The essence of good health

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chapter 6 The essence of good health

INTRODUCTION AND OVERVIEW

As community attitudes evolve, healthcare costs spiral and evidence accumulates, the community and general practitioners are steadily recognising the importance of moving towards more holistic and wellness-based models of healthcare. Models such as Dean Ornish’s lifestyle program for heart disease have been shown to significantly reduce costs while also leading to better therapeutic outcomes.¹

Among the great advances in healthcare in the twentieth century were antibiotics, anaesthetics and immunisation, with the genetic revolution just beginning to gain momentum. Despite these significant discoveries, the greatest burden of illness in affluent countries is due to lifestyle-related illnesses.² Cardiovascular disease is still the leading cause of death, followed closely by cancer. It is predicted that by 2030 depressive illnesses will be the leading burden of disease.³ The trends in obesity, inactivity, drug use and mental illness are far from encouraging, and the long-term impact of these determinants of health may be far greater than expected. They all interact synergistically to predispose towards illness; and conversely, positive strategies to enhance health also act synergistically.

An important aspect of a holistic or wellness approach is to empower the patient and their carers as much as is practicable. Responsible patient empowerment accords with most patients’ wishes and is also associated with better clinical and economic outcomes.

Initiatives instigated by health promotion organisations make a significant contribution to reversing the trends mentioned above, but for these initiatives to be effective they need to be targeted at, and reinforced by, various sectors in the healthcare community, spanning policy makers, individual therapists and consumer groups. The potential role that GPs and other primary health practitioners can play is enormous, although the economic and legislative systems in which doctors work do not always make this approach as easy to instigate as it should be.

THE ESSENCE MODEL

This chapter gives an outline of the ESSENCE model of healthcare. ESSENCE is a mnemonic:

ESSENCE extends and gives further structure to the biopsychosocial and environmental models of healthcare. Some brief comments about the relevance and application of each aspect are made below, along with some examples of how they are applied in practice.

The ESSENCE approach is a comprehensive framework to assist in the prevention and management of illness as well as promoting wellness. It is holistic in its focus, designed to complement conventional medical care and is eminently applicable to the primary care setting.⁴ ESSENCE has been the basis for the Health Enhancement Program (HEP) taught as core curriculum for all medical students at Monash University, Melbourne. It serves to enhance the personal wellbeing of the practitioner as well as to foster patient wellbeing and provide clinical knowledge and skills.⁵

The ESSENCE model forms a useful structure upon which educational, preventive and therapeutic approaches can be built and is readily adaptable for health professionals, individual patients, targeted groups suffering chronic illness, practice populations and public health campaigns.

For lifestyle interventions to be optimally effective, a structured, systematic and comprehensive approach to dealing with a range of relevant variables needs to be used. This helps the planning, implementation and evaluation of lifestyle and healthcare plans. This chapter gives an overview of the model and its relevance to a condition such as cardiovascular disease, and illustrates its application to a case of multiple sclerosis.

EDUCATION

In its broadest sense, education is at the core of what it means to be a doctor, for no condition could be said to be adequately treated without educating the patient, and their carers, about relevant aspects of their condition and its management. Education can therefore include:

• knowledge about the condition and its management, which, for chronic conditions especially, is beneficial in a number of ways—it improves cost-effectiveness, adjustment to the illness, perceived self-competence and compliance, and it reduces the use of medical services ⁶

• information about the effects of lifestyle factors on health, and about reducing or ceasing relevant behaviours such as smoking or alcohol use

• behaviour-change, motivational and self-mastery strategies, which are vital in activating knowledge so it is more than just information. Simple information about the ill-effects of various cardiac risk factors, for example, has little effect on reducing cardiac risk. If, however, this information is supported by strategies that improve ‘control’ or ‘autonomy’, such as stress management, behaviour change, self-mastery and motivational strategies, then the information can be acted upon and health benefits follow.^7,⁸

In the conventional sense, education is also protective of health, and a lack of formal education by itself is a risk factor for poor health.⁹ Indeed, one of the most powerful ways to improve health in developing countries is to improve literacy rates among women.

STRESS MANAGEMENT

In the ESSENCE model, ‘stress’ refers not just to stress in the common sense of the word, but also mental health in the broadest sense. Good mental health is central to being able to make and maintain other lifestyle improvements. This is illustrated in the Ornish lifestyle program for heart disease, in which stress management was the vital factor in ensuring that all the other lifestyle factors could be implemented and maintained.^1,¹⁰ We well know that making healthy lifestyle changes while stressed, anxious or depressed is difficult, if not impossible.

The need to cultivate positive mental and emotional health is an issue for everyone, not just those with significant mental illness. In our thinking and terminology, healthcare practitioners draw an imaginary line below which a person has mental illness and above which they don’t. A wellness model, on the other hand, acknowledges that health is a continuum. Although we draw arbitrary lines to assist us in defining and diagnosing various conditions, we are all moving in one direction or another towards more or less wellbeing. It follows therefore that all can benefit from applying positive mental health strategies. The benefits are both direct, in providing greater quality of life, and indirect, in providing improvements in lifestyle.

Mental health has a profound and direct effect upon physical health and recovery from illness. To illustrate, it is well known that depression is a major independent risk factor for cardiovascular disease (Fig 6.1)¹¹—chronic severe depression increases the risk of cardiovascular disease fivefold—but less well known is the evidence that the addition of a comprehensive psychologically based stress-management plan to conventional cardiac rehabilitation nearly halves the risk of subsequent cardiac events.¹² One effective stress-management program reduced cardiac events by 74% over a 5-year follow-up compared with usual care alone.¹³ So improving mental health is important for quality of life, to facilitate other healthy lifestyle changes and for its direct physiological health benefits.

FIGURE 6.1 Psychosocial factors contributing to cardiovascular disease

SPIRITUALITY

‘Spirituality’ is not confined to being ‘religious’. It can, depending on the individual’s view, be explored through an active search for ‘meaning’ or ‘purpose’, or it can denote a belief in something greater than oneself. Each individual explores and expresses spirituality in a way which is relevant to themselves and their cultural background. For some, spirituality is explored and expressed through science, or through altruism and philanthropy, or in art and creativity, or through a commitment to environment and ecology.

The influence of spirituality on health is not always easy to determine, and yet evidence clearly points to it having an important role in the prevention and management of a range of psychological and physical diseases ^14,¹⁵ as well as helping the individual to cope, especially with chronic and life-threatening disease.¹⁶

Although some doctors may believe that spirituality is not the domain of the medical practitioner, evidence suggests that approximately 80% of patients wish to discuss spiritual matters with their doctors in certain circumstances, such as when confronting a life-threatening illness.¹⁷ If doctors are to incorporate spiritual and religious issues where the need arises, then patient-appropriate language, an attitude of cultural and religious tolerance, and appropriate referral sources, will be essential in underpinning that conversation. These issues will be discussed in more depth in the chapter on spirituality (Ch 12).

EXERCISE

Exercise in itself is a therapeutic tool ¹⁸ and lack of exercise ranks second to smoking as a cause of disability and death in Australia.¹⁹ There is an enormous amount of evidence on the beneficial effects of exercise in preventing and managing virtually any condition, and yet exercise is not a central part of the management plan as often as it should be. Obviously the type, duration and intensity of exercise needs to be tailored to an individual’s needs, tastes, health and abilities.

The important role of exercise can be illustrated using an example of cardiovascular disease (CVD). Apart from reducing all-cause mortality,²⁰ regular exercise also decreases disease-specific mortality from CVD.²¹^–²³ This is through a variety of effects, such as improvements in lipid profile, reduced thrombogenesis, improvement in insulin resistance and reduction of blood pressure. If exercise is prescribed for CVD it has positive side effects, such as benefits for osteoporosis and diabetes,²⁴ and reduced cancer risk (including lung, colon, breast and prostate).²⁵^–²⁷ Exercise also has an important role in mental health for old and young—for example, it is therapeutic for depression²⁸ and anxiety.²⁹ These issues will also be explored in a subsequent chapter.