How and why do patients with Type 1 diabetes sustain their use of flexible intensive insulin therapy? A qualitative longitudinal investigation of patients’ self‐management practices following attendance at a Dose Adjustment for Normal Eating (DAFNE) course

Abstract

Clinical data have shown that flexible intensive insulin therapy can lead to improvement in glycaemic control. This study, drawing on patients' perspectives, provides further endorsement for flexible intensive insulin therapy by demonstrating patients' liking of, and their motivation to sustain, this approach over time. To help patients implement and sustain flexible intensive insulin therapy, follow-up support should encourage them to identify routines to better integrate this regimen into their lives.

Structured type 1 diabetes education delivered in routine care in Australia reduces diabetes-related emergencies and severe diabetes-related distress: The OzDAFNE program

“…Notwithstanding these findings, it is reasonable that the OzDAFNE program should seek ways to help participants achieve better glycaemic outcomes. In-depth qualitative UK studies have demonstrated that DAFNE graduates' recording and reflecting on self-monitoring of blood glucose results tends to wane over time [20,21]; that individuals tend to relax their blood glucose targets over time [22]; and that some people may require more support post-course than is provided currently [23]. This is consistent with the weak correlation observed here between change in HbA1c and number of months post-course at which HbA1c was checked.…”

The relationship between carbohydrate and the mealtime insulin dose in type 1 diabetes

“…Conversely healthy foods from core food groups, such as pasta, rice and fruit, were commonly inaccurately estimated (Smart, Ross, Edge, King, et al, 2010). Recent studies examining self-management practices after attendance at a DAFNE course found that subjects simplified food choices to make carbohydrate counting easier by purchasing more labeled, pre-packaged food and avoiding eating out (Lawton, Cooke, Clark, Elliot, & Heller, 2011;Rankin et al, 2011). Some participants reported that their fat consumption increased as carbohydrate free, high fat meals were perceived as the easy option .…”

Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes

“…Furthermore, despite the increased demands of SMBG and diary/record keeping, patients described a FIIT approach as more liberating than other treatments, such as those requiring them to consume meals at regular intervals with fixed carbohydrate contents to accompany fixed insulin doses. 75 However, despite the perceived benefits of the FIIT regimen, all patients, to varying degrees, reported difficulties with implementing and sustaining self-management practices, considered in the following sections. These findings were also reflected in the quantitative work (see RQ2).…”

“…Patients who followed, or were able to develop, routines also reported achieving more stable and predictable blood glucose readings than those, for instance, who worked irregular shifts (resulting in unpredictable levels of physical activity and/or irregular meal times) or who experienced major life disruptions/changes during the year of follow-up, for example because of a change in job, pregnancy or having to care for a chronically ill family member. 75 Major life changes not only disrupted patients' routines but also could affect their insulin requirements, necessitating dose adjustments. They also disrupted their motivation for and confidence in carrying out the complex behavioural demands of living with type 1 diabetes.…”