1. Clinical
Middle East Edition Volume 7 Number 4 Fall 2008
WWW.DIABETES.ORG/CLINICALDIABETES
Practical Information for Primary Care
An Official
Journal of the
American
Diabetes
Association
F e a t u r e s
148 Diabetes Education: Integrating Theory, Cul-
tural Considerations, and Individually Tailored
Content
Chandra Y. Osborn, PhD, MPH, and
Jeffrey D. Fisher, PhD
151 Treatment of Diabetes in Long-Term Care Fa-
cilities: A Primary Care Approach
Eric L. Johnson, MD; James D. Brosseau, MD, MPH;
Matt Sobule, MS-IV; and Jon Kolberg, MS-IV
D e p a r t m e n t s
146 Editorial: Improving Diabetes Care: Queries
Versus Commands
Tom A. Elasy, MD, MPH, Editor-in-Chief
156 Landmark Studies: The Quandary of Improv-
ing Hypertension Control in Diabetes
Reviewed by Paul Chelminski, MD, MPH, and
Michael Pignone, MD, MPH
159 Practical Pointers: Helping Patients Make and
Sustain Healthy Changes: A Brief Introduc-
tion to Motivational Interviewing in Clinical
Diabetes Care
Michele Heisler, MD, MPA, and Kenneth Resnicow, PhD
164 Physician Information: Motivational Inter-
viewing: Promoting Reflection
as a Cue to Change
165 Bridges to Excellence: Increasing Monofila-
ment Examinations as a Means of Teaching
Quality Improvement
Annie Whitney, MS; Brittany Bohinc, MD; Martin
Butler, MD; Debra Bynum, MD; Robb Malone,
PharmD; Darren DeWalt, MD, MPH; and Michael
Pignone, MD, MPH
168 Diabetes Foundation: Hypoglycemia
Michael J. Fowler, MD
172 Case Studies:
A Patient with Diabetes, Hepatitis C Virus
Infection, and Hemochromatosis Gene Muta-
tion
Aidar R. Gosmanov, MD, PhD, DMSc, and Guillermo
E. Umpierrez, MD
A Comparison Between Two Reactions to the
Diagnosis of Gestational Diabetes
Lois L. Exelbert, RN, MS, CDE, BC-ADM
Retrospective Review of Incidental Reti-
nal Emboli Found on Diabetic Retinopathy
Screening
Rehan Ahmed, BA; Vijay Khetpal, MD; Lawrence M.
Merin, RBP, FIMI; and
Amy S. Chomsky, MD
L O C A L ART I C L ES
181 Diabetes Education In The Arab World: A Call
For Action
MONIRA AL-AROUJ, MD, MEGAHED ABU AL-MAGD, MD,
SAMIR ASSAAD-KHALIL, MD .PHD, ANWAR BATEIHA ,
PHD, RADHIA BOUGUERRA, MD, MOHAMED FAHMY,
MD ,PHD, MARTHA FUNNEL , MS, RN,CDE, SHERIF
HAFEZ, MD, FACP,,MAHMOUD ASHRAF IBRAHIM, MD,
SUHAIL KISHAWI, MD, ABDULRAZZAQ AL-MADANI, MD,
ABDULLAH BEN NAKHI, MD1, KHALED TAYEB, MD
WWW.CLINICALDIABETESME.ONLINEDIABETES.NET

2. Middle East Edition, Volume 7, Number 4, 2008
From the Editor’s Desk
The issue of starting Insulin therapy very
early in newly diagnosed type 2 diabe-
tes cases is still a hot debate because of
the barriers for the use of insulin including in-
jection phobias , high cost , weight gain…etc
According to the established guidelines pub-
lished in 2008 like the ADA clinical practice
recommendations and NICE guidelines the
starting insulin therapy may be based on the
following criteria : if other measures do not
keep A1C to < 7% (or other agreed target),
Initiation with a structured programme ,
preferably begin with human NPH insulin
taken at bedtime or twice daily according
to need , alternatively, you may consider a
once-daily long-acting insulin analogue (in-
sulin Glargine) if: the person requires as-
sistance to administer insulin injections, or
his or her lifestyle is significantly restricted
by recurrent symptomatic hypoglycaemic
episodes, or twice-daily basal insulin injec-
tions plus oral glucose-lowering medications
would otherwise be needed.
Offer a trial of a long-acting insulin analogue
(insulin Glargine) if NPH insulin causes sig-
nificant nocturnal hypoglycaemia , consider
twice-daily biphasic human insulin (pre-
mixed) regimens, particularly where A1C >
9.0%. A once-daily regimen may be an op-
tion when starting this therapy, consider pre-
mixed insulin analogue preparations rather
than pre-mixed human insulin preparations
when immediate injection before a meal is
preferred, or hypoglycaemia is a problem, or
there are marked postprandial blood glucose
excursions , Review use of sulfonylurea if
hypoglycaemia occurs with insulin plus sul-
fonylurea. Intensifying the insulin regimen :
monitor those using basal insulin regimens
(NPH or a long-acting analogue [Glargine]
for need for mealtime or pre-mixed insulin ,
monitor those using pre-mixed insulin once
or twice daily for need for further preprandial
injection or eventual change to mealtime plus
basal regimen.
Related to the same issue , few days ago an
interesting paper from Taiwan was published
in Diabetes Care (1)
This paper addressed the Beneficial Effects
of Insulin on Glycemic Control and beta Cell
Function . The aim was to evaluate whether
treatment with insulin is advantageous com-
pared with oral antidiabetes agents in newly
diagnosed type 2 diabetes with severe hyper-
glycemia after short-term intensive insulin
therapy. Newly diagnosed type 2 diabetic
patients with severe hyperglycemia were hos-
pitalized and treated with intensive insulin
injections for 10–14 days. The oral glucose
tolerance test (OGTT) was performed after
intensive insulin treatment. After discharge,
the patients were randomized to receive either
insulin injections or oral antidiabetes drugs
(OADs) for further management. The OGTT
was repeated 6 months later, and beta cell
function and insulin sensitivity were evalu-
ated again. These subjects were continually
followed up for another 6 months to evalu-
ate their long-term glycemic control. the A1C
level was significantly lower in the insulin
group than in the OAD group (. During the
follow-up visit, the A1C level was still better
in the insulin group. All parameters regard-
ing beta cell function measured in the OGTT
were improved significantly in both groups
after 6 months of treatment. Compared with
the OAD group, the homeostasis model as-
sessment of beta cell function index, insulin
area under the curve, and insulinogenic index
were better in the insulin group. They con-
cluded that a 6-month course of insulin ther-
apy, compared with OAD treatment, could
more effectively achieve adequate glycemic
control and significant improvement of beta
cell function in new-onset type 2 diabetic pa-
tients with severe hyperglycemia.
All the above would confirm the benefits of
the early use of Insulin in newly diagnosed
type 2 diabetes cases.
However still you have a tough homework to
overcome the significant barriers!!
Reference
(1) Beneficial Effects of Insulin on Glycemic
Control and Cell Function in Newly Diag-
nosed Type 2 Diabetes With Severe Hyper-
glycemia After Short-Term Intensive Insulin
Therapy. HARN-SHEN CHEN, TZU-EN
WU, TJIN-SHING JAP, LI-CHUAN HSIAO,
SHEN-HUNG LEE, HONG-DA LIN, Diabe-
tes Care 31:1927–1932, 20
Mahmoud Ashraf Ibrahim
Editor , Middle East Edition

3. 181Volume 7, Number 4, 2008 • CLINICAL DIABETES (MIDDLE EAST EDITION)
L O C A L A R T I C L E S
MONIRAAL-AROUJ, MD1
, MEGAHED ABU
AL-MAGD, MD2
, SAMIR ASSAAD-KHALIL,
MD .PHD 3
, ANWAR BATEIHA , PHD4
,
RADHIA BOUGUERRA, MD5
, MOHAMED
FAHMY , MD ,PHD6
, MARTHA FUNNEL ,
MS, RN,CDE7
, SHERIF HAFEZ, MD, FACP8
,,
MAHMOUD ASHRAF IBRAHIM, MD9
,
SUHAIL KISHAWI, MD10
, ABDULRAZZAQ
AL-MADANI, MD11
, ABDULLAH BEN
NAKHI, MD1
, KHALED TAYEB, MD12
From the 1
Dasman Center for Research and
Treatment of Diabetes, Kuwait;2
Department
of Internal Medicine & Diabetes, Faculty
of Medicine, Mansura University, Mansura,
Egypt; 3
Department of Medicine & Diabetes,
Faculty of Medicine , Alexandria University
, Egypt 4
Director , NCD East Mediterranean
Office of WHO , EMRO , 5
National Institute
of Nutrition, Tunis, Tunisia; 6
Department of
Internal Medicine & Endocrinology, Faculty of
Medicine, Ain Shams University, Cairo, Egypt
, 7
Michigan Diabetes Research and Training
Center Ann Arbor, MI , USA; 8
Department of
Internal Medicine & Diabetes, Faculty of Med-
icine, Cairo University, Cairo, Egypt 9
Egyptian
Diabetes Center, Cairo, Egypt;, 10
Ministry of
Health, Palestinian National Authority, Shifa
Hospital, Gaza, Palestine; 11
Dubai Hospital,
Dubai, United Arab Emirates; 12
Al-Nour Hos-
pital, Mekkah, Saudi Arabia.
Address correspondence and reprint requests to
Mahmoud Ashraf Ibrahim, MD,
19 Nasouh St., Zeitoun, Cairo 11321,
Egypt. E-mail: mahmoud@arab-diabetes.com
Abbreviations:
TPE , Therapeutic Patient Education - HCPs,
Health Care Professionals - DSME , Diabetes
Self Management Education - NGOs, Non
Governmental Organizations - WHO , World
Health Organization .
ABSTRACT
Diabetes education is effective for improving
clinical outcomes and quality of life. The bar-
riers to patient education in the Arab World in-
clude: Attitude of the administration & policy
makers, the negative view of health profes-
sionals and patients towards education, lack of
curriculum / programs, lack of trained/certified
personnel in the field of Therapeutic Patient
Education (TPE), economic barriers, miscon-
cepts, environmental & ecological barriers, lack
of legislation for food labels, lack of premises
for TPE, the absence of a positive role for the
patients in their therapeutic choices, unaware-
ness of patients about their rights , lack of time
for both the patient and health care providers
and high prevalence of illiteracy. Strategic plans
should address all these barriers. Content areas
that need to be addressed are determined in col-
laboration with the patient. Any health care pro-
fessional can provide diabetes education. The lack
of trained personnel in the domain of TPE in our
region dictates the need to fill this gap by adopting
a strategic plan, implemented in successive steps,
starting by the formation of a number of Health
Care Professionals (HCPs) in short term training.
This document is a call for action, inviting all who
are concerned with diabetes to establish national
diabetes programs in the Arab World , and to start
to undertake educational initiatives.
DIABETES SELF-MANAGEMENT
Recent advances in knowledge, therapies, and
technology have greatly enhanced our ability
to effectively care for patients with diabetes.
In spite of these advances, people with diabe-
tes still achieve less than optimal blood glucose
levels and suffer acute and long-term complica-
tions. Health Care Professionals (HCPs) are of-
ten frustrated by their patients’ inability to make
changes in their behavior. On the other hand,
people with diabetes sometimes feel that they
are “just a blood sugar number” to their health
care providers. Clearly, there is a gap between
the promises and the reality of diabetes care.
One of the keys to closing the gap is effective
diabetes self-management.
Diabetes self-management refers to all activi-
ties in which patients engage in care for their ill-
ness; promote health; augment physical, social,
and emotional resources; and prevent long- and
short-term effects from diabetes. Education is
the essential first step in becoming an effective
self-manager. Traditional views of diabetes self-
management education (DSME) were based on
information transfer and compliance or adher-
ence. Based on more recent evidence, DSME
has evolved to recognize the right and respon-
sibility of patients to make decisions and set
self-selected goals that make sense within the
context of their lives. Effective DSME is a criti-
cal component in quality diabetes care.
Peer support is a closely related issue where
patients with diabetes provide support to newly
diagnosed patients. Different educational courses
for peer supporters have been designed and im-
plemented. Peer support in several randomized
trials has been shown to contribute to improved
diabetes management (1,2) .
DEFINITION AND OBJECTIVES
In the American Diabetes Association’s 2007
Standards for Diabetes Self-Management Edu-
cation (DSME), DSME is defined as the ongo-
ing process of facilitating the knowledge, skill,
and ability necessary for diabetes self-care (3).
This process incorporates the needs, goals, and
life experiences of the person with diabetes and
is guided by evidence-based standards. The
overall objectives of DSME are to support in-
formed decision-making, self-care behaviors,
problem solving and active collaboration with
the health care team, and to improve clinical
outcomes, health status, and quality of life.
GUIDING PRINCIPLES
1. Diabetes education is effective for im-
proving clinical outcomes and quality of
life, at least in the short-term ( 4-10).
2. DSME has evolved from primarily di-
dactic presentations to more theoretically
based empowerment models (6,11).
3. There is no one “best” education pro-
gram or approach, however, programs
incorporating behavioral and psycho-
social strategies demonstrate improved
outcomes.(12-14). Additional studies
show that culturally and age appropri-
ate programs improve outcomes (15-
19) and that group education is effec-
tive (7,9,10,20,21).
4. On-going support is critical to sustain
progress made by participants during
the DSME program. (6,16,22,23).
5. Behavioral goal setting is an effective
strategy to support self-management
behaviors (21).
SUGGESTED STRATEGIES TO OVER-
COME THE BARRIERS TO PATIENT
EDUCATION IN THE ARAB WORLD
1. Attitude of the Administration &
policy makers.
A call for action document, referring
to the UN resolution is needed (United
Nations Resolution 61/225 which unani-
mously designated World Diabetes Day
as a United Nations day to be observed
every November 14 beginning in 2007.).
This aims at inviting all who are con-
cerned with diabetes to establish a nation-
al diabetes program which should include
planning for educational initiatives.
2. The Negative View of health professionals
& patients towards education.
a. Awareness programs for the Health Care
Professionals [HCPs] showing the impor-
tance of adopting a team/multidisciplinary
approach towards the management of dia-
betes. Laying stress to include and put in re-
lief theTPE as an integral component of the
guidelines and the treatment algorithms.
b. Launching a campaign targeting sub-
jects with diabetes, their relatives, and
the general population. These messag-
es will include an emphasis on taking
diabetes seriously, the importance of
self-management, patient role in deci-
sion-making, and the benefits of TPE
for improved quality of life (e.g., Live
Better with Diabetes through TPE).
These messages would offer help and
hope for people with diabetes and
stress the value of recognized medical
therapies versus unproven therapies
and a healthy lifestyle.
3. Lack of approved curriculum of
educational programs.
Establishing an educational curriculum
based on international curricula de-
veloped by the International Diabetes
Federation, and adapted to the local/
regional needs.
4. Lack of trained/certified personnel in the
field of TPE
DIABETES EDUCATION IN THE ARAB WORLD:
A CALL FOR ACTION

4. 182 Volume 7, Number 4, 2008 • CLINICAL DIABETES (MIDDLE EAST EDITION)
L O C A L A R T I C L E S
Adopt strategic plan implemented in
steps starting by the formation of a
number of HCPs in short term training
workshops. The purpose of TPE is not to
convince patients to follow our advice,
but to help patients make decisions and
become active participants in their care.
Patients need to learn about diabetes
and how to safely care for it on a daily
basis. They also need information about
various treatment options, the benefits
and costs of each of these options, how
to make changes in their behaviors, and
how to solve problems. In addition, pa-
tients need to understand their role as a
decision-maker and how to assume re-
sponsibility for their care (Annex).
5. Economic barriers.
a. Invite NGOs, pharmaceutical companies,
institutions, associations, financial and
business establishments, clubs, etc… to
support educational activities.
b. Demonstrate to the policy-makers that
budgets for TPE are cost-effective on
long run.
c. Propagate the message that an extra-fi-
nancial burden of TPE is cost-effective
since it has a beneficial impact on the
metabolic control, and prevention of
complications (25-27)
6. Misconcepts.
a. Media:
i. Sensitization of people responsible
for the media about the issue of mis-
concepts.
ii. Implement a recognized code of eth-
ics e.g. WHO/EMRO code of ethics
in collaboration with the concerned
syndicates ( media, press, medical
professions, etc…) (28)
b. Health professionals:
Orientation of health professionals
about the ethical, legal, and the sci-
entific importance of following the
guidelines and ethical codes.
c. Patients and the public:
i. Launching campaigns targeting the
patients and the general population
about the hazards of following undoc-
umented therapeutic modalities, com-
plementary medicine, and others…
ii. Guide the patients to the source of
right information (e.g.: recognized in-
ternational associations, regional/local
associations, and other references such
as the pharmacopoeias).
d. Wrong beliefs:
Investigate and collect data about the
local myths, misconcepts and taboos
to be addressed in the campaigns
dealing with these issues.
e. Legislation for advertising:
Call for action to initiate legislations
forbidding advertising products in-
cluding food supplements of unprov-
en safety and therapeutic efficacy ac-
cording to the international standards
7. Environmental and Ecological
barriers:
Adapt the available guidelines to suit
the environmental /ecological circum-
stances of the area (e.g.: indoor sports
in hot climate countries, green areas,
walking paths, etc…).
8. Lack of legislation obliging the food in-
dustry to display food labels
Legislations obliging food industries to
display labels showing the nutritional
facts (calories, glucose, trans-fats etc…)
of each manufactured food item.
9. Lack of premises for TPE
Invite NGOs to take an active role in pro-
viding the places, premises, facilities, and
tools to provide TPE.
10.Patients do not have a positive role in
their therapeutic plans/choices.
This may negate their need for TPE. Thus
it is necessary to propagate the message
through education of the members of
HCP team that the patient should be the
center of the therapeutic decisions.
11.Patients are not aware about their rights
which include TPE
Disseminate patient’s rights among the
patients and their relatives.
12. Lack of time for both the patient and
health care providers.
Plan for providing sufficient time al-
located to TPE; since it has been dem-
onstrated that there is a positive cor-
relation between the time allotted to
the TPE and the metabolic outcome
. The effectiveness of DSME on A1C
levels has been directly correlated to
the amount of contact time spent be-
tween the edu¬cator and the patient.
Contact time with an educator was the
only sig¬nificant predictor of reduction
in A1C; 23.6 hours of educator contact
was needed for every 1% absolute de-
crease in A1C. The take-home message
is clear: the more time a patient has with
an educator, the better.(10 , 29).
13. High prevalence of illiteracy :
The rate of illiteracy among the over
15 population in the Arab countries are
31.3% both genders and 40.2% women
during 2000’s (30).Many persons with
diabetes are labeled noncompliant, ex-
perience repeated hospital admissions,
and have multiple complications due
to poor disease control. These prob-
lems may result from unrecognized low
health literacy. When communication
and patient education materials are ap-
propriate to literacy needs and prefer-
ences, people can succeed in managing
their disease. Health literature often
is written for skilled readers, contains
complex words and sentence structures,
and attempts to explain difficult scien-
tific concepts. Most patients, regardless
of literacy level, prefer simple, easy-
to-read materials. Patients with limited
reading skills take words literally rather
than in context, quickly tire of long pas-
sages, and often skip over unfamiliar
words. Those with low literacy often
guess their way through instructions and
read so slowly that they miss the context
of the information and draw incorrect
conclusions. Patients with inadequate
literacy usually have adequate intelli-
gence and are capable of learning new
information if it is presented in a way
that links it to information they already
know or is personally relevant.(31)
CONTENT AREAS
Content areas that need to be addressed are deter-
mined in collaboration with the patient. The as-
sessed needs of the individual with pre-diabetes
and diabetes will determine which of the content
areas listed below are to be provided (3):
• Describing the diabetes disease process
and treatment options.
• Incorporating nutritional management
into lifestyle, laying stress on the im-
portance of considering the total caloric
intake, the recommendations related to
composition of diet and the importance
of consuming healthy traditional meals
in particular the Mediterranean meal.
Also putting in relief the importance
of addressing emerging issues such as
minimizing trans-fat food content (32).
• Incorporating physical activity into
lifestyle putting in consideration and
adapting it to the social, economic and
weather barriers.
• Addressing issues related to sexual life
into the management of the disease.
• Addressing issues related to pregnancy
and contraception for people with dia-
betes.
• Using medication(s) safely and for
maximum therapeutic effectiveness
considering its cost benefit.
• Monitoring blood glucose and other
parameters and interpreting and using
the results for self-management and
decision-making. This should at least
meet the minimal care recommenda-
tions (33).
• Preventing, detecting, and treating
acute complications
• Preventing detecting, and treating
chronic complications
• Developing personal strategies to ad-
dress psychosocial issues and concerns
• Developing personal strategies to pro-
mote health , quality of life and behav-
ior change
• Develop personal strategies addressing
special local/ regional occasions such as
fasts, feasts, social occasions and tradi-
tions e.g. Ramadan fast (34) ,Hajj (Pil-
grimage)(35) Christian fasts (36) , wed-
dings etc …..
PROFESSIONALRESPONSIBLITIES: The
Diabetes Education Provider
While any health care professional
can provide diabetes education, dia-
betes educators are generally defined
as health care professionals who have
specialized training and knowledge
in diabetes care, effective educational
methods and strategies, effective com-
munication skills and behavioral goal
setting and other evidence-based tech-
niques effective in helping patients ad-
dress psychosocial issues and modify
their health-related behaviors.
The lack of trained personnel in the

5. 183Volume 7, Number 4, 2008 • CLINICAL DIABETES (MIDDLE EAST EDITION)
L O C A L A R T I C L E S
domain of TPE in our region dictates
the need to fill this gap by adopting
strategic plan implemented in succes-
sive steps starting by the formation of a
number of HCPs in short term training.
A further step would be to address the
academic institutions to plan for certi-
fied diplomas in the field. This would
further be consolidated by addressing
the Ministries of Health to accredit
these degrees.
Acknowledgments
The Egyptian Diabetes Center, with a
support from Les Laboratoires
Servier, made this work possible. We
are grateful to Dr. Richard Kahn Scien-
tific & Medical Officer of the ADA for
his continuous & sincere support .
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Annex
Protocol of Therapeutic Patient
Education (TPE)
Effective TPE includes four key elements:
• Opportunity to discuss the emotional as-
pects of living with diabetes
• Behavioral goal-setting (an example is
outlined in table 1)
• Clinical content
• Opportunity to reflect on their experi-
ences with goal-setting
Visit-based strategies for TPE
1. Begin the visit by asking patients to
identify what is hardest for them and/or
what questions or concerns they would
like addressed. (See table 2) Another
option is to use the Concerns Assess-
ment form outlined in table 3, which
patients complete in the waiting room
prior to the visit. Address the patients’

6. 184 Volume 7, Number 4, 2008 • CLINICAL DIABETES (MIDDLE EAST EDITION)
L O C A L A R T I C L E S
questions at the start of the visit.
2. Take advantage of teachable moments
that occur during each visit. As examples,
point out areas that need special attention
during a foot exam or use the patient’s lab
values to teach about risks for complica-
tions.
3. Before you end the visit, use the “teach-
back“ method and ask patients to tell you
in their own words about the information
you provided.
4. Close the loop at the end of the visit
by asking patients to identify one thing
they will do between now and the next
visit to better manage their diabetes.
Make a note of this goal so that you can
ask about progress at the next visit.
In addition, during visits,
• Stress the importance of the patients’
role in self-management and daily de-
cision-making. Describe your role as a
partner in the care process. Acknowl-
edge the patients’ right and responsibil-
ity to make self-care choices and to be
the primary decision-makers.
• Offer referrals to a TPE program and/or
a registered dietitian or other needed re-
sources, such as mental health workers.
• Ask for the patients’opinions about home
blood glucose monitoring results and
other laboratory and outcome measures.
• Review and revise diabetes treatment
plans as needed based on patients’ and
providers’ assessment of its effective-
ness.
• Provide ongoing information about the
costs and benefits of therapeutic and
behavioral options. Acknowledge that
there are many ways to treat diabetes,
and determine patients’ interest in or
concerns about each option.
• Provide information about behavior
change and problem solving strategies.
• Assist patients in solving problems and
overcoming barriers to self-manage-
ment.
• Support and facilitate patients in their role
as self-management decision-makers.
Practice-based strategies for TPE
• Establish TPE programs in your area that
are designed using proven and effective
methodologies and trained personnel.
• Link patient TPE with provider support
(e.g., system changes, patient flow, lo-
gistics).
• Supplement TPE provided with infor-
mation technology.
• Incorporate TPE into practical inter-
ventions, coordinated by nurse case
managers or other staff members.
• Create a team with other health care
professionals in your system or area
who have additional experience or
training in the clinical, educational, and
behavioral or psychosocial aspects of
diabetes care.
• Replace individual visits with group or
cluster visits to provide efficient and ef-
fective TPE.
• Assist patients in selecting one area of
self-management on which to concen-
trate that can be reinforced by all team
members.
• Create a patient-centered environment
that incorporates TPE from all practice
personnel and is integrated into the flow
of the visit.
Table 1: Goal-setting Protocol
Step I:
Explore the Problem or Issue (Past)
• What is the hardest thing about caring
for diabetes for you?
• Please tell me more about that.
• Are there some specific examples you
can give me?
Step II:
Clarify Feelings and Meaning (Present)
• What are your thoughts about this?
• Are you feeling (insert feeling) be-
cause (insert meaning) ?
Step III:
Develop a Plan (Future)
• What do you want?
• How would this situation have to change
for you to feel better about it?
• Where would you like to be regarding
this situation in (specific time, e.g. 1
month, 3 months, 1 year)?
• What are your options?
• What are barriers for you?
• Who could help you?
• What are the costs and benefits for each
of your choices?
• What would happen if you do not do
anything about it?
• How important is it, on a scale of 1 to
10, for you to do something about this?
• Let’s develop a plan.
Step IV: Commit to Action (Future)
• Are you willing to do what you need to
do to solve this problem?
• What are some steps you could
take?
• What are you going to do?
• When are you going to do it?
• How will you know if you have suc-
ceeded?
• What is one thing you will do when
you leave here today?
Step V:
Experience and Evaluate the Plan
(Future)
• How did it go?
• What did you learn?
• What barriers did you encounter?
• What, if anything, would you do dif-
ferently next time?
• What will you do when you leave
here today?
Table 2:
ALE Communication Strategy
Ask:
• What is your greatest concern about
diabetes?
• What are your thoughts and feelings
about this concern?
Listen
• Listen to the patient’s story without
interrupting, offering advice or an
opinion.
Encourage
• Why do you think that is?
• What has that been like for you?
• What are your thoughts or feelings
about that?
• Sounds like that has been for you.
Table 3:
Concerns Assessment Form*
Please answer the following questions before
your visit. Your answers will help ensure that
your concerns are addressed.
1. What is hardest or causing you the most
concern about caring for your diabe-
tes at this time? (e.g. following a diet,
medication, stress)
2. Lease write down a few words about
what you find difficult or frustrat-
ing about the concern you mentioned
above.
3. How would you describe your thoughts
or feelings about this issue? (e.g. con-
fused, angry, curious, worried, frustrat-
ed, depressed, hopeful)
4. What would you like us to do during
your visit to help address your concern?
(Please circle the letters in front of all
that apply)
A. Work with me to come up with a plan to
address this issue.
B. I don’t expect a solution. I just want you
to understand what it is like for me.
C. Refer me to another health professional
or other community services
5. I would like answers to the following
questions at this visit:
6. I would like answers to these questions
at some future visit:
7. Other (Please Explain)
*Available free from:
http://www.med.umich.edu/mdrtc/profs/index.
htm#conc