OzDAFNE for Health Professionals

The OzDAFNE principles

The main principles of the OzDAFNE 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 OzDAFNE program teaches participants to estimate the carbohydrate content of the food they wish to eat. They then match this with the appropriate bolus 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)
• Snacking
• Estimating carbohydrates in recipes and nutritional information panels
• Eating out
• Alcohol

The Carbohydrate Portion is one of the central principles of OzDAFNE. The program works on the basis that 1 CP equals 10 g of carbohydrate. Insulin doses are then adjusted to match the number of CPs eaten on a ratio basis. 

2. Insulin dose adjustment

The OzDAFNE insulin regimen is based on a basal/bolus regimen, with food covered by bolus insulin. 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 glucose result
• The results of previous glucose measurements
• Individual insulin-to-CP ratios at that meal time
• The quantity of the proposed intake of carbohydrate (number of CPs)

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 glucose values within the target range at the specified times. High pre-meal and pre-bed glucose levels can be corrected by taking extra bolus insulin. Low pre-meal and pre-bed glucose levels can be corrected by taking less bolus 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 program for in person sessions, and at home, are used as exercises to work through using the OzDAFNE Stepwise Approach. The aim is that participants learn from their own and others’ experiences of dose adjustment during the program.

3. Other topics

The OzDAFNE 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.

Health Professional Workshops

The OzDAFNE Health Professional Workshop gives you the confidence to support your clients as they continue using OzDAFNE guidelines and principles after they complete an OzDAFNE program.

One recent workshop attendee said they now have “more confidence in helping clients with insulin adjustment in relation to carbohydrates and blood glucose levels.”

The workshop is aimed at health professionals involved in the direct care and support of people with type 1 diabetes. Expert OzDAFNE Facilitators will explain the OzDAFNE approach to:

• Insulin adjustment
• Carbohydrate counting
• Hypoglycaemia management
• Ketone and illness management
• Exercise

The workshop also includes an opportunity to hear from an OzDAFNE program participant, and to learn about the accreditation and training process for OzDAFNE facilitators.*

*Please note: this workshop does not provide accreditation for running OzDAFNE programs. If you wish to deliver OzDAFNE programs, please see the DAFNE Health Professional Training section for more information.

Format: This workshop is delivered as a pre-recorded presentation with additional activities to help practise the guidelines you learn during the Workshop.
As the Workshop is pre-recorded, you will be able to view the presentation and participate in the activities at your own pace and in your own time. Please allow 5 to 7 hours to complete the full Workshop.
You can register at any time. Once you register, you will be sent the video link and supporting handouts via email within 2 business days.  

CPD Points: The OzDAFNE Health Professional Workshop is an ADEA Endorsed Educational Program. Successful completion of the workshop provides you with 7 CPD points. 

To register, click on this link to go to the registration page of the next available program.

Cost: $160 per person inc. GST. Group discounts are available for 7 or more attendees – please contact us via email to discuss a group discount. 
Workshop flyer: Download the OzDAFNE HP Workshop flyer.
Enquiries: Contact the OzDAFNE team via email or phone 03 9667 1719.

Health Professional training process

Becoming an OzDAFNE Facilitator

Health professionals must complete training to become an accredited OzDAFNE Facilitator. This training is known as the OzDAFNE Accreditation Training (OAT). To be eligible for OAT, you must:

• Be a Registered Nurse and Credentialled Diabetes Educator (RN-CDE) or an Accredited Practising Dietitian (APD)
• Have clinical experience working with people with type 1 diabetes
• Be committed to the philosophy of self-management and freedom to eat
• Be committed to the principles of OzDAFNE
• Be an effective communicator
• Preferably have had experience in facilitating group programs
• Work at an existing OzDAFNE centre or work in a diabetes service that meets the criteria for becoming a new OzDAFNE Centre

Becoming an OzDAFNE Centre

In order to become and to remain an accredited OzDAFNE Centre, your diabetes service must:

• Have strong management support to introduce and run OzDAFNE. This includes assigning sufficient staff time, resources and funding for:
  • The 5-day DAFNE courses
  • Pre-course appointments for participants
  • Half-day follow-up sessions
  • Administration
• Identify at least one Credentialled Diabetes Nurse Educator to complete the DEP
• Identify at least one Accredited Practising Dietitian to complete the DEP
• Ideally, you will also have a diabetes specialist or doctor who supports OzDAFNE in your service
• Pay the fee for initial training and resources
• Pay the yearly OzDAFNE Collaborative membership fee ($200 in 2022)
• Abide by the OzDAFNE Collaborative guidelines regarding ownership of intellectual property and the use of OzDAFNE resources
• Ensure that your OzDAFNE Facilitators complete the OzDAFNE Quality Assurance Program requirements. This includes:
  • Delivering the curriculum to a high standard
  • Completing a yearly internal peer review
  • Running the minimum number of courses per year as required

The training process – the OzDAFNE Accreditation Training (OAT)

The OAT is a three-part structured training course. It enables trainees to become accredited OzDAFNE Facilitators. A short description of each part of the OAT is below.

STEP 1 – Observation of a 5-day in-person OzDAFNE program

Trainees observe a full 5-day OzDAFNE program in person. Experienced OzDAFNE Facilitators deliver the course. Trainees complete a number of exercises during the week.

STEP 2 – Two-day workshop

Trainees attend a 2-day workshop. The workshop covers the OzDAFNE principles, how to deliver the OzDAFNE curriculum, and how to run the program in a diabetes service. Workshops are held in Melbourne or via Zoom as needed.

STEP 3a – Delivery of a 5-day in-person OzDAFNE program

Trainees deliver their first 5-day OzDAFNE program at their service. They receive peer support from an experienced OzDAFNE Facilitator.

STEP 3b – Peer review

The competency of the trainees is assessed by an experienced OzDAFNE Facilitator during delivery of their first program. 

The trainee is accredited as an OzDAFNE Facilitator once they finish the OAT. Each OzDAFNE Facilitator must then complete all quality assurance requirements each year to remain accredited.

Please contact the OzDAFNE Project Officer if you or your diabetes service is interested in training. We can give you more information about becoming an OzDAFNE Facilitator or OzDAFNE centre. Otherwise, you can come along to one of our OzDAFNE Health Professional Workshops. These workshops provide details about the training process and OzDAFNE in general.

A short history of DAFNE

Beginnings in Germany

A five day structured training program was created in Germany in the 1980s. It was designed by the diabetes team at the Diabetes Centre in Dusseldorf, led by the late Michael Berger. This inpatient program focused on intensive insulin therapy and the self-management of type 1 diabetes (references 1 – 3).

The educational approach is based on the Assal model of “therapeutic education” (4). People learn to match their insulin dose to their food on a meal-by-meal basis. The aim is that they can keep healthy blood glucose control without a higher risk of severe hypoglycaemia. They can then continue this with minimal support from their diabetes team.

Across to the UK

In 1998, the Dose Adjustment For Normal Eating (DAFNE) Project in the UK looked at creating a course based on the Dusseldorf model. The main change was that people would attend the course on an outpatient basis (5). A similar outpatient course was developed in Graz, Austria, led by Thomas Pieber (6). The Austrian course produced equally successful 12-year outcomes to those shown by the Dusseldorf model in Germany (7). This approach has now been widely adapted and developed across Europe.

The UK-based DAFNE Study Group translated the curriculum and carried out a randomised controlled trial of the Dusseldorf approach. The results showed significant improvement in glycaemic control, without increased risk of severe hypoglycaemia. Participants’ quality of life and treatment satisfaction were also significantly improved (5). Over 15,000 people with type 1 in the UK have now done a DAFNE course.

Down under to Australia

Diabetes teams from Victoria, Queensland and Western Australia visited the UK for DAFNE Educator training in November 2004. These teams started to run DAFNE courses in Australia for people with type 1 diabetes in 2005. Over 2000 people have now completed the course in Australia.

In Australia, we call the program “OzDAFNE”. There are now OzDAFNE courses in most Australian states. DAFNE has also spread to nearby countries like New Zealand and Singapore. You can find your nearest centre here.

Reference List

• 1. Mühlhauser, I., Jörgens, V., Berger, M., Graninger, W., Gürtler, W., Hornke, L., Kunz, A., Schernthaner, G., Scholz, V., & Voss, H.E. (1983) 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 25:470-476.
• 2. Mühlhauser, I., Bruckner, I., Berger, M., Cheta, D., Jörgens, V., Ionescu-Tîrgoviste, C., Scholz, V., & Mincu, I. (1987) Evaluation of an intensified insulin treatment and teaching programme as routine management of type 1 (insulin-dependent) diabetes. The Bucharest-Düsseldorf Study. Diabetologia 30:681-690.
• 3. Bott, S., Bott, U., Berger, M., & Mühlhauser, I. (1997) Intensified insulin therapy and the risk of severe hypoglycaemia. Diabetologia 40:926-932.
• 4. Assal, J.P., Mühlhauser, I., Pernet, A., Gfeller, R., Jörgens, V., & Berger, M. (1985) Patient education as the basis for diabetes care in clinical practice and research. Diabetologia 28:602-613.
• 5. The DAFNE Study Group. (2002) Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: the dose adjustment for normal eating (DAFNE) randomised control trial. BMJ 325:746.
• 6. Pieber, T.R., Brunner, G.A., Schnedl, W.J., Schattenberg, S., Kaufmann, P., & Krejs, G.J. (1995) Evaluation of a structured outpatient group education program for intensive insulin therapy. Diabetes Care 18:625-630.
• 7. Plank, J., Köhler, G., Rakovac, I., Semlitsch, B.M., Horvath, K., Bock, G., Kraly, B., & Pieber, T.R. (2004) Long-term evaluation of a structured outpatient education programme for intensified insulin therapy in patients with type 1 diabetes: a 12 year follow-up. Diabetologia 47:1370-1375.
• 8. Howorka, K. (1996) Functional insulin treatment. Berlin: Springer.

Does OzDAFNE work?

The OzDAFNE program has now been evaluated in a number of countries. Participants have seen improvements in a variety of key diabetes management areas. The following benefits have been shown in both Australia and the United Kingdom:

• Improved HbA1c (blood glucose control)
• Reduced diabetes distress, depression and anxiety symptoms
• Increased dietary freedom
• No weight gain
• No increase in blood fats
• No increase in severe hypoglycaemia (In Australian studies of OzDAFNE we have found that severe hypoglycaemia has been reduced).

Below is a brief summary of the findings of some key DAFNE research papers.

DAFNE Study Group.
(2002) 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; 325:746.

The DAFNE Study Group set up a randomised controlled trial to evaluate the DAFNE program in the UK. The program was based on the Dusseldorf model of intensive insulin therapy (read more). It was translated to English and run as an outpatient course in three clinics across the UK during the trial.

The trial demonstrated that DAFNE was effective over a short-term (12 month) period. Specifically, the HbA1c of participants significantly decreased from baseline to the 12 month mark (a mean difference of 0.5%). This improvement occurred without a significant increase in severe hypoglycaemia. Cardiovascular risk factors did not worsen despite the increased dietary freedom reported by participants. The trial results also showed significant improvements for participants’ psychological well-being, quality of life, and satisfaction with treatment.

Speight J, Amiel SA, Bradley C, Heller S, Oliver L, Roberts S, Rogers H, Taylor C, Thompson G.
(2010) 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 Research & Clinical Practice; 89:22–29.

This research aimed to assess the long-term outcomes for participants in the original DAFNE trial. Participants provided follow-up data at an average of 44 months after their DAFNE course. The results showed that the improvement in HbA1c reported at 12 months (0.5%) had deteriorated slightly to 0.32% at 44 months but this was still statistically significant.

On the other hand, the positive psychological outcomes reported at the 12 month point were fully sustained at 44 months. These improvements were maintained in areas such as the impact of diabetes on dietary freedom, the impact of diabetes on quality of life, and present quality of life.

The authors concluded that DAFNE “offers major long-term benefits for quality of life outcomes and treatment satisfaction and more modest long-term benefits for glycaemic control”.

McIntyre HD, Knight BA, Harvey DM, Noud MN, Hagger VL, Gilshenan KS.
(2010) Dose Adjustment for Normal Eating (DAFNE) – an audit of outcomes in Australia. Medical Journal of Australia; 192(11):637–640.

The aim of this research was to assess the short-term outcomes for participants in the DAFNE program in Australia. At 12 months post-course, the mean HbA1c of participants had fallen from 8.2% to 7.8% (a decrease of 0.4%). Overall, the decrease in HbA1c was found to be greater for those participants whose baseline HbA1c was the highest pre-course. The incidence of severe hypoglycaemic episodes decreased in Australian DAFNE participants. This is different to the earlier UK DAFNE studies, which showed no change in severe hypoglycaemia post-course. The Australian DAFNE audit also showed improvements in diabetes-related distress, and anxiety and depression symptoms.

Current DAFNE research

The DAFNE Collaborative is strongly committed to research and development to improve the DAFNE program. The DAFNE Research Group is currently working on a number of studies and research programs. Some of these are listed below. You can read more about further studies by visiting the UK DAFNE website.

Australian research & projects

TEAM T1 – Teens Empowered to Actively Manage Type 1 Diabetes

TEAM T1 is a five-day group education program designed for teenagers aged 14 to 18 years with type 1 diabetes. It has been adapted for adolescents from the DAFNE program for adults with type 1 diabetes.

A pilot version of the TEAM T1 program was run at three Australian locations in 2009 and 2010, with 19 teenagers. Results showed that the program was acceptable and helpful for teenagers and their parents. Most participants had improved HbA1c levels 3 months after the program. They also reported improved confidence to manage their diabetes and less diabetes-related distress.

Another 5 years of funding for TEAM T1 was received from the Australian Government under the Chronic Disease Prevention and Service Improvement Fund. However unfortunately this program funding has now expired and there are currently no centres in Australia running TEAM T1 programs. 

UK research & projects

Trial of 5-day vs 5-week DAFNE format

Research has shown that delivering DAFNE over a consecutive 5-day period is very effective. However, some people are unable to attend a full week program, and so miss out on doing a DAFNE course altogether. DAFNE in the UK responded to these requests by trialling an “intermittent” delivery format. These courses were delivered one day per week over five weeks (5-week DAFNE).

This research showed that there were no significant differences in outcomes for people who attended the standard 5-day courses compared with the 5-week courses. Both groups had similar improvements across all biomedical and psychosocial areas included in the study. The team concluded that both course formats should be made available.

As a result of these research findings, a number of Australian DAFNE centres have introduced the 5-week DAFNE format. Check directly with your preferred centre to see if they are offering this format.

REPOSE: Relative Effectiveness of Pumps Over MDI and Structured Education

Insulin pumps are sometimes seen as the ‘gold star’ method of delivering insulin to people with type 1 diabetes. This research looked at the effectiveness of pumps in comparison to multiple daily injections of insulin. One study group received the standard DAFNE program for people using MDI therapy. The second study group received DAFNE education that was adapted for people using pump therapy.

This study showed that both groups had improvements in their diabetes management, and that pump treatment was not significantly better than multiple daily injections when DAFNE training was used. Read the full article explaining the results here.

Irish research & projects

Ongoing care post-DAFNE

Research has shown that ongoing support assists with improving outcomes from education programs. The Irish DAFNE Study Group looked at two different methods of follow-up care after a DAFNE course. Their research also looked at economic concerns and the qualitative experiences of participants in both study groups. For more information about the results and outcomes of this research, please see the list of published articles and abstracts, or contact Professor Sean Dinneen.