Structured education programmes for individuals with type 1 diabetes have become a recognised means of delivering the knowledge and skills necessary for optimal self-management of the condition.
The Berger programme, named after Prof Michael Berger, an endocrinologist who recognised the value of teaching people how to adjust insulin to match their daily food intake, is a two and a half day structured education programme (see Table 1). This programme is designed for people with type 1 diabetes. People attending the programme learn how to adjust their insulin dose depending on their food choice. The course also focuses on enhancing diabetes self-management skills.
The Berger programme commenced in Tallaght Hospital in April 2010. A programme is now run every two months, recruiting up to eight people per group.
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Audit
We recently completed an audit of our first 10 groups (54 patients), which were facilitated over a 22-month period from April 2010 to January 2012. Group sizes ranged from four to seven individuals.
Our primary objective was to improve knowledge of their diabetes. We successfully achieved this with all participants, except one, moving into the 75-100% knowledge-scoring band (see Table 2).
We also looked at the effects of the programme on HbA1c, weight, body mass index (BMI) and lipid profile (see Table 3).
For the total group there was a slight decrease in HbA1c from baseline to post programme, however, this was not significant (pre 8.092 SD 1.08; post 7.975 SD 1.03; p = 0.309).
Twenty-one patients had a decrease in HbA1c and this was a significant decrease (8.58 SD 1.03 to 7.73 SD 1.01; difference 0.85%; p=0.000). Of this group, 14 patients had a baseline HbA1c well above target (HbA1c >8%). Following the programme, this group achieved a reduction in HbA1c from a mean of 9.2% to 8%.*
Twenty-four patients experienced an increase in HbA1c following the programme. However, an increase in HbA1c was warranted in five of these, in order to prevent severe hypoglycaemic events through running higher blood sugars. Six patients had no change in HbA1c.
There was a trend towards a significant reduction in weight of 0.72kg and BMI of 0.26 kg/m2. Results also demonstrated a significant reduction in total and LDL cholesterol, without any significant changes to HDL.
Structured education has been shown to improve quality of life (QOL) and we have only recently introduced a tool to measure this. Comments from patients, to date, reflect that all participants felt better able to cope with managing their diabetes after attending the programme.
Two of our Berger participants kindly offered feedback on the programme and on whether they would recommend it to others with type 1 diabetes. Patients’ names have been changed.
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Patient feedback
Brendan was diagnosed with type 1 diabetes 28 years ago. He described the benefits he derived from the Berger programme after completing it in July 2010:
“I am a 50-year-old fit diabetic with a condition rather than a disease. A condition can be managed. Since being diagnosed in 1985 I have managed my diabetes reasonably well and receive excellent medical support from professional advisors in Tallaght Hospital. When I got a call to participate in the Berger programme I was not sure what to expect. The team explained to me the purpose of the programme and I chose to participate, mainly because I trusted them and their positivity about the programme was clearly evident. The only reservation I had was that the course was taking place over a few days which was a significant commitment for me with my work commitments quite heavy at the time.
“The programme proved to be of huge personal benefit to me and I would certainly recommend it to others. It was excellently organised and presented, and was extremely interesting and informative. The content was leading edge, especially the whole concept of ‘carb’ counting, which was a great learning experience for me. My fellow participants were a wonderful, enthusiastic bunch and it was great to swap stories and experiences with fellow diabetics throughout the course. I found the course presenters were very willing to let the conversation deal with real issues that emerge in everyday life and yet they still managed to get the full programme covered.
“Since the programme, I have found that I have better blood glucose control and I am able to predict my blood glucose response to eating different foods and drinks. The challenge to carb counting I find is that you really have to put in some time and effort to get those benefits but as they say ‘no gain without pain’ and for me it’s proving to be pleasurable pain to date.”
Sarah completed the Berger programme in July 2011. She was diagnosed with type 1 diabetes 27 years ago. Sarah’s initial experience of the programme was a little different to Brendan’s. For a number of weeks after completing the programme, Sarah was quite frustrated as working out the correct insulin to carbohydrate ratios, as well as the correct amount of long-acting insulin, took a lot of fine-tuning. But, her persistence won: “As the saying goes ‘knowledge is power’ and the Berger programme has given me the knowledge to manage my diabetes. With the knowledge that I gained at the Berger programme I was, at last, able to get my HbA1c within a healthy range and my quality of life improved in all aspects. I struggled with my diabetes for over 25 years, having cycles of low and high blood sugars resulting in days feeling exhausted and guilty that I was getting it wrong.
“At the Berger programme I realised diabetics do struggle and if felt amazing to be able to share our experiences. The information given at the programme was relevant, particularly the interactive carbohydrate counting sessions and the practical case studies relating to exercise and diabetes; sick day management; and dose adjustment for hyper/hypoglycaemia. With these case studies we read the blood glucose diaries and then gave solutions. I found that really helpful as I ended up doing this at home – reading my diary trying to fix the puzzle.
“I would recommend having a structured ‘after’ programme to ensure all patients know that help and support is available and an opportunity for patients to share their experience (before and after), would be beneficial. The work really starts when you finish the programme as getting the ratios correct and learning the carb counting is challenging. After Berger you need to continue to learn and, therefore, having contact with the dietitian and diabetes nurses, directly after the programme, is the key to success. In my experience the support I received from Mary, the diabetes dietitian, and the diabetes nurses after the programme was invaluable.
“Today, my blood glucose monitor readings are no longer scary. I simply take the reading as a ‘call to action’ as with the knowledge I gained I can take the correct action effectively. The Berger programme was of significant benefit to me and I would highly recommend this to all diabetics.”
Knowledge brings confidence
Overall, these findings suggest that the Berger structured education programme had positive effects on knowledge, HbA1c, lipid profile, weight and BMI. Most importantly, however, was the positive feedback from Brendan, Sarah and many other Berger participants. Knowledge brings confidence, which allows individuals to take responsibility for their day-to-day control of their diabetes.
Berger centres
Tallaght Hospital, Dublin
Naas General Hospital
St James’s Hospital, Dublin
Mater Hospital, Dublin
Midland Regional Hospital, Portlaoise
Cork University Hospital
South Infirmary Hospital, Cork
* Study initiated before IFCC guidelines came into place
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