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Smile Healthy with your diabetes: A translational randomized trial of culturally specific health coaching intervention for patients with diabetes 


Aim: The present study is the first to our knowledge that to assess the effectiveness of HC (Health Coaching) compared with a health education (HE) intervention on the management of glycaemic control and periodontal health, by the use of clinical and subjective outcomes among diabetes type 2 (DM2) patients in Turkey and Denmark.

Rationale: `Besides sharing common biological mechanisms, DM2 and oral diseases [6, 7], so-called lifestyle diseases, share the same lifestyle related risk factors (poor dietaryhabits and smoking) [8, 9]. Better management of these diseases requires good self-care practices and adherence to daily regimes. However, many patients find themselves unable to follow recommended lifestyles (a healthy diet, regular physical exercise, no smoking, and tooth brushing twice daily),
which make them more prone to DM2-related complications and poor oral health, leading to a poor quality of life. Therefore, a common-risk factor approach to promote better oral health and successful DM2 management are proposed as an urgent need by WHO [10] and the International Diabetes Federation (IDF) [11]. Behavioral interventions are highly
recommended to meet this need [12].

Health Coaching (HC) is a new patient-centered behavioral/lifestyle intervention that facilitates individuals in
establishing and attaining health promoting goals in order to change lifestyle-related behaviors with the intent of reducing
health risks, improving self-management of chronic conditions, and increasing health-related quality of life [13]. HC,
in principal, focuses on transformation and maintenance of positive health behaviors by empowerment of patients. HC,
one of the most effective behavioral techniques, is directly associated with positive lifestyle outcomes (smoking cessation,
management of obesity, and diabetes) [14–18]. An assessment of the effect of HC on multiple chronic disease
management as a common approach has been a neglected issue.`
Cinar AB, Oktay I, Schou L. Smile healthy to your diabetes: health coaching-based intervention for oral health and diabetes management. Clin Oral Investig 2014; 18:1793-801.

Background of the Project

  • Development of health behaviour model as part of PhD thesis - Winner of 2004   L'OREAL- UNESCO Women in Science (Thesis for Doctorate in Dentistry. University of Helsinki, Institute of Dentistry, Oral Public Health Department, November 2008)

  • Adaptation of model to DM2 patients through consultation with Diabetes Associations (Steno, Turkish Diabetes Association, Danish Dental Hygienist Association), health care professionals, academicians, and people with diabetes

  • Running a pilot study to take feedback from DM2 patients on the design of the research and as well to assess their needs and challenges by use of self-assessed questionnaires

  • Building strategic alliances with International Diabetes Federation, International Dental Federation and several international universities, and hospitals (diabetes teams)



This project’s first phase was finalised in Turkey in 2012 and then the second phase in Denmark between 2012 and 2014. The study includes DM2 adults between the age of 39 and 79, living in Istanbul, Turkey
(n = 186), visiting a medical clinic for regular DM2 healthcare, and adults living in Denmark (n = 116), visiting dental clinics of the University of
Copenhagen, Denmark (Figure 1). The eligibility criteria for all participants were: (i) having a clinical diagnosis of DM2, (ii) aged 39–79,
(iii) having at least four functional teeth. Patients with severe somatic/mental illness, who were hospitalised, with severe kidney or cardiovascular disease or incurable cancer, were excluded. Those living outside Istanbul or Copenhagen were excluded.

The outpatient clinics of two hospitals (Istanbul, Turkey) were used to randomly select the participants with DM2. Sample size calculation and methodology were explained in detail in earlier publications.

The two stages of the study (6-months initiation-maintenance
phase, then 6 months follow-up), described in detail earlier, were as follows:
Initiation-maintenance phase
Health Coaching (HC Intervention): The HC approach (Table 1) in the present study is a dynamic and collaborative process between the coach and the patient to maintain and adopt healthy-lifestyles supported
by empowerment of capacity building skills (self-efficacy, diabetes coping skills). The HC sessions, conducted by a professional health coach (AB
Cinar) in both countries, focused on motivating and supporting the patients for maintenance and improvement of lifestyles with the aim of at least a 0.4–0.8% reduction in HbA1c (P < 0.05) in line with the earlier
The HC approach  uses a blend of specific psychological techniques and
some theories including motivational interviewing34, neurolinguistic programming and self-efficacy theory.
Patients in the HC group received 3–4 face-to-face sessions and 2–3 telephone calls. The timeframe for face-to-face HC sessions ranged between 20 and 60 minutes

Health Education (HE) Intervention: Health education sessions (Table 1) were conducted by a dental health professional. Participants in the HE group received standard lifestyle advice after baseline examination and were invited for two more face-to face and 1–2 telephone sessions during the initiation-maintenance period. The timeframe for face-to-face HE sessions ranged between 20 and
60 minutes, according to the patient’s needs, challenges and progress. The lifestyle advice included the oral hygiene and diabetes management (bloodglucose monitoring, dietary regimes, regular physical exercise, non-smoking, twice daily tooth-brushing).In addition, HE sessions were on the phone for 5– 8 minutes. Telephone advice was supported by the educational brochures. The HE sessions were
explained in detail earlier

Follow-up phase
The HC and HE group participants received 1–2 face to- face sessions to closely screen the maintenance and improvement of their transformation for positive lifestyles.

Motivational Incentives for all Participants: Oral health promotion tools such as toothbrushes and toothpastes as motivational incentives were given to all patients during both initiation-maintenance and follow-up phases. Dental scaling (cleanings) were provided at no cost to the participants during initiation-maintenance phase, and certificates of attendance at the cessation of the study were used as other motivational
tools. Periodontal cleaning was standard for every participant; thus did not vary according to baseline examination.


Figure 1 
Table 1


Clinical variables
The present data were taken from the routinely collected data [clinical measures and the medical records at baseline and after follow-up (12 months from baseline)]. The latest medical records at the hospitals were used to gather data on HbA1c, fasting blood glucose, LDL. HDL. For further analysis, participants with HbA1c ≥8% was recorded as poor glycaemic control and those with HbA1c <8% as good glycaemic control, based on the International Diabetes Federation guidelines.
Participants were invited for a periodontal clinical examination [Community Periodontal Need Index (CPI)] and a record of anthropometric measures. Two calibrated clinicians in Turkey (intraclass and interclass j value was 0.80 on average, as explained earlier) and one dental hygienist in Denmark,
performed the periodontal examinations. The CPI and Periodontal Need Index was used to monitor the alterations of the periodontal treatment needs over the intervention period. WHO guidelines were followed for the measurement
Anthropometric measures: Tanita TBF-300-A which utilises foot-to-foot bio-electrical impedance analysis to measure the body composition, was used for onsite measurement of body mass index (BMI) and fat mass percentage (BFP). Lean mass was calculated by subtracting weight from fat mass.
Behavioural variables: Self-assessed questionnaires composed of 8 scales and 40 questions were used. Some of the scales used: The Problem Areas in Diabetes Scale (PAID), WHO Quality of Life, Self-Esteem, Self-efficacy Scale. Questions are used to assess socio-economic variables, lifestyles, literacy on oral health an diabetes management. 


There was no statistical difference between the HC and HE groups in both Turkish and Danish study groups regarding the socio-economic background and clinical parameters. The majority of the Turkish HC and HE participants reported good control of HbA1c (70% vs. 63%, P ≥ 0.05). It was similar for the Danish groups (HC: 75% vs. HE: 80%, P ≥ 0.05).

Turkish results
In the HC group, HbA1c (0.8%) and periodontal treatment needs (CPI) significantly decreased compared with the HE group (Table 3), (P < 0.05).

Danish results
In the HC group, HbA1c and CPI, as observed in the Turkish group, were also significantly improved compared with the HE group (Table 3), (P < 0.05).

Table 3
Keyboard and Mouse
Mountain Climber
Keyboard and Mouse
We monitored HBa1c of Turkish patients for 2 years after the cessation of the project with no coaching contact/intervention. The data showed that TR Hc patients kept their improved HBa1C levels by being able to coach themselves!


  • There is a common global consensus on certain factors contributing to the successful management and the prevention of further complications of DM2. Health coaching can be an effective approach to achieve these factors under one umbrella.

  • Primary health-care systems should be inclusive of patient-centred interventions focusing not only on clinical outcomes but also on positive lifestyle changes, in order to achieve the long-term positive and sustainable changes at an earlier stage before there is a need for costly treatments.

  • Patients need to be actively engaged in decision making and they need to feel motivated and responsible for participating in their own health-care. HC will enable them to take the responsibility and maximize their potential to better manage their diabetes by their own daily solutions

  • Health professionals need to improve their competencies and skills about ‘how’ to motivate and encourage the patients to take the lead and have active participation in the maintenance and improvement of their health. ‘How’ can be implied in facilitating the patients to explore and unlock the internal self-resources and then engage in action and positive lifestyle changes to adopt and maintain health.

Peer-reviewed articles
  1. Cinar AB, Freeman R, L Schou. A new complementary approach for oral health and diabetes management: health coaching. Int Dent J. 2018;68(1):54-64. doi: 10.1111/idj.12334.

  2. Cinar AB, Schou L. New Patient Centered Approach to Unlock the Individual's Potential to Adopt Healthy Lifestyles: Health Coaching. Journal of Person Centered Medicine 2015; 5:182-191.

  3. Cinar AB, Schou L. Health Promotion for Patients with Diabetes: Health Coaching or Health Education? Int Dent J 2014; 64: 20-8. doi: 10.1111/idj.12058.

  4. Cinar AB, Schou L. Impact of Empowerment on Toothbrushing and Diabetes Management. Oral Health Prev Dent 2014; 12:337-44.

  5. Cinar AB, Schou L Health coaching increases self-esteem and healthy smiles. Diabetes Voice; (Special Issue) 2014 59:47-51.

  6. Cinar AB, Oktay I, Schou L. Smile healthy to your diabetes: health coaching-based intervention for oral health and diabetes management. Clin Oral Investig 2014; 18:1793-801.

  7. Cinar AB, Schou L. The role of self- efficacy in health coaching and health education for patients with type 2 diabetes. Int Dent J 2014; 64:155-63.

Peer-reviewed congress abstracts and workshops

  • Cinar AB. Value-based Health Coaching (VHC): A new person-centred approach (PCA) for WHO-2020 Goals and UN-Sustainable Development Goals. 10th Geneva Conference on Person-Centred Medicine, May, Geneva, Switzerland 2017

  • Cinar AB. Smile Healthy to Your Diabetes: Health Coaching as a New Person-Centered Complementary Therapy for Patients with Diabetes type 2.  CHRO ASIA, the World Coaching Congress, (Invited speaker).2017

  • Cinar AB, Dinesen C. A New Person-Centred Complementary Therapy within Clinical Best Practices for Patients with Chronic Diseases: Health Coaching". EMCC 6th International Mentoring and Coaching Research Conference, July, Budapest, Hungary. Oral Presentation 2016

  • Cinar AB. Health Coaching 4 All™: A new complementary approach for integrated care for patients with diabetes type 2. World Diabetes Congress-IDF. Vancouver, Canada. Poster Presentation. 2015

  • Cinar AB. New Patient Centered Approach to Unlock the Individual's Potential to Adopt Healthy Lifestyles: Health Coaching. 1st International Conference of Public Health and Primary Care, 3rd Congress of Person Centred Medicine. London, UK. October-November. Oral Presentation 2015

  • Cinar AB. Patient Focused Health Coaching for Patients with Diabetes type 2. Coaching in Leadership and Healthcare 2015, McLean University, Harvard School Affiliate, Boston, MA, US. Oral Presentation. 2015

  • Cinar AB. New Patient Centered Approach to Unlock the Individual's Potential to Adopt Healthy Lifestyles: Health Coaching. 1st International Conference of Primary Care and Public Health & 3rd international Congress of Person-Centered Medicine, Imperial College London, London 2015

  • Cinar AB, Schou L. Smile healthy to your diabetes: Oral health focused health coaching intervention for diabetes management International Centre for Oral Health Inequalities and Research Policy (ICOHIRP) Conference. London.2015

  • Cinar AB. The Impact of Health Coaching on Diabetes Type 2 Management by Health Behaviours and Body-Fat%.  UCPH LOM conference on exercise and physical activity in relation to lifestyle, obesity and metabolic diseases. Copenhagen, Denmark (Oral presentation).2015

  • Cinar AB, Dinesen C, Schou L. Patient Focused Health Coaching: Time to call for an Integrated Innovation for Diabetes Management? Coaching in Leadership and Healthcare Conference, September Belmount, MA, USA. (Poster presentation selected for competition) 2014

  • Cinar AB, Schou L. Can Women Lead the Social Entrepreneurship in Dentistry? One for All Approach-Health Coaching-for Management of Oral Health and Chronic Diseases. 5th The American Dental Education Association (ADEA), International Women's Leadership Conference, Barcelona, Spain.2014

  • Cinar AB. A holistic approach to empower communication skills of patients with diabetes type 2: Health Coaching. 12th International Conference on Communication in Healthcare, September, Amsterdam, the Netherlands. (Oral presentation) 2014

  • Cinar AB. How can we promote both oral health and diabetes?: A new patient-centered approach. Nordic Young Scientist Conference in Odontology, August, Malmö, Sweden 2014

  • Cinar AB, Schou L. Health Coaching: Positive Influence on Oral and Diabetes Management. The International Association for Dental Research, General Session and Exhibition, June, Cape Town, South Africa 2014

  • Cinar AB, Schou L. Health Promotion for Diabetes Patients: Health Coaching or Health Education? World Congress on Preventive Dentistry, October 9-12, Budapest, Hungary.2013

  • Cinar AB, Schou L. Smile Healthy to Your Diabetes: Toothbrushing Self-efficacy at Diabetes Management. CED/IADR, Florence, Italy.(Oral presentation)

  • Cinar AB. Behavioural Competency: A gateway to improve the health among patients with diabetes mellitus type 2? The European Association of Communication in Healthcare (EACH), September, St. Andrews, Scotland. (Oral presentation) 2012

  • Cinar AB, Schou L Toothbrushing competency: A key role player at glycemic control? IADR, June, Brazil. (Oral presentation) 2011

  • Cinar AB. Toothbrushing Self-Efficacy and Behaviour: A gateway to diabetes management and health among patients with diabetes mellitus type 2? International Diabetes Federation, Dubai, UAE.2011

  • Cinar AB. Smile Healthy with Your Diabetes: An Oral Health Coaching-Based Intervention. IADR, March, San Diego, USA.2011

  • Cinar AB, Dinesen C. Coaching at health-care: a communication-based intervention to improve the health-capacity building skills of health-care professionals and patients. EACH, September, Verona, Italy. (Workshop) 63.Cinar AB, Dinesen C. Transformational Leadership and Coaching to better communicate with patients. EACH, September, Italy. (Symposium) 2010

  • Cinar AB, Oktay I, Schou L. The role of self-efficacy in oral health behavior and diabetes. IADR, July, Barcelona, Spain.2010

  • Cinar AB, Murtomaa H. Health Coaching as an Oral Health Education Tool. 35th Association for Dental Education in Europe (ADEE) Meeting, Finland.2009

The project has been shown  among the top 2 behavioural interventions for effective diabetes management by a systematic review
Chess Pieces

Sherifali D et al. Evaluating the Effect of a Diabetes Health Coach in Individuals with Type 2 DiabetesCan J Diabetes2016 Feb;40(1):84-94. doi: 10.1016/j.jcjd.2015.10.006.

Award Winner
The present project has won 3 International Awards; European Mentoring and Coaching Council International Coaching Award (2016), 100 Best Global Coaching Leaders Award, 50 Outstanding Women in Healthcare Management–2016;
for promoting positive change and well-being in society through an international “health coaching” project for diabetes management, incorporating multiple areas of wellbeing, via building the bridges between the society, business, academia, public health and the NGOs.
Stone Tower
The project inspired a Master Student from at Master Oral Public Health Department , University of Dundee and he conducted a systematic review on The Use of Common Behavioural Interventions in Oral Health and Diabetes Management. He found out that the project by AB Cinar is 1 of the 2 studies assessing the impact of Common Risk  Factor Approach on Diabetes Management. He is currently assessing the knowledge about coaching among DM2 patients and healthcare professionals in Nigeria.
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