01 Jan 2012
By: J R Wu
Mr Ashley Su, a paralegal, was diagnosed with type 1 diabetes nine years ago when he was 15. Some of his worst hypoglycaemic episodes, when he fell into a faint or coma, occurred while he was asleep. For instance, one day after class, he felt really tired and took a nap at home unaware that he was in a state of hypoglycamia.
“I was actually in a state of hypo. I was foaming at the mouth. My mum tried to wake me up and she couldn’t. She was pretty scared. I had vague memories of her feeding me something sweet. I seemed to have been able to swallow, although I wasn’t conscious. I was fine when I woke up,” the 23-year-old recalled.
For people with diabetes, hypoglycaemia can occur when their sugar level suddenly drops. They may fall into a faint if the body's glucose is used up too quickly, or when too much insulin - a hormone that is needed to convert sugar, starches and other foods into energy - is released into the bloodstream. In type 1 diabetes, sometimes referred to as juvenile diabetes because it is usually identified in children and young adults, the body does not produce insulin, and patients need several insulin injections daily to manage the chronic condition.
With regular insulin injections, the diabetes patient follows a regimented meal schedule, eating at about the same time every day, and sticking to the same types of food to prevent their blood sugar or glucose levels from suddenly becoming too high or too low. For instance, if a Type 1 diabetes patient does not eat as planned or eats too little after his insulin shot, he effectively suffers from an overdose of insulin, leading to the danger of hypoglycaemia.
Mr Su’s diabetes physician, Dr Daphne Gardner, Associate Consultant, Department of Endocrinology, Singapore General Hospital (SGH), recommended the Dose Adjustment for Normal Eating (DAFNE) programme to him. Since joining the programme in April 2011, Mr Su has been able to manage his condition much better than before. He said his hypo episodes – when his blood glucose level falls below normal – occurr two to three times a month, much less frequently than the 10 or more occasions previously. “DAFNE helps a lot. I can enjoy life now compared to the past. I can have anything I want and, with a bit of care, just need to adjust the (insulin) dosage according to the food I eat,” he said.
Patients take control
What makes DAFNE different from older methods of controlling Type 1 diabetes is that it empowers the patient to manage his condition. The DAFNE programme underscores the trend of a more patient-centric (as opposed to physician- or disease-directed) management style, which is particularly necessary when it comes to coping with long-term chronic diseases.
“When they have a chronic disease like Type 1 diabetes, often patients – especially those who have been diagnosed in childhood or their teens – feel like the control is taken away from them. Somebody else is telling them what to do, how much insulin to give, and (telling them) a lot of ‘no’s’ and ‘cannot’s’,” said Dr Goh Su-Yen, Consultant and Head, Department of Endocrinology, SGH.
“Every single second of the day, they are living with diabetes. Everything can affect their blood sugar. The underlying principle of DAFNE is that we want to hand control back to the diabetic patient. This is his life,” she said.
Dr Goh led a small team to Melbourne in November 2010 to be trained on the DAFNE programme. When the team returned to Singapore, they worked on modifying it to the Singapore context. For example, the team found that diabetic patients in Singapore may be more insulin-sensitive than previously thought and, thus, do not need as much insulin as their peers globally.
"Eat what you like. Like what you eat." That’s the mantra of the DAFNE programme at SGH, the first of its kind in Asia. Before, patients took nutritional dictates from their doctors who might prescribe meal plans aimed at maintaining glucose levels and matching regimented insulin dosage, but which left little gastronomic flexibility.
The DAFNE programme imparts skills to Type 1 diabetics need to match their insulin dosage to whatever they eat, whenever they want to eat it. It also teaches patients how to deal with sick days and low-sugar situations, how to exercise safely and effectively, and how to handle drinking and dancing in social settings.
Counting carbs
Two classes have been held at SGH since the DAFNE programme started in April 2011. Each class, which teaches a set curriculum over five full days (spread out over weekends and public holidays), allows for up to eight participants.
The group setting is aimed at encouraging participants to share and compare experiences. Even after the intensive course is over, the group stays in touch with regular reviews.
For now, the DAFNE class, which has support from pharmaceutical giant Sanofi-Aventis Singapore as well as Abbott Diagnostics for glucometers (for home glucose monitoring), is free for SGH patients.
As with programmes launched in other countries, the SGH programme is tailored to the local population and foods found in Singapore.
A big part of the programme is teaching patients how to count the amount of carbohydrates they will consume. Teaching materials include pictures of full plate servings of hawker centre favourites such as char kway teow and laksa, as well as models of common fruits and vegetables.
Dietitians teach patients how to calculate the amount of carbohydrates their food has, so they can figure out how much insulin they need to inject themselves with. Participants are encouraged to keep weighing scales handy with them until they get used to accurately eyeballing the carbs in their meals.
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