Well, I finally got to meet
DAFNE! After 20 years of living with Type One Diabetes, I have, better late
than never, received the “education” to which we are all entitled to help us
live with a condition which demands so much of us in terms of self-care, self-monitoring
and self-treatment. Just in case you don't know, DAFNE stands for Dose Adjustment for Normal Eating, and is the recognised education course for people with Type One Diabetes. I'm now a DAFNE graduate, and I've got the certificate to prove it:-
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| My DAFNE Certificate |
Those readers who follow me on
Twitter, or who have read my previous blog posts, will perhaps know that I had
to fight quite hard to be allowed onto a DAFNE course. Fourteen years after
diagnosis, I was discharged from hospital care back in 2011 because of my “good
control” and lack of complications, and my D-care had been reduced to an annual
check-up with my GP. It was only when I started associating with other Type
Ones, thanks to the GBDOC, that I came to realise how minimal my input from the
health service had become, and with retirement from work and a twenty year
diaversary occurring at around the same time, I asked to attend a DAFNE course,
only to be told I was ineligible because I was not under hospital care.
So I referred myself back to the
hospital, only to be told there that my HbA1c was “too good” and that I “didn’t
need” a DAFNE course. I politely insisted, citing a wish to be better informed
in my judgements of insulin dose, rather than relying on semi-educated guesswork,
and eventually found myself at the start of 2018 on a course. It was the 5 x 1
format, rather than a full five day week - apparently more popular due to
peoples’ work commitments.
So how was it?
Well, most importantly there have been many
positives:
I have come home every week like
a new boy at school, clutching a shiny ring binder increasingly full
of paper, and the information both on paper and presented during the course is
detailed and useful. I have achieved my basic aim, namely to learn more about
the complex relationship between food, insulin and activity. The pocket-sized Carbohydrate
Portion List alone is a wonderful thing, and I have been genuinely
surprised and enlightened to learn of the carb content of some foods which are
a regular part of my diet. Some puzzling highs and lows over the years now make
much more sense!
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| DAFNE Swag |
The presenters, a dietitian and
DSN, have been thorough, attentive and caring in their approach to the diverse group of participants on my course, and display detailed knowledge of both diabetes and the
principles of DAFNE approach to its management. I cannot fault them for their knowledge of their material and their belief in it.
The opportunity to devote time
and mental space to my condition has been most welcome and useful. I developed
Type One at a time in my life when I was extremely busy both professionally and
personally, and so I have to say that I didn’t really give diabetes the
attention it warranted until quite recently. I just wanted to carry on as
normal, and indeed I was pretty successful in so doing. But looking back, I can
see moments when the cracks were starting to show, and I should perhaps have
given the condition a little more of my time. So being forced to “study”
diabetes, to note food intake and injection doses in minute detail and to
discuss outcomes has been good for me. Nobody has ever mastered diabetes.
My colleagues on the course have
proved to be very good company, as fellow PWD invariably are. Prior to this course,
I had never met any fellow Type Ones in my local area other than pupils at my
school, so it has been interesting to meet a small group who share the
condition. As always, it serves as a reminder of the completely random nature
of Type One to meet people who are a diverse group of individuals with
different backgrounds, lifestyles, tastes and experiences, yet with such a big
thing in common. We have had many laughs together, as well as sharing in our
difficulties.
What of the negatives?
Well, I am loathe to criticise,
not least having had to fight to get on the course. And in overall terms I feel
better-informed and therefore more confident for having done the course.
However, in all areas of life, I am not a fan of absolute rules and principles.
I prefer guidelines, and my experience of diabetes has taught me that it is a
condition where absolutes seldom work.
So the somewhat evangelistic
application of “DAFNE principles” that pervades every aspect of the course does not sit
comfortably with me. To be told to follow "rules", as if it is a matter of life and
death, such as do not pre-bolus, do not test after meals, change your lancet every time, wash your hands before every blood test, and to apply rigid mathematical formulae to doses and
corrections seems to me to run counter to the very nature of diabetes. It’s a
mercurial condition which defies logic a lot of the time. The same food, the
same activity on two apparently similar days can produce startlingly different
outcomes for no good reason. The same BG reading can feel very different to
different people. The same insulin works for some and not for others. My
favourite acronym from the online community is YDMV: Your Diabetes May Vary.
How very true, yet DAFNE somehow appears to suggest otherwise.
In personal terms, I was more
than a little dismayed to have a radical change of dose imposed on me at the
start of the course, a massive reduction in insulin intake (both long and short acting) compared to that
which had served me well for many years and given me an Hba1c of 46 (6.4). It
was inevitable that such a striking reduction would lead to uncomfortable
highs, and it did, such that over the five weeks, we gradually returned to the
previous levels. Having said that, an adjustment to the balance between basal and bolus has been
the most useful and significant outcome for me, but that could have been achieved by
less dramatic changes, as to reduce both at the same time didn’t give the
opportunity for true evaluation of cause and effect. I intend to persist with
experiments with these levels.
Now I fully recognise and understand
the difficulty of delivering a course to participants of varying degrees of
knowledge and experience of diabetes, and I repeat my admiration and respect
for those who have researched, devised and present such a valuable body of
knowledge to patients who need it. I also realise and accept that rules and
principles have to err on the side of safety, not least in our risk-averse age
and culture.
However, I do wonder whether a
limited dose of peer input might be helpful, to both the course presenters and
participants alike. My own experience of diabetes has been that in 20 years, all the
most useful hints, tips and knowledge has come in the past few years thanks to
the GBDOC. Perhaps some of that expertise and experience could be brought to
education courses such as DAFNE. I would willingly offer my time to meet fellow
PWD, provide a little real-life experience and above all assure them that it is
possible to live well with Type One. I would love to have met my 60 year old
self when I was newly diagnosed at 40.
In more general terms, I wonder
whether some thought should be given to the timing, nature and delivery of diabetes
education. What is the best timing for effective education following diagnosis?
Is it the best use of scarce resources to run five day courses delivered by two busy HCPs? I wonder whether two or more shorter courses might be more effective.
Perhaps one 6 - 12 months after diagnosis then another after around 5 years.
These could be as little as one day in duration, with additional content available in
print/online. And could they be delivered by HCPs with volunteer peer support?
And in the meantime, I’ll watch,
listen and observe, but when it comes to self-management, I’ll be as stroppy as
Eddie and the Hot Rods were in this classic of rebellion back in 1977:
And here’s my DAFNE playlist:
Disclaimer: I am very aware that I am not an expert, and have no qualifications other than experience and common sense. Please be aware that what works for me in managing my diabetes may not work for you.
