Diabetes education - International Diabetes Federation

November 2007 

Volume 52 I Special Issue 

G l o b a l p e r s p 

e c t i v e s o n d i a b e t e s 

Diabetes education

Contents 

IDF | Promoting diabetes care, 

prevention and a cure worlwide 

Diabetes Voice is published quarterly 

and is available online at 

www.diabetesvoice.org 

Editor-in-Chief 

Rhys Williams, UK 

managing Editor 

Catherine Regniers 

catherine@idf.org 

Editor 

Tim Nolan 

tim@idf.org 

Layout and printing 

Luc Vandensteene 

Ex Nihilo, Belgium 

www.exnihilo.be 

Advisory group 

Pablo Aschner, Colombia 

Ruth Colagiuri, Australia 

Patricia Fokumlah, Cameroon 

Attila József, Hungary 

Viswanathan Mohan, India 

All correspondence and advertising 

enquiries should be addressed to 

the Managing Editor: 

International Diabetes Federation 

Avenue Emile De Mot 19 

1000 Brussels 

Belgium 

Phone: +3--54316 

Fax: +3--5385114 

catherine@idf.org 

This publication is also available in 

French, Spanish and Russian. 

© International Diabetes Federation, 2007 

All rights reserved. No part of this publication 

may be reproduced or transmitted in any form 

or by any means without the written prior 

permission of the International Diabetes 

Federation (IDF). Requests to reproduce or 

translate IDF publications should be addressed 

to the IDF Communications Unit, 

Avenue Emile De Mot 19, B-1000 Brussels, 

by fax +32-2-5385114, or by e-mail 

communications@idf.org. 

Opinions expressed in the articles are 

those of the authors and do not 

necessarily represent the views of IDF. 

ISSN: 143-4064 

D I A B E T E S V I E W S 

Action on education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2 

Martin Silink 

The art of assisting discovery. . . . . . . . . . . . . . . . . . .3 

Margaret McGill 

T H E F U T U r E O F C A r E 

The benefits of diabetes education: 

better health outcomes through 

successful self-management. . . . . . . . . . . . . . . . . . . . . . .5 

Malinda Peeples, Janice Koshinsky, 

Janis McWilliams 

The complex and constantly 

evolving role of diabetes 

educators. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 

Trisha Dunning 

A case for including peers 

as providers of diabetes selfmanagement 

education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 

Kate Lorig 

Empowerment, education and 

discipline: implementing a diabetes 

self-management plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 

Michael Weiss 

Certification: a means for future 

recognition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 

Fern Vining and Joyce Bohren 

E D U C A T I O N F O r E D U C A T O r S 

Teaching and learning in diabetes: 

techniques and methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23 

Seyda Ozcan and Ozgul Erol 

Implementing a post-graduate 

degree course for diabetes 

educators in Argentina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 

Juan José Gagliardino, María del Carmen 

Malbrán, Charles Clark Jr 

The need for tact, openness and 

honesty when talking about 

complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29 


Using new technologies in 

diabetes education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 

Line Kleinebreil 

L I F E L O N g L E A r N I N g 

Providing support and education 

to children with diabetes – specific 

needs, special care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 

Barbara Anderson 

Young people’s needs and 

priorities for improved support 

and education: a call for action. . . . . . . . . .41 

Anja Østergren Nielsen, Dana Lewis, 

Caitlin McEnery, Jakob Pedersen, Martin 

Salkow, Søren Skovlund, Alex Greene 

The Steno Diabetes Center: 

from education to action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 

Ulla Bjerre-Christensen, Ebbe Eldrup, 

Christian Binder 

Improving the quality of diabetes 

education in Vietnam – a 

community-based approach. . . . . . . . . . . . . . . . . . . .46 

Ta Van Binh and Le Quang Toan 

© International Diabetes Federation, 2007 

Cover photo © iStockphoto 

November 2007 | Volume 52 | Special Issue

Diabetes views 

Action on education 

Martin Silink is 

IDF President. 

He is Professor 

of Paediatric 

Endocrinology 

at the 

University of 

Sydney and 

the Children’s 

Hospital 

in Sydney, 

Australia. 

Let us be clear: the recent and vertiginous increase in the 

number of people with diabetes worldwide constitutes the 

biggest disease epidemic in human history. It is estimated 

that close to 4 million deaths each year are directly related 

to diabetes – now the world’s fourth leading cause of 

mortality by illness – and the global epidemic shows no 

signs of abating. With 246 million people with diabetes 

now, and 380 million people with diabetes by 2025, 

diabetes is set to take a toll – in human and economic 

terms – on families and societies around the globe, the 

like of which our species has never experienced. 

In recent decades, a revolution in science has contributed 

to a greater understanding of diabetes, and the development 

of new cutting-edge therapies. However, prevalence 

of the disease and related death and disability have 

continued to grow rapidly. Of greatest concern is that 

diabetes prevalence is highest in the developing world. 

Indeed, a constellation of non-communicable diseases 

are threatening to stifle economic development in the 

countries where growth is most needed. 

Managing diabetes, a complex task in ideal circumstances, 

can be made extremely difficult in certain situations. 

In this special issue we read about people striving 

to provide (or receive) education that is suitable and 

relevant for young people; people living in isolated rural 

communities in a low-income African country; women 

with diabetes living in an isolated region in southern 

Europe; elderly people often with more than one chronic 

condition; healthcare providers striving to improve their 

diabetes care skills in southeast Asia and Latin America; 

and others. 

Whatever their circumstances or social status, IDF believes 

that all people with the condition and their healthcare 

providers have the right to receive high quality, culturally 

appropriate diabetes education. Note that when we talk 

about diabetes education, we talk about education for 

all – for doctors, and nurses and other health carers, as 

well as for adults with diabetes, children with diabetes 

and their teachers and family members. 

United by the UN Resolution on Diabetes (61/225. 

World Diabetes Day), which recognizes that ‘diabetes is 

a chronic, debilitating and costly disease associated with 

severe complications, which poses severe risks to families, 

Member States and the entire world’, the global diabetes 

community must act to address two major challenges: the 

prevention of diabetes, and the prevention of diabetesrelated 

complications in the millions already affected by 

the disease. Education must form the foundation in all 

plans and actions to surmount these challenges. 

A number of authors in this special issue warn that as 

the number of people with diabetes around the world 

continues to rise, so will the need for high standards of 

self-management. This can only be achieved by high 

quality therapeutic education delivered by skilled educators. 

IDF recognizes the urgent need to reach a greater 

number of healthcare providers with diabetes education 

materials and programmes in order to promote improved 

diabetes care and prevention. 

Improving access to diabetes education is central to IDF’s 

programme of action to reduce and eventually reverse the 

global diabetes epidemic. IDF, which encompasses member 

associations, Regions and Global, is to initiate – or is already 

engaged in – education-related projects which concentrate 

on a number of fronts. Initially, the focus will be on supporting 

the increased coverage and improved quality of diabetes 

education worldwide. The provision of sustainable training 

for healthcare providers is one of the priorities. 

To achieve this, IDF will establish a global framework for 

diabetes education activities, which will include appointing 

a global Diabetes Education Manager and setting 

up regional IDF Centres of Education within existing 

institutions. Regional Diabetes Education Coordinators 

will manage the regional IDF Centres of Education and 

educational projects around the world – like the multidisciplinary 

courses in Vietnam described in this issue. 

Readers should keep an eye on this magazine and on the 

IDF website for further developments and to learn how to 

benefit from IDF’s commitment to education worldwide. 


Diabetes views 

 

The art of assisting discovery 


is Manager of 

the Diabetes 

Centre, Royal 

Prince Alfred 

Hospital, 

Australia. She is 

Chair of the IDF 

Consultative 

Section on 

Diabetes 

Education and 

a Senior IDF 

Vice-President. 

Different learning theorists and developmental psychologists 

have come to different conclusions about the way children 

develop intellectually. Some believe that it is a smooth and 

continuous process; others believe that children develop in 

a more disjointed manner, in a series of relatively stable 

stages. The continuous development theory holds that as 

children get older, they constantly add new lessons and 

skills on top of old lessons and skills. In the staged development 

models (Jean Piaget’s cognitive-developmental stage 

theory, for example), children seem to develop chunks of 

abilities and to experience events at certain times in life. 

Both groups are no doubt correct. While it is true that 

development is a continuous and lifelong process, it is 

also true that there are stages to growth, and that developments 

occur at given times throughout life. The article by 

Barbara Anderson highlights the importance of considering 

children’s developmental issues in order to reconcile 

the inevitable conflicts that arise between normal child 

development and the complexities of managing diabetes. 

Educators must be able to identify potential challenges 

and to formulate solutions throughout childhood and 

adolescence. It is important to work collaboratively with 

young people and their families to prioritize education 

and treatment options, breaking down positive behaviour 

changes into small manageable steps to promote consistent 

and ongoing success. 

The relevance to adult diabetes education of such developmental 

models and the approaches to learning that 

are derived from them, both for people with the condition 

and diabetes educators, is reflected throughout this 

special issue. The constructivist principles of Piaget and 

Vygotsky value developmentally appropriate facilitatorsupported 

learning, where the learner stands at the centre 

of the educational process. Malinda Peeples and her 

co-authors describe the shortcomings in understanding 

among many medical healthcare providers of how best 

to approach the issues surrounding self-care. The authors 

advocate a person-centred approach to diabetes education 

which incorporates recognition of the critical role of 

psychosocial factors. 

Line Kleinebreil’s report on the application of new technologies 

in diabetes education demands an expanded 

view of constructivist principles, taking into account 

recent advances in information technology – which are 

increasing our potential for communication and the ability 

to store a variety of types of data. Huge benefits can be 

derived from a ‘communal constructivism’ where learners 

and educators become actively involved in creating 

knowledge that will benefit other learners. In this model, 

people with diabetes and diabetes educators will not simply 

complete a course, but instead leave their own mark 

on its development, on its materials, and on the subject 

itself. The IDF Diabetes Education Modules provide a 

nice example. Since their launch last year, the Modules 

have been morphing into region- and community-specific 

tools as they are used in diverse settings. 

Discovery learning is based on the constructivist approach. 

When people practise discovering for themselves, they 

learn in a way that makes information more readily viable 

in problem-solving: we ‘learn by doing’. In the words of 

an ancient Chinese proverb: tell me and I will forget; show 

me and I may remember; involve me and I will understand. 

In the multidisciplinary courses described by Ta Van Binh 

and Le Quang Toan, the learners – Vietnamese doctors 

and nurses aiming to enhance their diabetes care skills 

– build their knowledge by exploring and manipulating 

objects (glucometers), grappling with problems (preparing 

plans for education on preventing hypoglycaemia 

and sick-day management) and performing experiments 

(presenting to the rest of the group and later taking their 

newly acquired skills into the community). 

There is evidence that discovery learning is less effective 

for ‘beginners’ than direct instruction. Clearly, early 

learners need some direct instruction first before being 

able to apply what they have learned. But it seems 

equally clear that education for educators that is based 

on an eclectic constructivist approach will reflect the 

experiences of people with diabetes as they construct 

and apply knowledge on the road to becoming experts 

in living with their condition. 


The future of care 

 

The benefits of diabetes 

education: better health 

outcomes through successful 

self-management 

Malinda Peeples, Janice Koshinsky, Janis McWilliams 

Diabetes is mostly managed by people with the condition. 

In order to do so effectively, people with diabetes need 

to acquire and develop a broad base of knowledge and 

skills, and incorporate lifestyle choices into daily living 

which facilitate and enhance self-care. Diabetes education 

is an active process that supports people in building selfmanagement 

skills, and provides for shared decision making 

about how best to fit diabetes treatment into daily life. The 

authors describe some of the ways in which education can 

meet the many complex challenges involved in the effective 

self-management of diabetes. 

Diabetes education is known by a 

number of different terms, including 

‘patient education’, ‘diabetes self-management 

education’, ‘diabetes self-management 

training’, and ‘therapeutic 

patient education’. All these terms have 

a common theme: the position of the 

person with diabetes at the centre of a 

life-long intervention that involves communicating 

with a diabetes care team 

– in settings where these are accessible 

to people with the condition – and coordinating 

a treatment plan. Clearly, 

people with diabetes can benefit directly 

from education. These benefits 

are extended to society as a whole in 

terms of reduced healthcare spending 

when people are able to effectively 

manage their own condition, improve 

overall health and well-being, and thus 

reduce the risk of complications. 1 

Diabetes education is 

uniquely positioned to 

meet the challenge of 

addressing the global 

burden of diabetes. 

Increasingly, diabetes education is being 

integrated as a standard of care for 

people with the condition. 2 However, 

this is not universal; much work needs 

to be done to acknowledge the importance 

of diabetes education in promoting 

healthy lifestyle choices, improving 

quality of life and overall health status, 

and reducing direct healthcare costs 

and indirect costs to society (relating to 

lost productivity). Many governments, 

healthcare systems, and public health 


Diabetes educators learning 

how to support people with 

diabetes to integrate therapies 

in their daily routine.


 

organizations are searching for strategies 

to address this growing burden. 

Diabetes education as a ‘health intervention’ 

is uniquely positioned to meet 

the challenge. 

Costs 

It has been widely reported that inadequate 

diabetes self-management contributes 

to reductions in the health and 

well-being of people with diabetes. 

Access to effective diabetes education 

that focuses on education and support 

for self-management has been shown 

to improve care outcomes which translate 

into reduced healthcare costs. 3 It 

takes time and support to develop the 

skills that are needed to make informed 

decisions and solve the problems that 

arise in the daily self-management of 

diabetes. 

Education is not a single intervention; 

it is a continuous process. People’s 

educational needs evolve over time 

as their personal needs and treatment 

plans change based on the progression 

of their diabetes. It should be offered 

at the time of diagnosis, and assessed 

at least annually and/or as treatment 

changes. 

Complexities 

Diabetes is a complex condition, requiring 

effective medical management 

by healthcare providers and self-management 

by the person with diabetes. 

Healthcare providers and people with 

diabetes are able to talk about the 

medical aspects of diabetes using terminology 

that has become standard 

over the years. The use of terms such as 

retinopathy, nephropathy, and HbA 1c 

facilitate effective communication at the 

medical level. However, many medical 

healthcare providers have less of an 

understanding of how best to approach 

the issues surrounding self-care and psychosocial 

status. A person-centred approach 

to supporting self-management 

which incorporates recognition of the 

critical role of psychosocial factors is 

vital to effective diabetes education. 4 

Many medical healthcare 

providers have little 

understanding of 

how best to approach 

self-care and 

psychosocial issues. 

Indeed, diabetes education is evolving 

to deal with this dual approach 

to managing the condition. Work led 

by a national diabetes education organization 

is advancing the concept 

of a standard language on the subject 

of self-care behaviour. Behavioural 

categories provide a framework for assessing 

self-care behaviour and interventions 

which mirrors the traditional 

approach to physical examinations. 

These categories – healthy eating, 

being physically active, monitoring, 

taking medication, problem-solving, 

reducing risks, healthy coping 

– have been labelled the ‘American 

Association of Diabetes Educators 

(AADE) 7 Self-Care Behaviors’. It is 

hoped that using an evidence-based 

framework for educational assessment 

and interventions, and outcome 

measurement will provide a consistent 

means to measure a key benefit of 

education – behaviour change. 5 

Challenges 

The effective use of appropriate therapies 

supports optimum blood glucose 

control, which has been demonstrated 

to reduce diabetes-related complications. 

However, people with diabetes 

worldwide encounter many obstacles 

in attempting to follow therapeutic regimens. 

Education that acknowledges 

the cultural background of people with 

diabetes and their ability to understand 

information on health can improve their 

ability to follow a treatment routine. 

Educational programmes should be 

designed with appropriate strategies 

that address these areas as well as 

each person’s readiness and confidence 

to learn a skill, identify a need 

for change, and collaboratively set 

goals for making such changes. 

Those providing diabetes education 

should attempt to identify any barriers 

to incorporating self-care strategies, 

and support people with diabetes in 

integrating diabetes therapies into their 

daily routine. For example, the computer-based 

AADE 7 Outcomes System 

was piloted recently at an academic 

centre. Three quarters of the people 

with diabetes involved in the trial used 

the Internet to complete their assessment. 

Many of these people reported 

that the program helped them to reflect 

on how they were managing their condition 

and develop a self-management 

plan with their educator. 

Diabetes education, as well as addressing 

outcomes, can be expanded to respond 

to ongoing changes in practice. 

A study that placed a diabetes educator 

in a rural healthcare clinic found 

a significant increase in attendance 

at dilated eye exams, HbA 1c 

, lipids, 

urinalysis, and foot examinations using 

monofilaments and improvements in 

clinical measures such as HbA 1c 

as a 

result of diabetes education. 6 



Chronic care, co-morbidity 

and complications 

People with diabetes spend a limited 

amount of time with their healthcare 

provider – often dictated by healthcare 

management systems that limit 

the time and frequency of contact or 

do not provide/reimburse for diabetes 

education. Typically, people may be 

coordinating treatment for as many 

as five chronic conditions, often with 

different healthcare providers. 

People with diabetes 

may be coordinating 

treatment for as many as 

five chronic conditions, 

often with different 

healthcare providers. 

People spend most of their time in their 

community with family and friends, and 

at work. As medical systems work to 

increase understanding and support 

people with chronic conditions such 

as diabetes, chronic care models are 

evolving, which strive to connect the 

work of the healthcare system (medical 

care, treatment) with the work of 

the community (public health, ongoing 

support). The focus of the healthcare 

system is on individuals and their health 

and well-being – often measured in 

terms of death and disability; for public 

health, the focus is on populations – often 

measured in terms of the prevalence 

and/or incidence of disease. The task 

of diabetes educators is to help people 

to translate knowledge into effective 

self-care behaviour. This is measured 

in terms of healthful behaviour, quality 

of life and other factors. 

People with diabetes usually have other 

related conditions. In the case of people 

with type 2 diabetes, these typically 

include obesity, hypertension, and lipid 

abnormalities. People may develop 

complications affecting, among others, 

the nerves, kidneys, heart, and/or 

eyes. Depression occurs in up to 30 % 

of people with diabetes, making selfcare 

even more difficult. 7 Diabetes 

education addresses the prevention, 

monitoring, and management of these 

co-morbid conditions and complications, 

leading to better health outcomes 

and improved quality of life. 

Conclusion 

Diabetes education can have a wide 

range of positive effects at a number 

of levels. It constitutes a necessary intervention 

that can address the challenges 

involved in individualizing and 

coordinating costly care for people with 

diabetes. Integrated into a chronic care 

approach, diabetes education is an effective 

intervention that supports people 

as they move between the healthcare 

system and their community and workplace, 

as they deal with the complexities 

involved in following a therapeutic 

treatment plan while sustaining the selfcare 

behaviour that is necessary for 

effective self-management. 

Diabetes education which also addresses 

potential or existing complications 

and co-morbid conditions can 

ultimately lead to better outcomes. An 

educational intervention, therefore, 

can be as important and effective as 

a pharmacological intervention and 

should be used alongside all therapeutic 

options. 

Malinda Peeples, Janice 

Koshinsky, Janis McWilliams 

Malinda Peeples is Managing Director, 

Peeples Consulting, Baltimore, Maryland, 

USA, and Immediate Past-President of 

the American Association of Diabetes 

Educators (AADE), Chicago, Illinois, USA. 

Janice Koshinsky is Program Director, 

Lions Diabetes Center, University of 

Pittsburgh Medical Center McKeesport, 

Pennsylvania, USA. 

Janis McWilliams is Advanced Practice 

Diabetes Specialist, University of 

Pittsburgh Diabetes Institute, 

Pennsylvania, USA. 

References 

1 Assal JP, Jacquemet S, Morel Y. The added 

value of therapy in diabetes: the education of 

patients for self-management of their disease. 

Metabolism 1997; 12 (Suppl 1): 61- 4. 

2 International Diabetes Federation Clinical 

Guidelines Task Force. Global guideline 

for type 2 diabetes. IDF. Brussels, 2005. 

3 Keers JC, Groen H, Sluiter WJ, et al. 

Cost and benefits of a multidisciplinary 

intensive diabetes education programme. 

J Eval Clin Pract 2005; 3: 293-303. 

4 Peyrot M, Rubin RR, Lauritzen T, et al; on 

behalf of the International DAWN Advisory 

Panel. Psychosocial problems and barriers 

to improved diabetes management: 

results of the Cross-National Diabetes 

Attitudes, Wishes and Needs (DAWN) 

Study. Diabet Med 2005; 10: 1379-85. 

5 Mulcahy K, Maryniuk M, Peeples M, et al. 

Diabetes self-management education core 

outcomes measures. Diabetes Educ 2003; 

5: 768-70, 773-84, 787-8 passim. 

6 Piatt GA, Orchard TJ, Emerson S, et al. 

Translating the chronic care model into 

the community: results from a randomized 

controlled trial of a multifaceted diabetes care 

intervention. Diabetes Care 2006; 4: 811-7. 

7 Egede LE, Nietert PJ, Zheng D. Depression 

and all-cause and coronary heart disease 

mortality among adults with and without 

diabetes. Diabetes Care 2005; 28: 1339-45. 



 

The complex and 

constantly evolving role 

of diabetes educators 


Diabetes educators are professional healthcare providers who are qualified to work with 

people in the management of their diabetes. The role of diabetes educators is dynamic 

and shaped by the environment in which they practise and by developments in research 

and technology. Core components are clinical care, education, counselling, research, and 

management. The role of the diabetes educator encompasses health promotion and the 

prevention of diabetes and its complications, and is undertaken by healthcare providers 

from a variety of disciplines and, in some cases, people with a non-medical background. The 

degree of emphasis that is placed on the components listed above and their related tasks 

varies between settings, and between healthcare disciplines, which involve different scopes 

of practice. Trisha Dunning describes the history and progression of diabetes education 

and looks forward to developments in the constantly changing role of the educator. 

Prior to the discovery of insulin, the care of people with type 1 

diabetes consisted of reducing acidosis to prevent early 

death. In 1913, the Allen diet (also known as the ‘under-nutrition’ 

or ‘starvation diet’) was introduced. Diabetes nurses 

implemented the Allen diet and managed ketoacidosis in 

diabetes wards following detailed policies and procedures 

that included hourly oral fluid replacement, and restoring 

normal blood glucose levels and bowel function. Intravenous 

insulin infusions were introduced in the 1940s. 1 Other 

aspects of diabetes nursing included measuring levels of 

glucose and protein in urine, measuring and recording 

body weight, encouraging people to exercise, reducing 

stress, and providing general nursing care. 

The emergence of the educator’s role 

In 1914, Elliott Joslin published The Treatment of Diabetes 

Mellitus: With Observations Upon the Disease Based Upon 

One Thousand Cases, in which he stressed the importance 

of training nurses to undertake diabetes education and 

management, and stated that specializing in diabetes care 

offered ‘a new career for nurses’. 2 At that time, the role of 

educator was performed almost exclusively by nurses. 


10 


The challenges faced by 

diabetes educators differ 

between and within countries. 

countries. Diabetes care slowly 

moved into outpatient settings 

with people attending diabetes 

clinics for regular monitoring. 

Formal educator training 

programmes were introduced 

in the 1970s and moved to 

universities in the late 1980s 

and 1990s. 

By 1936, insulin had become widely available and diabetes 

nursing care had expanded to include teaching people to 

administer insulin and count carbohydrates. 1 The need for 

nurses to develop skills in education and counselling, and 

proficiency in clinical care was becoming apparent. In the 

USA, ‘wandering diabetes nurses’ played a key role in 

children’s diabetes care. These nurses provided outreach 

support to the families of young people with diabetes, such 

as accompanying them to hospital appointments, making 

home visits and providing advice to schools, and were 

supported through a fund established by Elliot Joslin. 1 

Oral blood glucose-lowering medications were introduced 

in the 1950s with the emergence of type 2 diabetes as a 

common and growing health issue worldwide, with specific 

requirements in terms of education, clinical care and 

daily management. Specialist nurses were described at this 

time as providing a high standard of care and capable of 

functioning autonomously. 3 Diabetes education was one of 

the first nursing specialties to emerge and has served as a 

model for other specialties ever since. 

Widespread implementation of the role of the diabetes 

educator began in the early 1970s in most developed 

countries and a decade or so later in many developing 

To the present day 

The publication of the results 

of the Diabetes Control and 

Complications Trial in 1993 

and the UK Prospective Diabetes 

Study in 1998 changed the focus of diabetes care from 

merely reducing levels of blood glucose and blood pressure 

to the active prevention of complications, and intensification 

of treatment with strict metabolic targets. This had a 

significant effect on the role of the diabetes educator. 

Diabetes educators in developed countries began to undertake 

key aspects of insulin dose adjustment, dietary 

modification and screening for complications, setting the 

scene for the roles of the advanced practice nurse and 

nurse practitioner. Other healthcare providers, such as 

dietitians, podiatrists, psychologists, and pharmacists, 

began to specialize in diabetes education. 

Advanced practice nurses and nurse practitioners have a 

broad role that encompasses individual health education and 

includes prescribing medications, referring people to medical 

specialists, and ordering and interpreting diagnostic tests. 

These roles usually require a post-graduate level qualification. 

In the person-centred multidisciplinary team approach 

to care, education is central to diabetes management and 

focuses on helping people to learn to meet the challenges of 

living with diabetes and become self-caring problem-solvers. 

Over the years, the importance of the role of the family and 

social support in diabetes management has emerged. 


The future of care 11 

In countries such as the USA, Canada, and Australia, 

the development of standards for diabetes education and 

accreditation processes have reflected increasing recognition 

of the value of diabetes educators. The International 

Diabetes Federation Consultative Sections on Diabetes 

Education and Diabetes in Children and Adolescents were 

established in 1993, marking a global leadership role for 

diabetes educators that has continued to expand. 

The Consultative Section on Diabetes Education developed 

standards and a curriculum to support diabetes education 

and the delivery of training; detailed content to support the 

curriculum was published in 2006. (See website below to 

access these materials.) Some countries have accreditation 

procedures for their education programmes and recognition, 

credentialing, and/or certification procedures for 

diabetes educators, which are becoming desired criteria 

for employment. 

In developed countries, diabetes educators are necessary, 

cost-effective members of multidisciplinary healthcare teams, 

operating autonomously and practising in a variety of 

healthcare settings. Diabetes education specialties other 

than paediatric care have emerged, and include gestational 

diabetes, insulin pump therapy, and care for elderly people. 

Over recent years, health promotion and the prevention 

of diabetes and its complications have emerged as key 

functions of the diabetes educator. 4 

Research continues to demonstrate the complex, progressive 

nature of type 2 diabetes and its associated multiple 

causes and asymptomatic progression. This is a challenge 

for many people who do not view diabetes as a serious 

chronic condition; inertia on the part of healthcare providers 

leads to delays in appropriate management. The high 

value placed on evidence from controlled trials means the 

findings from rigorous, methodologically sound, qualitative 

studies are often not incorporated in evidence-based 

clinical practice guidelines. Furthermore, psychological 

factors are not formally assessed as part of routine screening 

programmes for diabetes complication. Cost prevents 

many people from undertaking appropriate self-care and 

hampers optimal education and management. 

Looking forward 

It seems probable that the role and scope of practice of the 

diabetes educator will continue to evolve, largely driven by 

societal changes, developments in research and technology, 

and healthcare funding and service models. Capacity-building 

and ‘succession’ planning (for a seamless handover as 

posts are left open) are imperative to sustain the existing 

diabetes educator workforce and provide for the future. 

Enhanced research and partnerships will emerge between 

organizations advocating improvements in the care of different 

chronic conditions, industry, and academic institutions, 

as will new processes for implementing care. 

Challenges 

The challenges faced by diabetes educators differ between 

and within countries, depending on healthcare 

policies and the resources allocated to the prevention and 

management of diabetes. There is an urgent need for innovative 

diabetes education programmes to address the 

increasing global prevalence of diabetes and to mentor 

and support other healthcare providers to deliver effective 

diabetes care. 

Healthcare providers continue to negotiate new relationships 

as their scopes of practice evolve and conflicts around the 

boundaries of their roles arise. The functions of the specialist 

diabetes educator are largely accepted, but new conflicts 

are arising as the roles of the advanced practice nurse and 

nurse practitioner become more widespread. 


Trisha Dunning is Inaugural Chair in Nursing at Deakin 

University and Barwon Health, Geelong, Australia. 

The IDF International Curriculum for Diabetes Health 

Professional Education and supplementary content, the 

Diabetes Education Modules, can be obtained at www.idf.org 

References 

1 Allen N. The History of Diabetes Nursing, 1914-1936. The Diabetes Educator 

2003; 29: 976-89. 

2 Joslin EP. The Treatment of Diabetes Mellitus: With Observations Upon the Disease 

Based Upon One Thousand Cases. Lea and Febinger. Philadelphia, 1917. 

3 Georgopoulos BS, Christman S. The Clinical Nurse Specialist: A Role Model. 

The American Journal of Nursing 1970; 5: 1030-9. 

4 Dunning P. The diabetes educator: evolution of a nurse specialist. 

Practical Diabetes 1992; 6: 220-2. 


Make a Difference in Chronic Disease Care 

BUDAPEST 

2 0 0 8 

THERAPEUTIC PATIENT EDUCATION 2008 

PATIENT-CENTRED SELF MANAGEMENT EDUCATION IN DIABETES AND 

OTHER CHRONIC DISEASES 

Including 

DAWN 4th INTERNATIONAL DAWN SUMMIT 

Diabetes Attitudes Wishes & Needs 

Which will take place in the vibrant cultural hub of 

BUDAPEST, Hungary, November 5-8, 2008 

B U D A P E S T, 

H U N G A R Y 

N O V E M B E R 

5 

, 

- 8 

2 0 0 8 

This international congress builds on the success of TPE 

2006 including the 3rd DAWN Summit, which gathered 

more than 900 participants from 64 different countries, 

and will cover the latest advances in therapeutic patient 

education and self-management support in diabetes and 

other chronic diseases. 

A significant aim will be to clarify state of art strategies 

to facilitate motivation for permanent lifestyle changes 

and active self-management of people with chronic 

diseases. Along with scientific sessions, several optional 

master-classes will enable participants to exercise specific 

skills with the supervision of experts in the field. 

The 4th DAWN Summit, in collaboration with the IDF, will 

facilitate multi-disciplinary dialogue and better practice 

sharing for psychosocial and patient-centred care for 

people with diabetes around the world. In recognition of 

2008 being the Year of the Child with Diabetes, a special 

focus will be placed on the DAWN Youth initiative, 

a global partnership effort involving IDF, ISPAD and 

representatives of all stakeholders in childhood diabetes 

world-wide to improve psychosocial support to children 

with diabetes and their families. 

TPE 2008 offers a unique opportunity for health 

professionals, health researchers and advocates in chronic 

care, medicine, education, psychology, sociology, 

pedagogy, and related fields to exchange experiences in 

a truly multi-disciplinary and multi-national environment. 

We look forward to welcoming you in Budapest in 2008! 

For more information please visit: 

www. kenes.com/tpe2008 

Congress Organizers: 

G L O B A L C O N G R E S S O R G A N I Z E R S A N D 

A S S O C I AT I O N M A N A G E M E N T S E R V I C E S 

1-3 rue de Chantepoulet, PO Box 1726 CH-1211, Geneva 1, Switzerland 

Tel: +41 22 908 0488, Fax: +41 22 732 2850, E-mail: tpe2008@kenes.com 

Website: www.kenes.com/tpe2008


A case for including peers 

as providers of diabetes selfmanagement 

education 

Kate Lorig 

Diabetes distinguishes itself from many other chronic conditions 

because of the complexity of its day-to-day management 

– both medical management and self-management, which 

must be carried out by people with diabetes on a sometimes 

hourly basis. People require self-management education in 

order to master these complexities. Kate Lorig discusses the 

complexity of diabetes self-management education, how it 

is currently delivered, and suggests an effective additional 

means of offering this education. 

educator(s). This process includes: 

assessment of the individual’s specific 

education needs 

identification of the individual’s specific 

diabetes self-management goals 

education and behavioural intervention 

directed towards helping the individual 

achieve identified self-management 

goals 

evaluation of the individual’s attainment 

of identified self-management 

goals.’ 2 

Self-management has several definitions. 

In the UK, for example, it has 

been defined as ‘the individual’s ability 

to manage the symptoms, treatment, 

physical and psychosocial consequences 

and lifestyle changes inherent in living 

with a chronic condition. Efficacious 

self-management encompasses the ability 

to monitor one’s condition and to 

affect the cognitive, behavioural and 

emotional responses necessary to maintain 

a satisfactory quality of life. Thus, 

a dynamic and continuous process of 

self-regulation is established.’ 1 

According to the definition used by 

the American Association of Diabetes 

Educators (AADE), it is ‘an interactive, 

collaborative, ongoing process involving 

the person with diabetes and the 

The US Institute of Medicine has stated 

that ‘self-management relates to the 

tasks that an individual must undertake 

to live well with one or more chronic 

conditions. These tasks include gaining 

confidence to deal with medical 

management, role management, and 

emotional management.’ 3 

The first and last definition take a much 

broader perspective on the term than 


14 


does the AADE definition, which is 

more similar to the classic definition of 

health education that focuses mainly 

on medical management. One of the 

reasons for this is that in diabetes the 

lifestyle requirements for managing 

blood glucose levels are so complex 

that little time is left for dealing with 

either emotional issues or role management. 

Without attention to both role 

management and emotional management, 

it is almost impossible to manage 

blood glucose levels effectively. 

Lifestyle requirements 

for managing blood 

glucose are so complex 

that little time is left for 

dealing with other issues. 

A well-known scenario highlights the 

need for a broad definition of selfmanagement, 

and illustrates the complexity 

of this management. People 

with diabetes are usually taught to 

limit their intake of carbohydrates. 

Accomplishing this involves a range of 

skills and tasks, including reading and 

interpreting food labels, understanding 

portion sizes, being aware of which 

foods contain carbohydrates, and distinguishing 

foods that are high or low 

in carbohydrates. By accomplishing 

these tasks, people might have to forgo 

some of their favourite foods and thus 

feel frustrated with changes in their 

eating habits. At the same time, their 

roles within the family or at work might 

undergo changes. 

In other words, the dietary management 

of diabetes, while complex in 

itself, is made even more complicated 

by emotional and social factors. The 

healthcare community has risen to 

the challenge represented by these 

complexities: in many countries there 

are well-established programmes for 

delivering education in diabetes selfmanagement. 

Effectiveness 

In most situations, there is little doubt 

that the information given by diabetes 

educators is based on the best available 

evidence. At the same time, some 

content may be influenced by local customs 

or business interests. For example, 

the effectiveness of glucose monitoring 

for people with type 2 diabetes 

is somewhat equivocal. A Cochrane 

Review concluded that ‘self-monitoring 

of blood glucose might be effective in 

improving glycaemic control in patients 

with type 2 diabetes who are not using 

insulin.’ 4 However, a more recent 

large randomized trial found no effect 

of glucose monitoring in these same 

populations. 5 Yet the AADE recently 

released a policy statement supporting 

blood glucose monitoring for all people 

with type 2 diabetes. 6 

While some controversy exists over 

content, there is growing evidence of 

the effectiveness of diabetes education 

– especially when offered in a group 

format and/or community settings. 7 

Unfortunately, there are few studies on 

the effectiveness of one-to-one diabetes 

education. 

Access 

Most people with diabetes do not receive 

structured diabetes self-management 

education – due in some cases 

to a lack of personal motivation to 

seek such education; more commonly, 

however, to the lack of access to timely 

and appropriate education. Problems 

in reaching diverse populations of 

many cultures and languages are well 

documented. However, access is also 

limited by the number of personnel 

– considered eligible by healthcare 

systems – who are available to offer 

diabetes education. These are usually 

healthcare providers who sometimes 

are unable to offer education at sites, 

times, or in languages that meet the 

needs of the people with diabetes 

served by their institutions. 

A partial solution: peer 

educators 

Family members, friends and neighbours 

have for countless generations 

been an important provider of health 

information. In modern times, this has 

sometimes become institutionalized. 

Alcoholics Anonymous is one largescale 

example. For many years, developing 

countries have used people with 

limited medical training to deliver the 

bulk of the healthcare in their countries. 

More recently, developed countries 

have begun using community members 

to deliver community-based care. These 

people go by various names: ‘community 

health representative’, ‘community 

health worker’, ‘peer tutor’. Education 

is usually a large part of their job. 

Healthcare providers 

sometimes are unable 

to offer education that 

meet the needs of the 

people with diabetes. 

We have also seen a growth in the use of 

community volunteers in offering standardized 

health-related self-management 

programmes. Examples include 

the Reach to Recovery Program of the 

American Cancer Society, Alcoholics 



Anonymous, as previously mentioned, 

and other 12-step programmes – the 

Expert Patient Programme in the UK, 

and the Arthritis Self-Help Program in 

the USA, Canada and Australia. 

Questions still exist regarding the effectiveness 

of peer educators. A review 

was carried out in the early 1990s 

of 34 studies of the effectiveness of 

self-help and mutual aid groups, including 

Alcoholics Anonymous and 

similar structured programmes. Most 

of the studies showed benefits from 

the groups in terms of either improved 

health, or equal health and lower costs 

than traditional medical care. 8 

A 2006 review of 18 diabetes studies 

(including eight randomized controlled 

trials) that used peer educators concluded 

that the participants’ knowledge 

increased, and they were generally 

satisfied with their contact with community 

health workers. In some interventions, 

physiological improvements were 

noted; positive changes in lifestyle and 

self-care were recorded in a number of 

the studies. The reviewers also identified 

a decrease in inappropriate use 

of healthcare. 9 A 2007 initiative in the 

USA depended heavily on the use of 

peer educators. 10 

It is interesting to note that most of the 

studies in the 2006 review took place 

in majority communities; most of the 

diabetes studies in the 2007 review 

took place in minority communities. 

This suggests that while peer education 

is often the standard for addiction and 

mental health interventions, for diabetes 

it is seen as a solution for reaching 

communities that are not otherwise 

reached by healthcare providers. 

Discussion 

It appears that peer educators may 

have an important role in diabetes 

education. When properly supervised 

with an appropriate programme, they 

appear to be effective educators as 

judged by their ability to affect health 

status and, sometimes, the way healthcare 

is used. They are also able to 

reach populations that are underserved 

by most professional diabetes 

education programmes. If we make 

the assumption based on the above 

that peer educators may be a useful 

addition to traditional professional 

diabetes education, many questions 

remain unanswered. 

These concern the following: 

the comparative effectiveness of professional 

versus peer education, and 

more importantly, the ideal mix of 

these two 

the settings in which peers are effective, 

including primary care, among 

groups, home visits, Internet-mediated 

networks 

the populations for which peers are 

effective, for example minority communities, 

majority communities who 

do not participate in professional-led 

education, or all populations. 

Questions also arise concerning the 

training of peer educators and how 

they should be compensated for their 

efforts. Another important question is 

how to maintain the unique abilities of 

peer educators without professionalizing 

them. Yet while there are many 

questions to be answered, the use of 

peers as diabetes educators holds 

great potential and promise. 

Kate Lorig 

Kate Lorig is Professor of Medicine at 

the Stanford University School of 

Medicine, USA. 

References 

1 Barlow J, Wright C, Sheasby J, et al. 

Self-management approaches for people 

with chronic conditions: A review. Patient 

Educ Couns 2002; 48: 177-87. 

2 Mensing C, Boucher J, Cypress M, et 

al. National standards for diabetes 

self-management education. Diabetes 

Care 2007; 30: S96-S103. 

3 Adams K, Greiner AC, Corrigan JM, 

editors. Report of a summit. The 1 st annual 

crossing the quality chasm summit - A focus 

on communities. National Academies 

Press. Washington, DC, 2004. 

4 Welschen LMC, Bloemendal E, Nijpels G, et 

al. Self-monitoring of blood glucose in patients 

with type 2 diabetes who are not using 

insulin. Diabetes Care 2005; 28: 1510-7. 

5 Farmer A, Wade A, Goyder E, et al. Impact 

of self-monitoring of blood glucose in the 

management of patients with non-insulin 

treated diabetes: open parallel group 

randomised trial. BMJ 2007; 7611: 132. 

6 Austin MM, Haas L, Johnson T, et al. Selfmonitoring 

of blood glucose: benefits and 

utilization. Diabetes Educ 2006; 32: 835. 

7 Mensing CR, Norris SL. Group education in 

diabetes: effectiveness and implementation. 

Diabetes Spectrum 2003; 16: 96-103. 

8 Kyrouz EM, Humphreys K, Loomis C. A 

review of research on the effectiveness 

of self-help mutual aid groups. J Am 

Geriatr Soc 1992; 2: 147-50. 

9 Norris SL, Chowdhury FM, Van Le K, et al. 

Effectiveness of community health workers 

in the care of persons with diabetes. 

Diabetic Med 2006; 5: 544-56. 

10 Promising approaches to diabetes selfmanagement: 

lessons from the diabetes 

initiative of the Robert Wood Johnson 

Foundation. The Diabetes Educator 

2007; 6 (Special Issue): S122-S224. 


16 


Empowerment, 

education and discipline: 

implementing a diabetes 

self-management plan 

Michael Weiss 

Nowadays, few people would question the role of a person 

with diabetes as the central figure in his or her diabetes care 

team. But ‘patient’ empowerment extends well beyond the 

concept of self-determination. Diabetes does not occur in a 

vacuum, but interacts with a variety of emotional states and 

exists within many cultural and social boundaries. People 

with diabetes hold the power to manage their condition 

– not their healthcare providers or their family members. 

In this article, Michael Weiss argues that people can only 

make the many finely balanced management decisions that 

are required throughout each day based upon informed 

involvement in the development and implementation of a 

workable diabetes self-management plan. 

Modern diabetes healthcare providers 

have come to recognize the phenomenon 

dubbed ‘empowerment’; people 

with diabetes know it as common sense 

– gleaned sometimes from years of 

working hard to tackle this all-pervasive 

and relentless condition. From its introduction 

more than 15 years ago, 1 the 

empowerment approach to diabetes 

education and self-management has 

gained many disciples among diabetes 

healthcare providers worldwide, 

and is now a popular and accepted 

paradigm. 2 This approach recognizes 

that prescriptive mandates are likely 

to fail, and that behavioural changes, 

which are so integral to the effective 

treatment of diabetes, can only be 

achieved when the person with diabetes 

both understands and chooses 

the changes that will be made. Indeed, 

the empowerment approach might be 

the single greatest advance in diabetes 

education and self-management over 

the past 20 years. 3 

The perspective of people with 

diabetes 

The Diabetes Attitudes, Wishes and 

Needs study (DAWN) confirmed that the 

anger, fear and frustration that often accompany 

a diagnosis of diabetes – and 

the ensuing development of depression 

in some people – can adversely affect 

the person’s overall well-being. 4 These 

can also interfere with a person’s efforts 

to follow a diabetes self-management 

plan. Moreover, DAWN investigators 

found that social and economic factors 

have a major impact on people’s 

emotions and might complicate efforts 

to self-manage their condition. 

These and other obstacles relate directly 

to empowerment. The testimony 



Diabetes self-management 

requires understanding, 

commitment and a great 

deal of discipline. 

with diabetes, in collaboration with 

their healthcare team, is the ‘LIFE’ approach, 

which consists of four distinct 

yet fluid components: 

Learning as much as possible about 

diabetes 

Identifying three guiding principles – 

role, flexibility and targets 

Formulating a personal self-management 

plan 

Experimenting with and evaluating 

the plan. 5 

of a woman in her fifties with type 2 

diabetes, speaking at a community diabetes 

forum, demonstrated her awareness 

of the impact of these factors: she 

described the effects on her ability to 

effectively manage her diabetes of living 

in a neighbourhood without safe 

places to walk and without shops that 

sell fresh fruit and vegetables, and of 

having a low-paid job with no health 

insurance coverage. She also admitted 

to feelings of depression. 

None of this is to suggest that education 

is not a critical component of 

diabetes self-management; quite the 

opposite. Diabetes education must occur 

on two levels. While it is important 

to learn about the physiological effects 

of diabetes and how to treat it, it is 

equally important to have a holistic 

understanding of its impact. 

Think LIFE 

One plan that can be used by people 

Learning 

Diabetes education must extend beyond 

pancreatic mechanics, nutrition, and 

physical exercise, to encompass the 

concepts underpinning each person’s 

role in managing his or her condition. 

Education must address the very real 

effects of diabetes on people with the 

condition and their family members in 

emotional and practical as well as physical 

terms. While healthcare providers 

might be experts in technical aspects 

of diabetes and are able to offer many 

valuable recommendations, only people 

with the condition can become experts 

in living with diabetes and the intricacies 

of its affective and physical impact. 

Only people with diabetes 

can become experts in the 

impact of their condition 

on their own lives. 

Identifying available sources of emotional 

support can be vitally important. 

For most people, this support will come 


18 


from family members. However, it is not 

uncommon for people to seek support 

from friends, healthcare providers, religious 

or community leaders, and other 

people with diabetes. It is imperative to 

have access to someone with whom to 

share worries and concerns via honest 

and candid communication – the key 

to eliminating potential frustration and 

misunderstandings. 

Identifying guiding principles 

Creating a self-management plan 

One approach is to leave the design of 

the plan to healthcare providers. This 

may be helpful when a person is first 

diagnosed – until a deeper understanding 

is reached of individual needs and 

preferences, and interactions between 

other factors (social, emotional, environmental) 

that need to be addressed 

in the plan. Another approach, in order 

to ensure that these personal issues 

are taken into account, is to become 

an integral member of the team that 

designs the plan. Neither approach 

is right or wrong; the important thing 

is to develop a plan that can be used 

effectively. An increasingly active role 

might be assumed as a person becomes 

more familiar and comfortable 

with their diabetes. It may also be the 

case that one approach works well 

for some aspects of the plan while the 

second works better for others. 

Flexibility 

The degree of flexibility that is desired 

by each person must be considered. 

Some people prefer to follow a strict 

meal plan and timetable; others want to 

be able to change their daily routines 

to suit their own, perhaps more irregular, 

schedules. Again, a choice must be 

made – by the person with diabetes. 

More flexibility often involves more 

work – more daily decisions, more 

frequent monitoring of blood glucose, 

and perhaps more insulin injections 

– compared with a strict approach to 

meal planning. On the other hand, following 

a more rigid plan may require 

more self-discipline. 

Targets 

Large amounts of data have been 

published on ideal targets levels for 

HbA 1c 

, blood pressure, cholesterol, 

and weight. While these targets may 

indeed be applicable, it is important 

for people with diabetes to establish 

– with input from healthcare providers 

– a series of achievable short-term 

targets that are designed to bring them 

closer to these ideal levels. For example, 

a person might achieve ideal 

HbA 1c 

readings more effectively if he 

or she aims for interim reductions of 1% 

at a time rather than striving to bring 

their level down from 10% to 7% or 

below in a single step. 

If perfection is the goal, 

failure is a near certainty. 

Formulating the plan 

Thus refers to the actual workings of 

self-management – where decisions 

are made regarding the many options 

available for managing diabetes, such 

as meal planning, exercise, medications 

(including insulin), blood glucose 

monitoring, stress management and 

emotional support, and the steps that 

are necessary to integrate these components 

into a daily routine. 

Experimenting and evaluating 

To a large degree, implementing a 

self-management plan will involve trial 

and error. When something in the plan 

works, it should be continued. If a part 

of it is not working, honest reflection is 

required as to why this is the case, and 

any necessary adjustments should be 

made. It is important for people with diabetes 

to bear in mind that the key to the 

effectiveness of their self-management 

lies in what they do most of the time. 

As in other aspects of life, if perfection 

is the goal, failure is almost a certainty. 

Diabetes self-management is not easy. 

It requires understanding, commitment 

and a great deal of discipline. The first 

step must be to create and believe in a 

comprehensive plan. 

Michael Weiss 

Michael Weiss has had diabetes since 

1984 and is a frequent writer and 

speaker to international audiences 

about diabetes and empowerment. 

He is a past Chair of the Board of the 

American Diabetes Association. 

References 

1 Funnell MM, Anderson RM, Arnold MS, 

et al. Empowerment: an idea whose 

time has come in diabetes education. 

Diabetes Educ 1991; 1: 37-41. 

2 Anderson RM, Funnell MM. The Art of 

Empowerment: Stories and Strategies for 

Diabetes Educators, 2 nd ed. American 

Diabetes Association. Alexandria, 2005. 

3 Weiss MA. Empowerment, a patient’s 

perspective. Diabetes Spectrum 2006; 

2: 116-8. 

4 Skovlund SE, Peyrot M: on behalf of the 

DAWN International Advisory Panel. The 

Diabetes Attitudes Wishes and Needs 

(DAWN) program: a new approach to 

improving outcomes of diabetes care. 

Diabetes Spectrum 2005; 3: 136-41. 

5 Weiss MA, Funnell MM. The Little Diabetes 

Book YOU Need to Read. Running Press. 

Philadelphia, 2007: 32-43. 



Certification: a means for 

future recognition 


Since the National Certification Board for Diabetes 

Educators (the organization responsible for certification of 

diabetes educators in the USA) was established in 1986, the 

importance and prevalence of professional certification have 

increased dramatically. New certification programmes are 

increasingly being developed for more and more occupations 

and professional specialties, while existing certification 

organizations are expanding their certification offerings. The 

authors explain terminology and discuss a number of issues 

around certification, and describe key points for consideration 

by those planning to establish a certification programme. 

Professional certification is a voluntary 

process by which a non-governmental 

professional organization grants recognition 

to people who have met certain 

specified eligibility requirements. The 

end result of this process – the credential 

– demonstrates that an individual has 

mastered a specific body of knowledge 

and skills in a particular speciality. 

In the USA and Canada the term ‘licensure’ 

is the process by which a 

state admits people to the practice of 

an occupation or profession. The term 

‘registration’ is used in the rest of the 

world. Regulations for licensure are 

established in order to ensure that an 

individual practitioner meets established 

standards for education and 

training; they are designed to protect 

public health, safety, and welfare. To 

be able to practise in certain occupations, 

such as medicine and nursing, 

a licence is compulsory. Without a 

licence, it is illegal to engage in the 

practice of a profession for which licensure 

is required by law. 

Accreditation is defined as a nongovernmental, 

voluntary process that 

evaluates institutions and programmes, 

and grants public recognition if certain 

established standards are met. 

Accreditation usually involves the submission 

of a self-evaluation report, followed 

by an on-site inspection conducted 

by a team of experts who present 

an accreditation recommendation to 

a decision-making body. This differs 

from certification in that the certification 

process involves individuals, not 

programmes and institutions. 

The process of 

certification involves 

individuals; accreditation 

involves institutions. 

The term ‘credentialing’ is used in 

a general way to include licensure, 

the certification of individuals who 

have been tested for proficiency, and 


20 


Table 1: General questions to be addressed before proceeding with 

a diabetes educator certification programme 

Why is it important to have a certification programme and what purpose will it serve? 

What will be the objectives for a certification programme? 

What is the level of interest in such a programme? Is there a sufficient number of practitioners 

in the speciality who would support and participate in such a programme? 

To whom would a speciality credential be important? Who would recognize it as 

meaningful? 

On what knowledge base would the certification programme be founded? 

What professions would be recognized as qualified to perform the speciality and 

what would certification eligibility requirements be? 

What will the measurement instrument be? Will an examination be developed or 

would assessment take a different format? 

Does a population of diabetes educators currently exist and if so, is there a way to 

determine what percent of that population could potentially qualify for certification? 

Where would financial resources for such a programme come from? 

Are there established standards and definitions for what would constitute recognition 

of speciality knowledge and skills in the speciality of, say, diabetes education? 

Have a mission and purpose of a certification programme been considered or 

developed? 

Is there grassroots support by a larger community that would sustain the ongoing 

success of the programme? 

accreditation of institutions or educational 

programmes. For the most 

part, certification and accreditation 

are non-governmental, voluntary activities 

performed by associations or 

boards, whereas licensure exists as a 

legal condition and is performed by 

state governments in the USA. The term 

‘credential’ can refer either to a professional 

certification or a licence. 

Speciality certification 

programmes 

In the USA, the number of new certification 

programmes for specialities has 

increased significantly in recent years. 

Specialization in healthcare professions 

has also grown as advances in 

technology and medical science and 

the resulting improvements in care delivery 

have contributed to the growth 

of speciality medicine. 

Speciality credentials represent value, 

both tangible and intangible. Tangible 

value may include career advancement, 

job promotion or added responsibilities, 

salary increase, or other forms of 

compensation. Intangible value may 

include personal achievement and job 

satisfaction, prestige, recognition by 

colleagues, and preference by clients. 

Certification enables the public to distinguish 

professionals who have thus 

demonstrated their specialized skills and 

knowledge from those who have not. 

However, a word of caution is required. 

The fact that certification enables the 

public to distinguish those who are certified 

from those who are not does not 

mean that those who are not certified 

are necessarily less qualified to perform 

in a particular speciality. Some 

practitioners simply choose not to be 

certified, whether for financial reasons, 

or because employers do not provide rewards, 

such as salary increases or other 

recognition, or that the tangible and/or 

intangible values of certification are 

simply not meaningful enough for the 

individual to pursue certification. These 

practitioners may be just as competent, 

or perhaps even more competent, than 

their peers who are certified. 

Healthcare providers are encouraged 

to pursue certification as a way to 

demonstrate and validate that rigorous 

requirements have been met in 

education, experience and knowledge. 

Being certified is a way for healthcare 

providers to demonstrate to people 

in their care and employers that they 

have the knowledge and competence 

to practise. Credibility as a healthcare 

practitioner in any speciality is 

enhanced through certification. 

Credibility as a speciality 

healthcare practitioner 

is enhanced through 

certification. 

Important elements of a 

certification programme 

Certification programmes are developed 

for any number of reasons. For 

those who may be considering the 

development of a certification programme, 

it is advisable to analyse 

all reasons for wanting to establish 

such a programme before moving 

ahead. The information needed for 

such an analysis may be obtained by 

conducting some kind of feasibility 

study. General questions that need to 

be addressed in the case of a diabetes 

educator certification programme are 

listed in Table 1. 



The need for thorough planning is essential 

to the success of any certification 

programme and cannot be overemphasized. 

Rigorous research is absolutely 

necessary to ensure desired outcomes. 

It is important to acknowledge at the 

outset that well-planned certification 

programmes are complex and costly. 

As described above, certification can 

offer many advantages. But success 

depends very much on consideration 

of all the important factors that have 

the potential to impact on such a programme, 

prior to its implementation. 

Marketing should be used 

to establish awareness 

of a new programme, 

increase its visibility, 

and promote its value. 

Efforts to establish interest and commitment 

by potential programme participants 

require open communication at 

a national level by the organization or 

group that is considering setting up a 

certification programme. Certification 

programmes that are developed without 

indications of adequate support and 

commitment, or worse still, developed 

in a vacuum, with the naïve notion that 

the programme will somehow sell itself, 

may be doomed to fail. Promoting the 

concept of certification and convincing 

potential participants of its value and 

benefits requires marketing. Marketing 

should be used to establish awareness 

of the new programme, increase its 

visibility, and promote its value. The 

choice of marketing strategy is critical 

to success. 

Other elements to consider before establishing 

a certification programme 

include the assessment of any risks that 

may exist, such as competition. Goals 

for a certification programme must be 

developed and evaluated in terms of 

progress on a regular basis. 

If a decision is made to base achievement 

of certification on passing an 

examination, it is extremely important 

to consider conducting a practice 

analysis, also called a role delineation 

study, as the basis of development. The 

certification examination should be jobrelated 

and should distinguish people 

who are at least minimally competent 

from those who are not. The objective 

of a practice analysis is to define a job 

in terms of the behaviour that is necessary 

to safely and effectively perform 

the job at a specified level of expertise. 

In order to conduct such an analysis, 

the services of a recognized professional 

testing agency or a specialist 

consultant in testing and measurement 

should be sought. 

Who should be responsible? 

There are further elements to consider 

before establishing a diabetes educator 

certification programme. These include 

determining the current level of 

sophistication of the diabetes education 

profession, and knowing whether a 

professional organization for diabetes 

educators already exists. The decision 

about where the certification programme 

will be situated organizationally 

is key – independent of any other 

diabetes-related organization or within 

an already existing national diabetes organization? 

In either case, autonomy in 

decision making over activities relating 

to certification is crucial to prevent undue 

influence from competing interests, 

influence that could compromise the 

integrity of the certification process. 

Control over essential decisions relating 

to certification and recertification 

– without being subject to approval 

by another entity or organization – is 

critical. This is especially important if 

a professional organization sponsors a 

certification programme. But whether 

operated as a free-standing organization 

or as a component of a professional 

organization, establishing the certifying 

organization as an independent unit 

will ensure autonomy in most instances. 

Specific language in bylaws may also 

serve to specify the separate and autonomous 

nature of the certification organization, 

with complete control over 

all essential certification decisions. 

The development of policies related to 

certification should also be an independent 

function – free from undue influence 

or pressure from a professional, 

or ‘parent’, organization. While establishing 

the certification organization 

as a separate entity is not an absolute 

requirement, there is no question that 

independent operational management 

of the certification organization and 

its establishment as a separate legal 

entity will ensure autonomy. 


Fern Vining is the Retired Coordinator of 

the Diabetes Self Management Outpatient 

Program, William Beaumont Hospital, 

Royal Oak, Michigan, USA. 

Joyce Bohren is Chief Executive 

Officer of the US National Certification 

Board for Diabetes Educators. 


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Education for educators 23 

Teaching and learning 

in diabetes: techniques 

and methods 


The goals of diabetes education are to optimize blood 

glucose control, prevent chronic and potentially lifethreatening 

complications, and optimize quality of life, 

while keeping costs within acceptable limits. Research 

has shown that with appropriate education lower-extremity 

amputation rates, medication costs, emergency room visits 

and hospitalizations are reduced. Nowadays, diabetes selfmanagement 

education is an integral and critical part of any 

treatment plan. The authors outline a framework for diabetes 

education and describe the approaches and methodologies 

involved in current educational practice. 

ness to learn, cognitive ability, physical 

limitations, and financial status. 

While assessing people’s learning 

needs, educators must consider the 

following questions: 

What health information do the people 

need? 

Which attitudes should be explored? 

Which skills do people need to engage 

in healthful behaviour? 

What factors in a person’s environment 

might present barriers to the effectiveness 

of healthful behaviour? 

Diabetes education is a lifelong learning 

experience involving four steps that 

form an ongoing cycle: assessment, 

planning, intervention and evaluation 

(See Figure 1). As this cycle continues 

throughout life, it is developed and 

renewed according to the needs of 

people with diabetes. 

Assessment 

Although assessment is time-consuming, 

it is essential for tailoring individualized 

diabetes education. In order 

to determine a person’s educational 

needs and identify current and potential 

future problems, it is necessary 

to collect a series of data, including: 

demographic information, school or 

work schedule and conditions, medical 

history and current health status, diabetes 

knowledge, self-management skills 

and behaviour, health beliefs and attitudes, 

physical activity, social situation 

and personality, cultural factors, readi- 

There are several methods of gathering 

data. Reviewing people’s medical 

records, for instance, will provide valuable 

information about their general 

health history and past experiences 

of diabetes management. Information 

about people’s physical appearance, 

literacy level, leisure activities, the effectiveness 

of self-care activities, and family 

relations can be gleaned through observation. 

Verbal and non-verbal cues 

gathered by observation can provide 


4 

Education for educators 

Figure 1: The cycle of ongoing diabetes education 

STEP 1: Assessment 

Including data related to 

demographic information, 

Assessment 

lifestyle, medical history, 

diabetes knowledge, 

self-management, health 

beliefs and attitudes, 

social status, cultural 

factors, readiness to Evaluation 

learn, cognitive ability, 

physical limitations, 

financial status 

STEP 4: Evaluation 

Measuring effectiveness 

by evaluating health behaviour 

and health status 

valuable understanding of a person’s 

thoughts, feelings and beliefs. 

During the assessment process, data 

should be recorded as objectively as 

possible. The use of words such as 

‘seems’, ‘appears’, ‘acts’ and ‘looks’ 

should be avoided; writing direct observations 

or current behaviour is more 

useful. Where possible, the words that 

were used by the people themselves 

should be used. Educators should 

describe their perceptions: sounds, 

smells and feelings. Observations 

should be shared with the person in 

order to validate what was observed, 

and a note made of the source of the 

information. 

During an interview, people must be 

made to feel secure in the belief that 

their concerns are taken seriously, and 

their needs recognized and respected. 

Maintaining eye contact and listening 

actively are key elements of effective 

communication. More information can 

be sought by using phrases such as ‘go 

on’, asking ‘can you tell me more about 

that?’ or repeating the interviewee’s 

Implementation 

Planning 

STEP 2: 

Planning 

Setting individualized 

goals and selecting 

appropriate educational 

strategies 

STEP 3: 


Providing planned 

education in a suitable 

environment 

last words. Educators can use leading 

questions in order to learn the people’s 

perceived needs or problems. For example: 

‘If you could change one thing, 

what would it be?’ 

Planning 

This process includes setting appropriate 

goals that are reasonable, measurable, 

specific and mutually agreed 

by the people with diabetes and the 

educator. Educators must be sensitive 

to individual concerns or fears while 

setting these goals. It is important that 

the goals be written from the point of 

view of the person with diabetes. For 

example, ‘I will test my blood glucose 

accurately three times a day’ or ‘I will 

regularly check my feet before I go to 

bed’. These goals can be displayed 

at home – on the fridge, for example 

– as a constant reminder and source 

of motivation. 

Teaching and learning methods (individual, 

group classes), techniques 

(short lecture, discussion, problem-solving, 

role-play, case study) and materials 

(printed, audiovisual, games) should 

also be planned during this process. 

It is important to match self-management 

goals to appropriate methods 

of learning. 


Education can be offered in any suitable 

place – a classroom, at the bedside, 

in an office, at home, or even 

at a restaurant, market or gym. The 

environment should support learning 

and have adequate lighting, furnishing 

and minimal distractions. 

Simplicity and reinforcement are key 

principles. Simple concepts should be 

presented first before moving on to 

more complex ideas. Language should 

be used that people will find easy to 

understand – avoiding medical terminology. 

People need to know exactly 

what is required of them, so direct 

language is essential. 

In terms of reinforcement, target concepts 

should be presented at the beginning 

and again at the end of each 

session. In order to ensure understanding, 

people should be encouraged to 

describe what they have seen before 

leaving a session. Visual aids – using 

several senses improves learning – and 

written educational material – for people 

to revise at home – should always 

be used. 

Evaluation 

Evaluation should be pre-planned and 

carried out throughout the education 

process. The most effective interval for 

evaluation is likely to be every 3 or 6 

months – possibly less. Objectivity and 

performance will be enhanced by setting 

goals which are measurable, specific, 

timed, and people-centred. Evaluation 



can be carried out individually by 

looking at people’s lifestyle changes 

or health status; all forms of evaluation 

will provide an assessment of people’s 

additional educational needs. 

Outcome measures of education that are 

commonly used include the following: 

biomedical indicators (HbA 1c 

, blood 

glucose, lipids, blood pressure, weight/ 

BMI and so on), psychosocial indicators, 

(quality of life, satisfaction, well-being, 

attitudes, self-efficacy, locus of control, 

perceptions, social support, mental 

health), self-management behaviour, 

diabetes knowledge, costs. Evaluation 

tools might include written, oral or audiovisual 

material, or observational 

methods such as interviews, questionnaires, 

peer observation, or audio or 

video recordings of performance. 

Documentation 

Written records provide a means for 

members of the diabetes management 

team to effectively communicate 

progress, and meet quality and accreditation 

standards. All details of the educational 

process should be documented 

– content, goals, people’s participation 

and their results, facilities, and barriers 

to education. Documentation should 

be kept alongside treatment records 

so that other healthcare providers can 

follow and reinforce subsequent education 

plans. 

Teaching methods 

Education that is delivered in one-toone 

sessions can be tailored to individual 

learning needs and focused on 

a person’s specific self-management 

plan. For instance, people learn how 

to inject insulin effectively through oneto-one 

education. 

Group classes can be effective for up 

to eight people per session. This approach 

maximizes the time available to 

the educator and provides people with 

the opportunity to share their experiences 

in a structured manner, under 

the guidance of the educator. It also 

promotes peer learning and a socially 

supportive environment. 

Self-study, as its name suggests, is a flexible 

approach which relies on a person’s 

capacity for learning alone. For many 

people, the Internet has facilitated easy 

access to written and audio-visual diabetes 

information. Therefore, the guidance 

of an educator is very important in order 

to protect people from inaccurate and 

potentially harmful information. 

Self-management behaviour 

Diabetes management almost always 

requires changes in people’s life-long 

habits. Healthcare providers should 

have knowledge and skills related 

to achieving and maintaining those 

changes. There are many behaviour 

models – self-efficacy, adult learning, 

health belief model, locus of control, 

role modelling. 

Looking to the future 

Research into diabetes education has 

shown efficiency in the short term; beneficial 

effects diminish or disappear in 

the long term. Therefore, diabetes educators 

should be highly skilled in the 

organization of effective educational 

programmes. They should follow the 

literature and apply the latest information 

in their daily practice. 

As an endemic health problem throughout 

the world, diabetes directly or indirectly 

affects everybody. Diabetes 

education is therefore needed by all 

people, including those without diabetes 

but who are relatives, friends, or teachers 

of people with the condition, those 

at risk, as well as those with diabetes. 

Thus, with the aim of preventing the 

condition, diabetes education should 

be rolled out in the form of information 

to increase public awareness. 


Seyda Ozcan is an associate professor 

at the Florence Nightingale School of 

Nursing, Istanbul University, Turkey. She 

is a member of the executive committee 

of the Diabetes Nursing Association of 

Turkey and advisor to the Federation of 

European Nurses in Diabetes. 

Ozgul Erol is a research assistant at the 

School of Nursing of Trakya University, 

Edirne, Turkey and a doctorate student 

at the Nursing Division, Istanbul 

University Health Science Institute. 

Further reading 

1 International Diabetes Federation 

Consultative Section on Diabetes Education. 

Diabetes Education Modules. International 

Diabetes Federation. Brussels, 2006. 

2 Rankin SH, Stallings KD. Patient Education, 

Principles & Practice 4 th Edition. Lippincott 

Williams and Wilkins. Philadelphia, 2001. 

3 Funnell MM, Brown TL, Childs BP, et al. National 

Standards For Diabetes Self-Management 

Education. Diabetes Care 2007; 6: 1630-7. 

4 Funnell MM, Mensing CR. Diabetes 

education in the management of diabetes. 

In Complete Nurse’s Guide to Diabetes 

Care. American Diabetes Association. 

Alexandria, 2005: 188-98. 

5 Knight KM, Dornan T, Bundy C. The diabetes 

educator: trying hard, but must concentrate more 

on behaviour. Diabet Med 2006; 23: 485-501. 


26 


Implementing a postgraduate 

degree course 

for diabetes educators 

in Argentina 

Juan José Gagliardino, María del Carmen Malbrán, Charles Clark Jr 

One reason for poor diabetes outcomes – the development of 

disabling, potentially life-threatening complications – is the 

lack of effective participation by people with diabetes in the 

management of their own condition. This participation is the 

key to successfully achieving therapeutic goals. To be able to 

follow a difficult and complex life-long regimen requires high 

levels of motivation and knowledge. Yet although extensive 

evidence supports this concept, only a minority of people 

receive appropriate diabetes education. Thus, many people 

with diabetes are handicapped in their self-care by limited 

knowledge and skills. The authors describe an initiative 

in La Plata, Argentina, which aims to promote and diffuse 

high-quality diabetes education by training healthcare 

providers to become expert educators. 

Diabetes education programmes require 

large blocks of time, specific 

training, skills in teaching and communication, 

a supportive attitude, and 

readiness on the part of learners and 

educators to listen and negotiate. 1 

Training, in other words, both in what 

to teach and how to teach it. Moreover, 

even if public funding suddenly were 

made available for the implementation 

of diabetes education, in many 

countries there would not be a sufficient 

number of qualified diabetes educators 

to cope with the current demand. It is 

therefore imperative that we begin to 

develop highly skilled diabetes educators 

worldwide. 

It is imperative that 

we develop highly 

skilled diabetes 

educators worldwide. 

The master’s programme, 

National University of La Plata 

Caring for people with diabetes goes 

far beyond the traditional tasks of 

making a diagnosis and providing 

medications. This was the primary 

premise underpinning the development 

of the master’s programme in 

La Plata. To be successful, a postgraduate 

programme for diabetes 

educators must cover approaches to 

facilitate learning of ways in which 

to acquire knowledge and skills for 

day-to-day self-management, as well 

as motivational techniques to implement 

and apply these in an ongoing 

daily procedure. This requires that the 

master’s students learn to understand 



Caring for people with 

diabetes goes far beyond 

making a diagnosis and 

providing medications. 

– and is delivered in one full day every 

two weeks, during which two modules 

are presented. It has been found 

that this format best suits students at 

the university, who all work full-time 

and in some cases have to travel long 

distances to attend classes. Between 

these onsite activities, participants are 

assigned homework that is then verified 

during the subsequent presentation. 

Each module is designed to attain a 

specific educational objective and consists 

mainly of interactive activities and 

formal short lectures. 

The lectures are delivered by experts 

in the fields of diabetes, psychology, 

pedagogy, communication science, 

and disease management. This multidisciplinary 

approach provides students 

with a range of perspectives on 

the practical problems that people with 

diabetes are likely to face, and with 

the tools they will need to solve them. 

Each lecture summarizes the essential 

elements of a given topic or problem, 

and is followed by practical group 

exercises. The attendees also receive 

written material to review the theoretical 

basis of the target subject after 

each session. 

the impact of differences in personality, 

health beliefs, the degrees to 

which people accept and embrace 

their condition, and the influence of 

the family and social environment. 

To accomplish this effectively, healthcare 

providers and diabetes educators must 

acquire skills that are not traditionally 

included in their curricula. Indeed, a 

paradigm shift is needed, away from the 

traditional, authoritarian, paternalistic 

attitude of doctors and other healthcare 

providers towards one of acceptance, 

empathy, and encouragement, sharing 

responsibilities for treatment and dayto-day 

diabetes management. 

The curriculum of the National 

University of La Plata post-graduate 

programme is structured around 23 

half-day modules – a total of 180 hours 

The teaching staff shares the responsibility 

for organizing sessions, workshops 

and entire modules. Given the highly 

interactive nature of the activities, a 

maximum of 30 students can be enrolled 

in the programme. To promote the 

students’ effective participation, several 

interactive techniques are used, including 

brainstorming and sharing ideas, 

role-playing, and problem-solving. 

Evaluation 

Evaluation is ongoing throughout the 


28 


course – performed before, during, 

and at the end of the programme. 

Multiple-choice questionnaires are 

used to evaluate the participants’ 

knowledge. Each lecturer prepares 

six multiple-choice questions on his or 

her topic. These are similar in terms of 

their characteristics and level of complexity, 

and are reviewed by an expert 

committee to ensure homogeneity of 

difficulty and inclusion of appropriate 

distractors (incorrect options). 

Skills are evaluated based on performance 

in a given test or practice. Attitudes 

are evaluated through practical tests 

and observational rating scales. 

Post programme follow-up 

and evaluation 

Having completed their formal coursework, 

students must establish and evaluate 

a diabetes education programme 

based on a thesis proposal, which is 

submitted at the end of their first year. 

An advisor helps the students to develop 

their proposal. The programme 

must be implemented and evaluated 

during the second year as part of the 

final degree requirement. 

Discussion 

As early as 1875, Bouchardat was promoting 

diabetes education for people 

with the condition, alongside daily urine 

tests and weight reduction as cornerstones 

of therapy in type 2 diabetes. 2 In 

1925, Joslin spoke of the need for ‘an 

education programme that explains to 

the community the importance of diet 

and physical activity to prevent the development 

of obesity and of diabetes. It 

should also demonstrate the importance 

of these interventions for the control 

and treatment of diabetes. However, 

this type of programme should start 

with the doctors.’ 3 Education is now 

widely accepted as integral part of 

diabetes therapy, 4 but its implementation 

is not the norm among people 

with diabetes. 

This may be in part because of its low 

priority in healthcare systems. Health 

financing organizations tend to support 

recovery and rehabilitation rather than 

prevention. 5 Additionally, effective education 

requires training in its delivery, 

and programmes to educate educators 

are few in number and largely 

absent in most developing countries. 

Although several organizations – the 

International Diabetes Federation, 

the Declaration of the Americas, 

the Asociación Latinoamericana de 

Diabetes, the European Association 

for the Study of Diabetes – have published 

guidelines for programmes to 

educate diabetes educators, these have 

not been widely tested in developing 

countries. At the National University 

in La Plata, our first objective was to 

ascertain whether we could effectively 

incorporate these educational guidelines 

into a master’s degree programme 

in diabetes education. 

Our experience demonstrates that these 

guidelines can indeed be successfully 

incorporated into such a programme. 

Furthermore, there is clearly a demand 

for this kind of course. We were able to 

enrol 22 busy healthcare providers, 20 

of whom have successfully completed 

their coursework. That we were able 

to provide scholarships – from pharmaceutical 

companies – to all of the 

students is a measure of the support for 

the development of diabetes educators 

within the healthcare community. 

Juan José Gagliardino, María del 

Carmen Malbrán, Charles Clark Jr 

Juan José Gagliardino is a member of the 

CONICET research team and Director of 

the Center of Experimental and Applied 

Endocrinology (National University of 

La Plata – National Research Council, 

PAHO/WHO Collaborating Center), La 

Plata, Argentina. 

María del Carmen Malbrán is responsible 

for pedagogical postgraduate training 

at the National University of La Plata, 

Argentina. 

Charles Clark Jr is Associate Dean and 

Continuing Medical Education 

Professor of Medicine at Indiana 

University School of Medicine, Division 

of Continuing Medical Education, 

Indianapolis, USA. 

Acknowledgments 

This article was adapted from: 

Development and Implementation of an 

Advanced Training Course for Diabetes 

Educators in Argentina, Diabetes 

Spectrum 2007; 20: 24-30. 

See the original article for a detailed 

description of course content, aims and 

materials. 

References 

1 Maldonato A, Bloise D, Ceci M, et al. Diabetes 

mellitus: lessons from patient education. 

Patient Educ Couns 1995; 26: 57-66. 

2 Bouchardat A. Of Glycosuria and Diabetes 

Mellitus. Libraire Germer Bailliere. Paris, 1875. 

3 Joslin EP. Treatment of Diabetes Mellitus. 3 rd 

ed. Lea and Febriger. Philadelphia, 1925. 

4 Assal JP, Mühlhauser I, Pernet A, et al. 

Patient education as the basis for diabetes 

care in clinical practice and research. 

Diabetologia 1985; 28: 602-13. 

5 Karter A, Stevens M, Herman WH, et al; 

Translating Research into Action for Diabetes 

Study Group. Out-of-pocket costs and 

diabetes preventive services: the Translating 

Research Into Action for Diabetes (TRIAD) 

study. Diabetes Care 2003; 26: 2294-9. 



The need for tact, 

openness and honesty 

when talking about 

complications 


Discussing the sensitive issue of long-term complications is difficult for people with 

diabetes and the healthcare providers who work with them. Consequently, this area of 

diabetes management is often not handled well. In some situations, healthcare providers 

are reluctant to impose ‘unpleasant’ information on people who might be struggling to 

cope with diabetes; in others, the potential risk of developing complications might be 

used as a threat in an attempt to scare people into following medical advice. In this article, 

Margaret McGill argues that neither of these approaches is acceptable, and considers the 

role and responsibilities of healthcare providers when offering diabetes information to 

people with the condition. 

It was found as long as 15 years ago that although people 

with diabetes are keen to learn about complications – at 

diagnosis and again after a decade living with the condition 

– healthcare providers in fact often underestimate their 

wishes. 1 One of the key objectives of effective diabetes selfmanagement 

is to ensure that people play a central role in 

determining their care. However, particularly concerning 

diabetes complications, this has the potential for raising 

as well as reducing anxiety. 

A randomized controlled trial was carried out in the mid- 

1990s to evaluate the impact on anxiety levels in people 

with type 2 diabetes of potentially worrying information 

about eye damage (retinopathy). Interestingly, it was found 

that people were prepared to learn about retinopathy and 

that lower levels of anxiety were generated when choices 

regarding the selection of information were made by the 

people themselves rather than by healthcare providers. 2 

It is important for healthcare providers not to give guarantees 

– ‘if you look after yourself you will not develop 

complications’ – about the long-term consequences of diabetes 

self-management; varying blood glucose levels have 

different effects on different people. Moreover, if people 

subsequently develop complications despite receiving assurances 

that effective self-care will prevent problems, they 


30 


are likely to feel guilty because they have failed to look 

after themselves properly. 

People with diabetes need to be aware of the strategies 

available to them to reduce the risk of developing or exacerbating 

complications. Equipped with this information, they 

are then able to make decisions regarding the risks they 

are prepared to take versus the effort they are prepared to 

make – never the healthcare provider’s choice. 

Education, screening and treatment 

People need to learn about the microvascular and macrovascular 

complications associated with their condition. It is of 

fundamental importance that people understand that diabetes 

complications can be entirely asymptomatic in the early 

stages. Because of the lack of outward signs, screening for 

such diabetes-related problems is essential. People with type 1 

diabetes who are under 30 years old should be screened 

for complications within 5 years of diagnosis; after 2 years 

for those over 30. People with type 2 diabetes, on the other 

hand, should be screened immediately upon diagnosis, given 

that the duration of their diabetes is often unknown and that 

30% of newly diagnosed people have already developed 

some form of complication at diagnosis. Following this initial 

screening, all people with diabetes of either type should then 

be assessed every 12 to 24 months. 

Eyes 

The early detection and treatment of eye damage can 

minimize the risks of severe sight loss. Therefore, yearly 

eye examinations are essential. It is important for people 

with diabetes to know that most retinopathy does not 

inevitably lead to loss of vision. It is equally important for 

healthcare providers to reassure people that even if a few 

aneurysms are found on the retina, there is no imminent 

threat of blindness. Indeed, it is essential at this time to 

underline the need for improved blood glucose control 

– the unequivocal means of preventing or delaying the 

progression of eye damage – and help people to consider 

strategies to achieve this. 

People should be aware of the different grades of retinopathy, 

the corresponding therapy options should problems 

develop, and the potential pitfalls of these treatments. Laser 

therapy might be required for advanced eye problems, for 

example. This option has been proven to save people’s 

vision, and is particularly effective if given early – before 

vision dips below 6/18. Although laser therapy has a 

number of potential side-effects, including loss of peripheral 

vision, night blindness and colour blindness, when these are 

balanced against the potential to help preserve sight, most 

people are prepared to tolerate these side-effects. 

It is essential to help people to 

consider strategies for achieving 

improved blood glucose control. 

Feet 

People’s feet should be checked at least once a year for 

evidence of reduced sensation or poor circulation, or a 

combination of both, as well as for any deformities, calluses 

or dry skin. Each person should be asked about the 

symptoms of nerve problems, including numbness, tingling 

or burning pain. More than 50% of people with neuropathy 

in fact show no symptoms. It is therefore essential that some 

form of quantitative testing of sensation – such as with a 

biothesiometer – is carried out. 

People with insensate feet, having lost nature’s protective 

‘gift’ of pain, are at higher risk of amputation than those 

with painful neuropathy. People with painful neuropathy 

should be reassured that they are probably at less imminent 

risk of amputation. However, living with chronic pain can 

have a major impact on the person’s quality of life and 

treatments should be instituted in an attempt to relieve 

some of this pain. 

Symptoms of poor circulation can include: 

cramps which are present in the calves when walking but 

go away after resting 

redness of the feet when sitting 

whiteness when feet are propped up on a stool or chair 

a lack of normal hair growth on the legs and feet. 

If, following a check-up, feet are found to be at risk of ulceration, 

intensive preventive education is necessary on how to 

care for feet. Furthermore, many people who have lost the 

sensation of pain, as they get caught up in busy daily activities, 

forget that their feet might be at risk. Intensive preventive 

education therefore needs to be repeated frequently. 



People with painful neuropathy 

need reassuring: they are at less 

imminent risk of amputation. 

people should be made aware of the potential 

side-effects and encouraged to seek an alternative 

should side-effects occur. In many countries, 

there is a wide choice of medications so one 

can usually be found to suit. 

Kidneys 

In order to prevent or delay kidney disease (nephropathy), 

kidney function should be assessed at least once a 

year – checking for protein in the urine and assessing 

the glomerular filtration rate. If there are signs of kidney 

damage, blood pressure needs to be treated intensively 

to a target of less than 130/80 mmHg. Dietary changes 

are required to achieve this target, and in some cases 

multiple blood pressure-lowering medications are required 

to achieve this target. Commonly, people feel taking too 

many tablets can be harmful. In fact, with regard to treating 

blood pressure, the reverse is true: the person should 

be encouraged to take as many medications as necessary 

to reduce their blood pressure to target. Nevertheless, 

Such drugs are not without risk. However, most 

people who take drugs to lower blood pressure 

do not develop any side-effects, or only have 

mild side-effects. The most common drugs and 

their side-effects are: 

ACE inhibitors – sometimes cause an irritating 

cough 

angiotensin receptor blockers – sometimes 

cause dizziness 

calcium channel blockers – sometimes cause 

dizziness, facial flushing, swollen ankles, and 

constipation 

diuretics – can cause gout attacks in a small 

number of users, or can make gout worse if a 

person already has gout; impotence develops 

in some users 

beta-blockers – can cause cool hands and 

feet, poor sleep, tiredness, and impotence 

in some users. 

Reducing salt in the diet, reducing alcohol intake and 

avoiding drugs (such as anti-inflammatory medications) 

can contribute to reductions in blood pressure. Healthcare 

providers should encourage people with diabetes to become 

familiar with their blood pressure level and whether 

this is at target. It should be made very clear that evidence 

of the early stages of kidney disease (microalbuminuria) 

is not necessarily a precursor to dialysis. In countries or 

settings where the family income permits, it might be 

helpful for a person with diabetes to buy a device to 

measure blood pressure in order to be able to monitor 

daily levels and notify a healthcare provider should these 

rise above target. 


32 


Cardiovascular health 

Compared with the general population, people with diabetes 

are at increased risk of heart attack or stroke. The 

underlying abnormality is atherosclerosis – clogged arteries 

– which increases the risk of heart and blood-vessel 

disease. People should become familiar with their levels 

of triglycerides and cholesterol – HDL and LDL. If heart or 

blood-vessel disease is present, target levels may need to be 

lowered to below those of the general population in order 

to prevent further problems. Dietary modification, weight 

loss, exercise and smoking cessation are vital elements in 

order to reduce cardiovascular risk. Furthermore, many 

people with diabetes require cholesterol-lowering medications, 

which have an established role in both primary and 

secondary prevention. 

Large-scale clinical trials in both type 1 diabetes (the DCCT/ 

EDIC Study) and type 2 diabetes (UKPDS post-study monitoring) 

have demonstrated that blood glucose control achieved 

early in the course of diabetes significantly reduces the 

development and progression of all diabetes-related complications, 

including cardiovascular diseases. It was found that 

where intensive intervention is delayed, the momentum of 

complications is harder to slow. Interestingly, the protective 

effects of a 5- to 7-year period of intensive therapy persist 

for at least 10 years – known as ‘metabolic memory’. When 

they become aware of these findings, many people with 

diabetes are highly motivated to improve blood glucose 

control early in the course of their condition. 

Young people 

For many young people with diabetes and their parents, 

talking about or even considering long-term complications 

is frightening. Moreover, it is difficult for young people to 

find the motivation to make lifestyle changes in order to 

reduce the risk of health problems that might not develop 

for decades. Nevertheless, discussing complications is essential 

to increase a young person’s chances of enjoying a 

healthy future. Healthcare providers need to guide young 

people and their parents through the best approaches to 

diabetes management. 

Tact, openness and honesty 

Healthcare providers have an ethical and legal commitment 

to ensure that the people with diabetes in their care are fully 

aware of all the possibilities associated with a diagnosis 

of diabetes. There is also a moral responsibility to present 

these in such a way as to minimize any harm that might 

be associated with negative information. 

Withholding unpleasant facts or possibilities is risky and 

can be highly counter-productive: if and when a person 

becomes aware that information has been withheld from 

them, the basic trust which underlies a therapeutic relationship 

is likely to be compromised. On the other hand, 

aggressive discussions about the long-term consequences 

of poor blood glucose control can provoke or compound 

entrenched denial and equally damage the potential for a 

balanced professional relationship. 

Withholding unpleasant facts or 

possibilities is risky and can be 

highly counter-productive. 

People need different information at different times. It is 

paramount, in the context of long-term complications, that 

healthcare providers make every effort to help people 

with diabetes to minimize any feelings of guilt – duration 

of diabetes is a major factor in the development of microvascular 

diabetes complications. Above all, healthcare 

providers should be open and honest when discussing 

diabetes-related problems. Negative findings should not 

be considered a failure; they should be taken as an opportunity 

to implement strategies to reduce or reverse the 

progression of complications. 


Margaret McGill is Manager of the Diabetes Centre, Royal Prince 

Alfred Hospital, Camperdown, New South Wales, Australia, and a 

Senior IDF Vice-President. 

References 

1 Genev NM, Flack JR, Hoskins PL, et al. Diabetes education: whose 

priorities are met? Diabet Med 1992; 5: 475-9. 

2 McGill M, Molyneaux L, O’Dea J, Yue DK. Discussing diabetic retinopathy 

with NIDDM patients. An evaluation of varying the content of information 

given to patients and its impact on anxiety. Practical Diabetes International 

1995; 4: 173-6. 



Using new technologies 

in diabetes education 


A complex and ever-growing network of satellites, antennas, 

cables and fibre optics enables human beings to establish 

dialogues with each other between one place and another 

just about anywhere on the planet. While new technologies 

have made a deep and irreversible impact on many aspects 

of daily life, in health services, these have, for the time being, 

only penetrated the niches of pilot projects. In this report, 

Line Kleinebreil explores some of the issues surrounding 

the implementation of new technologies in the field of 

diabetes care and education, citing examples of effective 

initiatives, and describing the obstacles faced by projects 

in the developing world. 

Education is not limited to the acquisition 

of information. We receive 

education in core human values and 

life skills from parents, for example; 

teachers constantly repeat instructive 

messages and lead us into problemsolving 

situations. With books alone, 

a person might acquire knowledge 

without receiving an education. By 

the same token, therapeutic education 

requires people to talk to each other, 

either face to face or at distance. New 

technologies are widely available to 

make this possible. 

While this technology is reliable, and the 

evaluations of pilot projects are positive, 

questions remain over the costs of imple- 

menting high-technology approaches to 

diabetes care and education. Although 

the economic model has to be finalized, 

there are a number of examples of the 

effective implementation of technological 

innovations in developed countries. 

These might serve as models in similar 

economies, where the costs of communication 

are moderate. 

Effective projects in developed 

countries 

Education and management in France 

Whether a woman’s diabetes is known 

before her pregnancy or whether gestational 

diabetes is discovered during an 

antenatal consultation, it is imperative 

that she monitors closely her blood glucose 

levels until her baby is born. To be 

able to do so, a pregnant woman should 

receive regular sessions of specialized 

education in order to reduce the risks for 

the fetus and herself. This was found to 

be almost impossible for women living 

in remote regions in the south of France 

– far from the University Hospital of 


34 


Stakeholders in healthcare 

could forge partnerships 

to accelerate investment in 

communication technology. 

Toulouse where this education is dispensed 

to women in the region. 

A solution was found in a videoconference 

link between the University 

Hospital and a number of maternity 

hospitals in the region. The pregnant 

women were able to limit their movements 

as much as possible by attending 

the nearest maternity hospital, 

where they were able to join groups 

in Toulouse by videoconference. The 

interactive system allows the teacher 

to see distant learners, listen to them 

and answer their questions. The results 

have been excellent. 

The Centre National d’Etudes Spatiales 

(CNES), also based in Toulouse, has 

tried out a second solution. They transmit 

lectures given at the University 

Hospital to a satellite that covers Europe 

and North Africa. With a special box 

people are able to follow the lecture on 

television in their own home. Questions 

can be asked by phone, e-mail or mobile 

phone message. With the same 

system, the CNES could broadcast 

– live or pre-recorded – courses given 

in different countries. 

Family education in Italy 

Ketoacidosis in children living with 

diabetes is a potentially life-threatening 

condition, which requires a rapid 

and personalized intervention. In the 

province of Parma in northern Italy 

during the 1990s, ketoacidosis was 

found in 78% of newly diagnosed children, 

largely due to late diagnoses. 

In response, a group of healthcare 

providers in the region initiated a programme 

to reduce the time it took to 

diagnose diabetes in children and thus 

reduce the risks from ketoacidosis. In 

conjunction with a community-based 

awareness programme, a call centre 

was set up, providing toll-free access 

to diabetes-related medical advice. 

The programme was facilitated by mobile 

phone technology, which enabled 

physicians who were confronted with an 

emergency situation to be guided from 

a distance according to established 

protocols, with information on the fam- 

ily situation of the young person. The 

initiative has been so effective that emergency 

hospitalizations for ketoacidosis 

in the region have been reduced to 

zero. Under the supervision of the team 

from Parma, this model will be set up in 

Cairo, Egypt, a country with huge needs 

and many and complex challenges. (For 

more on the Parma programme, see the 

Diabetes Voice 2007 special issue on 

diabetes in young people.) 

A daily educational link in The 

Netherlands 

The Netherlands, like the rest of Europe, 

has an ageing population. A Dutch 

company, Meavita, provides social 

and medical home care to 300 000 

elderly people, many of whom have 

one or more chronic health condition. 

Driven by the incentive to reduce costs, 

the company developed a daily coaching 

system which could be followed 

on television using a remote control 

that was specially designed for use 

by elderly people. 

Every day, people receive personalized 

advice and short films according 

to their health status – regarding the 

injection of insulin and blood glucose 

monitoring, for example. Where necessary, 

an elderly person or visiting staff 

can activate a webcam, connecting 

them with the company to ask for advice 

or help. The system proved highly 

cost-effective with an initial cohort of 

1500 people, and is being extended 

to a further 40 000. 



Challenges in the developing 

world 

A second series of examples illustrates 

the needs and the obstacles faced by 

people striving to establish technologically 

advanced healthcare communications 

projects in the developing 

countries. 

India 

In terms of the acceptance and implementation 

of new technologies, India 

is one of the most committed and dynamic 

countries. The emerging burden 

of diabetes in the country is enormous. 

Satellite-mediated communications, including 

mobile phones and Internet, 

cover almost the entire country. Various 

diabetes-related distance education 

programmes, initiated by modern 

hospitals, are in progress. However, 

because the people who benefit from 

these are often too poor to pay for an 

inscription, financing for such initiatives 

is uncertain. 

One possibility for improving the education 

of people living with diabetes 

would be to utilize the existing infrastructures 

for distance learning that 

were set up for schooling or HIV/AIDS 

programmes. 

Mali 

In Mali, unlike India, the penetration 

of new technologies and the Internet 

is minimal. In terms of exploiting new 

technologies then, whatever has been 

possible in Mali might be repeated in 

any other developing country. 

Various complementary educational 

programmes are currently underway. 

To support the Faculty of Medicine, a 

satellite-transmitted programme has 

been initiated for nurses and family 

doctors, together with an Internet-based 

interactive programme which is accessible 

in hospitals. Meanwhile, an innovative 

experience in health education 

in isolated rural communities is proving 

effective. Malian migrants living 

and working in Europe have financed 

the building of a school, community 

clinic and post office with parabolic 

antenna and Internet link via satellite. 

On the occasion of World Diabetes 

Day in 2006, which coincided with 

the inauguration of the system, about 

a thousand people from the region 

attended an informative session. 

But the project faces political obstacles. 

Authorization to use the satellite link in 

this isolated rural area is temporary; 

for the moment, the Malian authorities 

have not been willing to establish 

a long-term connection. Many other 

initiatives face similar problems: a lack 

of funding and political will. 

Possible solutions 

One possibility might be an international 

coalition of stakeholders in healthcare 

(specifically diabetes care), communications, 

and new technologies to focus 

on needs and identify digital solutions. 

The International Diabetes Federation, 

having achieved the approval of a UN 

Resolution on diabetes, might be in 

a position to forge partnerships with 

organizations like the World Health 

Organization, the Digital Solidarity Fund 

– a Geneva-based agency that finances 

telecommunications projects in developing 

countries – or the International 

Society for Telemedicine and eHealth in 

order to create favourable conditions to 

accelerate investment in communication 

technology in the field of health. 


Line Kleinebreil is a physician, currently 

working for the department of medical 

information technology at the George 

Pompidou European Hospital in Paris, 

France. She is Vice-President of Primary 

Care Diabetes Europe, secretary of the 

Université Numérique Francophone 

Mondiale (www.unfm.org), and works 

within the network for telemedicine in 

French-speaking Africa (www.raft.org). 

Relevant websites 

International Society for Telemedicine 

and eHealth – www.isft.net 

Digital Solidarity Fund – www.dsf-fsn.org 

World Health Organization – www.who.int 

Call for abstracts 

The 6 th edition of Med-e-Tel will take 

place in Luxembourg from 16 to 

18 April 2008. The international 

conference brings together representatives 

from industry, healthcare, 

government, research and others 

from around the world. 

Focusing on eHealth, telemedicine 

and health ICT, Med-e-Tel 2008 will 

feature a wide variety of eHealth 

and telemedicine cases, experiences 

and research projects. Topics to be 

addressed include mobile eHealth 

solutions, eLearning, diabetes management, 

eHealth for developing 

countries, telenursing and more. 

Med-e-Tel particularly welcomes abstracts 

from people who have been 

using new technologies in diabetes 

care with a view to developing a 

focus on eDiabetes and eHealth 

solutions for diabetes management. 

Abstracts can be submitted 

until deadline 12 January by email 

(education@medetel.lu) or online at 

www.medetel.lu 


Lifelong learning 37 

Providing support and 

education to children 

with diabetes – specific 

needs, special care 


Ground-breaking research findings from the end of the last 

century demonstrated that the disabling and potentially 

life-threatening chronic complications of type 1 diabetes 

can be delayed or prevented by early and intensive blood 

glucose control. However, this strict and demanding regimen 

can present a major challenge for young people with the 

condition. In this article, Barbara Anderson identifies some of 

the research-based barriers to optimal blood glucose control 

that are common in children, and explores ways in which an 

understanding of these barriers helps to identify special needs 

and special concerns with respect to diabetes education of 

young people with type 1 diabetes and their families. 

Intensive management of type 1 diabetes 

is increasingly becoming the ideal 

standard of care at paediatric diabetes 

centres in developed countries. 1,2 This 

ideal standard is based on two landmark 

studies which documented that 

blood glucose levels kept as close to 

normal as possible, and as early in the 

disease course as possible, help to prevent 

or delay the devastating long-term 

complications of type 1 diabetes. 

Data from the Diabetes Control and 

Complications Trial (DCCT) demonstrated 

that intensive treatment compared 

with conventional treatment 


38 

Lifelong learning 

Diabetes educators must be sensitive to the normal developmental tasks of children. 

reduced the risk of microvascular 

complications of type 1 diabetes by 

about 50%. 3 Data from the observational 

follow-up study of the DCCT, the 

Epidemiology of Diabetes Interventions 

and Complications, demonstrated that 

a period of optimal blood glucose 

control early in the course of diabetes 

has a protective effect against later 

complications of type 1 diabetes. 4 

Barriers and challenges 

For people of any age, the treatment 

regimen for type 1 diabetes is complex 

and demands constant attention, 

problem-solving, and self-discipline. 

Children with type 1 diabetes and their 

family require age-appropriate and 

comprehensive diabetes education at 

diagnosis, as well as ongoing access to 

a competent multidisciplinary diabetes 

team composed of a paediatric endocrinologist, 

diabetes educator, dietitian, 

and mental healthcare provider, as 

recommended in the current American 

Diabetes Association (ADA) standards 

of care for children with diabetes. 1 

There is consensus in the paediatric 

diabetes behavioural literature on 

three barriers that have been documented 

to interfere with optimal selfcare 

behaviour and blood glucose 

control in children and adolescents 

with type 1 diabetes. 5 

Family socio-economic and family 

structure risk factors 

There is evidence that young people 

with type 1 diabetes in developed countries 

who are at risk for poor metabolic 

control and acute complications 

in childhood are disproportionately 

from single-parent homes, from minority 

ethnic backgrounds, and from lower so- 



cio-economic backgrounds, often with 

inadequate insurance or without health 

insurance. Moreover, young people 

with type 1 diabetes in developing 

countries without access to essential 

diabetes medications, supplies or education 

are at extreme risk for death, or 

poor health and poor quality of life. 

Conflict between normal child 

development and managing the 

complex type 1 diabetes regimen 

The normal developmental tasks of 

school-age children – between 7 and 

12 years of age – include making a 

smooth adjustment from the home to 

the school environment, forming close 

friendships with other children, developing 

new intellectual, athletic, and 

artistic skills, and forming a positive 

sense of self as a unique person within 

the school and family settings. 

The primary developmental tasks for 

adolescents – around 13 to 18 years of 

age – involve adjusting to a physically 

maturing body, building strong relationships 

with peers, becoming an individual 

by separating from parents psychologically, 

and developing personal goals, 

values, and opinions. Thus, the tasks 

of normal school-age and adolescent 

development often compete and conflict 

with the requirements of intensive 

diabetes management regimens. 

Family conflict and inappropriate 

parental involvement 

Parents and other family members 

play a profound role in the evolving 

development of young people. The 

literature on diabetes self-management 

in children and adolescents indicates 

that both diabetes-specific family behaviour 

and general aspects of family 

functioning are associated with the 

degree to which children follow their 

management regimen and control their 

blood glucose levels. 

Parents who produce less 

conflict have children 

with the most positive 

diabetes outcomes. 

General family conflict and diabetes-specific 

conflict between parents 

and young people are both frequently 

reported to be associated with poor 

diabetes management and blood glucose 

control. Family stress and conflict 

may impact directly on blood glucose 

control by triggering stress hormones; 

or family stress may interfere indirectly 

with blood glucose control by disrupting 

self-management behaviour. Research 

in the general child development area 

documents that parents who are consistent, 

warm, set realistic limits on their 

child’s behaviour, and interact in a style 

which produces less conflict have children 

with the most positive emotional 

and behavioural outcomes. 

In diabetes-specific research, this style 

of parenting has also been shown to be 

linked to positive adjustment and excellent 

health outcomes in young people 

with type 1 diabetes. The current ADA 

standards of care recommend that ‘the 

goal should be a gradual transition 

toward independence in management 

through middle school and high school. 

Adult supervision remains important 

throughout the transition’. 1 Thus, while 

there is now consensus that parental 

involvement in the child’s diabetes 

self-care behaviour must be sustained 

across the childhood-adolescent period, 

it is also recognized that effective 

parental involvement in diabetes management 

is a complex and dynamic 

process as the child matures. 

Given the current era of intensive management 

in young people with diabetes, 

as well as the consensus in behavioural 

studies as to the barriers facing 

children in achieving optimal glucose 

control, it is clear that there are both 

specific needs and special concerns 

with respect to the diabetes education 

of children with type 1 diabetes. 

Specific needs 

From the day of diagnosis, family members 

(parents, siblings, grandparents, 

other important family members) should 

receive education along with the child. 

As children grow and develop, there is 

an ever-widening circle of people who 

also should be educated about diabetes: 

school personnel, coaches, camp 

counsellors, extra-curricular teachers 

(music or dance for example). 

The child and family must 

practise interdependence 

in the tasks of managing 

diabetes. 

Diabetes educators need to promote 

sharing of diabetes responsibilities 

among family members so that developing 

children are empowered to engage 

in their own care while remaining 

open to support and assistance from 

others. In other words, the child and 

family must practise interdependence 

in the tasks of managing diabetes. 

The child’s functioning in peer, academic, 

and family contexts must be 

assessed by the diabetes educator so 

that his or her quality of life can be 


40 


balanced with the increasingly demanding 

regimens that are developed 

to optimize blood glucose control in 

type 1 diabetes. Diabetes educators 

need to ensure that children are able 

to develop a sense of competence and 

confidence in managing their diabetes 

and avoid ‘burn-out’, particularly during 

difficult periods such as puberty. 

This will help to ensure that young 

people with diabetes can face the future 

with resilience and optimism, and 

continue to benefit from advances in 

diabetes treatment. 

Diabetes educators 

should ensure that 

children avoid ‘burnout’, 

particularly 

during difficult periods 

like puberty. 

Special concerns 

Children with diabetes are, first and 

foremost, children. Diabetes education 

must be age-appropriate in content and 

delivery. Educators must be sensitive 

to the normal developmental tasks of 

children and try to work diabetes management 

into the normal activities of 

childhood – sports, trips, parties, and 

so on. This will help young people with 

diabetes to balance a sense of belonging 

with a sense of uniqueness. 

There should be ongoing assessment 

of each child’s functioning – emotionally, 

with peers, at school, and within 

the family. There is also a need for 

ongoing assessment of mental health 

barriers to optimal control, such as 

depression, anxiety disorders, and eating 

disorders, which put the child with 

diabetes at high-risk for poor blood 

glucose control. 

Conclusion 

We live in an era in which we know 

that intensive management of type 1 

diabetes is the best choice to prevent 

the long-term complications of the condition. 

Moreover, we know that all children 

living with type 1 diabetes need 

two teams to manage the complex 

regimen associated with this intensive 

management: a multidisciplinary diabetes 

care team, and a family team. 

In addition, children with type 1 diabetes, 

wherever they live, bring specific 

needs to diabetes education: the need 

for all caregivers to receive diabetes 

education; the need for families to 

learn how to negotiate the sharing of 

diabetes responsibilities; the need for 

quality of life (of children and parents) 

to be balanced with the burdens of the 

diabetes treatment regimen; and the 

need for children to achieve a sense 

of competence and confidence in managing 

diabetes as they develop into 

young adulthood. 

There are special concerns involved in 

providing diabetes education to children 

with type 1 diabetes. Diabetes education 

must be age-appropriate in content 

as well as delivery. The diabetes treatment 

regimen must be worked into the 

normal tasks of child and adolescent 

development. Diabetes education must 

include ongoing assessment of emotional 

functioning, especially with respect to 

depression, anxiety, and eating disorders. 

Once the child and family have 

full access to insulin and critical diabetes 

supplies, attention to these specific needs 

and special concerns in diabetes education 

will help to insure that young people 

with type 1 diabetes and their families 

face a healthier, happier future. 


Barbara Anderson is a clinical 

psychologist and behavioural scientist. 

She is Professor of Pediatrics at Baylor 

College of Medicine, Houston, Texas, USA. 

References 

1 Silverstein J, Klingensmith G, Copeland K, 

et al; A Statement of the American 

Diabetes Association. Care of children 

and adolescents with type 1 diabetes. 

Diabetes Care 2005; 1: 186-212. 

2 International Society for Pediatric and 

Adolescent Diabetes. Consensus Guidelines 

for the Management of Type 1 Diabetes 

Mellitus in Children and Adolescents. ISPAD. 

Medical Forum International. Zeist, 2000. 

3 Diabetes Control and Complications Trial 

Research Group. The effect of intensive 

treatment of diabetes on the development 

and progression of long-term complications 

in insulin-dependent diabetes mellitus. 

N Engl J Med 1993; 329: 977-86. 

4 Epidemiology of Diabetes Interventions and 

Complications Research Group. Beneficial 

effect of intensive therapy of diabetes during 

adolescence; outcomes after the conclusion 

of the Diabetes Control and Complications 

Trial. J Pediatr 2001; 139: 804-12. 

5 Anderson BJ, Svoren B, Laffel L. Initiatives 

to promote effective self-care skills in young 

patients with diabetes. Disease Management 

and Health Outcomes 2007; 15: 101-8. 



Young people’s needs 

and priorities for improved 

support and education: 

a call for action 

Anja Østergren Nielsen, Dana Lewis, Caitlin McEnery, Jakob 

Pedersen, Martin Salkow, Søren Skovlund, Alex Greene 

Most young people’s lives are hectic. They all involve a 

degree of chaos, and the usual trials and tribulations of 

friendships, romance, college, and so on. Add the diabetes 

into the mix, with its unique challenges, and the situation can 

feel overwhelming. The authors of this report, young people 

who have been living with diabetes for some years, have all 

met several diabetes healthcare providers. Unfortunately, 

although many adults involved in diabetes care are keen 

to help young people to make the most of their life, this 

does not always appear to be the case. Since the majority 

of healthcare providers do not have diabetes themselves, 

they do not understand the real challenges and issues, and 

how these impede the persistent attempts of young people 

to achieve good blood glucose control. 

At the International Diabetes Federation 

(IDF) Congress in Cape Town 2006, 

the IDF Youth Ambassadors found that 

despite the diversity of our geographical 

locations and cultures, many of us 

had experienced similar issues relating 

to diabetes. Diabetes can feel like a 

complex puzzle with many parts that 

have to fit together for us to be able to 

live life to its fullest. To get an overview, 

we decided it would be useful to compile 

the many thoughts and issues that 

were prioritized by an international 

group of young people. 

The youth leadership workshop, prior 

to the IDF Congress, included training 

in applying business leadership 

frameworks for our volunteer work in 


42 


Figure 1: Prioritized attitudes, wishes and needs 

Urgency 

diabetes advocacy. We learned how 

to determine key priorities in order 

to allocate resources effectively and 

maximizing positive results. Once the 

issues have been clearly defined, a 

strategy and plan of action can be 

devised to tackle each one appropriately. 

Once issues have 

been defined, a plan of 

action can be devised 

to tackle each one. 

Impact 

Low Sign Major 

Low 5 7 

Sign 8 1, 9 

Pressing 2 3, 4, 6 

1. Lack of focus on siblings 

2. Lack of connections to 

other children with diabetes 

3. Needs for support for 

parents (networks, education, 

money, time to 

let go) 

4. Deficit of communication 

within the family (family 

code-of-conduct/agreement) 

5. Stigma of living with 

diabetes 

6. Apathy/burn-out from 

living with diabetes 

7. Lack of support to make 

smart/healthy choices 

8. Distrust of own and 

other’s capabilities of 

dealing with the child 

with diabetes 

9. Lack of comprehension 

of how the emotions are 

connected to diabetes 

This analysis was applied to the 

DAWN (Diabetes Attitudes, Wishes 

and Needs) youth initiative, a global 

Novo Nordisk A/S initiative in partnership 

with IDF and the International 

Society for Pediatric and Adolescent 

Diabetes to improve psychosocial support 

for children with diabetes and 

their families. Having recently spent 

several days sharing stories about 

living with diabetes in various different 

countries, we were invited by the 

DAWN youth committee to list and 

prioritize the issues that in our opinion 

were key to improving the life 

of young people with diabetes, particularly 

with regard to psychosocial 

issues (Figure 1). 

A strong emphasis was placed on the 

need for improved support and education 

to be provided in a number of 

ways. Diabetes advocates and healthcare 

providers need to target young 

people, their parents, and siblings 

with education and support. Indeed, 

society as a whole needs an increased 

understanding of diabetes in order to 

be able to provide effective support 

for those of us with diabetes. 

We placed a strong 

emphasis on the need 

for improved support 

and education. 

Some of our issues were related to 

day-to-day living within the family; others 

aimed to challenge fundamental 

problems in society. Other issues are 

directly related to individuals living 


We would very much like to encourage 

all people who are involved in diabetes 

care to look closely at the way we have 

prioritized our wishes and needs. In 

this way, we can unite as a team in our 

treatment, rather than parents dealing 

with rebellious teenagers they struggle 

to understand. 

Anja Østergren Nielsen, Dana 

Lewis, Caitlin McEnery, Jakob 

Pedersen, Martin Salkow, 

Søren Skovlund, Alex Greene 

Anja Østergren Nielsen is a student 

of molecular biomedicine at the 

University of Copenhagen, Denmark, 

and a youth advisor on the DAWN 

Youth Global Steering Committee. She 

is 23 years old and was diagnosed 

with type 1 diabetes in 1999. 

Dana Lewis is a student of public 

relations and political science at the 

University of Alabama, USA. She is 19 

years old and has had type 1 diabetes 

since she was 14. 

Caitlin McEnery is 22 years old 

and has had type 1 diabetes for 19 

years. She recently graduated from 

Georgetown University, USA. 

Jakob Pedersen is a student of 

business economics at Aalborg 

University in Denmark. He is 23 years 

old and has had type 1 diabetes since 

1992. 

Martin Salkow is 23 years old and 

was diagnosed with type 1 diabetes 

when he was 6. He studies finance and 

entrepreneurship at the University of 

South Africa in Johannesburg. 

Søren Skovlund is global programme 

director of patient focused 

programmes, Novo Nordisk. 

Alex Greene is a social anthropologist 

and senior research fellow at the 

Health Services Research Unit at the 

University of Aberdeen, Scotland. 



The Steno Diabetes Center: 

from education to action 

Ulla Bjerre-Christensen, Ebbe Eldrup, Christian Binder 

The Steno Diabetes Center was founded in 1932. It has 

since been a leading player in the struggle against diabetes 

through clinical care and development, and wide research 

activities. During the 1980s, the paternalistic model of care 

was shown to be inadequate to cover the demands of people 

with diabetes. The need for coaching, learning and education 

became clear. A team approach was gradually developed, 

involving nurses, dietitians and foot specialists, as well 

as physicians. In 1991, the Steno Education Center was 

established with the purpose of organizing international 

courses in diabetes treatment for diabetes teams. As well as 

updates on recent developments in diagnosis and treatment, 

the Steno model focused on the importance of the process 

of education and learning. 

Within 10 years of its founding, 35 

courses were held at the Steno Education 

Center (SEC) in Copenhagen, with more 

than 1200 participants from 59 countries. 

In addition, similar courses were 

held in various parts of the world, where 

the Steno faculty teamed up with national 

colleagues. The courses developed 

into a model that proved to be efficient 

in disseminating knowledge about diabetes 

and teaching in the regions where 

the participants were recruited. 

Expanding the scope 

While the incidence of type 2 diabetes 

increased at an epidemic rate in both 

developed and developing countries, 

evidence indicated that early detection 

combined with proper preventive 

measures could relieve some of the 

burden of the condition. The need to 

upgrade healthcare staff quantitatively 

and qualitatively to meet the growing 

health burden became obvious. The 

International Diabetes Federation and 

the World Health Organization pushed 

for action. While initiatives were taken 

by some governments and health authorities, 

NGOs played an important role. 

The Novo Nordisk Foundation, whose 

objective is to support scientific, humanitarian 

and social purposes and provide 

a stable basis for the commercial and 

research activities of the companies 

within the Novo Nordisk Group, decided 

to institute an educational grant 

– the Steno Training and Application of 

Resources (STAR) project – with the aim 

of increasing knowledge about diabetes 

and care for people with the condition 

in developing countries. 

India and China were 

selected as countries 

in which the Steno 

programmes could have a 

strong impact on treatment. 

India and China were selected as initial 

target countries in which the Steno educational 

programmes could be expected 

to have a strong impact on diabetes 

treatment. Many countries qualified, but 

a major cause of this choice was that 

the infrastructure of Novo Nordisk A/S 

in those two countries was prepared 


44 


Chinese nurses at recent 

diabetes nurse forum 

in Shanghai, China. 

to offer unrestricted logistical support. 

They took care of recruitment according 

to rules that were agreed upon, and of 

all local logistics without any interference 

in terms of content and execution 

of the course programmes. 

From planning to practice 

In preparing for the expansion of the 

Steno model, the Steno Education 

Center performed a thorough analysis 

of the diabetes needs in India and 

China. There were two major pillars in 

the educational effort from SEC: 

dissemination of the insights gained 

from year-long clinical experience 

transfer of the educate-the-educator 

approach in order to further disseminate 

knowledge effectively. 

In order to ensure an optimal acceptance 

of the educational efforts, it was 

decided to involve local diabetes care 

staff in the course faculty and planning. 

With strong local partnerships, duplication 

of existing educational efforts was 

also avoided. 

A senior faculty member from Steno performed 

a fact-finding tour throughout India 

and China, discussing these plans with 

key opinion leaders among diabetologists 

and healthcare officials. It became clear 

that the chosen approach was in line with 

local needs and wishes. Moreover, differences 

between the healthcare services of 

the two countries led to an understanding 

of the need for local modifications to the 

educational approach. 

Differences between 

healthcare services in India 

and China highlighted the 

need for modifications of 

the educational approach. 

Tailoring courses 

In India, there was a demand for the 

preparation of teams at the community 

level, as well as a need for courses in 

research methodology. Consequently, 

one type of course focused on teaching 

practical diabetology and sharing best 

practices to doctors, nurses and diabetes 

specialists who were seeing people 

with the condition on a daily basis. The 

emphasis was placed on a didactic 

approach – as practised at Steno. The 

participants were encouraged to write 

down how they would design their future 

clinic, and how implementation could 

be initiated. In this way, an analysis of 

barriers to local implementation formed 

an important part of the group work. 

The staff from Steno was comprised of 

a chief physician, a staff specialist, two 

nurses, a course administrator and an 

educational advisor. The local staff was 

comprised of a senior diabetologist, an 

orthopaedic surgeon and a dietitian. 

Another type of course focused on training 

young physicians in research methodology. 

The topics were epidemiology, 

statistics and molecular genetics. The 

teaching was performed by principal 

investigators and scientists from the 

Steno Diabetes Center. 

In China, leading diabetologists expressed 

a need for courses for internists 

and endocrinologists from major hospitals. 

These courses, which are ongoing, 

include workshops focusing on screening 

programmes and experiencing diabetes. 

The Chinese courses also include 

training in the transfer of knowledge in 

an educate-the-educator model in order 

to initiate a cascade effect, disseminating 

knowledge at the local level. The 

Steno faculty is comprised of six senior 

diabetologists; leading diabetologists in 

the region are chairing the sessions. 



Course evaluation 

During the first years of the courses, 

minor adjustments in form and content 

were made, guided by the feedback 

from course participants. After four 

years, a major evaluation was undertaken 

to assess whether the content and 

performance of the courses were still in 

accordance with the needs perceived 

by the healthcare providers of each 

country, and whether the goal of inducing 

an educate-the-educator knock-on 

effect was reached. 

In both countries, interviews were 

performed within the same group of 

opinion leaders that were initially consulted 

and among younger heads of 

department. The impact of the courses in 

India was evaluated by means of questionnaires 

distributed one or two years 

after course completion. In general, 

the response was enthusiastic. There 

was broad agreement that the courses 

effectively contributed to the spread of 

knowledge and improved treatment of 

diabetes in both countries. 

The courses contributed to 

the spread of knowledge 

and improved the 

treatment of diabetes. 

In India, the teaching of teams at community 

level received high ratings. 

Many participants had implemented 

changes in their own clinic, but there 

were only minor indications that the 

acquired knowledge had spread to 

other centres. There was, however, a 

clear desire to upgrade teaching in 

future courses. It was also found that 

the medical treatment, practice and 

screening habits of the Indian diabetes 

clinics were in line with international 

recommendations. It was estimated that 

the treatment of more than 500 000 

people with diabetes may have been 

influenced by the first five years of the 

STAR courses. The research courses 

were also highly praised, but did not 

seem to have initiated or furthered scientific 

work – mainly due to lack of local 

research facilities – and the courses 

were brought to a halt. 

In China, the courses were judged to 

be highly successful. More than 1600 

doctors were taught during the first 

five years of the STAR programme. 

The educate-the-educator effect was, 

however, not visible, since few local 

courses based on the Steno model have 

been introduced. But the participants 

recommended prioritizing the concept 

in future courses. 

Current and future course needs 

A number of governments have 

made diabetes a key healthcare target. 

Educational activities have been 

launched and improved around the 

world. Based on the evaluations, the 

Steno courses were further improved. 

In India, the courses in practical diabetology 

continue inviting teams with some 

diabetes experience. Educating-the-educators 

and education of the participants 

have been given a much higher priority 

than top-down lecturing. 

In China, the general evaluation also 

led to adjustments in the courses, which 

continue to be held several times a year. 

The programme is now comprised of 

lectures, discussions, case studies and 

workshops – equal time is allocated 

to each. The content is a combination 

of lectures in basic science, clinical 

excellence and didactic measures, with 

the aim of initiating the concept of the 

educate-the-educator knock-on effect. 

Furthermore, a new concept has been 

introduced in China, where nurses are 

invited to attend an advanced diabetology 

course. This is run by two diabetes 

nurses and a dietitian from SEC. 

Lessons have been 

learned; a more interactive 

approach is to be tried out. 

The Steno way of practising courses 

in diabetes for professionals who see 

many people with diabetes has been 

successful in the sense that it has led to 

changes and improvements in clinical 

settings. The courses have also furthered 

interaction among participants at the 

national and international levels. We 

have learned that one-way teaching 

is not learning. We have yet to learn 

how to really reach out to the many by 

inducing a knock-on effect following 

an educate-the-educator model. Some 

lessons have been learned, but a more 

interactive approach will be tested. 

Ulla Bjerre-Christensen, Ebbe 

Eldrup, Christian Binder 

Ulla Bjerre-Christensen is chief physician 

at the Steno Diabetes Center. 

Ebbe Eldrup is chief physician at the 

Steno Diabetes Center and Manager of 

the Steno Education Center. 

Christian Binder is chairman emeritus of 

the Steno Diabetes Center and one of the 

founders of the Steno Education Center. 

The Steno Diabetes Center is owned 

by Novo Nordisk A/S and operates as a 

partner in the Danish national Health 

service. 


46 


Improving the quality 

of diabetes education in 

Vietnam – a communitybased 

approach 


Recent economic development in Vietnam, 

which has a population of nearly 90 million 

people, has been accompanied by rising 

prevalence of type 2 diabetes. However, 

diabetes management in general is far 

from optimum, due largely to the lack of 

specific education available to people with 

the condition. There is only a small number 

of specialized educators, and diabetes 

education is generally provided by doctors 

who do not have the time or background to 

carry out this work adequately. Ta Van Binh 

and Le Quang Toan report on a project to 

improve the quality of diabetes education in 

Vietnam and in doing so, provide good quality 

diabetes education to large numbers of 

people with diabetes in their communities. 

According to a 2002 nationwide survey, the prevalence of 

diabetes in people aged 30 to 64 years in Vietnam stands 

at around 2.7%. According to the survey, nearly 80% of 

people with the condition did not follow a specific diet or 

engage in physical exercise; 60% had poorly controlled 

blood glucose levels. One of the key reasons for this worrying 

situation is the lack of adequate education for people 

with diabetes in Vietnam. No institution officially provides 

training for diabetes educators and consequently there is an 

important shortfall in the number of diabetes educators. 

Trainees will organize courses 

for other diabetes educators 

and people with diabetes. 

In response to this urgent need for educators, the International 

Diabetes Federation (IDF) Consultative Section on Diabetes 

Education and the National Endocrinology Hospital in Hanoi, 

Vietnam recently set up a project to improve the quality of 

diabetes education via a community-based approach. The 

primary objective is to enhance knowledge and skills relating 

to diabetes education and management among healthcare 

providers. These healthcare providers will develop the skills 



Participants practise 

carbohydrate counting during 

the IDF multidisciplinary diabetes 

care and education programme. 

they need to organize courses for other diabetes educators 

and people with diabetes. Following the course, other 

healthcare providers will receive training locally from the 

course participants. 

Multidisciplinary training 

In September 2006, a five-day multidisciplinary course 

in diabetes care and education for healthcare providers 

was held in Hanoi. The participants were 25 doctors and 

nurses working in large endocrinology centres or general 

hospitals. The trainers were experts in the fields of diabetes 

and diabetes education from Vietnam and abroad. 

Theoretical sessions were 

complemented by practical sessions, 

group work and presentations. 

The course, based on the IDF International Curriculum for 

Diabetes Health Professional Education, covered all aspects 

of diabetes management, including nutrition therapy, physical 

exercise, management and prevention of hypoglycaemia, 

care during sick days, blood glucose self-monitoring, foot 

care, and prevention of complications. 2 Interactive theoretical 

sessions were complemented by practical sessions, group 

work and presentations. 

In the practical sessions, participants 

learned how to use a glucometer 

to measure blood glucose, 

and how to examine feet for risk of 

foot complications. In small groups, 

plans were prepared for education 

on preventing acute complications 

such as hypoglycaemia, 

and management of sick days. The 

preparation of meal plans was also 

covered in the group work, including 

carbohydrate counting and the 

use of case studies to assist people 

in making adjustments to their meal plan. Some aspects of 

education, such as the principles of teaching and learning, 

were also addressed, including the assessment of learning 

needs and lesson planning. Some time was also given to 

teaching practice. 

By the end of the course, every participant or group of 

participants had written a short project on diabetes education 

to be implemented locally during the year following the 

course – one of the objectives of the overall project. The 

topics chosen were nutrition, blood glucose self-monitoring, 

the use of insulin, foot care, and physical exercise. All the 

projects were reviewed and approved by a project steering 

committee. Some received a budget for implementation. 

The educational materials used in the projects were 

based on the materials used during the course in Hanoi, 

adapted to local needs and cultural differences – nutrition, 

for example. 

The aim is that, during the year following the course, each 

participant should provide training on their chosen topic for 

five nurses, each of whom in turn should provide education 

for 50 people with diabetes in their area. In total, more 

than 6000 people with diabetes are expected to receive 

education during the year. 


48 


Education in the community 

The activities of some of the projects are being integrated into 

some of the activities of another project: a community-based 

approach to improving the quality of diabetes management 

in Vietnam – supported by the World Diabetes Foundation. 

One of the objectives of this project is to build up a network 

that is capable of preventing, monitoring and managing 

diabetes at the community level. Two provinces, Thai Binh 

and Thanh Hoa, have been chosen to pilot the project, and 

a third is to be identified. The provincial endocrinology 

centres have responsibility for implementing the project, 

together with the National Endocrinology Hospital. 

The provision of education for people with diabetes to enhance 

their self-monitoring and self-care is a key objective 

of the project. Activities in the two provinces so far have 

included radio and television programmes, newspaper 

articles, and the dissemination of diabetes education materials 

in leaflets to all communities. Another key element 

is the organization of diabetes education clubs for people 

with the condition. Two diabetes clubs were set up in 2005 

– one in each provincial centre. 

the project. Outcomes are evaluated by indicators of blood 

glucose control – fasting blood glucose and/or HbA 1c 

. 

The course curriculum focuses on important aspects of diabetes 

education: nutrition, behaviour change and counselling 

skills, group education, and numerous case studies that will 

help participants to enhance their competency in further 

educational work. After the course, the participants will be 

expected to provide training for other healthcare providers, 

who will in turn provide education for many more people 


Into the future 

The present situation of diabetes management in Vietnam 

needs urgent attention. The community approach is an effective 

way to improve its quality. A number of communitybased 

projects have started recently and require further 

efforts if they are to be successful. Careful monitoring and 

evaluation of these will identify advantages and challenges 

in diabetes education. This will reveal effective approaches 

to further improve its quality in the future. 

Community-based activities will 

extend into all rural and urban 

districts in both provinces. 

Currently, there are about 400 club members in Thai Binh 

and 700 Thanh Hoa. An average of about 300 people 

attend the monthly or three-monthly club meetings, during 

which healthcare providers from the provincial endocrinology 

centres offer sessions in diabetes education. The healthcare 

providers have received training from the trainers at the 

National Endocrinology Hospital; some attended the IDF 

training course described above. The activities are planned to 

extend into all rural and urban districts in both provinces. 

Advanced training 

The second IDF advanced training course is scheduled for 

late 2007. Participants in the first course will be enrolled 

provided they have successfully completed their project. 

During this second course, participants will report on their 

project results, including the number of healthcare providers 

who have received training, the number of people with diabetes 

receiving education, and clinical outcomes related to 


Ta Van Binh is Director of the National Hospital of Endocrinology 

in Hanoi, Vietnam, Director of National Institute of Diabetes and 

Metabolic Disorders Control Strategy Researches, Head of the 

sub-committee of the Vietnam National Diabetes Control Project, 

and Editor-in-Chief of the journal Endocrinology and Metabolic 

Disorders. 

Le Quang Toan works for the Department of Training and Research 

at the National Hospital of Endocrinology, Hanoi, Vietnam. 

References 

1 Ta Van Binh, et al. Epidemiology of diabetes mellitus in Vietnam, 

methods of treatment and preventative measure. Medical Publishing 

House. Hanoi, 2006. 

2 International Diabetes Federation Consultative Section on Diabetes 

Education. International Curriculum for Diabetes Health Professional 

Education. International Diabetes Federation. Brussels, 2002. 


International Diabetes Federation 

Executive Board 

Regions 

Corporate Partners 

President 

Martin Silink, Australia 

President-Elect 

Jean-Claude Mbanya, Cameroon 

Vice-Presidents 

Anne-Marie Felton, United Kingdom 

Michael Hirst, United Kingdom 

Nigishi Hotta, Japan 

Debbie Jones, Bermuda 

Massimo Massi-Benedetti, Italy 

Marg McGill, Australia 

Valentina Ocheretenko, Ukraine 

Kaushik Ramaiya, Tanzania 

Shaukat Sadikot, India 

Denis Taschuk, Canada 

Brian Wentzell, Canada 

Wim Wientjens, The Netherlands 

Executive Office 

Luc Hendrickx, Executive Director 

Marleen Vanden Berghe, Executive Assistant 

Alain Baute, e-Project Manager 

Delice Gan, Special Project Manager 

Chloé Harkness-Pierre, Programme Manager 

Olivier Jacqmain, Project Coordinator 

Ronan L’Heveder, Project Manager 

Kerrita McClaughlyn, Media 

Relations Coordinator 

Tim Nolan, Editor 

Vivian Okonkwo, Congress Assistant 

Lorenzo Piemonte, Communications Coordinator 

Anne Pierson, Press Events Manager 

Marcel Pirlet, Finance Manager 

Joël Quenum, Accounting Assistant 

Catherine Regniers, Project Manager 

Celina Renner, Administrative 

and Events Manager 

Philip Riley, Communications Manager 

Dominique Robert, Special Project Coordinator 

Kari Rosenfeld, Special Project Manager 

Africa 

Chair: Alieu Gaye, Gambia 

Chair-Elect: Maria Mupanomunda, Zimbabwe 

Office Manager: Nancy Njie 

Phone: +220-4224174 

idfafrica@mail.gm – www.idf-africa.org 

Eastern Mediterranean 

and Middle East 

Chair: Morsi Arab, Egypt 

Chair-Elect: Amir-Kamran 

Nikousokhan Tayar, Iran 

Office Manager: Ali El Sherif 

Phone: +203-5433505 

Fax: +203-5431698 

alyshrf@hotmail.com – www.idf-emme.org 

Europe 

Chair: Eberhard Standl, Germany 

Vice-Chair: Chris Delicata, Malta 

Office Manager: Lex Herrebrugh 

Phone: +32-2-5371889/6392094 

Fax: +32-2-5371981 

lex@idf-europe.org – www.idf-europe.org 

North America 

Chair: Frank Vinicor, USA 

Chair-Elect: Lurline Less, Jamaica 

Office Manager: Linda Cann 

Phone: +1-703-5491500 

Fax: +1-703-5491715 

lcann@diabetes.org – www.idf-na.org 

South and Central America 

Chair: Susana Feria de Campanella, Uruguay 

Chair-Elect: Manuel Vera Gonzalez, Cuba 

Office Manager: Vasco Campanella Lemes 

Phone: +598-2-7095457 

Fax: +598-2-7072963 

susanafe@adinet.com.uy – www.saca-idf.org 

South-East Asia 

Chair: Mahen Wijesuriya, Sri Lanka 

Chair-Elect: Dhruba Lall Singh, Nepal 

Office Manager: Farzana Hameed 

Phone: +94-11-2872951 

Fax: +94-11-2872952 

dasl@sltnet.lk – www.idf-sea.org 

Western Pacific 

Chair: Gordon Bunyan, Australia 

Chair-Elect: Yutaka Seino, Japan 

Office Manager: Esther Ng 

Phone: +65-64587172 

Fax: +65-65531801 

idf_wpr@diabetes.org.sg – www.idf-wp.org 

Long Term Partner (Lawrence Circle) 

Eli Lilly and Company 

Novo Nordisk A/S 

Roche 

Servier 

Corporate Partners (Mayes Circle) 

AstraZeneca 

Bayer Corporation 

Becton Dickinson 

Eli Lilly and Company 

LifeScan 

Merck KgaA 

Merck and Co. 

Novo Nordisk A/S 

Pfizer 

Roche Diagnostics 

Sanofi-Aventis 

Servier 

Takeda 

Contributor 

Abbott 

Amylin 

Medtronic 

Novartis 

The International Diabetes Federation (IDF) is not engaged in rendering medical services, advice or recommendations. The material provided in this publication is therefore intended and can be used for educational and informational purposes only. 

It is not intended as, nor can it be considered or does it constitute, medical advice and it is thus not intended to be used or relied upon to diagnose, treat, cure or prevent diabetes. Readers should seek advice from and consult with professionally 

qualified medical and healthcare professionals on specific situations and conditions of concern. Reasonable endeavours have been used to ensure the accuracy of the information presented. However, the International Diabetes Federation (IDF) 

assumes no legal liability or responsibility for the accuracy, currency or completeness of the information provided herein. Any views, opinions, and/or recommendations contained in this publication are not those of IDF or endorsed by IDF, unless 

otherwise specifically indicated by the IDF. The International Diabetes Federation assumes no responsibility or liability for personal or other injury, loss, or damage that may result from the information contained within this publication. Acceptance 

of advertisements in Diabetes Voice should not be construed as an endorsement by IDF. IDF does not test advertised products and, therefore, cannot ensure their safety and efficacy. Acceptance of advertising does not imply that IDF has conducted 

an independent scientific review to validate product safety and efficacy of advertising claims. The Federation reserves the right to reject any advertisement for any reason which need not be disclosed to the party submitting the advertisement.

Diabetes education - International Diabetes Federation

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