Previous structured education attendance and the relationship with HbA1c and hypoglycaemia awareness in people living with type 1 diabetes mellitus using FreeStyle Libre: insights from the Association of British Clinical Diabetologists (ABCD) Nationwide Audit


  • Najeeb Shah Hull University Teaching Hospitals NHS Trust and the University of Hull.
  • Harshal Deshmukh Hull University Teaching Hospitals NHS Trust and the University of Hull.
  • Emma G. Wilmot University Hospitals of Derby and Burton NHS Foundation Trust, Derby.
  • Jane Patmore Hull University Teaching Hospitals NHS Trust, Hull.
  • Pratik Choudhary Leicester General Hospital, University of Leicester, Leicester.
  • Peter Christian William Harvey Hospital, East Kent Hospitals University NHS Foundation Trust, Kent.
  • Roselle Herring Royal Surrey County Hospital, Guildford.
  • Niall Furlong St Helens and Knowsley Teaching Hospitals NHS. Trust, St Helens.
  • Simon Saunders Warrington and Halton N.H.S. Foundation Teaching Trust, Warrington.
  • Parth Narendran Queen Elizabeth Hospital Birmingham and the University of Birmingham, Birmingham.
  • Dennis J. Barnes Tunbridge Wells Hospital, Kent.
  • Chris Walton Hull University Teaching Hospitals NHS Trust, Hull.
  • Robert E.J. Ryder Sandwell and West Birmingham NHS Trust, City Hospital, Birmingham.
  • Thozhukat Sathyapalan Hull University Teaching Hospitals NHS Trust and the University of Hull.



Type 1 diabetes mellitus, FreeStyle Libre monitoring, DAFNE structured education, Structured education in diabetes, Self-management in diabetes, improvement in HbA1c


Background: Dose Adjustment For Normal Eating (DAFNE) is the gold standard National Institute for Health and Care Excellence (NICE) recommended structured education programme that promotes self-management in people living with type 1 diabetes (T1D). We have recently shown that FreeStyle Libre (FSL) is associated with improved haemoglobin A1c (HbA1c) and hypoglycaemia awareness.

Aims: To explore the effect of structured education including DAFNE on HbA1c and GOLD score when combined with FSL use.

Methods: The ABCD national audit data on FSL users were used to conduct this prospective longitudinal study. The Stu- dent’s t test was used to compare the baseline and follow-up HbA1c and a change in the GOLD score for hypoglycaemia awareness. The baseline demographic and clinical characteristics of the study population were compared using ANOVA. Linear regression analysis identified predictors of change in HbA1c with FSL use.

Results: The study consisted of 14,880 people living with insulin-dependent diabetes mellitus (IDDM), 97% of whom had T1D, of which 50% were female, with a mean±SD base- line HbA1c of 70±18 mmol/mol and baseline body mass index (BMI) of 25.3±6.2 kg/m2. Follow-up data for HbA1c were avail- able for 6,446 participants while data for GOLD score were available for 5,057 participants. The study population was divided into three groups: 6,701 people with no prior structured education (Group 1), 3,964 with other structured education (Group 2), and 4,215 had previously attended DAFNE structured education (Group 3). Groups 2 and 3 who had previously attended structured education had a lower initial HbA1c than those in Group 1 (p<0.0001). However, there was a significant but similar magnitude of the fall in HbA1c across all groups (−8.10 mmol/mol vs −6.61 mmol/mol vs −6.22 mmol/mol in Groups 1, 2 and 3, respectively), with p (ANOVA)=0.83. Similarly, the decline in GOLD score was comparable in Groups 1, 2 and 3 (−0.33 vs −0.30 vs −0.34, respectively), with p (ANOVA)=0.43. Linear regression analysis identified higher baseline HbA1c (β=0.585, p<0.0001), number of FSL scans over 14 days (β=−0.026, p=0.00135) and other structured education (β=−1.207, p=0.02483) as predictors of HbA1c reduction. Prior DAFNE training was not associated with improved HbA1c reduction in the linear regression model.

Conclusions: FSL use was associated with improvements in HbA1c and GOLD score. Although DAFNE is an evidence- based intervention to improve outcomes in those with T1D, DAFNE attendance prior to commencing FSL did not influence HbA1c or GOLD score outcomes when compared with FSL use alone. Other structured education was identified as a predictor of HbA1c reduction when combined with FSL use.


Leelarathna L, Wilmot EG. Flash forward: a review of flash glucose monitoring. Diabet Med 2018;35:472–82. dme.13584

Daneman D. Type 1 diabetes. Lancet 2006;367:847–58. 10.1016/s0140-6736(06)68341-4

NHS. NHS England flash glucose monitoring guidelines for CCGs. 2019. guidelines-for-ccgs/ (accessed 17 May 2021).

Fonseca VA, Grunberger G, Anhalt H, et al. Continuous glucose monitor- ing: A Consensus Conference of the American Association of Clinical Endocrinologists and American College of Endocrinology. Endocr Pract 2016; 22:1008–21.

Peters AL, Ahmann AJ, Battelino T, et al. Diabetes technology-continuous subcutaneous insulin infusion therapy and continuous glucose monitoring in adults: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2016;101:3922–37.

Vincze G, Barner JC, Lopez D. Factors associated with adherence to self- monitoring of blood glucose among persons with diabetes. Diabetes Educ 2004;30:112–25.

Renard E. Monitoring glycemic control: the importance of self-monitoring of blood glucose. Am J Med 2005;118:12–19. j.amjmed.2005.07.052

Blum A. Freestyle Libre glucose monitoring system. Clin Diabetes 2018; 36:203–4.

Evans M, Welsh Z, Ells S, et al. The impact of flash glucose monitoring on glycaemic control as measured by HbA1c: a meta-analysis of clinical trials and real-world observational studies. Diabetes Ther 2020;11:83–95.

Bolinder J, Antuna R, Geelhoed-Duijvestijn P, et al. Novel glucose-sensing technology and hypoglycaemia in type 1 diabetes: a multicentre, non- masked, randomised controlled trial. Lancet 2016;388:2254–63.

Haak T, Hanaire H, Ajjan R, et al. Flash glucose-sensing technology as a re- placement for blood glucose monitoring for the management of insulin- treated type 2 diabetes: a multicenter, open-label randomized controlled trial. Diabetes Ther 2017;8:55–73. 0223-6

Elliott J, Lawton J, Rankin D, et al. The 5x1 DAFNE study protocol: a cluster randomised trial comparing a standard 5 day DAFNE course delivered over 1 week against DAFNE training delivered over 1 day a week for 5 consecutive weeks. BMC Endocr Disord 2012;12:28. 1472-6823-12-28

Association of British Clinical Diabetologists. FreeStyle Libre Nationwide Audit. htm (accessed 1 April 2021).

Gold AE, MacLeod KM, Frier BM. Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia. Diabetes Care 1994;17:697–703.

Dover AR, Stimson RH, Zammitt NN, et al. Flash glucose monitoring im- proves outcomes in a type 1 diabetes clinic. J Diabetes Sci Technol 2017;11:442–3.

Ish-Shalom M, Wainstein J, Raz I, et al. Improvement in glucose control in difficult-to-control patients with diabetes using a novel flash glucose monitoring device. J Diabetes Sci Technol 2016;10:1412–13. 10.1177/1932296816653412

McKnight JA, Gibb FW. Flash glucose monitoring is associated with im- proved glycaemic control but use is largely limited to more affluent people in a UK diabetes centre. Diabet Med 2017;34:732.

Stimson RH, Dover AR, Ritchie SA, et al. HbA1c response and hospital ad- missions following commencement of flash glucose monitoring in adults with type 1 diabetes. BMJ Open Diabetes Res Care 2020;8. 10.1136/bmjdrc-2020-001292

Tyndall V, Stimson RH, Zammitt NN, et al. Marked improvement in HbA1c following commencement of flash glucose monitoring in people with type 1 diabetes. Diabetologia 2019;62:1349–56. s00125-019-4894-1

Deshmukh H, Wilmot EG, Gregory R, et al. Effect of flash glucose monitoring on glycemic control, hypoglycemia, diabetes-related distress, and re- source utilization in the Association of British Clinical Diabetologists (ABCD) Nationwide Audit. Diabetes Care 2020;43:2153–60. 10.2337/dc20-0738

National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. NICE Guideline 17, 2015. (accessed 21 March 2021).

DAFNE Study Group. 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 2002;325:746.

Gunn D, Mansell P. Glycaemic control and weight 7 years after Dose Adjustment For Normal Eating (DAFNE) structured education in type 1 diabetes. Diabet Med 2012;29:807–12. 5491.2011.03525.x

Hopkins D, Lawrence I, Mansell P, et al. Improved biomedical and psycho- logical outcomes 1 year after structured education in flexible insulin therapy for people with type 1 diabetes: the UK DAFNE experience. Diabetes Care 2012;35:1638–42.

Owen C, Woodward S. Effectiveness of dose adjustment for normal eating (DAFNE). Br J Nurs 2012;21:224, 226–8, 230–2. bjon.2012.21.4.224

Walker GS, Chen JY, Hopkinson H, et al. Structured education using Dose Adjustment for Normal Eating (DAFNE) reduces long-term HbA1c and HbA1c variability. Diabet Med 2018;35:745–9. dme.13621

Dinneen SF, O'Hara MC, Byrne M, et al. Group follow-up compared to in- dividual clinic visits after structured education for type 1 diabetes: a cluster randomised controlled trial. Diabetes Res Clin Pract 2013;100:29–38.

Kruger J, Brennan A, Thokala P, et al. The cost-effectiveness of the Dose Adjustment for Normal Eating (DAFNE) structured education programme: an update using the Sheffield Type 1 Diabetes Policy Model. Diabet Med 2013;30:1236–44.

Garden G, Hunt DW, Mackie K, et al. HbA1c and hypoglycaemia outcomes for people with type 1 diabetes due to the introduction of a single-day struc- tured education programme and flash glucose monitoring. Br J Diabetes 2021 [published Online First].

Cobry E, McFann K, Messer L, et al. Timing of meal insulin boluses to achieve optimal postprandial glycemic control in patients with type 1 dia- betes. Diabetes Technol Ther 2010;12:173–7. dia.2009.0112

Slattery D, Amiel SA, Choudhary P. Optimal prandial timing of bolus insulin in diabetes management: a review. Diabet Med 2018;35:306–16.






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