Type 1 diabetes in adults: supporting self management Monika Reddy specialist registrar, diabetes and endocrinology 12 , Sian Rilstone diabetes specialist dietitian 2 , Philippa Cooper has type 1 diabetes 3 , Nick S Oliver consultant diabetologist 12 1 Department of Diabetes, Endocrinology and Metabolism, Imperial College London, St Mary’s Hospital Campus, London W2 1PG, UK; 2 Diabetes and Endocrinology, Imperial Healthcare NHS Trust, London; 3 London Type 1 diabetes affects 300 000 people in the United Kingdom. 12 Despite regular specialist multidisciplinary input, responsibility for glucose monitoring and insulin administration is devolved to the person with diabetes, or their care giver. Empowering effective self management of type 1 diabetes is critical to achieve HbA 1c targets, minimise hypoglycaemia and optimise quality of life. Structured education programmes for diabetes self management should be offered to everyone with type 1 diabetes. It is important for healthcare providers to understand what structured education involves before referral. This review examines the meaning and evidence for self management, and provides advice on how general physicians and non-specialists can support and enable people with type 1 diabetes to self manage their condition. What is required for self management of type 1 diabetes? Insulin requirements and glucose concentrations are affected by multiple internal and external factors (see box 1), and maintaining glycaemic control while minimising hypoglycaemia with a flexible daily routine is a challenge. The benefit of intensive glucose control in reducing long term complications in type 1 diabetes is well established, based on the Diabetes Control and Complications Trial (DCCT). 3 However, this was at the expense of an increase in severe hypoglycaemia (61.2 per 100 patient years in the intensive control group compared with 18.7 in the control group). 4 Newer analogue insulins and modern insulin pumps have enabled HbA 1c reduction with an associated reduction in the frequency and severity of hypoglycaemia. 56 Self management remains challenging, and 73% of people with type 1 diabetes do not achieve an HbA 1c target of <58 mmol/mol (7.5%). 1 What is a structured education programme for type 1 diabetes? A structured education programme for type 1 diabetes is defined as “a planned and graded process that facilitates the knowledge, skills and ability for diabetes self management and empowers individuals to live healthily, to maintain and improve their quality of life, and assume an active role in their diabetes care team.” Structured education programmes are required to be evidence based, theory driven, quality assured, audited regularly, and have a formal written curriculum delivered by trained educators. 7 It includes education on self monitoring of blood glucose (SMBG), carbohydrate counting, and insulin dose adjustment at mealtimes 89 to achieve optimal glycaemic control and quality of life. Examples of structured education programmes are the Dose Adjustment for Normal Eating (DAFNE) course 9 (adapted from a German programme) and PRIMAS (Programme for diabetes education and treatment for a self determined living with type 1 diabetes). 10 Box 2 summarises the principles and syllabus content of structured education. Do structured education programmes for type 1 diabetes work? In a multicentre randomised controlled trial, DAFNE reduced HbA 1c and improved quality of life 12 months after completion. 9 Further follow-up at four years showed that the psychosocial benefit was sustained. 8 A meta-analysis of 15 randomised controlled trials of structured education for type 1 diabetes 9-24 suggested no overall impact on HbA 1c at either six or 12 months’ follow-up. However, DAFNE 9 and PRIMAS 10 were the exceptions to this, with DAFNE showing a reduction in HbA 1c of 1% (95% confidence interval 0.58% to 1.42%) and PRIMAS achieved a reduction of 0.4% (0.15% to 0.65%) from baseline to six months. Who should receive a structured education programme? All adults with type 1 diabetes should be offered an evidence based, structured education programme, and have its benefits explained, after 6-12 months of diagnosis. 7 The delay from diagnosis to education allows people time to adjust to their diagnosis and to be established on an insulin regimen beyond the initial honeymoon phase, which is characterised by partial recovery of endogenous insulin secretion. If a person is unable Correspondence to: N S Oliver nick.oliver@imperial.ac.uk For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2016;352:i998 doi: 10.1136/bmj.i998 (Published 10 March 2016) Page 1 of 7 Clinical Review CLINICAL REVIEW