ORIGINAL ARTICLE

“Smile healthy to your diabetes”: health coaching-basedintervention for oral health and diabetes management

Ayse Basak Cinar & Inci Oktay & Lone Schou

Received: 8 May 2013 /Accepted: 6 December 2013# Springer-Verlag Berlin Heidelberg 2013

AbstractObjectives This study is the first to our knowledge that aimsto evaluate the impact of Health Coaching (HC) compared toHealth Education (HE) on oral health and diabetes manage-ment among patients with diabetes type II (DM2).Material and methods The study is part of a prospectiveintervention among randomly selected DM2 patients(n =186), Istanbul, Turkey. The data analyzed were Commu-nity Periodontal Need Index (CPI) and HbA1c (glycatedhemoglobin percentage). Data was collected initially and atthe end of the intervention. The participants, both attendingoral examinations and filing out questionnaires (n =179), wereallocated to HC (n =77) and HE (n =102) groups by means ofa block table of random numbers.Results At baseline, there was no statistical difference be-tween HC and HE groups in terms of CPI and HbA1c(p >0.05). At postintervention, the HC group had significantlylower CPI and HbA1C than the HE group (p <0.01). Therewas a significant reduction at HbA1c (0.8 %) and CPI (74 %)in HC group (p<0.05). The impact of HE on CPI was lesssignificant (21 % reduction) (p =0.001); however, it was notsignificant on HbA1c (p =0.68). The improvement at CPI

from baseline to postintervention had significant impact onreduced HbA1c in the HC group (p <0.05).Conclusions and clinical relevance The present findings im-ply that HC has a significantly higher impact on better man-agement of diabetes and oral health when compared to formalHE. This calls for the use of HC by dentists, physicians, anddiabetes educators in order to improve quality of life of DM2patients by facilitating better oral health and diabetes self-management.

Keywords Diabetes type II . Oral health . Health coaching .

Health education . Common risk factor approach

AbbreviationsHC Health CoachingHE Health EducationWHO World Health OrganizationCPI Community Need IndexHbA1c Glycated hemoglobin expressed as the percentage

of hemoglobin that is exposed to glucoseDI Duygu Ilhan (examiner)AB Arzu Beklen (examiner)BEA Bilge Ertoglu Akmenek (performed periodontal

cleaning for all participants)

Introduction

Diabetes, a largely preventable chronic disease, is character-ized as globally pandemic due to its distribution and severeconsequences [1]. There have been 347, 000 million peoplewith diabetes, and these have been expected to at least doubleby the year 2030. Type 2 diabetes (DM2) comprises 90 % ofpeople with diabetes around the world [2].

A. B. CinarOral Public Health Department, Department of Odontology,University of Copenhagen, Copenhagen, Denmark

I. OktayOral Public Health Department, Yeditepe Dental Faculty,Istanbul, Turkey

L. SchouSection of Global Oral Health Promotion, Department ofOdontology, University of Copenhagen, Copenhagen, Denmark

A. B. Cinar (*)Department of Odontology, University of Copenhagen,Norre Alle 20, 2200 Copenhagen, Denmarke-mail: aci@sund.ku.dk

Clin Oral InvestDOI 10.1007/s00784-013-1165-2

Promoting good oral health is essential in order to preventand reduce the negative consequences of DM2 and to main-tain good health, as proposed among the World Health Orga-nization (WHO) European health goals [3]. Periodontal dis-ease significantly contributes to the risk of dying from DM2[4]. Periodontal inflammation in early old age tends to beassociated with mortality in older age [4], and DM2 patientsare more likely to have periodontal disease than people with-out DM2 [5]. Besides sharing common biological mecha-nisms, DM2 and oral diseases [6, 7], so-called lifestyle dis-eases, share the same lifestyle related risk factors (poor dietaryhabits and smoking) [8, 9]. Better management of these dis-eases requires good self-care practices and adherence to dailyregimes. However, many patients find themselves unable tofollow recommended lifestyles (a healthy diet, regular physi-cal exercise, no smoking, and tooth brushing twice daily),which make them more prone to DM2-related complicationsand poor oral health, leading to a poor quality of life. There-fore, a common-risk factor approach to promote better oralhealth and successful DM2 management are proposed as anurgent need by WHO [10] and the International DiabetesFederation (IDF) [11]. Behavioral interventions are highlyrecommended to meet this need [12].

Health Coaching (HC) is a new patient-centeredbehavioral/lifestyle intervention that facilitates individuals inestablishing and attaining health promoting goals in order tochange lifestyle-related behaviors with the intent of reducinghealth risks, improving self-management of chronic condi-tions, and increasing health-related quality of life [13]. HC ,in principal, focuses on transformation and maintenance ofpositive health behaviors by empowerment of patients. HC ,one of the most effective behavioral techniques, is directlyassociated with positive lifestyle outcomes (smoking cessa-tion, management of obesity, and diabetes) [14–18]. An as-sessment of the effect of HC on multiple chronic diseasemanagement as a common approach has been a neglectedissue. The present study is the first to our knowledge that aimsto evaluate the impact of an HC-focused intervention com-pared to HE on oral health and diabetes management amongpatients with DM2.

Material and methods

The present study is part of a prospective intervention studyamong DM2 patients (n =186), randomly selected from theoutpatient clinics of two hospitals in Istanbul, Turkey. Thepower and sample size are previously explained [19–21].Eligibility criteria were as follows: (1) confirmed type IIdiabetes, (2) 30–65 years old with at least four functionalteeth, and (3) no psychological treatment and hospitalization.

Ethical approval and written permission were granted bythe Ministry of Health to conduct the study. The methodology

of the study is previously explained [19, 21]. Informationregarding HbA1c was taken from the latest medical recordsat the hospital, while the patients were invited for periodontalclinical examination (Community Periodontal Need Index(CPI)). Of the patients participating, 96 % (baseline visit,n =179; final visit, n =178) attended the clinical examina-tions. Of 186 participants, the drop out was 7 patients (4 %)and the corresponding figure for the participants who did notregularly participate in all sessions was 24 (13 %).

Back translations to and from Turkish were performed forhealth behavior questionnaires by two native speakers toensure comparability with the original forms in English.

The data in the present study were extracted from theclinical measurements and from the medical records taken atbaseline and at the end of follow-up: CPI and glycated hemo-globin expressed as the percentage of hemoglobin that isexposed to glucose (HbA1c) (Fig. 1).

Procedure and randomization

The patients were randomly assigned to either HC or HealthEducation (HE) groups by means of a block table of randomnumbers (block randomization by physician). Patients werereferred to the study by their physicians. All physicians wereblind to groups, and they were asked to refer their patientswith a paper signed by them, to the researcher who was blindto outcome measures and examinations. Two hospitals, eachwith two physicians were included so that all patients allocat-ed from one of the physicians for each of the hospital partic-ipated in HC, and all patients from the other two physiciansfrom each hospital participated in HE. This assignment result-ed in HC group of 79 patients and in HE group of 107 patients.A kind of similar randomization technique was used by Soriaet al (2006) to assess the impact of Motivational Interviewing(MI) compared to education, and it also resulted in nonequalnumber of patients in each group [22].

At the baseline visit, participants provided informed con-sent and filled out questionnaires (including demographicbackground, psychosocial, and behavioral variables). The lastcurrent medical reports (HbA1c, HDL, LDL, and triglyceride)were drawn from the hospital. Subsequently, all participantswere invited for baseline oral examination which was run bytwo calibrated examiners. Examiners were blind to groupassignments. Following the oral examination, patients enteredHC or HE groups as explained above. The intervention in-cluded two phases (10 month-initiation and maintenance, and6-month follow-up). During the 10-months initiation andmaintenance, all participants in both groups were invited forfree periodontal cleaning and three seminars about oral healthand diabetes management. Periodontal cleaning was offeredfree of charge, and it was performed by a dentist (BEA) at adental polyclinic; there were no oral health care facilitiesavailable at the hospitals. In connection with the periodontal

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cleaning to all participants, standard oral HE was given. Allpatients were called between one and three times for anappointment. The cleaning included the removal of soft andcalcified deposits by an ultrasonic device. At the end of the 6-month follow-up phase, the same outcome measures werecollected.

Health Coaching group: One coach provided HC interven-tion. She had an internationally accredited coaching training aswell as a Master-level degree in Behavioral Sciences and PhDin Community Dentistry. Participants randomized to the HChad a face–face session with the coach within 2 weeks of thebaseline visit. They were then scheduled for another sessionafter 3 weeks. After three following weeks, participants wereoffered one 10–20 min coaching sessions over the telephone.That was followed by one face–face and one telephone HCsession during the last 6 months of the 10-months initiation–maintenance phase. The intervention continued with less fre-quent coaching sessions (one face–face and two telephoneHC)during the last 4 months. During the 6-months follow-up, oneface–face and one telephone HC were provided.

Health Coaching (described earlier in detail [20]) is fo-cused on empowerment of patients for daily health-relatedpractices, compliance to diabetes and oral health related self-care regimes, building up health-related capacity buildingskills, self-monitoring, and taking responsibility for healthand quality of life. Besides, it targets increasingly the aware-ness of patients for risk factors and possible complicationsconsidering diabetes and oral diseases. The primary method isthat patients set up the goal and an action plan, focusing onimprovement of lifestyle and clinical measures, under the

supervision of the coach. Each coaching session as the foun-dation for the next coaching session is used for subsequentmonitoring of patients’ progress toward the achievement ofthe target goal. Preset time frame for face–face coachingsessions is 20–60 min, determined by needs, expectations,hindrances, and progress of patient.

AWheel of Health was administered during the initial HCsession visit to explore values, establish priorities, and setgoals: participants reported how satisfied they were (0–100 %) recently and how satisfied they would like to be inthe future. Each domain of health was defined by participantsso each Wheel of Health was specific for the participantidentifying his/her priorities, needs, and expectations referringto health (Fig. 2). Participants chose one domain and set up aspecific goal and action plan during each face–face session.

16-months10-months

HE

Outcome

measuremen

t

Study sample(n=186)

Randomization

BASELINE* FOLLOW-UP

(intervention)

Health Coaching Group(HC)

Health Education Group

(HE)

HC

Outcome

measuremen

t

INITIATION-MAINTENANCE

(intervention)

Time

Fig. 1 Research protocol of the study. Data included initial oral exami-nations (CPI, Clinical Attachment Loss, and number of teeth lost), an-thropometric measures (BMI and body-fat percentage), medical records

(HbA1c, HDL, and LDL), and self-assessed questionnaires (e.g., healthbehaviors, self-efficacy, and self-esteem). The CPI and HbA1c measuresin the present study were extracted from these data

0 %

Diet/Weight

Oral Health

Physical Exercise

100 % 100 %

100 %

Fig. 2 An example for Wheel of Health, each domain defined by patienthimself/herself

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The progress of the patient was supported by telephone calls.Although the coach regularly asked participants to explore thegoals mainly in terms of oral health and diabetes care (diet andexercise), participants were free to select any goal such asstress management.

The HC was supported by educational and motivationalbrochures, designed for the project. Brochures in the format ofwritten text were given to each patient. Two copies of thebrochures were given to the leader and the head nurses of thepolyclinics of the hospitals for informing and any possiblecomments. Later on, the brochures were used at “DiabetesSchool Seminars” by the hospitals.

Health Education group : Participants randomized to theHE group received standard lifestyle advice referring to oralhealth care practices, diet, and physical exercise. One dentistprovidedHE intervention. At the initial sessionwithin 2 weeksof the baseline oral examination, it was discussed what thepatients knew about these main areas of health. After 4 weeksparticipants were invited for another education session. Thesesessions were supported by education by a dietician and/ordiabetes nurse in outpatient clinics. Following these two ses-sions, participants were offered advisory telephone-calls onceevery 8 weeks during the first 5 months (initiation phase).Telephone advicewas supplemented by educational brochuressent out by post. At maintenance stage, a face–face educationwas first provided, followed by telephone advice once inevery 8 weeks which was finalized by a focus-group meeting.During the 6-month one telephone-education was provided.HE group patients were supported by the same educationalbrochures for HC group.

All participants both in the HC and HE groups were sup-ported by eight text messages at the initiation phases and onspecial occasions (Ramadan feasts, New Year Eve). They alsoreceived health promotion samples (toothbrush, toothpaste,sweeteners, and Pilates exercise balls).

Outcome variables

Oral examination, in particular periodontal examinations, wasperformed by two calibrated clinicians (at baseline DI andABC, and postintervention AB and DI). The recording ofclinical parameters was calibrated. Intraclass and interclass kvalues were between 0.80 and 0.90 (0.82, DI and ABC; 0.86,AB and DI). WHO periodontal probe with a 0.5-mm ball tipwas used to determine CPI by measuring the pocket depth andto detect subgingival calculus and bleeding response. The indexteeth at six sextants [11, 16, 17, 26, 27, 31, 36, 37] were probed,and the highest score for each six sextants was recorded, in linewithWHO recommendations for measurement of CPI [23, 24].If no index teeth or tooth were/was present in a sextant quali-fying for examination, at least two nonindex remaining teeth inthat sextant were examined and the highest score was recordedfor each sextant. Then the highest score among six sextants was

taken, and based on that score, CPI was categorized intoCPI=0: “healthy gums” and CPI=1: “gingival bleeding onprobing but no calculus”; or CPI=2: “calculus and bleeding,”CPI=3: “shallow periodontal pockets (4–5 mm),” and CPI=4:“deep periodontal pockets (6 mm or more),” exactly like de-scribed by WHO guidelines [23].

Diabetes management was measured in terms of HbA1c.Taking the target level (HbA1c: <6.5 %) (IDF) as cut-point,respective variable taken from the last health records, provid-ed by either hospital or the participants, were dichotomized as“favorable”=0 and “unfavorable”=1.

Data analysis

Statistical analyses were performed using SPSS v.17 (Chicago,Illinois). For assessment of correlation and baseline similarities/differences between HC and HE groups, respectively, Spear-man rank correlation and independent-sample t test were used.Time-by-group interaction effects were measured withrepeated-measures ANOVA to compare pre-intervention vs.postintervention within each group and between coaching vs.control group. Paired-sample t tests were used for normallydistributed data to assess change over time for each groupalone. Statistical significance was set at 0.05 for each test.

Results

The sociodemographic characteristics of participants areshown in Table 1. No statistically significant differences werefound between HC and HE groups. The majority of partici-pants both at HC and HE groups were 50–59 years old (55 vs.41 %), retired/housewives (75 vs. 78 %), and had primaryschool or less education (54 vs. 60 %).

At baseline, there were no statistically difference betweenHC and HE groups in terms of means HbA1c and CPI(p >0.05) (Table 1). Statistically there was no correlationbetween CPI and HbA1c (p >0.05). In the HE group, 71 %had unfavorable HbA1c (6.5 %≤) and 45 % had periodontalpocket (CPI=3 or 4). The corresponding figures for the HCgroup were 73 and 38 %.

The dropout rate was 3 % (n =2) for the HC group and 5 %(n =5) for the HE group. Socioeconomic characteristics of thetwo groups at postintervention were statistically similar(p >0.05).Even though all participants were offered free peri-odontal cleaning and if not responding, they were re-invitedthree times, 95% in the HC group attended periodontalcleaning, and only 43 % in the HE group attended (p =0.001).

At postintervention, the improvement at CPI and HbA1c inthe HC group was significantly higher than the HE group(p <0.01) (Table 2). The interaction of HC on HbA1c wassignificant (F =10.7, p =0.002). Interaction of HE withHbA1c was not significant (F =0.16, p =0.68).

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Improvement of CPI for HC group was 73.9 % (F =14.56,p =0.001), and it was 20.8 % for HE group (F =14.19,p =0.001) (Table 3). The improvement at CPI from baselineto postintervention had significant impact on reduced HbA1camong HC group (F =7.41, p =0.008). The similar impactwas observed in the HE group (F =5.6, p =0.02).

Discussion

To our knowledge, this is the first randomized controlledintervention study comparing the impact of individualizedHC to formal HE. The improvement at HbA1c levels by

coaching intervention observed in the present study is in linewith the earlier studies [18, 25–29]. However, these studiesare few in number and some of them refer to telephonecoaching [26, 27]. Whittemore R et al. (2004) [18] found thatcoaching groups have reduced HbA1c from 7.7 to 7.5 during a6-months intervention, and similar trend has been observed atthe education group. The findings by Frosch and his col-leagues (2011) [26] are similar, i.e., that phone-coachingintervention had a significant impact on HbA1c. However,there was no significant difference between coaching and thecontrol group in terms of effect. On the contrary,Wolever at al.(2010) [28] found a significant impact of coaching interven-tion compared to education group at reducing HbA1c levels.

Table 1 The characteristics of participants at baselinea

N (total=186)a Coaching Education p

n n Percentage n n Percentage

Gender 77 109 0.76Female 46 60 68 61

Male 31 40 41 39

Age (years) 72 92 0.2930–39 9 11 10 11

40–49 13 18 21 23

50–59 39 55 38 41

60–69 11 16 23 25

Education 74 101 0.46Primary school or less 40 54 61 60

At least middle school (≤8–11 years of education) 23 31 23 23

At least university 11 15 17 17

Current employment 77 98 0.72Housewife/retired 57 75 76 78

Employed 20 25 22 22

Clinically diagnosed history of diabetes 72 86 0.51≤11.9 years 45 62 49 57

>11.9 years 27 38 37 43

HbA1c (Mean±SD) 77 7.5±1.52 % 102 7.8±1.57 % NS

Bold significance refers to the number of people responded the selected item

NS not significanta The total number for each variable differs because the same participants did not answer all the questions. ConsideringHbA1c, few patients at (n=2) atHC group and HE (n =5) group did not provide their medical records; they had them at other health care settings

Table 2 Outcome measures for Health Coaching and Education group

Health Coaching (Mean±SD) p Health Education (Mean±SD) p

(n=77) (n =76) (n =102) (n =101)Baseline Postintervention Baseline Postintervention

HbA1c 7.5±1.52 % 6.7±1.53 % 0.001 7.8±1.60 % 7.7±1.58 % NS

CPIa 2.3±0.86 0.6±0.9 0.001 2.4±1.23 1.9±1.5 0.001

SD standard deviation, CPI Community Periodontal Need IndexaCPI: Code=3: shallow periodontal pockets (4–5 mm), Code 2=Calculus, Code 1=Bleeding, Code 0=Healthy

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As these studies vary in design and population type/size, it isdifficult to draw some conclusions referring to the findings ofthe present study. However, it is evident that coaching inter-vention has a higher significant impact on reduction of HbA1ccompared to the education group. The findings of the presentstudy are in line with this.

Psychological interventions may produce improvements inperiodontal health as it has been reported in a Cochrane review[29]. MI has been found to be the most effective interventionapproach for altering health behaviors at clinical settings [30].However, such interventions are scarce in dentistry. The indi-vidually tailored oral health educational program by Jonssonand his colleagues, based on social cognitive theory [31] andMI [32], has been more efficacious in improving periodontalhealth compared to the education group [33]. Similar resultshave been found by other recent studies. Structured and indi-vidually tailored psychological interventions based on behav-ioral theories, in particular, social cognitive theory and MI,have been significantly effective at improving oral health[34–37]. The findings of the present study are in line withthese recent studies that coaching intervention, based on MI,social cognitive theory, and Neuro-Linguistic Programming(NLP) [37], had significantly higher impact on reduction ofCPI scores compared to the education group.

A recent Cochrane review [38] has reported that studiesassessing the impact of improved periodontal health onHbA1c provide some evidence of improvement in metaboliccontrol. However, these are scarce in number. The findings ofthe present study are in line with these and, to our knowledge,this is the first study comparing a behavioral health-coachingversus education group in terms of the effect of improvedperiodontal health on HbA1c. It is noteworthy that partici-pants in the HC group have a significantly reduced HbA1ccompared to the education group. This may be explained bythe multi-targeted structure of HC. It has a specific focus toimprove healthy lifestyles by management of specific goalsdefined by patients based on their own needs and expecta-tions. HC targets achievement of an “umbrella” of health goalsby using “Wheel of Health” that enables patients to assess theinterrelation between goals. In the present study, the focus wasto set oral health based goals at first hand and then connectingthem to other healthy lifestyle goals such as diet and physical

activity. As to view the outcome of brushing twice a day interms of less bleeding gums or reduced oral odor will mostprobably take less time than to observe the outcomes of aweight loss related goal. Oral health related goals may be agood start to change/improve healthy lifestyles. HC has im-pact on improved CPI levels; the intervention in HC groupseems to be more effective in stabilizing the long-term effectof the periodontal cleaning. Thus, improved periodontal healthhas a positive effect on reduction of HbA1c. Therefore, HCseems to affect HbA1c in two patterns: directly having impacton HbA1c and indirectly through change at CPI levels throughthe improved overall health behavior by empowerment ofpatients on diabetes-management and oral health managementskills. This can be supported by the findings that change at CPIin the HE group had an impact on reduction of HbA1c but thatdid not lead to any significant changes at HbA1c. This is in linewith a recent study [39] that showed that intensive oral HE didnot have any significant changes at CPI levels from baseline topostintervention among patients with DM2.

A limitation of the present study is the small sample size.However, studies in the field, measuring the impact of peri-odontal health onHbA1c [38] and behavioral interventions forHbA1c and periodontal health [29], mostly refer to smallsample sizes. Another limitation is that the interaction be-tween HbA1c and CPI has not been assessed further andmay be due to biological and/behavioral factors. Additionally,the impact of periodontal cleaning was not measured 4–8 weeks after the cleaning. Therefore, we cannot preciselydifferentiate the effect of the periodontal cleaning from theeffect of the interventions used. However, the results of thisstudy can be interpreted as a long-term effect of the interven-tions in stabilizing periodontal health. Additionally, atten-dance to periodontal cleaning sessions based on free will isused as a positive health behavior measure, which was clearlybetter in the HC group compared to HE group. However, therationale for periodontal cleaning is to measure the impact ofHC and HE on stabilizing the long-term effect of the peri-odontal cleaning in the long run. Additionally, attendance to

Table 3 Comparison of improvement at outcome measures betweenHealth Coaching and Health Education

Health Coachingreduction (%)

Health Educationreduction (%)

p

Baseline—postintervention

Baseline—postintervention

HbA1c 0.8 0.1 0.001

CPI 73.9 20.8 0.001

CPI Community Periodontal Need Index

Table 4 Comparison of traditional health education model and patient-focused approach—Health Coaching

Traditional health educationmodel (advice giving)

Patient-focused model(Health Coaching)

Told Asked

Informed Guided

Good patient Challenging

Doing to Doing with, listening

Reactive Proactive

Clinician centered Patient centered

Options presented Informed choice

Medical professional/educatoris the expert for patient’s health

Patient is the expert for his/herown health

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periodontal cleaning sessions based on free will is used as apositive health behavior measure. In general, the aim of thepresent study was to evaluate the impact of an HC-focusedintervention on diabetes management and oral health amongpatients with DM2. DM2 and oral diseases, so-called lifestylediseases [40, 41], share the same lifestyle-related risk factors(poor dietary habits and smoking) [8, 9] and common biolog-ical mechanisms [6, 7]. Better management of these diseasesrequires good self-care practices and adherence to daily re-gimes. However, many patients find themselves unable tofollow recommended lifestyles (a healthy diet, regular physi-cal exercise, no smoking, and twice daily tooth brushing),which makes themmore prone to DM2-related complications,poor oral health, and obesity, leading to a poor quality of life.Therefore, a common risk factor approach to promote betteroral health and successful weight and DM2 management areproposed as urgent needs by WHO and IDF; behavioralinterventions are highly recommended to meet this need [1].This is vitally important because about 40 % of deaths attrib-utable to DM2 may be prevented by improvement of lifestyle[42]. The present intervention may be one approach to thisneed further studies are required. However, the findings maysuggest a new focus in the field by presenting the impact of aholistic behavioral intervention—HC—that speaks for bettermanagement of both diabetes and oral health.

The randomization procedure of patients may be regardedas a limitation. However, Table 1 shows that at baseline, thetotal study had no statistical significant differences betweenthose allocated to HC andHE groups. Circumstances at clinicson daily life may lead to unequal sample size as in our studythat is in line with the earlier studies [22, 43].

Implications and relevance

Dentists, diabetes educators, and physicians, in particular, mayintegrate HC in their practice. In HC, patients are the expertand reliable resource of information regarding personal strate-gies for oral-related and diabetes-related behavior/lifestylechanges. This differs somewhat from traditional oral health/diabetes education where the dentist/physician by definition isthe expert who provides information (Table 4). In coaching,education is provided in line with the patient’s goals, andinformation must be meaningful in the context of the patient’sneeds and expectations. Coaches elicit ideas and resourceful-ness from patients, encouraging them to explore and to under-stand about their health problems in the framework of theirdaily life routines and social environment. The coach alwaysasks permission before offering education, reinforcing the ideathat the patient is in control. The coach investigates and pro-vides an opportunity to set up/maintain healthy behaviors bythe questions such as “What makes you” instead of “why”; as“why” may implicate why the patients behaves (or does notbehave) in a certain way, and therefore, patients may feel a

need to defend current unhealthy behaviors/habits. Dentists,physicians, and diabetes educators feel pressure and are evenoffered incentives for having their patients achieve certainbetter oral health and behaviors (brushing twice a day andusing tooth floss) and/or reduced HbA1c levels. However,regular tooth brushing or favorable oral health/HbA1c mayseem arbitrary and meaningless or a very hard task to handlefor the patient in the scope of his or her life priorities andvalues. Considering that a patient is responsible for not takingaction for his/her own health, the so-called victim-blamingapproach, is an outdated approach that will lead to reducedquality of life and ineffective medical outcomes among pa-tients. There is a need to assess patient’s needs, expectations,and also challenges in his/her daily life and social life. Thismay clarify “how” and “what” will make the patient takeaction for his/her own life. HC speaks for such an approach.

While dentists , physicians, and diabetes educators under-go extensive education and training to learn “what is best”for patients , the education /training mostly misses “how” toachieve that best . “How” is implied in the patient’s motivationand patient’s needs to find out his/her motivators with supportand encouragement of health care providers who take off their“medical profession” shoes and put on “ HC” shoes. It is vitalthat patients learn to connect their health goals and lifestyle toa vision of health in a greater picture , which is a critical stepin developing the best strategies for lasting behavior change[28], thereby to maintain better oral health and diabetesmanagement . Therefore, dentists, physicians, and diabeteseducators need to engage patients under the “umbrella” ofhealth behaviors considering that health behaviors includingoral health co-occur as separate clusters as either health-enhancing or health-detrimental behaviors in the same indi-vidual [44]. Engagement either in health-enhancing or inhealth-detrimental behaviors is proposed to represent an indi-vidual’s health-related lifestyle [45]. Stemming from that fig-ure, HC provides a holistic approach to motivating andsupporting patients for setting up health goals connected toeach other.

Acknowledgments We express our deepest thanks to Prof. NazifBagriacik (Head, Turkish Diabetes Association), and Associate Prof.Mehmet Sargin and Head Diabetes Nurse Sengul Isik (Diabetes Unit,S.B. Kartal Research and Education Hospital) for all their support andhelp during the research. We thank Prof. Aytekin Oguz for his help on thepreparation of the documents for the ethical permission. We also thankProf. I Oktay and periodontologist Duygu Ilhan for training for clinicaloral examinations. We also thank ZENDIUM for oral health care kits,SPLENDA (TR) for the promotional tools, ChiBall World Pty. Ltd. forexercising chi balls, and to IVOCLARVivadent, Plandent, Denmark forprovision of CRT kits. Many thanks are due to our patients for theirparticipation and cooperation.

The research is part of an international project that it has two phases:Turkish phase which is presented here is supported by FDI and theInternational Research Fund of University of Copenhagen. The secondphase is in Denmark. It is supported by BRIDGES, and BRIDGES is anIDF program supported by an educational grant from Lilly Diabetes.

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Conflict of interest The authors declare that they have no conflict ofinterest.

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