Recommended reading
(the papers marked with asterisks *** are free to download, see links at end of the
references, all last accessed 05/12/16)
1. The original German publication showing the outcomes form the ITTP which was the course
from which DAFNE originated. The German team have continued to publish their outcomes
since then.
 Mühlhauser I, Jorgens V, Berger M, Graninger W, Gurtler W, Hornke L et al.
Bicentric evaluation of a teaching and treatment programme for type 1 (insulindependent) diabetic patients: improvement of metabolic control and other measures of
diabetes care for up to 22 months. Diabetologia 1983; 25(6): 470-6 DOI:
10.1007/BF00284453
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1007/BF00284453
Copy provided by inter-library loan.
2. * * * The original trial paper showing an HbA1c improvement of 1% at 6 months, and 0.5% at
12 months. No reductions in severe hypoglycaemia (numbers too small).
 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: 746-752. DOI: 10.1136/bmj.325.7367.746
Free access through NCBI:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC128375/pdf/746.pdf
Print/save from link provided.
3. * * * The first published audit of real world data showing a decrease in HbA1c of 0.3% at 1
year, severe hypoglycaemia reduction of 64%, and improvements in quality of life measures.
 Hopkins D, Lawrence I, Mansell P, Thompson G, Amiel S, Campbell M, Heller S. Improved
biomedical and psychological outcomes 1 year after structured education in flexible insulin
therapy for people with type 1 diabetes. Diabetes Care 2012; 35: 1638-1642. DOI:
10.2337/dc11-1579
Free access through NCBI:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402270/pdf/1638.pdf
Print/save from link provided.
4. * * * An analysis of the research database showing that DAFNE reduces DKA by 62%
and severe hypoglycamia events requiring emergency treatment by 82%, therefore
saving on average £92 per patient.
 Elliott J, Jacques R, Kruger J, Campbell M, Amiel S, Mansell P, Brennan A, Heller S.
Substantial reduction in episodes of diabetic ketoacidosis and savings in emergency
treatment costs following structured education in patients with Type 1 diabetes. Diabetic Med
July 2014, 31(7), 847-853. DOI: 10.1111/dme.12441
http://onlinelibrary.wiley.com/doi/10.1111/dme.12441/epdf
Free access through publisher under Creative Commons licence. Should be
able to print and distribute copies. Better way to link to DOI:
http://dx.doi.org/10.1111/dme.12441
Print/save from link provided.
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5. * * * An analysis of the research database and data from Glasgow showing that only patients
on twice a day, as opposed to once a day NPH, levemir, or glargine significantly decrease
their HbA1c at 1 year post DAFNE.
 Hopkinson HE, Jacques RM, Gardner KJ, Amiel SA, Mansell P. Twice- rather than oncedaily basal insulin is associated with better glycaemic control in Type 1 diabetes mellitus 12
months after skills-based structured education in insulin self- management. Diabetic Med
Aug 2015, 32(8), 1071-6. DOI: 10.1111/dme.12806
http://onlinelibrary.wiley.com/doi/10.1111/dme.12806/epdf
Free access through publisher under Creative Commons licence. Should be
able to print and distribute copies. Better way to link to DOI:
http://dx.doi.org/10.1111/dme.12806
Print/save from link provided.
6. A follow-up of patients from the original trial showing that quality of life improvements
following DAFNE are sustained for at 4 years, whilst the mean HbA1c improvement had
decreased to 0.36%.
 Speight J. Amiel SA, Bradley C, Heller S, Oliver L, Roberts S, Rogers H, Taylor C,
Thompson G. 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 Res & Clin Prac 2010
89(1):22-29. DOI: 10.1016/j.diabres.2010.03.017
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1016/j.diabres.2010.03.017
Copy provided by inter-library loan.
7. * * * The government endorsement for DAFNE showing the £93,000 saving per 100,000
population annually if DAFNE is provided to all type 1 diabetes patients. This was published
before reference 4 therefore savings likely to be higher.
 NICE. Quality and Productivity: Proven Case Study. Improving the quality of care for patients
with type 1 diabetes: dose adjustment for normal eating (DAFNE) 2013.
Free access through NHS. Available at http://www.evidence.nhs.uk/qipp (type
‘DAFNE’ into the search tool)
Print/save from link provided.
8. * * * A must read for all healthcare professionals looking after patients with
hypoglycaemia unawareness. By providing real quotes it describes very effectively the
immense burden this condition puts on family members (and has no p values!).
 Lawton J, Rankin D, Elliott J, Heller S, Rogers H, De Zoysa N, Amiel S. The experiences,
views and support needs of family members of people with Hypoglycaemia Unawareness:
Interview study. Diabetes Care Jan 2014, 37(1): 109-115. DOI: 10.2337/dc13-1154.
http://care.diabetesjournals.org/content/37/1/109.full.pdf+html
Free access through publisher under Creative Commons licence. Should be
able to print and distribute copies. Better way to link to DOI:
http://dx.doi.org/10.2337/dc13-1154
Print/save from link provided.
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9. * * * A pilot study in 24 patients showing that by using group psychological / educational
interventions hypoglycaemia unawareness can be improved without glycaemic control
deteriorating, baseline HbA1c 7.8% and at 1 y unchanged at 7.8%. So improving
unawareness is about avoiding hypoglycaemia, not raising the BG targets above the upper
end of the DAFNE target range.
 De Zoysa N, Gianfrancesco C, Beveridge S, Britneff E, Choudhary P, Elliott J, Heller S,
Amiel S. A psychoeducational program to restore hypoglycemia awareness: the DAFNEHART pilot study. Diabetes Care Mar 2014, 37(3): 863-866. DOI: 10.2337/dc13-1245
http://care.diabetesjournals.org/content/37/3/863.full.pdf+html
Free access through publisher under Creative Commons licence. Should be
able to print and distribute copies. Better way to link to DOI:
http://dx.doi.org/10.2337/dc13-1245
Print/save from link provided.
10. An audit of outcomes in Nottingham showing that benefits in HbA1c of 0.3% are maintained
for at least 7 years, without any excess weight gain.
 Gunn D, Mansell P. Glycaemic control and weight 7 years after Dose Adjustment for Normal
Eating (DAFNE) structured education in Type 1 diabetes. Diabetic Med Jun 2012, 29(6):
807-12. DOI: 10.1111/j.1464-5491.2011.03525.x
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1111/j.1464-5491.2011.03525.x
Copy provided by inter-library loan. Can print/save through our
subscriptions (follow link above, should recognise our IP and allow
access)
11. This is not a paper about DAFNE, but does explain the reasoning behind some of what we
teach around hypoglycaemia. Its an analysis of 89 CGM traces showing that nocturnal
hypos are followed by low fasting glucoses (average 5.5mmol/l); only on 2/89 occasions
was the fasting level >10mmol/l (likely following hypo treatment). When fasting glucoses
were <5mmol/l there was evidence of nocturnal hypoglycaemia in 94% of cases. Therefore
DAFNE does not teach the rebound theory, evidence shows it does not exist, and fasting
glucose levels ought to be 5.5mmol/l.
 Choudhary P, Davies C, Emery CJ, Heller SR. Do high fasting glucose levels suggest
nocturnal hypoglycaemia? The Somogyi effect-more fiction than fact? Diabet Med Aug 2013,
30(8): 914-7. DOI: 10.1111/dme.12175
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1111/dme.12175
Copy provided by inter-library loan. Can print/save through our
subscriptions (follow link above, should recognise our IP and allow
access)
12. The results of a RCT showing that DAFNE delivered over one day a week for 5 weeks is as
effective as 5 days in one week in terms of HbA1c, severe hypoglycaemia and quality of life
outcomes.
 Elliott J, Rankin D, Jacques R, Emery C, Campbell M, Lawton J, Heller S. A cluster
randomized trial comparing a 5 day DAFNE course delivered over 1 week against DAFNE
training delivered over 1 day a week for 5 consecutive weeks. Diabet Med. 2015 32(3): 3918 Doi: 10.1111/dme.12621
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1111/dme.12621
Copy provided by inter-library loan. Can print/save through our
subscriptions (follow link above, should recognise our IP and allow
access)
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Further Reading
13. * * * Bolus advisors are useful but patients may forget their ratios and not know how to
change them. So without support they may hinder the process of reflection on glucose
readings, and subsequent dose adjustments.
 Lawton J, Kirkham J, Rankin D, Barnard K, Cooper CL, Taylor C, Heller S, Elliott J.
Perceptions and experiences of using automated bolus advisors amongst people with type 1
diabetes: a longitudinal qualitative investigation. Diabetes Res Cin Pract. 2014, Dec 106(3):
443-50. Doi: 10.1016/j.diabres.2014.09.011.
Free access through publisher under Creative Commons licence. Should be
able to print and distribute copies. Better way to link to DOI:
http://dx.doi.org/10.1016/j.diabres.2014.09.011
Print/save from link provided.
14. Real life quotes of how patients with hypoglycaemia unawareness perceive their condition
 Rankin D, Elliott J, Heller S, Amiel S, DeZoysa N, Lawton J for the UK NIHR DAFNE Study
Group. Experiences of hypoglycaemia unawareness amongst people with type 1 diabetes: a
qualitative investigation. Chronic Illness Sep 2014; 10(3): 180-191 PMID: 24302225 DOI:
10.1177/1742395313513911
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1177/1742395313513911
Copy provided by inter-library loan.
15. Whilst knowledge around hypos is increased post DAFNE some patients need
psychological one-to-one help to overcome their fears of hypoglycaemia not just DAFNE
training.
 J Lawton , Rankin D, Cooke DD, Elliott J, Amiel S, Heller S. Self-treating hypoglycaemia: a
longitudinal qualitative investigation of the experiences and views of people with type 1
diabetes. Diabet Med, Feb 2013, 30(2): 209-215. DOI: 10.1111/dme.12007, PMID:
22946549
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1111/dme.12007
Copy provided by inter-library loan. Can print/save through our
subscriptions (follow link above, should recognise our IP and allow
access)
16. After DAFNE BG targets often drift, and we as HCPs do not revisit them often enough in
clinic visits, hence glycaemic control may worsen.
 D. Rankin, D.D. Cooke, S. Heller, J. Elliott, S. Amiel, J. Lawton. Experiences of using blood
glucose targets when following an intensive insulin regime: a qualitative longitudinal
nvestigation involving patients with Type 1 diabetes. Diabet Med, Aug 2012, 29(8): 10791084 DOI: 10.1111/j.1464-5491.2012.03670.x PMID 22486156
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1111/j.1464-5491.2012.03670.x
Copy provided by inter-library loan. Can print/save through our
subscriptions (follow link above, should recognise our IP and allow
access)
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17. * * * Most patients say they need tailored and individualized support from DAFNE trained
HCPs following a DAFNE course.
 Rankin D, Cooke DD, Elliott J, Heller SR, Lawton J. Supporting self-management after
attending a structured education programme: a qualitative longitudinal investigation of type 1
diabetes patients' experiences and views. BMC Public Health, 2012 Aug 14; 12(1):652
PMID 22891794. DOI: 10.1186/1471-2458-12-652
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3490905/pdf/1471-2458-12652.pdf
Free access through NCBI.
Print/save from link provided.
18. Food choices post DAFNE often do not change as much as one might expect because patients
usually continue to eat the same kinds of foods, whilst some choose to avoid
carbohydrate at certain meal times to avoid an injection.
 J. Lawton, D. Rankin, D.D. Cooke, M. Clark, J. Elliott, S. Heller for the UK NIHR DAFNE
Study Group. Dose Adjustment for Normal Eating: A qualitative longitudinal exploration of
the food and eating practices of type 1 diabetes patients converted to flexible intensive insulin
therapy in the UK. Diabetes Res & Clin Prac, Jan 2011, 91(1), 87-93. DOI:
10.1016/j.diabres.2010.11.007
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1016/j.diabres.2010.11.007
Copy provided by inter-library loan.
19. * * * It describes in detail the methods for the DAFNE pump vs DAFNE MDI RCT
 White D, Waugh N, Elliott J, Lawton J, Barnard K, Campbell M, Dixon S, Heller S. The
Relative Effectiveness of Pumps Over MDI and Structured Education (REPOSE): study
protocol for a cluster randomised controlled trial. BMJ Open 2014, 4:e006204.
DOI:10.1136/bmjopen-2014-006204
Free access through publisher under Creative Commons licence. Should be
able to print and distribute copies. Better way to link to DOI:
http://dx.doi.org/10.1136/bmjopen-2014-006204
Print/save from link provided.
20. Assessing a patients psychological status prior to DAFNE does not reliably predict who will
do well, and therefore this is not a cost-effective way in which to target education.
 Kruger J, Pollard D, Basarir H, Thokala P, Cooke D, Clark M, Bond R, Heller S, Brennan A.
Incorporating psychological predictors of treatment response into health economic simulation
models: a case study in Type 1 diabetes. Med Decis Making Oct 2015, 35(7): 872-87. DOI:
10.1177/0272989X15590143
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1177/0272989X15590143
Copy provided by inter-library loan.
21. Group follow-up is as effective as individual clinic visits in relation to outcomes in this study
 Dinneen SF, O’Hara MC, Byrne M, Smith D, Courtney CH, McGurk C, Heller SR, Newell J,
Coffey N, Breen C, O’Scannail M, O’Shea D; Irish DAFNE Study Group. Group follow-up
compared to individual clinic visits after structured education for type 1 diabetes: A cluster
randomised controlled trial. Diabetes Res Clin Pract 2013; 100(1): 29-38. DOI:
10.1016/j.diabres.2013.01.017
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1016/j.diabres.2013.01.017
Copy provided by inter-library loan.
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22. When we asked patients what arm they would want to be randomized to in the 5x1 trial the
spilt was 50:50, usually citing reasons around work or childcare etc. However, when we
asked them after the course they virtually all said that if given the choice again they would
opt for the course they got, i.e., patients rationalize the outcome to make them feel better.
So is asking patients what they want in the future a worthwhile thing to do?
 Lawton J, Rankin D, Elliott J. Is consulting patients about their health service preferences a
useful exercise? Qualitative Health Research Jul 2013, 23(7): 876 - 886. DOI:
10.1177/1049732313485161. PMID: 23618684
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1177/1049732313485161
Copy provided by inter-library loan.
23. A paper explaining how a model of Type 1 diabetes has been created in order to evaluate
DAFNE and other structured education programmes.
 Thokala P, Kruger J, Brennan A, Basarir H, Duenas A, Pandor A, Gillett M, Elliott J, Heller S.
Assessing the cost-effectiveness of Type 1 Diabetes Interventions: The Sheffield Type 1
Diabetes Policy Model. Diabet Med Apr 2014, 31(4): 477-486 DOI: 10.1111/dme.12371
No free access. People will need to request a copy from their library.
http://dx.doi.org/10.1111/dme.12371
Copy provided by inter-library loan. Can print/save through our
subscriptions (follow link above, should recognise our IP and allow
access)
24. * * * For those with a lot of spare time on their hands / or thinking of doing a PhD around
DAFNE then this monograph details all the research undertaken in the first DAFNE
programme grant.
 Heller S, Lawton J, Amiel S, Cooke D, Mansell P, Brennan A, Elliott J, Boote J, Emery C,
Baird W, Basarir H, Beveridge S, Bond R, Campbell M, Chater T. 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. Programme Grants for Applied
Research 2 : December 2014, DOI: 10.3310/pgfar02050
Free access through NCBI.
https://www.ncbi.nlm.nih.gov/pubmed/25642502
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