The DAFNE principles
The main principles of the DAFNE 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 DAFNE program teaches participants to estimate the carbohydrate content of the food they wish to eat. They then match this with the appropriate 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 DAFNE. The program works on the basis that 1 CP equals 10g of carbohydrate. Insulin doses are then adjusted to match the number of CPs eaten on a ratio basis.
2. Insulin dose adjustment
The DAFNE insulin regimen is based on a basal/bolus regimen, with food covered by quick-acting insulin. Blood 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 blood glucose result
- The results of previous blood glucose measurements
- Individual insulin-to-CP ratios at that meal time
- The quantity of the proposed intake of carbohydrate (number of CPs)
The standard DAFNE blood glucose targets are:
4.0 to 8.0 mmol/L
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 blood glucose values within the target range at the specified times. High pre-meal and pre-bed blood glucose levels can be corrected by injecting extra quick-acting insulin. Low pre-meal and pre-bed blood glucose levels can be corrected by injecting less quick-acting 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 course and at home, are used as exercises to work through using the DAFNE Stepwise Approach. Insulin dose adjustment starts on the first day so that each participant has at least 12 opportunities to practice this across the five days (and more if they eat snacks). The aim is that participants learn from their own and others’ experiences of dose adjustment during the program.
3. Other topics
The DAFNE 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.