Intended for healthcare professionals

Rapid response to:


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 doi: (Published 05 October 2002) Cite this as: BMJ 2002;325:746

Rapid Response:

DAFNE: improved quality of life with intensified treatment is counter-intuitive to many clinicians

Many of the early rapid responses to the DAFNE trial paper (1) [see] claimed that improved quality of life (QoL) resulting from
flexible intensified insulin treatment was well established prior to the
DAFNE trial (Ullman, 5th Oct; Black, 6th Oct; Chaufan, 12th Oct). However,
the only evidence cited was anecdotal.

Early German studies did not measure QoL, patient satisfaction or
well-being and the authors gave only passing mention to possible lifestyle
benefits in the small print of the methods section: "they should gain a
certain ‘liberalisation’ of lifestyle with respect to exercise and eating
schedules" (2, p471). In contrast, Kinga Howorka who, in Vienna, developed
Functional Insulin Treatment (3) (similar to the Düsseldorf-derived DAFNE
approach) not only acknowledged that this approach enables dietary freedom
but also that this "represents the most important factor in the long-term
motivation of patients" (4, p23). Unfortunately, both in Düsseldorf and in
Vienna, psychological outcomes were measured only after many patients had
already adopted the approach and it was routine practice in the clinics
concerned. Thus, it was not possible to measure the QoL benefits in those
settings. Further, the names used for the two treatment approaches
("structured teaching and treatment programme" and "functional insulin
treatment") did not imply any lifestyle benefits. "Dose Adjustment For
Normal Eating" indicates short-term benefits to be gained from
intensifying treatment and the motto "like what you eat, eat what you
like" makes explicit the potential for DAFNE training to improve dietary

DAFNE clinicians were far-sighted in their desire to evaluate a
flexible, intensive approach to insulin treatment in the UK, and in
choosing the DAFNE name and motto, but even they were concerned that
increased injections and blood glucose monitoring might be too big a price
to pay for increased dietary freedom. Many observers of the DAFNE trial
have also taken this view. However, our work in developing the ADDQoL (a
measure of the impact of diabetes on quality of life) had shown that
dietary freedom is the aspect of life which, of all the 18 aspects of life
included in the questionnaire, is most negatively impacted by diabetes and
its treatment (5,6). Such evidence made us confident that the increased
dietary freedom afforded by DAFNE would have major benefits for QoL,
despite the need for more injections and blood glucose monitoring. After
observing a Düsseldorf training course, DAFNE clinicians were more
prepared to accept that DAFNE would not further damage QoL but few
expected QoL benefits. In addition, despite Diabetes UK's interest and
support, such was their doubt about the acceptability of this approach to
UK patients that only the recruitment phase of the DAFNE trial was funded
initially. Funding of the main trial was approved only after we had
demonstrated that sufficient numbers of participants could be recruited.

Now that DAFNE has been shown to provide significant QoL benefits for
adults with type 1 diabetes, it is likely that many more people will be
interested in adopting this form of intensive diabetes management.
However, these benefits had not been demonstrated empirically prior to the
DAFNE trial and were counter-intuitive to many clinicians specialising in
diabetes care.

1. 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. British
Medical Journal 2002;325:746-749.

2. Mühlhauser I, Jörgens V, Berger M, Graninger W, Gurtler W, Hornke
L, et al. 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 1983;25:476.

3. Howorka K. Functional insulin treatment. 3rd English ed. Berlin:
Springer, 2003 in press.

4. Howorka K. Functional Insulin Treatment. 2nd English ed. Berlin,
Heidelberg, New York: Springer-Verlag, 1996.

5. Bradley C, Todd C, Gorton T, Symonds E, Martin A, Plowright R. The
development of an individualised questionnaire measure of perceived impact
of diabetes on quality of life: the ADDQoL. Quality of Life Research

6. Bradley C, Speight J. Patient perceptions of diabetes and diabetes
therapy: assessing quality of life. Diabetes/Metabolism Research and
Reviews 2002;18:S64-S69.

Competing interests:  
None declared

Competing interests: No competing interests

06 November 2002
Jane Speight
Health Psychologist
Clare Bradley, Professor of Health Psychology
Department of Psychology, Royal Holloway, University of London, Egham, Surrey, TW20 0EX, UK