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.

NUTRITION

The prevalence of unhealthy diet and obesity is escalating in most affluent countries. Nutritional advice can mean providing guidelines about things such as the amount of fat or salt to eat in the diet, but it also includes the use of ‘food as medicine’.

Deficient diets are a more major source of illness than tends to be acknowledged in medical education and this no doubt is reflected in clinical practice. Carefully chosen supplements may play a role in some circumstances, but they are not a replacement for a healthy diet. For example, beta-carotene supplements are probably not effective in preventing cancer,³⁰ whereas beta-carotene-rich foods are.^31,³² Research has shown that:

Women in the highest quartile of plasma total carotenoid concentration (marker of intake of vegetables and fruit) had significantly reduced risk for a new breast cancer event (HR 0.57) [that is, a 43% reduction in risk of recurrence].³³

and that:

Vegetable and, particularly, fruit consumption contributed to the decreased risk … These results indicate the importance of diet, rather than supplement use, in concert with endogenous antioxidant capabilities, in the reduction of breast cancer risk.³⁴

A similar picture is seen in CVD. Fish oils, due to their high concentration of omega-3 fatty acids, for example, produce benefits for triglyceride ³⁵ and very low-density lipoprotein (VLDL) profiles,³⁶ prevention of arrhythmias,^37,³⁸ reduction of blood pressure³⁹ and reduction of atherogenesis,⁴⁰ and they have antithrombotic and antiplatelet activity.

For the greater part of clinical practice, the dietary advice given by doctors tends to be non-specific. Perhaps this is a reflection of the level of attention given to the topic in medical education and literature, but if the effects attributable to healthy nutrition were attributable to a pharmaceutical product, then a doctor would probably be negligent in not knowing about it in detail and prescribing it widely. The important role of nutrition will also be explored in Chapter 10.

CONNECTEDNESS

‘Connectedness’ or social support is important at any age or situation in life. For children and adolescents, connectedness at home and at school is strongly protective against comorbidities such as depression, suicide, drug and alcohol abuse, teenage pregnancy, crime and violence.⁴¹ The presence of ‘functional relationships’ is associated with a better recovery from depression. Social marginality or isolation has been shown to predispose to heart disease, cancer, depression, hypertension, arthritis, schizophrenia, tuberculosis and overall mortality.⁴² All-cause mortality in socially isolated males was 2–3 times higher and in women was 1.5 times higher over a 12-year follow-up than in people who were more socially connected.⁴³ With regard to heart disease, socioeconomic and occupational factors are independent risk factors,^44,⁴⁵ but even when a person has well-established heart disease, their social context has a profound effect on recovery. There was a fourfold increased in the death rate following acute myocardial infarction (AMI) for people who were socially isolated and experiencing high levels of stress.⁴⁶ Those over 65 years of age were three times more likely to die following an AMI if they had poor social support, as measured by the simple question: ‘Can you count on anyone to provide you with emotional support (talking over problems or helping you to make a difficult decision)?’⁴⁷ So connectedness plays an important role in the prevention and management of any disease and at any stage of the life cycle. The GP is well placed to provide emotional support, to encourage patients to seek out sources of social support, and in some settings to facilitate support in the form of support groups.

ENVIRONMENT

‘Environment’ means much more than air, water and earth, as important as these are. It includes the number and types of chemicals we are exposed to, domestically and occupationally. It includes the radiation and electromagnetic fields to which we are exposed.⁴⁸ Importantly, it includes the social and sensory environment we create for ourselves. An overly noisy medical environment, for example, is associated with poorer health and higher stress.⁴⁹

Sunlight can play both a positive and a negative role for health, depending on the amount and type of sun exposure. Although sunburn increases the incidence of malignant melanoma, regular moderate doses of sunlight help to reduce the incidence of a range of illnesses including depression, heart disease, a number of cancers including melanoma, multiple sclerosis and osteoporosis, to name a few.⁵⁰

Obviously it is beyond the power of the doctor to change most types of environmental exposure, but nevertheless they can help to give practical advice about environmental issues and exposure. Furthermore, some doctors play an important role as community advocates, policy makers or researchers.

USING ESSENCE IN PRACTICE

The ESSENCE model is designed to give a structure to lifestyle and holistic management. Without structure it is often difficult for doctors and patients to set systematic, specific and achievable goals. When confronted by a number of potential goals it can be prudent to work on one goal at a time. As improvement is established with regard to one goal, another can be tackled according to the patient’s motivation and priorities. Many aspects of ESSENCE, such as making healthy dietary changes, may well need the support and engagement of relevant others such as family members. An example of applying ESSENCE to a case is provided here.

CASE STUDY

Helen is a 37-year-old woman with a past history of multiple sclerosis (MS) diagnosed when she was 32 years old. She has recently moved from interstate with her husband and two children and now presents to you with a view to finding a new GP. At the initial consultation you find that she has only mild ongoing neurological impairment by way of some weakness in her left leg and numbness in the right leg. She is interested in taking an active part in the management of her MS and wants to take a holistic approach to her illness.⁵¹ You encourage her in her endeavour and make a long appointment for next week for her to come back to discuss the ESSENCE approach. In the meantime you explore further background information about lifestyle factors and MS to help inform yourself more fully. At the follow-up consultation you discuss the following issues with her.

Education

You provide the patient with education in the following information and self-help strategies, as well as by suggesting a readable and authoritative text on the subject of lifestyle factors and MS.⁵²

Stress management

Psychological health has a significant impact on the progression of MS and on how a person copes with it.⁵³^–⁵⁵ You inform Helen about the basic principles of how stress affects immune function and autoimmune conditions, and suggest that stress management is a vital part of improving psychological wellbeing and of assisting her in making and maintaining other lifestyle changes. Helen expresses interest in joining the evening stress management classes being held in your practice.

Spirituality

Helen states that although she is not overly religious, looking for meaning in dealing with her illness has helped her to cope. You encourage her to continue to explore this area of her life.

Exercise

For MS patients, regular exercise can increase general fitness and strength, reduce disability,⁵⁶ improve mood and coping, reduce the number of falls and fractures, enhance social interaction and improve immune function. You discuss and agree on an ‘exercise prescription’, which includes attending her local fitness centre and walking regularly with her husband, in the morning and late afternoon sun where possible. You also encourage Helen to explore the MS Society’s hydrotherapy program.

Nutrition

Studies of dietary interventions for the management of MS ⁵⁷^–⁵⁹ have suggested that MS patients on a low-fat diet (less than 20 g/day) may have lower death rates, disability and numbers of MS exacerbations than those not on a low-fat diet. Supplements with omega-3 fatty acids may also be associated with significant reductions in the frequency and severity of relapses.⁶⁰ Fish and flaxseed oils, high in omega-3 fatty acids, have significant anti-inflammatory properties in a range of conditions including MS, and fish oils are also an excellent source of vitamin D. Vitamin D enhances immune function, and seems to reduce the incidence and progression of MS.⁶¹ Potentially protective nutrients for MS patients include vegetable protein, dietary and cereal fibre, other vitamins (C, thiamin and riboflavin), calcium and potassium.⁶² You inform Helen of these findings, and she is keen to start including these dietary changes in her diet and will also explore using some selected dietary supplements under your guidance.

Connectedness

Stressful life events and an unsupportive social life are associated with the onset and exacerbation of a variety of autoimmune diseases.⁶³ Helen says that she gets great support from her family, although moving interstate has been a source of potential concern. She also finds that going to the MS Society has given her great support and that attending the hydrotherapy classes will enhance this even further.

Environment

Countries with lower levels of sunshine have significantly higher incidences of MS. Within countries, those regions with more sunlight also have a substantially lower incidence.^64,⁶⁵ The progression of MS over an 11-year period was nearly halved (odds ratio (OR) 0.53) for those with higher residential sun exposure.⁶⁶ High residential exposure and occupational exposure combined was associated with an OR of 0.24, that is, a quarter chance of dying over that 11-year period compared to those with low sun exposure. The benefits of sunlight may be due to the direct effects of sunlight on immune function, melatonin levels⁶⁷ and vitamin D.⁶⁸ Helen says that she has tended to avoid sunshine and will make an effort to get at least 20 minutes of sun exposure daily and that linking it to her exercise times will be a sensible way of doing that.

You make plans to review Helen’s progress in two weeks.