Structured education

Offer all adults with type 1 diabetes a structured education programme of proven benefit, for example, the Scottish Type 1 Education Programme (STEP), Dose Adjustment For Normal Eating programme (DAFNE) or Bournemouth Type 1 Diabetes Education Programme (BERTIE).

There are a number of accredited structured education courses available, including, but not limited to STEP, DAFNE and BERTIE.

Ensure that any structured education programme for adults with type 1 diabetes (including carers and family members):

• is evidence based, and suits the needs of the person
• has specific aims and learning objectives, and supports the person and their family members and carers in developing attitudes, beliefs, knowledge and skills to self manage diabetes
• has a structured curriculum that is theory driven, evidence based and resource effective, and has supporting materials, and is written down
• is delivered by trained educators who:
• have an understanding of educational theory appropriate to the age and needs of the person and
• are trained and competent to deliver the principles and content of the programme
• is quality assured, and reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency
• has outcomes that are audited regularly.

Structured education programmes for people with type 1 diabetes (including carers and family members) should include the following essential topics:

• self monitoring of blood glucose 
• carbohydrate counting
• insulin dose adjustment
• sick-day rules
• physical activity and diabetes
• living with diabetes, including relevant topics like travel, alcohol, sexual health and pregnancy
• how to access follow up and support, including any peer groups. 

Teams should work ensure that effective education resources of proven benefit are available to people with diabetes (including carers and family members) by signposting content on the Diabetes in Scotland website. Education programmes should be in a format and mode of delivery that is suitable for the person with diabetes, such as in-person (group or one to one) or online (synchronous or asynchronous), and at times suitable for them, including outside standard working hours.

External quality assurance and audit for structured education courses, including regular internal and external evaluation of educators is desirable to ensure people with type 1 diabetes, their carers and family members are confident managing their condition after attending the structured education programme.

Include continuous glucose monitoring (CGM) in the structured education programme provided to all adults with type 1 diabetes and ensure that people are empowered to use CGM devices.

Include CGM, which should encompass real-time CGM and flash glucose monitoring, in the continuing programme of education provided to all children and young people with type 1 diabetes and their families or carers.

All people with type 1 diabetes attending structured education should be offered real-time continuous glucose monitoring (rtCGM) based on their needs and the functionality of the devices available. The education programme should include using information from the rtCGM to adjust prandial, correction and basal insulin doses, and respond appropriately to trend arrows and alarms. People with type 1 diabetes should be trained to review their ambulatory glucose profile to assess time in range and make appropriate behaviour and therapeutic decisions to achieve their desired treatment goals.

Where relevant, education on CGM should be available to parents and carers to support individuals with diabetes.

See section on glucose-lowering and glucose monitoring technologies.

There are four critical times to evaluate the need for diabetes self-management education to promote skills in regimen implementation, medical nutrition therapy, and wellbeing: at diagnosis, annually and when not meeting treatment targets, when complicating factors develop (medical, physical, psychosocial), and when transitions in life and care occur.

It is important for clinical teams to recognise critical times when people with diabetes will need review. Given the burden that appointments can place on individuals, it is important that reviews are organised at a time and delivered in a personalised manner to maximise the self-management benefit for the person with type 1 diabetes.

The timing of the education will depend on the type of education programme. The STEP programme is aimed at people with newly diagnosed diabetes, whereas there is evidence that DAFNE improves HbA1_c, quality of life and other outcomes at both 6 and 12 months after diagnosis. Programmes like DAFNE and Bertie should be offered 6 to 12 months after diagnosis.

For adults with type 1 diabetes who are unable or prefer not to take part in group education, provide an alternative of equal standard.

All resources should be in a format and language that suits the age, learning styles and preferences of the person with type 1 diabetes. Teams should ensure that effective education resources of proven benefit are available to people with diabetes by signposting content on the Diabetes in Scotland website. Resources should be accessible to adults who do not speak or read English, and should be culturally appropriate. If necessary patients and families should have access to an interpreter or advocate during the educational sessions. For people with additional needs related to a disability, impairment or sensory loss, information should be provided as set out in public health national guidance (Accessible Information Policy from healthscotland.scot).

Provide information about type 1 diabetes and its management to adults with type 1 diabetes at all opportunities from diagnosis onwards. Follow the principles in this toolkit or local guidance for people with type 1 diabetes.

Clinical teams should ensure that relevant information to guide self management is up to date, well signposted, easily accessible and available to adults with type 1 diabetes, their carers and families in both printed and digital formats. It is important that the information is provided in a stepwise and relevant manner from diagnosis onwards to avoid overwhelming the individual.

Carry out an annual review of self care and needs for all adults with type 1 diabetes. Decide what to cover each year by agreeing priorities with the person.

Individuals (with input from carers and families, where appropriate) should have the opportunity, preferably using a preconsultation questionnaire, to set priorities for discussion during the review. Annual review should ensure that the essential care processes have been completed and age-appropriate and life-stage relevant topics of education are covered in a personalised and culturally sensitive manner.

See the related recommendation on offering related education at key times.

Offer carbohydrate-counting training to adults with type 1 diabetes as part of structured education programmes for self management.

Carbohydrate counting is a key element of structured education about type 1 diabetes. Individuals, carers and families should have the opportunity to revisit the topic on a regular basis, particularly at critical points, such as when transitioning from young people's services, during pregnancy, when starting a new diabetes technology or after a significant change in lifestyle. If there are issues in providing timely access to the full structured education course (eg long waiting times/staffing issues), access to standalone carbohydrate-counting courses should be made available until they can attend a structured education course.

Tailor the education programme to each child or young person with type 1 diabetes and their families or carers, taking account of issues such as:

• personal preferences
• emotional wellbeing
• age and maturity
• cultural considerations
• existing knowledge
• current and future social circumstances
• life goals.

Structured education programmes for children and young people with type 1 diabetes and their families and carers should be age-appropriate and be tailored to their emotional, social and cultural needs. Children and young people with type 1 diabetes have a greater risk of emotional and behavioural difficulties than their peers without diabetes and it important that education is personalised to the individuals needs and preferences.

Diabetes teams should offer comprehensive advice to children and young people with type 1 diabetes who want to play sports that have particular risks for people with diabetes. Support groups and organisations (including sports organisations) may be able to provide more information.

Physical activity is highly recommended for all people with type 1 diabetes and benefits vascular and mental health. Diabetes teams should offer comprehensive advice in how to manage insulin adjustments, carbohydrate and fluid intake to people with type 1 diabetes undertaking physical activity.

See My Diabetes My Way and Runsweet for further learning resources. The EXercise for Type 1 Diabetes (EXTOD) programme provides evidence-based support for people with type 1 diabetes to undertake safe and effective exercise, and to enjoy its associated health benefits. The EXTOD website includes resources for healthcare professionals and advice for people with type 1 diabetes.

Offer education for children and young people with type 1 diabetes and their families, carers, and teachers about recognising and managing hypoglycaemia.

People with type 1 diabetes, their carers and families should have access to home blood glucose monitoring to allow the accuracy of technology to be tested if symptoms are incongruent with CGM readings.

See section on glucose-lowering and glucose monitoring technologies.