Authors
Dr Mohammad Arif Shahar
Dr Mohd Faiz Md Tahir
First published: 13 September 2020
Last update: 13 September 2020
Framework
Key points
- Therapeutic lifestyle changes or lifestyle modification is important for the management on non-communicable diseases such as diabetes and obesity
- Sustainable Healthy Lifestyle Behaviour is a move towards inculcating a more persevered behavioural change among patients that would help to manage their medical conditions
- SHLB is defined by the patients’ bio-psycho-social and spiritual factors
- Biological factors include existing medical conditions, pharmacotherapy, and fitness (physical activities)
- Psychological factors include stress and other psychological conditions
- Social factors include family, friends, financial and other social issues
- Spiritual factors include religious beliefs and religiosity
- It is important that health-care providers (HCP) identify patients’ capabilities and facilitate them to discover the kind of healthy lifestyle which is sustainable for them. Capabilities and willingness would depend on cultures, backgrounds, education levels, concerns and socioeconomic status among other things; apart from concurrent medical conditions and treatment.
Brief explanation
Therapeutic Lifestyle Changes (TLC) in guidelines
Therapeutic lifestyle changes (TLC) was originally introduced in the United States in 1985 as a cholesterol lowering strategy in order to reduce cardiovascular risk. The TLC diet is prescribe alone or concurrently with pharmacotherapy. Although originally, TLC is meant for the management of dyslipidemia[1], the concept of lifestyle modifications has crept into various guidelines using different names.[2]
In current days and age, TLC is advocated in various non-communicable diseases such as type 2 diabetes mellitus, hypertension, dyslipidemia and obesity. However, it comes in various terminologies such as ‘lifestyle modifications’[3] and ‘lifestyle interventions’[4] and In essence, these interventions entail certain dietary programme such as ‘medical nutrition therapy’[5] and regular physical activities suitable with the medical condition. They are part of non-pharmacological therapy for these NCDs.
Examples are diabetic diet which contains lower amount of carbohydrate and low glycaemic index food for diabetics; restricted calories for obesity; low salt, plant based diet for hypertensive patients and low fat diet for those with dyslipidemia. Physical activities ranges from moderate to high intensity exercises. These non-pharmacological strategies are included in all major guidelines for the management of these diseases.
In the usual setting, various health-care providers (HCP) are involved in implementing TLC. These mainly include dietitians, physiotherapists and diabetic educators. Often doctors refer patients with type 2 diabetes mellitus, hypertension, dyslipidemia and obesity to them for dietary and exercise counselling. More often than not, TLC is prescribed to patients.
Shifting from TLC to SHLB
Lifestyle changes require long term commitment and adherence to enable long lasting effect and prevent relapses of unhealthy conditions. Changes (modifications) by definition and spirit are dynamic and inconsistent as it is a ‘process’. Considering the TLC concept, often HCP emphasize on lifestyle ‘changes’ during consultations. Adherence is only emphasize when relapse of unhealthy lifestyle occurs. Perhaps that is the reason why TLC is short-lived and more often than not does not stand the test of time. Over months, patients would not be able to adhere to these changes. Most studies on lifestyle changes lasted for two years. Studies are controlled environment that ensures patient’s compliance. It is often that we hear, patients were unable to adhere to these changes longer than the study periods.
Thus we came up with a concept just a step further from TLC, emphasizing sustainable ‘behaviour’ rather than ‘changes’. Behaviour would have the potential of being permanent. In Bahasa Melayu, behaviour is perangai, tabiat (formal Malay) or fiil (colloquial Malay), iaitu sesuatu yang berkaitan dengan kebiasaan atau biasa dilakukan. In addition to that, behaviour are sometimes subconscious after long periods of training. When the concept of behaviour is infused into healthy lifestyle, we should be able to address non-adherence to TLC in the long run. Thus we emphasize not simply changes (i.e. modification) of lifestyle, but long lasting adherence. The term Sustainable Healthy Lifestyle Behaviour (SHLB) was coined.
The term behaviour was chosen as it is associated with the notion of ‘regularity’, ‘accustomed to’, and ‘always’. Sustainability is mentioned because patients’ willingness and capabilities varies from one to another. Capabilities and willingness would depend on cultures, backgrounds, education levels, concerns and socioeconomic status among other things; apart from concurrent medical conditions and treatment. It is important that HCP identify patients’ capabilities and facilitate them to discover the kind of healthy lifestyle which is sustainable for them.
In essence SHLB is defined by the patients’ bio-psycho-social-spiritual factors.
- Biological factors include existing medical conditions, pharmacotherapy, and fitness (physical activities)
- Psychological factors include stress and other psychological conditions
- Social factors include family, friends, financial and other social issues
- Spiritual factors include religious beliefs and religiosity
In short, individualized healthy lifestyle behaviour is unique for each patient. Having a lifestyle tailored to their needs, concerns and capabilities ensures sustainability of that behaviour. (Read more on understanding human behaviour and how to facilitate behavioural changes towards healthy lifestyle)
What does SHLB means for Muslims?
For Muslims, Sustainable Healthy Lifestyle Behaviour (SHLB) means practising Islamic teachings and values with regards to health.
Inculcating the Prophet’s (s.a.w) dietary habits among patients, such as prohibition of gluttony (Sunan Ibn Majah, Book 29: Hadith 3351), eating in moderations (Syamail Muhammadiyyah: Hadith 142) and not eating to your fullest (Jami’ at-Thirmidhi: Hadith 2380) are principles that prevent over-nutrition, obesity and subsequently type 2 diabetes mellitus. Feeding other people rather than oneself is also encouraged in Islam (Sunan Ibn Majah, Book 29: Hadith 3251), which is a strategy that may curb the obesity pandemic.
In addition to that, the Quran advocate eating what is lawful and good (Quran 2:168, 5:88, 7:31). What is good can be understood as nutritious. By integrating the teachings from the Quran and Sunnah, we would be telling patients that it is better to eat healthy, not only for the purpose of your health, but rather a commendable act as far as the religion is concern.
Apart from that, regular fasting which is a form of calorie restriction, is also a well-known Islamic tradition. In Islam, other than the obligatory fasting in the month of Ramadan (Quran, 2:183-185), the Prophet encourages regular fasting twice a week (Jami’ at-Thirmidhi: Hadith 745) and three days in a month (Sunan an-Nasa’i: Hadith 2411). However, the Prophet forbade fasting to the extreme (i.e. perpetual fasting); as an alternative fasting every other day, as practiced by the Prophet David (a.s) is permissible (Sahih Muslim: Hadith 1162 b).
Being active is also part of preventing and treating obesity. Interestingly, the Prophet was a physically active and fit person. He used to race against his wife, Aishah (r.a), as a form of recreation (Sunan Abi Dawud: Hadith 2578). It was also reported that the Prophet walked with a fast pace (Syamail Muhammadiyyah: Hadith 122). Physical fitness is an important aspect of Muslims’ lives. He said, “A strong believer is better and is more lovable to Allah than a weak believer” (Sahih Muslim: Hadith 2664). One could imagine how fit he was. He made Hijra at the age of 53; he was involved in the battle of Badr at the age of 55 and fought against the Romans in Tabuk when he was 62 years old. Advocating physical activity is part of integrating the Prophet lifestyle into the prevention of obesity and type 2 diabetes mellitus.
The very fact that values in Islam – which are universal – with regards to eating and physical activities – did not only kept the Prophet himself fit throughout his life, but also the early Muslim society healthy over the years. We would surely agree that these values defined Sustainable Healthy Lifestyle Behaviour (SHLB) for many Muslims.
Sources from the Quran and Sunnah
| Lifestyle Advice | Islamic source documents | |
| Eating | Eat what is lawful and good | Quran 2:168,[6] Quran 5:88, Quran 7:31 |
| Prohibition of gluttony | Sunan Ibn Majah, Book 29: Hadith 3351[7] | |
| Eating in moderations | Syamail Muhammadiyyah: Hadith 142 | |
| Not eating to your fullest | Jami’ at-Thirmidhi: Hadith 2380 | |
| Feeding other people rather than oneself | Sunan Ibn Majah, Book 29: Hadith 3251 | |
| Fasting | Fasting in Ramadan | Quran 2:183-185 |
| Fasting two days every week | Jami’ at-Thirmidhi: Hadith 745 | |
| Fasting three days every months | Sunan an-Nasa’i: Hadith 2411 | |
| Fasting every other day | Sahih Muslim: Hadith 1162 b | |
| Prohibition of perpetual fasting | Sahih Muslim: Hadith 1162 b | |
| Physical activity | Sports (racing) | Sunan Abi Dawud: Hadith 2578 |
| Brisk walk | Syamail Muhammadiyyah, Book 18: Hadith 122 | |
| Encouragement of having fitness and strength | Sahih Muslim: Hadith 2664 |
End notes
[1] National Institute of Health, NCEP ATP III (United States: 2001)
[2] TLC here is not referring to the original TLC introduced in 1985 for the management of dyslipidaemia. Rather, we refer to all type of lifestyle modifications and interventions which is part of non-pharmacological therapy for non-communicable diseases.
[3] Ministry of Health, Clinical Practice Guidelines Management of Type 2 Diabetes Mellitus (Malaysia: 2015)
[4] Caroline M. Apovian, Louis J. Aronne, Daniel H. Bessesen, Marie E. McDonnell, M. Hassan Murad, Uberto Pagotto, Donna H. Ryan, Christopher D. Still, Pharmacological Management of Obesity: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 100, Issue 2, 1 February 2015, Pages 342–362
[5] Malaysian Endocrine and Metabolic Society, Clinical Practice: Guidelines Management of Type 2 Diabetes Mellitus (Kuala Lumpur, Malaysia: 2015)
[6] Quran translations and references are taken from http://www.quran.com
[7] Hadith translations and references are taken from http://www.sunnah.com