DAFNE Collaborative Report

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marke Site Administrator
South East Kent PCT
642 posts

Disclaimer: I am not a Health Care Professional, I have no medical training and as such everything is my layman’s interpretation of what was said. It is merely a personal interpretation and should not be treated as fact.

What is the DAFNE Collaborative ? It is a conference day where everyone involved with DAFNE in the UK gets together for presentations and updates regarding the DAFNE program. There were 152 delegates in total at the meeting, representing 63 of the 72 DAFNE centres in the UK and Southern Ireland (only 9 centres were not represented) along with reps from Australia DAFNE and New Zealand DAFNE and representatives from Diabetes UK. The DAFNE Online team were invited to attend to publicise the web site. It also gave us an opportunity to attend the day as a whole and see and understand what is involved in the day.

The day started with DAFNE Online having a projector and laptop set-up in the ‘coffee’ area just outside the main meeting room. This area also had posters from DAFNE centres detailing outcomes from local services / national audits and also centre QA audit outcomes from 2007-2008. A number of DAFNE Educators were handed leaflets about the web site and were given a demo. A couple signed up for the site there and then. The biggest surprise came when both the New Zealand and Australian representatives of DAFNE in their country asked if they could sign-up to DAFNE online ! We of course said yes and hopefully in the not too distant future you will start to see postings in the forums from DAFNE Graduates in those countries.

The meeting then started in the main meeting room and so focus moved to listening to presentations from various speakers that are described below.

First up was a presentation on the changes to the reporting of HBA1c. This has already started to happen as from the 1st June 2009, HBA1c will be reported in two ways. The original percentage figure and a new mmol/mol value. Why ? Well before june 1st there were a number of different ways of reporting HBA1c around the world. This lead to issues when converting from one set of units to another, all conversions introduce minor variations and thus could introduce inaccuracies in an data used. Therefore the IFCC (International Federation of Clinical Chemistry) have managed to get agreement for a new measure of HBA1c, which is a measure of mmol’s of glycosolated haemoglobin to mol’s of haemoglobin. This results in a value rather than a percentage, for example 6.5% in the old measure is 48 mmol/mol in the new measure. The change won’t be immediate in that the old measure will continue to be reported along with the new measure until 1st June 2011, so you have two years to get your head around it all ! It is also not a totally global standard as yet, but it is hoped that it will become one in the not too distant future. Another point relating to HBA1c that was made is one that all DAFNE graduates should know, there is NO fixed range of values that you should have to be inside since all Diabetics are different. Your new HBA1c target values should be agreed by you and your Diabetes Care Team, not taken from some fixed standard range. Things that could vary your target range are diabetes complications, renal problems, liver problems, abnormal haemoglobin or abnormal red blood cell turnover, both of which make it hard to measure HBA1c.

The next presentation was regarding Psychotherapy research and what works. It was said there were similarities between DAFNE and Psychotherapy with respect to the social interaction factor of both. The key thing that has been found about Psychotherapy approaches is they are all as good as each other, it’s the doing that’s more important than the approach. It was suggested that this is also true of Diabetes Structured Education, that is we should focus on what works from all types of education not which one is better. The various characteristics of the therapist ( or DAFNE educator) were then detailed with their effect on the outcome of the treatment. Age, gender and ethnicity have no effect. More patient involvement results in a better outcome. Qualification and professional background have no effect. Competence and empathy result in better outcomes as does user feedback. The various characteristics that effect the outcome for the patient ( or DAFNE Graduate) were then detailed. These were realistic expectations, pre-therapy function, trouble with relationships, verbal intelligence, motivation and support. Finally the ‘service’ ( or course characteristics) were detailed with their effect on the outcome. More sessions resulted in a better outcome but at a slower rate, that is after a certain number of sessions the benefits tail-off. It was suggested that 8-16 sessions give the best overall outcome for most people. Follow-up and maintenance after the sessions was also important on the outcome. Supervision of the therapist( or educator) i.e discussion of cases with a superior gave better outcomes.
There was then a coffee break and a few more HCP’s were signed up to the DAFNE Online website with a number of others taking leaflets and promising to sign up soon.

The next two speakers give a presentation relating to background insulin and its capability to last over 24 hours and probably more interestingly the misconceptions surrounding the Somogyi effect or rebound Hyperglycemia. It has been suggested that many high blood sugars in the morning are caused by night-time hypos. The presenters contended that this is generally NOT the case, the night time hypos only result in a relatively small rise in blood sugar. So if this is not the cause then what is ? It was suggested that the cause is a form of the Dawn Phenomenon where the body releases hormones. The factors that cause this rise are length of sleep, duration that a person has had diabetes and horizontal posture. The biggest issue with this hormone release is it occurs from 5am onwards. This means using an increase of background insulin the night before is not a good way to treat it, since a hypo would occur in the hours before the increase in hormones. The only effective way to treat it is by injecting fast acting insulin, which is a bit of an issue since most people are not awake at 5am. One method would be the use of insulin pumps, but since these are still not widely available to all Diabetics there is no easy solution.

The next presentation was an update on developments in the DAFNE research program, volunteer DAFNE Centres were asked for to undertake two Pilot Studies. The first was on the use of pumps verses multiple injections with the DAFNE approach. The second was a DAFNE Course run over 5 weeks rather than 5 consecutive days. At this stage studies would only be trials to look into these potential approaches.

The final presentation of the morning was an update on the psychosocical study being made of DAFNE.
Details of this presentation will be added later once we have permission to produce it online, since it is research work it needs to be cleared for publication first.

It was then lunch time and the overwhelming urge in a room of 100+ DAFNE educators to pull out a set of scales was very hard to resist !

After lunch 2 workshops were attended by all attendees, there were 8 different workshops and hopefully we will have write-ups from them appearing on the site at a later stage. After the workshops a brief summary of each workshop was given to all attendees and the meeting was closed.

Alzibiff DAFNE Graduate
Pennine Acute Hospitals
21 posts

Thank you for that write up Marke. I found the "dawn phenomenon" bit of interest and eagerly await DAFNE guidance for pump users now that I have switched to one of those after 42 years of injections. As said - very much appreciated.

Alan

Jennifer DAFNE Graduate
NHS Grampian
11 posts

Hi marke,

Thanks for that. I have recently been having trouble with really high BGLs in the mornings even when all seems well at night time. I found it really interesting what you mentioned about the Dawn Phenomenon. Perhaps I will have to investigate more!!

marke Site Administrator
South East Kent PCT
642 posts

I get the problem of high BG's in the morning as well, so it interests me too. Unfortunately this theory probably needs further investigation/research especially to find an effective solution. What is needed is an injection of quick acting insulin about 5am, obviously this is not convenient to most people so another solution needs to be found. Perhaps by using a pump, however that would need solid evidence before PCT's could be persuaded to issue pumps.
The collaborative speaker did not have a solution at this time, just an identification of a possible cause of high morning BGs. Like most things medical it takes a while to move from 'theory' to accepted solution.