Patients’ experiences of adjusting insulin doses when implementing flexible intensive insulin therapy: A longitudinal, qualitative investigation
Introduction
People with type 1 diabetes are required to use insulin to compensate for the lack of beta cell function. Flexible intensive insulin therapy, comprising long-acting basal insulin (BI) injected once or twice daily, and quick acting (QA) bolus insulin adjusted to carbohydrate intake at meals, is generally recommended for type 1 diabetes management. Similar principles are utilised in pump therapy. By adopting physiological principles, flexible intensive insulin therapy can promote effective diabetes management without increasing, and often reducing, risk of significant hypoglycaemia [1], [2], [3]. This regimen also permits greater dietary flexibility than is possible with other (e.g. twice daily pre-mixed insulin) treatment approaches [2], [4]. Flexible intensive insulin therapy was pioneered in the Diabetes Treatment and Teaching programme in Düsseldorf [5]. It is now used in many countries and is often taught as part of structured education programmes based on the Düsseldorf model [4], [6], an exemplar being the Dose Adjustment for Normal Eating (DAFNE) programme in the UK [4], [7].
Like other programmes, DAFNE draws on theories of empowerment and uses goal-setting and problem-based learning to promote self-efficacy and self-care [6], [8]. Patients are taught how to count carbohydrates (expressed as 10-g carbohydrate portions) and calculate QA mealtime insulin dose requirements as ratios to the number of carbohydrate portions consumed [9]. Patients are advised to undertake regular review of self monitoring of blood glucose readings (normally taken pre-meal and pre-bed) and instructed how to interpret patterns and/or changes in readings to calculate and adjust mealtime ratios and basal insulin dose requirements to meet or maintain pre-prandial and bedtime targets. Patients also learn how to use corrective insulin or additional carbohydrate portions to help maintain blood glucose readings within recommended target ranges (5.5–7.5 mmol/l before breakfast, 4.5–7.5 mmol/l before other meals, 6.5–8.0 mmol/l before bed in the DAFNE programme) [10], [11]. Patients attend the programme over five consecutive days and are taught in groups of 6–8. Courses are normally facilitated by a diabetes specialist nurse and dietitian. Patients are given the opportunity to attend a group follow-up session 6 weeks post-course, with some DAFNE centres also offering group follow-ups at 6 and/or 12 months.
Research undertaken with graduates of DAFNE and similar programmes has highlighted similar, short-term improvements in glycaemic control and quality of life [1], [7], [11], [12], [13] and reductions in incidence of severe hypoglycaemia [3]. However, while improvements in psychological measures may be sustained, patients experience a decline in their glycaemic control over time [3], [14], [15], [16], possibly beginning as early as 1–3 months post-course [8]. The reasons for this glycaemic drift are poorly understood, and have prompted calls for research drawing on patients’ own understandings and experiences [4]. Hence, to understand the clinical outcomes of programmes such as DAFNE, we conducted an in-depth, longitudinal study involving DAFNE course graduates. A key aim was to explore patients’ experiences of, and views about, making adjustments to their insulin doses following their courses and over time. Our objective was to inform development of future resources and professional support for patients, to optimise and sustain effective use of flexible intensive insulin therapy.
Section snippets
Methods
As detailed elsewhere [17], [18], patients were interviewed on course completion (baseline) and 6 and 12 months later. This design enabled patients’ experiences to be tracked and compared over time, and the factors and considerations informing the kinds of dose adjustments made (or not made) to be identified and explored.
Experiences of adjusting QA insulin doses
On course completion, virtually all patients described feeling confident, motivated, and able to adjust QA insulin doses to food. Six and twelve months interviews also revealed that patients had persisted with this dose adjustment practice over time; albeit, most had adapted or simplified food choices to make carbohydrate estimation, and hence determination of QA doses, easier and more accurate [18].
A key reason presented for adopting and sustaining this aspect of their regimen was that
Discussion
This is one of the first qualitative studies to examine patients’ experiences of using flexible intensive insulin therapy. Through use of a longitudinal design, we have demonstrated that patients like and are motivated to sustain use of a regimen which allows them to adjust QA insulin doses according to the food they consume. However, we have also shown that flexible intensive insulin therapy is often perceived and experienced as a technically complex regimen, requiring numerical and analytical
Conflict of interest
The authors declare that they have no conflict of interest.
Acknowledgements
This article presents independent research commissioned by the National Institute for Health Research (NIHR) under “Improving management of type 1 diabetes in the UK: the DAFNE programme as a research test bed” [Grant number: RP-PG-0506-1184]. The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.
We gratefully acknowledge the support of the other members of the DAFNE research collaborative and the patients and
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