Authors

Dr Mohammad Arif Shahar
Dr Mohd Faiz Md Tahir
Dr Siti Nordiana Dollah

First published: 13 September 2020
Last updated: 13 September 2020

Framework
Supported Lifestyle Modification (SLiM)©

Supported Lifestyle Modification (SLiM).
Empowering individuals to make better choices …

Key points
  1. Supported Lifestyle Modification (SLiM) programme focuses on patient empowerment in implementing therapeutic lifestyle changes for non-communicable diseases
  2. The final objective of this programme is to help patient achieve Sustainable Healthy Lifestyle Behaviour (SLHB) leaving unhealthy habits
  3. SHLB is defined by the patient’s own bio-psycho-social-spiritual factors
  4. Motivational Interviewing principles are implemented using the bio-psycho-social-spiritual framework to help patient change from unhealthy lifestyle to Sustainable Healthy Lifestyle Behaviour
Brief explanation

Introduction

SLiM is a programme that focuses on ‘therapeutic lifestyle changes’ in an effort to combat non-communicable diseases; especially diabetes and obesity among Malaysians.

The Problem: Adherence to Treatment and Therapeutic Lifestyle Changes

In 2013, Dr Faiz Tahir, a Psychiatrist, and I (Dr Arif Shahar) began to delve into and study as to why only a minority of patients with diabetes have optimal sugar control. 1–5 No more than 25% of patient with diabetes have HBA1C of less than 7%. Ironically this observation was seen in an age where the treatment for diabetes has advanced and become more sophisticated. Not only at our place of practice, but it is also observed nationwide. 6,7

Later, as with many others, we concluded that, good diabetes control does not depend on the treating doctor alone, but also the patients’ commitment. The responsibility of managing diabetes is placed not only on the shoulders of health-care workers; patients themselves have to play a substantial role.

In other words, in order to succeed, patients should be empowered in the management of their diabetes. Adherence to lifestyle changes and medication area among crucial aspects of diabetes management; and this requires a change in attitude. The treating doctors cannot change the patients; rather, the patients have to decide on making that change. (Read more on understanding human behaviour)

Therapeutic life style is nothing new. All clinical guidelines in the world in the world, including the Malaysian guideline, place ‘therapeutic lifestyle changes’ as the first treatment that needs to be carried out concurrently; and even before the first medications being prescribed.8 However, the implementation of ‘therapeutic lifestyle changes’ are challenging.

‘Therapeutic lifestyle changes‘ could not be successfully carried out without patients’ participation. Uncommonly, we may find a situation where glucose control is not optimal, doctors put the blame on patients – with accusations of no commitment towards health, non-compliance to medicine, eating too much, lack of exercise and so forth. On the opposite perspective, the patient blames the doctor – the medicine given is of poor efficacy, poor advice and so on.

Of course, this blaming game never brings about any positive changes. 

The Solution: Empowerment, Supported Lifestyle Modification© and Sustainable Healthy Lifestyle Behaviour©

In 2018, we were joined by Col Dr Noor Ashikin Mohd Rusly (a Physician), Col Dr Siti Nordiana Dollah (a Psychiatrist) and Lt Col Dr Nurzeti Shaik Ahmad (a Family Medicine Specialist); who upheld the same idea that patients with diabetes and obesity should be empowered to help themselves. Thus ‘Supported Lifestyle Modification’ or simply the SLiM programme was born.

The program applies the principles of motivational interviewing (MI) in facilitating patients to embrace change toward healthy lifestyle. SLiM emphasizes adherence to long-term intended behaviours – we coined the term ‘Sustainable Healthy Lifestyle Behaviour’ – rather than short-term changes. Decisions to undergo healthy lifestyle changes are elicited from the patients themselves; while we act as facilitators. The decision to change is a partnership venture between both doctors-and-patients – where patient being the centre focus – rather than a one-way street advice (doctors-to-patients) or a paternalistic style.

This programme is seen to be able to complement the existing approach in implementing ‘therapeutic lifestyle change’. SLiM provides guidance on how ‘therapeutic lifestyle changes’ can be initiated, implemented and monitored.

There are two components in the SLiM approach; (Read more on the SLiM approach) 

  1. Using the principles of motivational interviewing to help patients change;
  2. Multi-dimensional approach using the bio-psycho-social and spiritual framework to execute the first component in order to find the best method for patients to achieve ‘Sustainable Healthy Lifestyle Behaviour’; the final objective. (Read more on Sustainable Healthy Lifestyle Behaviour)

Due to certain constraints, treating doctors may fall into the mono-dimensional approach trap, which focuses only on biological perspectives. For example, during a limited 15 minute consultation, often the treating doctor focuses too much on blood glucose control and detection of target organ damage. 

SLiM instead tries to bring back treating doctor to practice a multidimensional approach within a bio-psycho-social-spiritual framework that is no stranger to them since medical school; in which every doctor need to understand; every aspect of the patient – including the biological perspectives (glucose control, food intake, exercise and medication); psychology (stress management); social (social support) and spiritual aspects (religious beliefs).

Conclusions

The SLiM programme empowers patients to take charge of their medical conditions.

The results are extremely exciting. Many patients have successfully dealt with their obesity and concurrently seen improvement in their glucose control. Most patients manage to reduce the amount of medication they take; some are capable of even discontinuing their diabetes medication altogether – of course with the supervision of their treating doctors – while at the same time remained having normal glucose levels. Not only is the cost of diabetes treatment has been successfully reduced; patients are also less burdened with complex medication regimes; their quality of life improved; they are healthier and are more active.

The application of the SLiM concept traverses beyond diabetes and obesity. SLiM empowers patients to make better lifestyle choices. We help patients change.

Supported Lifestyle Modification (SLiM).
Empowering individuals to make better choices…

References:

  1. Shahar MA, Md Tahir MF, Marzuki OA. Perception of Diabetes Control Among Patients with Poor Glycated Hemoglobin. Int Med J Malaysia. 2017;16(1):37.
  2. Shahar MA, Anwardeen AK, Mustakim M, Muhammad Isa MS, Omar AM, Kamaruddin NA. How well have we been education our patients? Patients’ perception of control and knowledge, attitude and practice of their diabetes mellitus management. In: Malaysian Endocrine and Metabolic Society Annual Congress. ; 2013.
  3. Shahar MA, Mohd Rafee AR, Mohd Hazim H, Saiful Bahari AS, Mohamad R, Tuhiran MF. Seeing patient longer at each consultation will improve their knowledge on diabetes but may not necessarily improve their diabetic control and metabolic parameters. In: Malaysian Endocrine and Metabolic Society Annual Congress. ; 2014.
  4. Shahar MA, Omar AM, Loh HH. High Proportion of Adults With Type 2 Diabetes and Poor Glycated Hemoglobin Perceived That Their Diabetes Control Was Excellent. Can J Diabetes. 2018:2-4. doi:10.1016/j.jcjd.2018.06.003
  5. Shahar MA, Mohd Rafee AR, Mohd Hazim H, Saiful Bahari AS, Mohamad R, Tuhiran MF. Patient perception, actual control and KAP of their diabetic management: A comparison between patients seen at Primary Care Clinic and Tertiary Hospital. In: Malaysian Endocrine and Metabolic Society Annual Congress. ; 2014.
  6. Mafauzy M, Hussein Z, Chan SP. The Status of Diabetes Control in Malaysia: Results of Diabcare 2008. Med J Malaysia. 2011;66(3):175-181.
  7. Mohamed M, Hussein Z, Nazeri A, Chan SP. DiabCare 2013 : A cross-sectional study of hospital based diabetes care delivery and prevention of diabetes related complications in Malaysia. 2016;71(4):177-185.
  8. Malaysian Endocrine and Metabolic Society. Clinical Practice Guidelines: Management of Type 2 Diabetes Mellitus. 5th ed. Kuala Lumpur, Malaysia; 2015.