Introduction

DAFNE stands for ‘Dose Adjustment For Normal Eating.’ The original DAFNE course is for people over 17 years old with type 1 diabetes who use multiple daily injections (MDI) of insulin. It is a comprehensive and often life-changing experience. Participants on a DAFNE course learn the skills to self-manage their diabetes using insulin dose adjustment and carbohydrate counting principles.

DAFNE  enables people with type 1 diabetes to lead as normal a life as possible whilst maintaining glucose within healthy targets, thus reducing their risk of developing acute and long term complications of diabetes.

In October 2025, DAFNE celebrated its 25th anniversary (see Figure 1: DAFNE Timeline) and in this article, we will discover how DAFNE has developed to meet the needs of people with type 1 diabetes and of diabetes specialist healthcare professionals. We will also look to the future of DAFNE and how it is meeting the needs of people with type 2 diabetes who use insulin, with its innovative VICTOR course.

Why provide structured education for people with type 1 diabetes?

Treating complications of diabetes costs the NHS around £6.2 billion annually1. Providing effective diabetes care means many of these complications can be avoided, improving the quality of life for people with diabetes and reducing costs. The National Institute for Health and Care Excellence (NICE) states that people with type 1 diabetes should be offered a structured education programme of proven benefit, such as DAFNE.

Supporting people to self-manage their diabetes through DAFNE is a cost-saving way to improve outcomes and reduce the risks of complications.

How it began

In 1998, there was no standardised structured education for people with type 1 diabetes in the UK. Outcomes for people with diabetes in Germany were significantly better than for those in the UK. Intrigued by the work of Dr Michael Berger in Dusseldorf, Professors Stephanie Amiel and Simon Heller and Dr Sue Roberts visited his diabetes service, to see for themselves the education that was provided for people with type 1 diabetes in Germany. Inspired by the work of Dr Berger the team developed the original DAFNE course and commenced a randomised controlled trial (RCT) to test its effectiveness in the UK.

The DAFNE course was a 5-day course delivered by trained educators in person over one week (Monday to Friday). A DAFNE trained doctor would be present for some of the course.

The RCT showed improvements in HBA1c of 1% at 6 months and 0.5% at 12 months.

The NHS recognised the benefits that providing DAFNE structured education could bring to people with diabetes and so the DAFNE rollout began in 2000. By 2010 DAFNE had been adopted in Australia, New Zealand, Singapore and Kuwait. In 2010, a research study which followed up the original RCT participants showed that quality of life improvements were maintained for at least four years after completing a DAFNE course.

In its 25th anniversary year, DAFNE is delivered by 117 services in over 230 localities in the United Kingdom, Republic of Ireland, Crown Dependencies and overseas. Over 65,000 people with type 1 diabetes have completed a DAFNE course.

(See Figure 2: DAFNE numbers October 2025)

Over the last 25 years, the DAFNE portfolio has grown and the number of courses offered for people with type 1 diabetes has increased. (See Table 1: The DAFNE portfolio for people with type 1 diabetes.) The courses are delivered either face-to-face or remotely using a video conferencing platform.

The Remote DAFNE course

Remote DAFNE was developed in a rapid response to the lockdown in March 2020 when all structured diabetes education ceased overnight. It was piloted in the summer of 2020 and rolled out across the UK from 2021. It combines online learning from home with group support sessions run via a video conferencing platform, or in person. Remote DAFNE continues to form approximately half the number of DAFNE courses delivered each year.

Some DAFNE services deliver blended courses, in which the participants complete online learning at home but the group support sessions take place in person.

Key Performance Indicator data (KPI)

Audit of participant outcomes is a vital component of the DAFNE portfolio because it provides evidence of the programmes’ efficacy. Participants provide baseline biomedical data prior to the course and again at one year. The DAFNE course for people using MDI is associated with:

• a reduction in HbA1c levels, nearly 50% of participants achieve the target of <58 mmol/mol.
• a reduction in the prevalence of severe hypoglycaemia by 72-82%.
• a reduction in episodes of diabetic ketoacidosis by 74-89%.
• 12 months after a DAFNE course 82% of course graduates report improved quality of life.

In recent years, the use of continuous glucose monitoring (CGM) and flash glucose monitoring has increased. It is estimated that > 90% of people with type 1 diabetes now rely on CGM or flash glucose monitoring when managing their diabetes. The DAFNE KPI data continues to show a consistent fall in HbA1c and a consistent reduction in episodes of severe hypoglycaemia and diabetic ketoacidosis. This suggests that when technology is provided alongside structured education, the person with type 1 diabetes is empowered to achieve more improved outcomes than with a single intervention alone. When the pilot of Remote DAFNE was delivered, the one year data analysed the fall in HbA1c in participants using flash glucose monitoring against those using finger pricking. Those using finger pricking achieved a fall in HbA1c of 8.7 mmol/mol while those using flash monitoring achieved a reduction in HbA1c of 6.8 mmol/mol.

Person Reported Outcome Measures (PROMs)

In 2022, DAFNE started to collect PROM data for participants. Participants are invited to complete SurveyMonkey questionnaires prior to the course, immediately upon course completion and at one year. Participants rate their response to the Diabetes Distress  questions using a scale from 1 ‘not a problem’ to 6 ‘a very serious problem; the response to the Problem Areas In Diabetes (PAID) question is on a scale from 1 ‘Not a problem’ to 5 ‘A serious problem.’

The PROM data show consistent and sustained improvements in their sense of feeling less overwhelmed by their diabetes (see figure 3: Diabetes Distress Scale 1) Is feeling overwhelmed by the demands of diabetes…?), less feeling as if they are failing with their diabetes routine (see figure 4: Diabetes Distress Scale 1) Is feeling that I am failing with my diabetes routine…?) and less feeling alone with their diabetes (see figure 5: Problem Areas In Diabetes (PAID): Is feeling alone with your diabetes…?).

Healthcare professional training

When a diabetes service becomes a DAFNE service, training is provided free of charge for the diabetes specialist healthcare professionals who wish to become DAFNE educators or DAFNE doctors.

The DAFNE Educator Programme (DEP) and DAFNE Doctor Programme (DDP) are delivered remotely and fulfil the Department of Health’s requirements for structured education. The DEP includes assessment of the trainees’ knowledge in the DAFNE principles for insulin dose adjustment and carbohydrate counting. During the online workshop, the educator trainees are assessed in educator skills and behaviours.

Trainees in the DDP are assessed in the DAFNE principles for insulin dose adjustment and carbohydrate counting.

Feedback received from healthcare professional trainees is positive.

(See figure 6: Feedback from the DAFNE Doctor Programme 2025.)

(See Figure 7: DPP trainees' confidence with insulin dose adjustment before and after their DAFNE training)

(See figure 8: Feedback from the DAFNE Educator Programme 2025.)

(See Figure 9: DEP trainees’ confidence with insulin dose adjustment before and after their DAFNE training.)

Doctors who do not work in a service where DAFNE is delivered may undertake the DDP. This training is free of charge and is accredited by the Royal College of Physicians for 53 external CPD points.

Healthcare professionals who do not wish to become DAFNE educators, or who do not work in a service where DAFNE is delivered, may undertake the free non-DAFNE healthcare professional training. This comprises online learning units in insulin dose adjustment and carbohydrate counting and includes a knowledge assessment at the conclusion of each unit. This training will not enable them to become DAFNE educators but will enable them to better support people with type 1 diabetes who have completed a DAFNE course. These training programmes are all delivered remotely and all are free of charge.

(See Table 2: DAFNE training opportunities for healthcare professionals.)

The next 25 years

There were an estimated 5.8 million people living with diabetes in the UK in 2023 – 2024; 4.6 million people living with a diagnosis of diabetes and the remainder living with diabetes but without a diagnosis yet. These figures have risen by over 185,000 from 2022/23 to 2023/24.7 The majority of these, ≥ 90 % will have type 2 diabetes. As more people develop the condition, it is possible that the number of people requiring insulin will increase.

The VICTOR course

In March 2025, the VICTOR course was piloted. VICTOR stands for ‘Varying Insulin doses for Changes To Routine’ and is for people with type 2 diabetes who use basal insulin and at least one injection of quick-acting insulin per day at a meal.

The course combines some online learning from home and group support sessions which may be held in person or remotely. VICTOR focuses on the positive actions and behaviours a person may choose that will increase their insulin sensitivity; it is based on the Smart Seven (See Figure 10: VICTOR Smart Seven) and Carb Smart principles (see Figure 11: VICTOR Carb Smart). It includes carbohydrate counting and insulin dose adjustment principles.

VICTOR participants are invited to complete PROM surveys before and after the course:

• 100% of participants leaving feedback said they would recommend the course to other people with type 2 diabetes.
• 100% of participants leaving feedback said the VICTOR course provided them with information they needed.

Comments received from VICTOR participants after completing the course include:

• ‘The course was brilliant. It has completely changed my approach to using insulin and I’m now confidently determining the doses I need with excellent results.’
• ‘I learned how to count carbs. I eat my regular meals but now take my insulin 15 minutes before meals. My time in range is getting better just from these small adjustments.’
• ‘I previously had a limited diet as I could not tolerate gaining so much weight with set doses. Now I have been able to add some foods back into my diet and can match the insulin to the carb content.’

As with DAFNE participants, the VICTOR participants provided baseline biomedical data prior to starting the course. The one year data will be collected in Spring 2026 and outcomes reported later in the year.

The VICTOR participants also provided PROM data prior to the course and immediately after the course. The one year PROM data will be collected in Spring 2026.

Participants who completed the PROM data at baseline and immediately after the course reported improvements in their confidence when matching insulin to carbohydrate (see Figure 12: Confidence matching insulin to carbohydrate). Participants also reported changes in their emotional wellbeing with improvements in their feelings of being overwhelmed by the demands of diabetes, (see Figure 13: Diabetes Distress Scale: 1) Is feeling overwhelmed by the demands of diabetes...?) in feeling that they are failing with their diabetes routine (see Figure 14: Diabetes Distress Scale: 2) Is feeling that I am failing with my diabetes routine...?) and in feeling alone with their diabetes (see Figure 15: Problem Areas In Diabetes (PAID) Is feeling alone with your diabetes...?).

DAFNE educators undertake additional training free of charge to become VICTOR educators prior to delivering this innovative new course to their participants.

DAFNE Closed Loop Essentials course

The DAFNE Closed Loop Essentials (CLE) course was launched in 2024. It is a self-directed online course for people with type 1 diabetes who are being considered for hybrid closed loop therapy (HCL). They may currently be using MDI or pumps prior to changing to HCL. This course has no educator-led sessions and there are no group sessions when completed online. A face-to-face version of the CLE course is available for people who do not wish to complete the course online.

All courses provided by DAFNE are available within DAFNE services only. However, in keeping with DAFNE’s aim to improve the lives of all people with type 1 diabetes, the CLE course is also available to people with type 1 diabetes who receive their diabetes care from a publicly funded service in the UK and RoI where DAFNE is not delivered. The roll out of the Closed Loop Essentials course is supported with sponsorship from the following companies for 2025-2026. These companies have provided funding but have had no input to, or influence over the course content.

We are grateful for the support of our industry partners. (See figure 16: Industry partners for the DAFNE Closed Loop Essentials course)

HCPs can access the course free of charge.

Closed loop essentials facts and figures:

• 5,440 people have accessed the course from the UK and Republic of Ireland.
• 3,536 people with diabetes have completed and passed.
• 99.7% pass rate.  
• 39% of graduates completed the course in 2-4 hours. 
• 46% of graduates completed the course in 4-6 hours. 
• 91% of graduates rated the course excellent or good.
• 91% of graduates would recommend the course to another person with type 1 diabetes.

DAFNE Closed Loop Optimisation course

Research and real-world data tell us that not everyone using a hybrid closed loop achieves the results they want. The DAFNE team is working on the development of a group based structured education course to help people gain more from the closed loop system. The course will cover multiple topics including exercise, travel, celebrations and illness. It focuses on the actions and behaviours people may choose to achieve their time-in-range targets.

Early Stage Type 1 Diabetes module

Increasing information is coming to light about the early stages of type 1 diabetes that occur before insulin therapy is required. It is possible to screen for insulin autoantibodies and some immunotherapies are being trialled in an effort to delay or even halt the progression to type 1 diabetes needing insulin.

The Early Stage Type 1 Diabetes module is available for people with type 1 diabetes and their families who may be concerned about the likelihood of a family member developing type 1 diabetes. There is also a module available for healthcare professionals who may be involved in caring for someone who wishes to be screened for autoantibodies or who knows they have autoantibodies for type 1 diabetes.  

Both modules will take 1 – 2 hours to complete, they are free to access and once accessed, the user may dip and out of the module as often as they wish. There is no educator involvement and no group support sessions.

Learn more about DAFNE and VICTOR

DAFNE continues to be a nimble and agile organisation, adapting to the needs of people with diabetes in a rapidly changing and fast paced environment. Centres can join the DAFNE consortium for approximately £5,000 per year. Joining the consortium gives centres access to all DAFNE courses, materials and health care professional training. If you would like more information about any aspect of the DAFNE portfolio, contact us using the details below:

Email: dafne@nhct.nhs.uk                                 

Website: www.dafne.nhs.uk                                            

X: @DAFNEUK | Facebook: @UKDAFNE | @dafneuk.bsky.social

References

• Hex N, MacDonald R,Pocock J, et al. Estimation of the direct health and indirect societal costs of diabetes in the UK using a cost of illness model. Diabet Med. 2024;41
• Diabetes UK. Cost of devastating complications highlights urgent need to transform diabetes care in the UK. [online] DUK: London; 2024 [Accessed 01.10.2025]. Available from: https://www.diabetes.org.uk/about-us/news-and-views/cost-complications-highlights-urgent-need-transform-diabetes
• NICE.  Type 1 diabetes in adults. Quality statement 1: Structured education programmes. [online] NICE: London; 2023 [Accessed 01.10.2025]. Available from: https://www.nice.org.uk/guidance/qs208/chapter/quality-statement-1-structured-education-programmes#quality-statement-1-structured-education-programmes
• NHS England. Diabetes high impact interventions. [online] NHS England: London;  [Accessed 01.10.2025]. Available from: https://www.england.nhs.uk/ourwork/prevention/secondary-prevention/diabetes-high-impact-interventions/
• DAFNE study group (2002); ‘Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial.’ BMJ 325
• Speight, J. et al (2010): ‘Long-term biomedical and psychosocial outcomes following DAFNE (Dose Adjustment For Normal Eating) structured education to promote intensive insulin therapy in adults with sub-optimally controlled Type 1 diabetes.’ Diabetes Research and Clinical practice, 89/01, 22-29
• Diabetes UK 2025

Tables and Figures