BMJ 2016;352:i998 doi: 10.1136/bmj.

i998 (Published 10 March 2016) Page 1 of 7

Clinical Review

CLINICAL REVIEW

Type 1 diabetes in adults: supporting self management

1 2
Monika Reddy specialist registrar, diabetes and endocrinology , Sian Rilstone diabetes specialist
2 3 1 2
dietitian , Philippa Cooper has type 1 diabetes , Nick S Oliver consultant diabetologist
1
Department of Diabetes, Endocrinology and Metabolism, Imperial College London, St Mary’s Hospital Campus, London W2 1PG, UK; 2Diabetes
and Endocrinology, Imperial Healthcare NHS Trust, London; 3London

Type 1 diabetes affects 300 000 people in the United quality of life, and assume an active role in their diabetes care
Kingdom.1 2 Despite regular specialist multidisciplinary input, team.” Structured education programmes are required to be
responsibility for glucose monitoring and insulin administration evidence based, theory driven, quality assured, audited regularly,
is devolved to the person with diabetes, or their care giver. and have a formal written curriculum delivered by trained
Empowering effective self management of type 1 diabetes is educators.7
critical to achieve HbA1c targets, minimise hypoglycaemia and It includes education on self monitoring of blood glucose
optimise quality of life. Structured education programmes for (SMBG), carbohydrate counting, and insulin dose adjustment
diabetes self management should be offered to everyone with at mealtimes8 9 to achieve optimal glycaemic control and quality
type 1 diabetes. It is important for healthcare providers to of life. Examples of structured education programmes are the
understand what structured education involves before referral. Dose Adjustment for Normal Eating (DAFNE) course9 (adapted
This review examines the meaning and evidence for self from a German programme) and PRIMAS (Programme for
management, and provides advice on how general physicians diabetes education and treatment for a self determined living
and non-specialists can support and enable people with type 1 with type 1 diabetes).10Box 2 summarises the principles and
diabetes to self manage their condition. syllabus content of structured education.
What is required for self management of
type 1 diabetes? Do structured education programmes for
Insulin requirements and glucose concentrations are affected
type 1 diabetes work?
by multiple internal and external factors (see box 1), and In a multicentre randomised controlled trial, DAFNE reduced
maintaining glycaemic control while minimising hypoglycaemia HbA1c and improved quality of life 12 months after completion.9
with a flexible daily routine is a challenge. The benefit of Further follow-up at four years showed that the psychosocial
intensive glucose control in reducing long term complications benefit was sustained.8 A meta-analysis of 15 randomised
in type 1 diabetes is well established, based on the Diabetes controlled trials of structured education for type 1 diabetes9-24
Control and Complications Trial (DCCT).3 However, this was suggested no overall impact on HbA1c at either six or 12 months’
at the expense of an increase in severe hypoglycaemia (61.2 per follow-up. However, DAFNE9 and PRIMAS10 were the
100 patient years in the intensive control group compared with exceptions to this, with DAFNE showing a reduction in HbA1c
18.7 in the control group).4 Newer analogue insulins and modern of 1% (95% confidence interval 0.58% to 1.42%) and PRIMAS
insulin pumps have enabled HbA1c reduction with an associated achieved a reduction of 0.4% (0.15% to 0.65%) from baseline
reduction in the frequency and severity of hypoglycaemia.5 6 to six months.
Self management remains challenging, and 73% of people with
type 1 diabetes do not achieve an HbA1c target of <58 mmol/mol Who should receive a structured
(7.5%).1
education programme?
What is a structured education All adults with type 1 diabetes should be offered an evidence
programme for type 1 diabetes? based, structured education programme, and have its benefits
explained, after 6-12 months of diagnosis.7 The delay from
A structured education programme for type 1 diabetes is defined diagnosis to education allows people time to adjust to their
as “a planned and graded process that facilitates the knowledge, diagnosis and to be established on an insulin regimen beyond
skills and ability for diabetes self management and empowers the initial honeymoon phase, which is characterised by partial
individuals to live healthily, to maintain and improve their recovery of endogenous insulin secretion. If a person is unable

Correspondence to: N S Oliver [email protected]

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CLINICAL REVIEW

What you need to know

• Glucose concentrations in type 1 diabetes are affected by multiple interacting and independent complex factors
• Structured education programmes support effective self management and should be available to everyone with an established diagnosis
of type 1 diabetes
• Long term self-management of type 1 diabetes is challenging and requires ongoing support from an expert multidisciplinary team
• Insulin dose adjustment involves carbohydrate estimation and mental arithmetic, which can be supported with technology
• Healthcare professionals should be alert to signs of depression or distress in people with type 1 diabetes, and access to psychosocial
support is critical

Sources and selection criteria

A PubMed search using the terms “self management in type 1 diabetes” and “structured education in type 1 diabetes” was performed. The
clinical evidence base included in the NICE guidelines on diagnosis and management of type 1 diabetes (NG17 2015) was reviewed. The
reference list included in this review is not exhaustive, but includes the most relevant up to date studies.

Box 1: Factors affecting glucose concentrations and insulin requirements

• Circadian rhythm
• Type and quantity of food ingested
• Alcohol consumption
• Exercise
• Illness
• Travel
• Stress
• Menstrual cycle
• Pregnancy
• Work patterns
• Weather and temperature

Box 2: Structured education principles and content

• Structured education programmes should be evidence based, quality assured, and delivered by trained educators (diabetes specialist
nurses, dieticians, diabetologists)
• Generic components of structured education programmes must include:
– Self monitoring of blood glucose and ketones
– Dietary advice, including alcohol
– Carbohydrate counting
– Physical activity
– Prevention and managing hypoglycaemia
– Psychological support
– Peer support
– Driving

or unwilling to participate in group education, an alternative Self monitoring of blood glucose and
education method of equal standard should be provided, such
as one-to-one education sessions with a diabetes specialist
ketones
dietitian and nurse. In addition, Blood Glucose Awareness Self monitoring of blood glucose guides changes to insulin
Training (BGAT), a separate psychoeducational intervention treatment and is a core component of self management of type
designed to improve recognition and interpretation of relevant 1 diabetes. Observational studies show that such self monitoring
symptoms, should be considered for people with recurrent is associated with reduced HbA1c.25-27 A cost effectiveness
hypoglycaemia.20 analysis carried out by the National Institute for Health and Care
Excellence (NICE), based on four randomised controlled trials
Supporting self management in primary and 31 observational studies, found that self monitoring of blood
glucose 8-10 times a day was the most cost effective strategy
care to optimise glucose levels.7 Only one of these studies, a cross
Type 1 diabetes is ideally managed by the person with type 1 sectional study with 8914 participants, included a frequency of
diabetes, with support from a multidisciplinary team including self monitoring of blood glucose of more than 10 per day.28
primary and specialist care. The components of structured There is limited evidence to suggest the best timing of blood
education are outlined below with an evidence based summary glucose measurements throughout the day29 or to provide optimal
for each section. blood glucose targets. One small observational study (n=31)
reported that nocturnal hypoglycaemia is unlikely to have

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CLINICAL REVIEW

occurred if blood glucose was >5.5 mmol/L on waking.30 of carbohydrate (grams) covered by 1 unit of insulin) and an
Another observational study established blood glucose targets insulin sensitivity factor (ISF, the reduction in blood glucose
to achieve specific HbA1c goals. To achieve an HbA1c of by 1 unit of insulin). The insulin bolus for each meal can be
6.5-6.99% (48–53 mmol/mol), the mean fasting blood glucose calculated using a simple formula, taking into account the target
concentration was 144 mg/dL (8 mmol/L) and mean pre-prandial glucose, current glucose, carbohydrate content of meal (grams),
glucose level was 140 mg/dL (7.8 mmol/L).27 The NICE insulin:carbohydrate ratio, and ISF (example given in box 4).
recommendations4 on frequency of self monitoring of blood Bolus calculators are incorporated into most insulin pumps and
glucose and targets are listed in box 3. also into some capillary blood glucose metres for multiple dose
When choosing a glucose meter it is important to take into insulin injection users. Randomised controlled trials have shown
account the needs of the individual user (such as option to that bolus calculators can improve glucose control42 43 but require
measure ketones, incorporated bolus calculator, compatibility regular review of the fixed insulin:carbohydrate ratios and ISF
with web based software for data upload, ease of use, parameters by the patient, as these parameters may change over
practicality), but also to ensure that International Organisation time or in certain circumstances (such as after exercise and
for Standardization (ISO) standards are met.31 Self monitoring during intercurrent illness) due to factors such as weight, stress,
of either urine or blood32 ketones should be considered to medication, hormonal changes, exercise, weather and work.
facilitate self management of hyperglycaemia, especially during It is important to empower people with type 1 diabetes to count
illness, to prevent development of diabetic ketoacidosis33 and carbohydrate content but also to understand the impact of
for guidance on when to seek medical help. differing carbohydrates, fats, and proteins on their glucose
concentrations and insulin requirements. Starches and sugars
Are there recommended diets for type 1 may be digested at different rates depending on natural structure
and degree of processing, and a high fat or protein content may
diabetes? delay carbohydrate absorption and decrease insulin sensitivity.44
People with newly diagnosed type 1 diabetes should be offered
a dietetic review with a type 1 diabetes specialist dietitian for What should patients do about exercise?
nutritional information to discuss a dietary management plan.
Dietitians should continue to be available after diagnosis, either If there are no contraindications to exercise, people with type
as part of a group education programme or on a one-to-one basis 1 diabetes should be encouraged to exercise regularly to reduce
to teach people to count carbohydrates and to support personal medium to long term cardiovascular risk.45Box 5 provides
eating choices. Individuals should be able to adopt a balanced general advice on nutritional support, blood glucose monitoring,
diet to promote good overall health, manage glycaemia, and and insulin dose adjustment before, during, and after exercise.
maintain a healthy weight, blood pressure, and blood lipids in Managing insulin requirements before, during, and after exercise
line with evidence based guidelines.7-36 The amount of is particularly important as exercise promotes glucose uptake
carbohydrate and available insulin are the most important factors in skeletal muscle independently of insulin and increases
influencing glycaemic control in people with type 1 diabetes.34 peripheral insulin sensitivity, increasing the risk of
The evidence is inconclusive as to what the ideal total hypoglycaemia, both during exercise and for several hours
carbohydrate intake is in people with diabetes.7-36 The advice afterwards.46 Blood glucose management during exercise can
for the general population is that 50% of energy should come be challenging, and different exercises can have different
from carbohydrate,37 but a healthy diet can contain a range of impacts on glucose, with hyperglycaemia commonly seen after
energy from carbohydrate, and this is greatly influenced by the anaerobic or competitive exercise, and hypoglycaemia after
source of carbohydrate and general balance of the diet. People moderate aerobic work.
with type 1 diabetes should be enabled to follow a healthy,
balanced, cardioprotective diet with meal sizes appropriate to How to manage hypoglycaemia
their weight. The most important feature is that carbohydrate
People with diabetes should be made aware of the symptoms
intake and insulin doses should be matched.35
of hypoglycaemia, which may include hunger, irritability,
Adults with type 1 diabetes should not routinely be advised to anxiety, sweating, and palpitations. As the glucose concentration
follow a low glycaemic index diet.38 A prospective randomised falls further, cognitive impairment with confusion may occur,
controlled trial found no clinical benefit of a low glycaemic but this varies from person to person and may change over time.
index diet versus a high glycaemic index diet. Multiple anecdotal Treatment for impending hypoglycaemia is recommended at a
and observational reports support other diets in type 1 diabetes, threshold of 4 mmol/L, though international definitions of
including low carbohydrate diets. However, there are no hypoglycaemia vary. Recognising symptoms of hypoglycaemia
randomised controlled trials to support these diets, and people and promptly self treating are crucial, as severe hypoglycaemia
with type 1 diabetes should have access to a specialist dietitian (defined as requiring the assistance of another person to treat)
to discuss the risks and benefits of diets—with support, where or prolonged hypoglycaemia is distressing and can result in
appropriate, to safely, and effectively self manage their diabetes. seizures, cardiac arrhythmias, and death.47 The commonest
recommendation for self treatment of biochemical or
How are meal insulin boluses adjusted? symptomatic hypoglycaemia is 15 g of fast acting carbohydrate
(such as dextrose tablets, a sugary drink, or, in the UK, Bassett’s
Mealtime insulin bolus doses are estimated according to the Jelly Babies (as they are almost exactly 5 g of carbohydrate per
carbohydrate content of the food ingested and current blood “baby”)).7 However, a recent randomised controlled crossover
glucose. Structured education includes training in “carbohydrate study suggested that weight based treatment of hypoglycaemia
counting,” which estimates the amount of carbohydrate (in using 0.3 g/kg glucose is more effective in resolving
grams) contained in a meal. Carbohydrate counting has been hypoglycaemia than a standard 15 g.48
shown to improve overall glycaemic control in randomised
controlled trials.39-41 Structured education also teaches how to
estimate individualised insulin:carbohydrate ratios (the amount

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CLINICAL REVIEW

Box 3: Recommendations for self monitoring of blood glucose (from NICE guidelines (NG17)7 and the DVLA
regulations; see continuing medical education resources box for links)
Frequency of testing
• Adults with type 1 diabetes should be supported to test their blood glucose at least four times a day, and up to 10 times a day during
certain circumstances (such as sports, driving, illness, and impaired awareness of hypoglycaemia) to assess whether their insulin
regime needs adjustments

Blood glucose targets

• Fasting glucose levels of 5-7 mmol/L and pre-meal levels of 4-7 mmol/L. It is recognised that achieving these targets consistently is
challenging

When driving
• Blood glucose must be checked within 2 hours before driving and every 2 hours thereafter if it is a long journey
• Blood glucose should be >5 mmol/L; if it is lower, a snack should be consumed
• If the blood glucose is <4 mmol/L or if there are symptoms of hypoglycaemia then the person should not drive.

Box 4: Insulin bolus estimation using carbohydrate counting and self-testing of blood glucose
Equation used for meal bolus estimation:
(CHO ÷ ICR) + ((G − GT) ÷ ISF) = insulin bolus dose
where
CHO = carbohydrate content of meal (in grams) (Carbs&Cals (www.carbsandcals.com) provides guidance on carbohydrate estimation)
ICR = insulin:carbohydrate ratio (the amount of insulin required for a fixed amount of carbohydrate, usually expressed as units per 10
grams of carbohydrate)
G = Capillary blood glucose
GT = Capillary blood glucose target
ISF = Insulin sensitivity factor (the glucose decrease for 1 unit of insulin given)

Example of a meal bolus calculation

For a breakfast meal consisting of 40 g of carbohydrate and pre-breakfast capillary blood glucose of 10 mmol/L:
Carbohydrate content (CHO) of a bowl of cereal with milk = 40 g
Capillary blood glucose (G) measured just before breakfast = 10 mmol/L
Examples of individualised parameters used:
Glucose target (GT) = 6 mmol/L
Insulin:carbohydrate ratio (ICR) = 10 g (1 unit of insulin for every 10 g of carbohydrate)
Insulin sensitivity factor (ISF) = 2 (1 unit of insulin to bring down the blood glucose by 2 mmol/L)
Bolus calculation for the breakfast meal using the information outlined above:
Insulin bolus dose = (40 ÷ 10) + ((10 − 6) ÷ 2) = 6 units

Box 5: Points to consider before and during exercise (adapted from www.runsweet.com)
• Ensure safe levels of pre-exercise blood glucose (such as 7-12 mmol/L)
• Consider ingesting extra carbohydrates if blood glucose is <7 mmol/L before exercise
• Measure blood-glucose before, during, and after exercise
• Consider reduction in insulin dose by at least 20%, possibly with additional quick acting carbohydrates to be consumed during moderate
intensity endurance exercise (general guide, 1 g/kg/hour)

Impaired hypoglycaemia awareness hypoglycaemia and other complications can cause emotional
Recurrent hypoglycaemia can lead to a reduction in a person’s stress. This can affect glycaemic control, relationships with
ability to recognise symptoms of hypoglycaemia (impaired family and friends, and psychological wellbeing. Emotional
hypoglycaemia awareness).49 50 Annual specialist review includes stress can also result from interactions with doctors who do not
assessment of hypoglycaemia awareness using the Gold or acknowledge their limitations on type 1 diabetes management
Clarke score (box 6). If this is impaired, options include and, as a result, unintentionally create a barrier to empowering
additional education focused on hypoglycaemia avoidance11-14 self management and give unrealistic expectations.54 Data
without relaxing glucose targets, or continuous subcutaneous derived from a meta-analysis showed a statistically significantly
insulin infusion therapy. Hypoglycaemia and fear of higher prevalence of depression among people with type 1
hypoglycaemia can affect the quality of life of people with type diabetes compared with the non-diabetic population (21.7% v
1 diabetes and their families.53 Specialist care is important to 8.6%, P<0.001).55 Healthcare professionals supporting type 1
manage recurrent or severe hypoglycaemia to reduce cost, diabetes self management must be alert to early signs of
morbidity, and mortality and improve quality of life. depression and anxiety, in particular in those who find the
challenges of self management distressing.
Psychological support A referral to a specialist diabetes psychologist should be
considered if a person has diabetes related distress or persistent
Demands of frequent self monitoring of blood glucose, insulin psychological barriers to effective glycaemic management.
injections, lifestyle changes, disturbed sleep, and worry about
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CLINICAL REVIEW

Box 6: Calculation of Gold or Clarke score for assessment of hypoglycaemia awareness

Gold score—Based on the response to a single question: “Do you know when your ‘hypos’ are commencing?” Results are derived from
a 7-point Likert scale, where 1 is “always aware” and 7 is “never aware”51
Clarke score—Made up of eight questions characterising exposure to episodes of moderate and severe hypoglycaemia to assess the
glycaemic threshold for and symptomatic response to hypoglycaemia.52
A value of ≥4 in both scoring systems suggests impaired hypoglycaemia awareness

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Glucose Awareness Training (BGAT III) in Switzerland and Germany. J Behav Med

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Invest 2011;34:101-5. doi:10.1007/BF03347038. 20440106.
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doi:10.2337/dc09-1327. 19808926. software enabling individualized insulin dose adjustments combined with telemedicine
19 Rossi MC, Nicolucci A, Lucisano G, et al. Did Study Group. Impact of the “Diabetes support improves HbA1c in poorly controlled type 1 diabetic patients: a 6-month,
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BMJ 2016;352:i998 doi: 10.1136/bmj.i998 (Published 10 March 2016) Page 6 of 7

CLINICAL REVIEW

Box 7: Role of the multidisciplinary diabetes team

The team must include, or have ready access to, members of the following specialist groups:
• Consultant with training in adult diabetes
• Diabetes specialist nurse with appropriate expertise
• Diabetes specialist dietitian with appropriate expertise
• Clinical psychology with experience in long term conditions
• A diabetes foot multidisciplinary team including:
o Vascular, orthopaedic, and plastic surgeons
o Other medical staff including microbiologists
o Diagnostic and interventional radiologists
o Podiatrists and podiatric surgeons
The specialist multidisciplinary team should have access to the following services:
• Education for people with type 1 diabetes at diagnosis and throughout the diabetes journey
• Structured education programme for type 1 diabetes in line with NICE guidance
• Insulin pump services
• Hypoglycaemia specialist services for recurrent or severe hypoglycaemia
• Diabetes foot clinics
• Retinopathy screening
• Diabetes renal services

A patient’s perspective
Living with type 1 diabetes can be challenging. Most people only see their clinical team for around an hour a year, so the remaining 8759
hours we manage on our own.
My type 1 diabetes management isn’t perfect, but I don’t believe anyone’s is. It is impossible to list all the factors that go into this, but below
are some of the areas I believe enable me to live well with my diabetes.
After receiving little training since diagnosis, I attended a week-long DAFNE course three years ago. I learnt so much. It provided a framework
to adapt in different situations and access to the trainers (a diabetes specialist nurse and specialist dietician) after the course ended. It was
also the first time I had spoken to another person with type 1 diabetes in the 17 years since my diagnosis. It was life changing and a relief
to know I wasn’t in this alone. Everyone should have access to ongoing education. Length of diagnosis does not necessarily indicate a
person’s level of knowledge.
After the course, I kept in contact with the trainers, and this led to my diabetes care moving from my general practice to the diabetes centre
at the local hospital. I now have a team around me with specialist knowledge in type 1 diabetes and who are better able to support me. I
still see my practice nurse and appreciate her perseverance in more difficult times—never judging me and being supportive, plus persuading
me to attend DAFNE. She was one of the first healthcare professionals who seemed to accept I also had a life outside of my type 1 diabetes.
I now have a team I trust. I am a member of that team and expect to be an active participant in any discussions.
It is important to have the right tools for the job. This ranges from the right needles and insulin pens right through to insulin pumps and
continuous glucose monitoring. I used an insulin pen for many years, but didn’t know half-unit pens existed—I am sure this simple change
could have helped me. Having a glucose meter I like and enough test strips are a vital part of my care. I now use an insulin pump which
gives me more options and flexibility in delivering insulin. Although I wasn’t keen when it was first suggested, I now cannot imagine life
without it. I also self-fund a continuous glucose monitor. The information and alerts it gives me are invaluable. It has opened my eyes to how
my glucose levels react, and motivates me to carry on making adjustments and tweaks which improve my management.
Exercise and type 1 diabetes can be a difficult combination. When I used injections the chaos that exercise caused with blood glucose levels
outweighed any benefits for me. Moving to a pump and the flexibility it gave inspired me to give exercise another go. It can still be challenging
but attending a sports weekend run by Animas gave me access to so much new information and options. Exercise still effects my blood
glucose levels, but I am more aware of what’s happening and can take the appropriate action. It inspired me seeing what others were able
to achieve. I believe being more active helps me both physically and mentally. I wish there were more specialist help even for un-athletic
people like me.
I now recognise type 1 diabetes has a psychological impact as well as a physical one. It is just one part of my everyday life, but it can be
unpredictable and is unrelenting. I try to acknowledge the efforts I put in and be more accepting of its changeable nature. The language
used around type 1 diabetes also has an effect. Any language used should be non-judgemental. I no longer take a blood glucose “test” that
I either pass or fail but rather “check” to see what’s happening. A number is neither “good” nor “bad” just above, below, or in range.
The final piece in the puzzle for me is peer support. For many years I didn't know any people with type 1 diabetes, but I am now part of a
community both in real life and on-line. I have learnt so much and no longer feel isolated. We are able to support each other, share experiences,
and celebrate even the smallest win. It is the difference between knowing the theory and actually living the life.
This list is not all encompassing. It offers a taste of what my life involves, and even after 20 years I am still learning.

Ongoing research questions

• Can diabetes technologies prevent and resolve impaired hypoglycaemia awareness?
• What methodologies can be used to increase uptake of structured education and to improve their clinical benefit?
• Is there an optimal carbohydrate intake for people with type 1 diabetes?
• How can we incorporate fat and protein content in addition to carbohydrate content in insulin bolus calculations?
• Is peer support effective in improving self management efficacy and confidence in people with type 1 diabetes?

44 Laxminarayan S, Reifman J, Edwards SS, Wolpert H, Steil GM. Bolus estimation-rethinking atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology
the effect of meal fat content. Diabetes Technol Ther 2015;17:860-6. doi:10.1089/dia. (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition,
2015.0118. 26270134. Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation
45 Thompson PD, Buchner D, Pina IL, et al. American Heart Association Council on Clinical 2003;107:3109-16. doi:10.1161/01.CIR.0000075572.40158.77. 12821592.
Cardiology Subcommittee on Exercise, Rehabilitation, and Prevention American Heart 46 Galassetti P, Riddell MC. Exercise and type 1 diabetes (T1DM). Compr Physiol
Association Council on Nutrition, Physical Activity, and Metabolism Subcommittee on 2013;3:1309-36.23897688.
Physical Activity. Exercise and physical activity in the prevention and treatment of

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CLINICAL REVIEW

Continuing medical education resources for healthcare professionals

NICE guidelines (NG17): Type 1 diabetes in adults: diagnosis and management. www.nice.org.uk/guidance/ng17
DVLA driving regulations (Link: At a glance Section 3. Diabetes Mellitus, page 47). www.gov.uk/government/publications/at-a-glance
ISO standards for glucose meters. www.iso.org/obp/ui/#iso:std:54976:en

Online resources for self management of type diabetes for patients

Dose Adjustment For Normal Eating (DAFNE) online resource. www.dafne.uk.com
The Bournemouth e-learning programme. www.bdec-e-learning.com
Diabetes UK. www.diabetes.org.uk/Guide-to-diabetes/Managing-your-diabetes
Guidance on carbohydrate estimation. www.carbsandcals.com
Guidance of exercise. www.excarbs.com
Information of diabetes and sports. www.runsweet.com

Education into practice

• Do you feel you have the knowledge to recommend structured education to people with type 1 diabetes? How could this be improved?
• How many people with type 1 diabetes in your centre have been referred for structured education? How many attended and completed
the course?
• What options are there for ongoing education and refresher courses in your area?

How patients were involved in this article

Author Philippa Cooper has lived with type 1 diabetes for 20 years. Her experience has informed the structure and content of the review,
and she has provided a patient’s perspective box.

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