Carbohydrate counting in type 1 diabetes: time to REACCT

Abstract

AbstractThe National Institute for Clinical Excellence Technology Appraisal Guidance No. 60 recommended that structured patient education be made available to all people with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need. The Dose Adjustment for Normal Eating (DAFNE) programme was recommended as an option for individuals with type 1 diabetes, being one means of enabling people to self‐manage this condition.As a centre wishing to implement insulin pump therapy, we therefore required a cost effective method of delivering advanced carbohydrate counting, without the resources of a DAFNE centre. Consequently, we devised the REACCT ‘Re‐Education And Carbohydrate Counting Training’ programme according to the Social Learning Theory of Bandura. The latter states that people learn from observing other people, and is used to develop confidence to be able to carry out the skills. Our intervention consists of two, two‐hour morning sessions, six weeks apart, delivered by a diabetes specialist nurse and a diabetes specialist dietitian. Each group contains five to 10 patients. The topics covered include back to basics insulin education and lifestyle issues. The emphasis is on adjusting basal insulin dose to achieve optimal fasting blood glucose levels.Our audit found that in 80 patients who completed the programme there was: improved self‐perceived quality of life (56%), reduced total insulin dose (44%), and improved glycaemic control with less glycaemic excursions (63%). While overall there was no reduction in mean body weight, after the introduction of carbohydrate counting more patients lost weight than gained weight. There was also a reduction in the average total daily dose of insulin and HbA1c.We have shown that REACCT can be implemented in a typical district general hospital diabetes department with a minimal resource cost. We are aware of the limitations of our data and intend to continue observing our patients. However, when challenged to justify the time devoted to non‐conventional patient contact, we feel these results are highly encouraging and we hope may be useful for other diabetes teams to consider as well. Copyright © 2007 John Wiley & Sons.