 1 diabetes. It has been adapted for adolescents from the DAFNE program for adults with type 1 diabetes.
A pilot version of the TEAM T1 program was run at three Australian locations in 2009 and 2010, with 19 teenagers. Results showed that the program was acceptable and helpful for teenagers and their parents. Most participants had improved HbA1c levels 3 months after the program. They also reported improved confidence to manage their diabetes and less diabetes-related distress.
Another 5 years of funding for TEAM T1 was received from the Australian Government under the Chronic Disease Prevention and Service Improvement Fund. However unfortunately this program funding has now expired and there are currently no centres in Australia running TEAM T1 programs.
UK research & projects
Trial of 5-day vs 5-week DAFNE format
Research has shown that delivering DAFNE over a consecutive 5-day period is very effective. However, some people are unable to attend a full week program, and so miss out on doing a DAFNE course altogether. DAFNE in the UK responded to these requests by trialling an “intermittent” delivery format. These courses were delivered one day per week over five weeks (5-week DAFNE).
This research showed that there were no significant differences in outcomes for people who attended the standard 5-day courses compared with the 5-week courses. Both groups had similar improvements across all biomedical and psychosocial areas included in the study. The team concluded that both course formats should be made available.
As a result of these research findings, a number of Australian DAFNE centres have introduced the 5-week DAFNE format. Check directly with your preferred centre to see if they are offering this format.
REPOSE: Relative Effectiveness of Pumps Over MDI and Structured Education
Insulin pumps are sometimes seen as the ‘gold star’ method of delivering insulin to people with type 1 diabetes. This research looked at the effectiveness of pumps in comparison to multiple daily injections of insulin. One study group received the standard DAFNE program for people using MDI therapy. The second study group received DAFNE education that was adapted for people using pump therapy.
This study showed that both groups had improvements in their diabetes management, and that pump treatment was not significantly better than multiple daily injections when DAFNE training was used. Read the full article explaining the results here.
Irish research & projects
Ongoing care post-DAFNE
Research has shown that ongoing support assists with improving outcomes from education programs. The Irish DAFNE Study Group looked at two different methods of follow-up care after a DAFNE course. Their research also looked at economic concerns and the qualitative experiences of participants in both study groups. For more information about the results and outcomes of this research, please see the list of published articles and abstracts, or contact Professor Sean Dinneen.
Frequently Asked Questions
Below are the answers to some frequently asked questions about OzDAFNE. If you have a question that is not answered here, please contact your nearest OzDAFNE Centre or the OzDAFNE Project Officer.
Where is my nearest OzDAFNE centre?
There are DAFNE centres in most Australian states. DAFNE is also run in New Zealand, Singapore, the United Kingdom, Ireland, and Kuwait. Please click here to find the details for the centre nearest to you.
How much does it cost to do an OzDAFNE program?
The cost of the course varies from location to location. This is because each DAFNE centre has a different funding structure and different local costs, like room hire fees. Please contact your nearest DAFNE centre directly to find out how much their course will cost.
I have been adjusting my own insulin for years, so what is different about OzDAFNE?
Some people are already adjusting their own insulin doses. However, they may be basing their decisions on their blood glucose levels alone rather than also taking into account what they eat. DAFNE teaches carbohydrate counting skills that take the guesswork out of insulin dose adjustment. This lets you quickly build up the confidence to make changes to your doses as needed.
Confidence in adjusting your insulin is not the only benefit of going to a DAFNE course. There are many other topics covered during the five days including:
- How to manage hypoglycaemia.
- How to manage illness.
- How to adjust insulin for sport and exercise.
- Preventing complications.
People who have done the course also say that one of the best things they got out of the program was the chance to meet others with type 1 diabetes and share their experiences.
What happens if I can't get time off work to do the program?
We understand that sometimes it is hard to take five full days off work, study or other commitments. Managing diabetes already takes many hours out of people’s working lives. The DAFNE program may help to reduce this amount of lost work time. For example, DAFNE has been shown to improve blood glucose control, which lowers the risk of long-term complications. It can also decrease the risk of severe hypos. In turn, this means that you should not have to take as much time off work.
Some employers let people have paid leave to go to the course, while other people take annual leave for the five days. We can give you a letter for your employer to help you get the time off. This letter explains the DAFNE program and the benefits that it may have for your diabetes management.
What if OzDAFNE isn't for me?
It is important that you are able to manage your health in a way that you are comfortable with. Some people who have done the course have decided not to keep using the DAFNE approach. However, these people still found the course very useful and they still use some of the principles they learned to help them manage their diabetes.
Why can't I do OzDAFNE by myself? Do I really need to go to a group program?
The DAFNE program has been tested as a five-day group education course. This is the format that has been most successful in trials in Europe. Other ways of delivering the course could be successful for some people, but this hasn’t been proven yet.
The five-day intensive course format means that you can receive diabetes-specific education without the distractions of everyday life. It also lets you talk about your progress each day with ongoing support from experienced health professionals. The group format of the program means that you can meet others with type 1 diabetes, and can share and learn from each other's experiences during the course. Many DAFNE graduates say that the group sharing was the part of DAFNE that they learned the most from and enjoyed the most!
My blood glucose control (HbA1c) is already pretty good. Do I still need to do OzDAFNE?
Better blood glucose control is only one of the benefits of DAFNE. Research about the DAFNE program shows us that DAFNE can improve your quality of life. It can also reduce the risk of severe hypoglycaemia by helping you get your hypo symptoms back if you have lost them. DAFNE can give you new ideas to help manage illness, exercise, and hypoglycaemia too.
If my glucose is better, won't I have more hypos?
We know that 1 or 2 mild hypos a week are not unusual and this is a normal part of living with diabetes. However, research into the Australian DAFNE program (OzDAFNE) has shown that severe hypos happen less often after a person has done a DAFNE course. The program may also bring back your hypo awareness symptoms. This lowers your risk of having a severe hypoglycaemic episode (where you need someone to help you treat the hypo).
Is it dangerous to change my insulin doses?
No. The DAFNE program is delivered over five days with support from experienced Credentialled Diabetes Nurse Educators and Accredited Practising Dietitians. Your endocrinologist or doctor must agree for you to participate, and we keep them informed of any changes that you make during the program.
The DAFNE program teaches you how to make changes to your insulin one step at a time, based on the patterns of your blood glucose results. During the DAFNE course, you will practice adjusting your insulin doses at lunch time with the group and with guidance from the DAFNE health professionals. You will also talk about your experiences at evening meal times. This means that you will have many opportunities to practice adjusting your insulin doses, as well as hearing about the experiences of other members of your group.
I have type 2 diabetes - would OzDAFNE be suitable for me?
The DAFNE program was designed for people with type 1 diabetes. There are major differences between type 1 and type 2 diabetes – lifestyle changes are much more important in type 2 diabetes. It is true that people with type 2 diabetes who use insulin may benefit from the DAFNE principles for insulin adjustment. However, the DAFNE program as a whole would need to be significantly changed to make it suitable for people with type 2. If you have type 2 diabetes, we suggest that you speak to your diabetes care team about education programs that would suit your personal needs.
Is OzDAFNE suitable for children or teenagers with type 1 diabetes?
DAFNE was designed as a program for adults with type 1 diabetes, using adult learning and education principles, and covering adult topics. In this format, it is not suitable for children or teenagers under 18 years old.
However, we do know that some of the DAFNE principles are useful for children and teenagers under 18 years old. In 2012, Diabetes Australia – Vic received an Australian Commonwealth Government grant to design and run a new program for 14 to 18 year olds that is based on the adult DAFNE program. This program is called Teens Empowered to Actively Manage Type 1 Diabetes, or TEAM T1. Read more about TEAM T1.