Long-term evaluation of a structured outpatient education programme for intensified insulin therapy in patients with Type 1 diabetes: a 12-year follow-up

Abstract

Aims/hypothesis. This study was conducted to evaluate the long-term outcome of a structured outpatient diabetes teaching and treatment programme (DTTP) for intensified insulin therapy in patients with Type 1 diabetes, which aims to improve metabolic control without increasing the risk of severe hypoglycaemia. Methods. All 123 diabetic outpatients (age 41±14 years; 64 women; BMI 23.5±3.1; diabetes duration 17± 11 years; HbA 1 c 7.9±1.6%; 32 patients with a history of severe hypoglycaemia; 18 with overt nephropathy; 22 with proliferative retinopathy) who participated in the DTTP between June 1989 and June 1990 were invited for follow-up visits after 3, 6 and 12 years. Results. Out of the 123 patients, 11 died during the follow-up period, two were lost for follow-up, and one was not willing to participate in re-evaluation after 12 years. Mean HbA 1 c levels decreased from 7.9± 1.6% to 7.1±1.2% (p<0.01) after 3 years, and were 7.8±1.5% (NS) and 7.8±1.2% (NS) after 6 and 12 years respectively. Frequency of hypoglycaemia decreased from 0.49 episodes per patient per year to 0.14 after 3 years (p<0.01), 0.19 after 6 years (p<0.01) and 0.16 after 12 years (p<0.01). Of the participants, 41% were able to lower HbA 1 c levels without episodes of severe hypoglycaemia and to maintain this improvement at all follow-up visits over the 12-year period. At follow-up, intensified insulin therapy was carried out by 94% of the patients. Conclusions/interpretation. A sustained reduction of the incidence of severe hypoglycaemia was observed in patients with Type 1 diabetes after participation in a structured outpatient DTTP over a 12-year period.

Glycaemic control and severe hypoglycaemia following training in flexible, intensive insulin therapy to enable dietary freedom in people with type 1 diabetes: a prospective implementation study

“…In study groups with poor glycaemic control at baseline, HbA 1 c values decreased by up to 3% at stable risks of severe hypoglycaemia [5,7]. In several long-term cohort studies in Germany and Austria, where patients had lower initial HbA 1 c values and higher rates of severe hypoglycaemia, the DTTP was consistently followed by significant decreases in the risk of severe hypoglycaemia and sustained but less-pronounced improvements of glycaemic control [2,3,11,14].…”

“…Before intervention, the incidence of severe hypoglycaemia was three times higher in the lowest compared with the highest quartile of HbA 1 c, whereas the risk was almost identical across HbA 1 c ranges during the year after the DTTP. Although we did not measure quality of life, there is good evidence from the DAFNE study and other trials that participants benefit from introducing dietary freedom [2,3,6,10,13], which was a primary goal of the courses.…”

“…However, there is increasing evidence that intensive insulin therapy is not necessarily associated with a high risk of severe hypoglycaemia [2][3][4][5][6][7]. In the DAFNE trial (Dose Adjustment for Normal Eating), a UK multicentre randomised controlled study, the incidence of severe hypoglycaemia remained unchanged while HbA 1 c and quality of life improved [6].…”

“…Patients are taught to match insulin doses to their food choices, while keeping blood glucose close to normal. In several controlled clinical trials the programme has shown sustained improvements in glycaemic control without increasing the risk of severe hypoglycaemia [2][3][4][5]7]. The DTTP has become the standard treatment approach for individuals with type 1 diabetes in Germany.…”

From 'pleasure to chemistry': the experience of carbohydrate counting with and without carbohydrate restriction for people with Type 1 diabetes

“…4 This approach uses variable mealtime rapid-acting insulin dosages, dependent on carbohydrate intake, combined with long-acting daily background insulin. People with Type 1 diabetes make up between 5% and 10% of the diabetes population.…”