Tips

From Other Journals

Greater Dietary Freedom vs. Glycemic Control

Am Fam Physician. 2003 Feb 1;67(3):594-596.

Strict glycemic control is associated with better outcomes in type 1 diabetes, but few patients alter their daily insulin dosage appropriately to maintain ideal blood glucose levels relative to calorie intake. Studies of strict glycemic control have required the intensive use of health resources and reported an increased risk of hypoglycemic reactions and a lowered quality of life. In one alternative approach, patients are given intensive education about matching insulin dosages to food and lifestyle choices. Heller and colleagues studied the effect of using dosage adjustment for normal eating (DAFNE) to manage type 1 diabetes in patients attending hospital diabetic clinics in two English cities.

The 169 study participants (mean age, 40 years) had moderately to poorly controlled type 1 diabetes, with average glycosylated hemoglobin (HbA1c) levels of 7.5 to 12.0 percent for more than two years but no evidence of advanced complications. The participants were randomly assigned to attend DAFNE training immediately or after usual care for six months. The delayed-DAFNE group acted as control subjects in the initial analysis of outcomes.

DAFNE training consisted of a five-day out-patient program on matching insulin dosages to desired carbohydrate intake, meal by meal. The principal outcomes measured were HbA1c levels, patient-reported hypoglycemic episodes (i.e., episodes resulting in coma or requiring assistance from another person), and the findings of a standardized diabetes-specific quality-of-life questionnaire. Other aspects monitored included the number of insulin injections and the amount of insulin used, frequency of hyperglycemia, psychologic well-being, changes in weight, blood pressure, cholesterol levels, and blood lipid values.

Primary Outcomes: Differences Between Immediate-DAFNE and Delayed-DAFNE Groups at Six Months*

Group HbA1c(%) Severe hypoglycemia in previous 6 months, number (%) Present quality of life ‡

Immediate DAFNE

Baseline

9.4 (1.2)

15/68 (22)

1.0 (0.9)

Six months

8.4 (1.2)

12/67 (18)

1.3 (0.9)

Delayed DAFNE

Baseline

9.3 (1.1)

8/ 72 (11)

1.1 (0.8)

Six months

9.4 (1.3)

11/72 (15)

1.0 (1.1)

Difference between groups at 6 months

Mean (95% CI)

1.0 (0.5 to 1.4)

0.3 (−0.1 to 0.6) §

Statistical values

t = 4.4, P <0.0001

x2 = 0.17, P = 0.68

t = 1.7, P = 0.095


DAFNE = dose adjustment for normal eating; HbA1c = glycosylated hemoglobin; CI = confidence interval.

*—Values are means (standard deviations) unless otherwise stated.

†—Percentage of participants: x2 test performed for differences between groups at 6 months.

‡—Scored from −3 (extremely bad) to +3 (excellent); 0 = neither good nor bad, 1 = good, 2 = very good.

§—CI should be interpreted with caution because variables were transformed before parametric analysis was performed, but natural data are reported.

Adapted with permission from 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;325:748.

Primary Outcomes: Differences Between Immediate-DAFNE and Delayed-DAFNE Groups at Six Months*

View Table

Primary Outcomes: Differences Between Immediate-DAFNE and Delayed-DAFNE Groups at Six Months*

Group HbA1c(%) Severe hypoglycemia in previous 6 months, number (%) Present quality of life ‡

Immediate DAFNE

Baseline

9.4 (1.2)

15/68 (22)

1.0 (0.9)

Six months

8.4 (1.2)

12/67 (18)

1.3 (0.9)

Delayed DAFNE

Baseline

9.3 (1.1)

8/ 72 (11)

1.1 (0.8)

Six months

9.4 (1.3)

11/72 (15)

1.0 (1.1)

Difference between groups at 6 months

Mean (95% CI)

1.0 (0.5 to 1.4)

0.3 (−0.1 to 0.6) §

Statistical values

t = 4.4, P <0.0001

x2 = 0.17, P = 0.68

t = 1.7, P = 0.095


DAFNE = dose adjustment for normal eating; HbA1c = glycosylated hemoglobin; CI = confidence interval.

*—Values are means (standard deviations) unless otherwise stated.

†—Percentage of participants: x2 test performed for differences between groups at 6 months.

‡—Scored from −3 (extremely bad) to +3 (excellent); 0 = neither good nor bad, 1 = good, 2 = very good.

§—CI should be interpreted with caution because variables were transformed before parametric analysis was performed, but natural data are reported.

Adapted with permission from 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;325:748.

Complete data were available for 140 patients who took DAFNE education immediately and 68 patients who had delayed DAFNE education. After six months, HbA1c levels were significantly improved in the immediate-DAFNE group, but no significant difference was found in hypoglycemic episodes (see the accompanying table). Patients in the immediate-DAFNE group also reported significant improvements in quality of life, specifically, the impact of diabetes on dietary freedom. At 12 months, HbA1c levels remained significantly improved, and the beneficial impact on quality of life and dietary freedom was maintained.

The authors conclude that patients with type 1 diabetes who underwent dietary skills training were better able to follow intensive insulin therapy over the short term and had sustained improvement in glycemic control without an associated increase in hypoglycemic episodes.

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. October 5, 2002;325:746–9.


Copyright © 2003 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Article Tools

  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

Navigate this Article