Type 2 & DAFNE

Hi,

I received this question via the Contact DAFNE Online system so thought I'd post it here as the Admin team are DAFNE Graduates, thus not well-placed to answer this question. If we could get an HCP response for this it would be much appreciated:

"Hi I just want to know. If you can tell me something. I'm type 2 on insulin and on metformin i was told i was unsuitable for the DAFNE course, can you tell me why. and is they any help for people like me." (User name and contact details supplied)

Thanks,

Simon

To add to what Simon says, I can maybe add 'some' advice.

DAFNE is very much directed at Type 1 because of the insulin management it teaches. Whilst insulin use is not exclusive to Type 1, use of
tablets probably has an effect that doesn't match the DAFNE process quite as well. Is there help for Type 2's ? Yes absolutely, the equivalent
training for Type 2 is generally called DESMOND (http://www.desmond-project.org.uk/ ) although it has different names in some regions under some PCT's. I would suggest you speak to your GP or Diabetes care team about DESMOND, to be honest they should have already known about it when they told you that you were not suitable for DAFNE. Diabetes education is VERY important and anyone who is keen to do it should at least be given the option ( although it may involve waiting to get a place on a course).

This is not a definitve answer since I'm not a HCP, but hopefully it will help until a better answer is provided.

This is a difficult thing though. For example I am a type 1. But my healthcare team believe I need to lose weight and want to put me on Metformin. I did DAFNE last year luckily, but if I had not, and had started the tablets prior to DAFNE, I would still presumably be allowed to do it whereas a type 2 who takes insulin and tablets would not. I would be interested to find out the HCP response.

Perhaps it is also due to content - the DESMOND course I assume is more strict on carb counting and diet management since some will be using only diet to control their condition, whereas type 1s on DAFNE can be a little more flexible. DESMOND presumably also includes stuff on different tablets which most - but not all - type 1s would not be interested in. Also the science part would be different in each course.

Once again I want to stress I am just a Diabetic and NOT a HCP, it would be better if a HCP provided some input, but in the meantime:

I think you have to understand/remember that Type 2 is NOT the same as Type 1. In Type 1 you cannot produce insulin because your islet cells have been destroyed ( pretty much). This means your body responds 'normally' to insulin and its effect is similiar to insulin produced by the pancreas. In Type 2 your body 'resists' or does not process insulin fully in the process of moving sugar into the cells. For this reason a course aimed at dynamically altering insulin intake (DAFNE) to manage blood sugar is NOT going to work for people whose bodies resist the insulin. For this condition a different approach is needed, I would presume one that IS more focused on Carb Counting. I will know more after the 17th March, we have a 'DESMOND' trainer giving my Diabetes support group a presentation on it. I can provide more info then if anyone is interested or you can visit the web site above.

One thing I'm sure of, any kind of Diabetes education is a good thing and as many people as possible should get the chance to do it. Any one who has done DAFNE knows of the many many benefits it brings....

Hi, I'm a Dietitian, DAFNE and DESMOND trained. The above is essentially correct. However, DESMOND does not cover carb counting, it is generally focus on reducing sugar and fat in the diet. Generally, but not always, the main problem in Type 2 diabetes is being overweight and lack of physical activity which increase insulin resistance. So DESMOND is more focused on healthy lifestyle changes. I would definitely agree that both DAFNE and DESMOND provide valuable education enabling people to make their own decisions about managing their diabetes, whether type 1 or 2.

Thanks for a more 'official' reponse on this. On this site we are obviously more focused on Type 1 and DAFNE, but thats not to say we should exclude any questions. If we can help any Diabetic then we are more than happy to try ! Obviously responses from HCP's are preferred on this subject since you are the people trained on these subjects, so thanks for your input.

Hi

this is a question that we get asked alot via the dafne.uk.com website; and marke's response pretty much covers it, however below is the standard response from the DAFNE Drs and Educators on the DAFNE Executive Group that we use:

The evidence base for DAFNE relates entirely to Type 1 diabetes; we do not know of any evidence that supports the use of intensive insulin therapy in Type 2 diabetes.

Having said that, several of my colleagues have either knowingly or unknowingly included a few Type 2 / Type ? patients on their DAFNE courses. Those knowingly placed on courses have been insulin deficient / sensitive. Some of these patients did appear to do quite well on DAFNE although some reported weight gain, however these are only observational comments.

However my colleagues also reported that it is a very different situation when the patient is insulin resistant these patients have very different needs which disrupted the learning of the other group members with Type 1 diabetes during the DAFNE week. One of my colleagues commented that their service tends to offer 1 to 1 education for such patients where they obtain carb counting skills from a specialist Dietitian DAFNE Educator, with emphasis on portion size reduction, lifestyle choices and weight loss as well as improving glycaemic control.

My colleagues agree that whilst we do not have any evidence to support beneficial outcomes for Type 2 insulin sensitive/ deficient patients following a DAFNE course, individuals should discuss the appropriateness of participating in DAFNE training with their local team. Although it is not a situation where an absolute dictum can be applied but in general the approach of matching insulin to food works best if pure insulin deficiency is the underlying cause of the diabetes although generally the different disorders require different approaches to management.

Digth - what is you and your colleagues' feelings about type 1 insulin resistant diabetics like me who also have high insulin requirements? I went on a DAFNE course last year which was the best thing I have ever done for my diabetes. I do not feel I "disrupted" the learning of other group members - could you please clarify what you mean by using that word? To me it implies some degree of deliberate thought, in the sense of a child disrupting other childrens learning by misbehaving. I must say I am a little hurt by your use of that word as I would never want to disrupt anyone and I do not feel that I did.

Hi Lizzie

sorry that you have been offended by my posting.

There was absolutely no deliberate thought in the use of 'disrupted'

Type 1 and Type 2 diabetes are essentially different conditions with essentially different treatment pathways, in general Type 2 care pathways involve lifestyle management.

This merely reflected the feedback from DAFNE Educators and applied to different needs of individuals with Type 2 diabetes not covered in the DAFNE curriculum, which was developed for people with Type 1 diabetes and in no way was intended to be interpreted that people with insulin resistance behave inappropriately.

The term disrupted refers to these differing lifestyle requirements and medical needs of the individual(s) with Type 2 diabetes which results in some areas of the DAFNE curriculum being inappropriate for the individual with Type 2 diabetes and the educator having to more spend time ensuring that the different needs of all individual are met.

Another comment from an HCP. I have managed to slip a couple of people with Type 2 diabetes into a DAFNE course and both enjoyed it and have used it to maintain tight glucose control and their weight. The issue is that DAFNE is teaching the skills of insulin replacement and dose adjustment with a philosophy of eating freely. In Type 2 diabetes, control of BP and cholesterol are equally important and don't get big coverage on a DAFNE course. I agree with suggestions above that where the need is for skills in insulin adjustment and someone with Type 2 diabetes is up for taking 5 injections for insulin (relatively unusual) then they can use DAFNE skills to control both blood glucose and weight. However Gill is right that there has never been a trial to prove that people with Type 2 diabetes can do as well as people with Type 1 so there is a nervousness among HCPs in referring them.