ESSENCE of Health Care by Dr Craig Hassed

As community attitudes change, healthcare costs and adverse events spiral, and evidence accumulates, the healthcare system is steadily recognizing the importance of moving towards more holistic and wellness-based models. Such models reduce costs and lead to better therapeutic outcomes. The ‘ESSENCE of Health’ is the basis for the Health Enhancement Program (HEP)(1) taught as core curriculum for all medical students at Monash University since 2002. This program has been found to significantly benefit medical student’s wellbeing as well as teach important clinical skills and scientific content. The ESSENCE of Health is outlined more fully in a book of the same name.(2) (3) It is an acronym which stands for:

• Education
• Stress management
• Spirituality
• Exercise
• Nutrition
• Connectedness
• Environment

It forms a useful structure upon which educational, preventive and therapeutic approaches can be built and is readily adaptable for health professionals, individuals and public health campaigns. In ‘westernised’ cultures lifestyle-related illnesses continue to be the major source of illness. Patterns of obesity, inactivity, drug use and mental health are far from encouraging and the long-term impact of these may be far greater than we predict.

Another important aspect of a holistic or wellness approach is to empower the patient and their carers as much as possible. Empowerment, or becoming a more active participant in our own health, accords with the majority of patient’s wishes and is associated with better clinical and economic outcomes. For lifestyle interventions to be optimally effective a structured and systematic approach needs to be used. All the elements in the ESSENCE model is related to the others and they build synergistically. Some brief comments about the relevance and application of each aspect will be made below.

Education

Education, in its broadest sense, is at the very core of healthcare for no condition could be said to be adequately treated without being educated about relevant aspects of one’s condition and its management. Thus education can include:

• Knowledge about the condition and its management. This improves cost-effectiveness, adjustment to the illness, self-empowerment and compliance, and it decreases the need for medical services. (4)
• Information on the effects of lifestyle factors on health and reducing or ceasing relevant behaviours such as smoking or alcohol use.
• Behaviour-change and self-mastery strategies are vital to activate that health 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. (5) (6)
• Education, in the conventional sense, is also protective for health and a lack of formal education by itself is a risk factor for poor health.(7)

Stress management

‘Stress’, for the sake of the model, covers mental health and the mind-body interaction. In Ornish’s lifestyle program for heart disease and cancer, stress management was the vital factor to ensure all the others.(8) (9) We well know that making healthy lifestyle change while stressed or depressed is difficult if not impossible. Mental and emotional health is important for everyone and not just those with significant mental illness. A wellness model acknowledges that health is a continuum in which we draw arbitrary lines and within which we move in one direction or another. Therefore, there are no people who cannot benefit from applying positive mental health strategies. 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 heart disease (10) but less well known is that the addition of stress management plan to cardiac rehabilitation nearly halves the number of ongoing cardiac events. (11) Some of the more effective programs reduce cardiac events by 74% over 5-year follow-up compared to usual care alone. Our mental and emotional state also has profound effects on our immunity and every other part of our bodies, even right down to the levels of our genes. So improving mental health is important for quality of life, to facilitate other healthy lifestyle changes, and for its direct benefits for health.

Spirituality

‘Spirituality’ is not necessarily about being ‘religious’. In the ESSENCE model it relates to ‘meaning’ or ‘purpose’ although it could obviously also relate to religion if that is where a person searches for meaning. Each individual will explore and express it in a way relevant to themselves and their cultural background whether it is through religion, philosophy, science, altruism, creativity or environmentalism. 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 illnesses (12) (13) as well as helping one to cope, especially with chronic and life-threatening conditions. (14) Many doctors do not feel that spirituality is the domain of the medical practitioner despite the fact that approximately 80% of patients wish that doctors would discuss it with them in a range of circumstances particularly for debilitating and life-threatening illnesses. (15) The sharp increase in youth suicide may be related to the turning away from the search for meaning among young people. (16) If doctors are to be open to spiritual and religious issues being an important aspect of healthcare then appropriate language, an attitude of cultural and religious tolerance, and appropriate referral sources will be essential in underpinning that conversation.

Exercise

There is so much said and written about the benefits of exercise in preventing and managing any condition that it almost goes without saying. Obviously the type, duration and intensity of exercise needs to be tailored to the individual’s needs, age, tastes and abilities. Exercise in itself is a therapeutic tool (17) and the lack of exercise ranks second to smoking in being a cause of disability and death in Australia.(18) Regular exercise reduces death rates from any cause. (19) For example, it protects from heart disease (20) (21) (22) due to improvements in blood lipids, thinning of the blood, reducing insulin resistance, and improving blood pressure. It is central to preventing osteoporosis, diabetes, (23) and a range of cancers (including lung, colon, beast and probably prostate).(24) (25) (26) (27) If someone gets cancer they are far less likely to die from it if they exercise regularly. Exercise also has an important role in mental health for old and young, for example, in helping to raise self-esteem, and prevent or treat depression(28) and anxiety.(29)

Nutrition

The predominance of unhealthy diet and obesity is escalating in Australia. Healthy nutrition advice is more than a few guidelines about the amount of fat or salt to eat in the diet. Food is a powerful medicine. A deficient diet is a major source of illness and supplements are no replacement for a healthy diet. For example, beta-carotene or antioxidant supplements are probably not effective in the prevention of cancer (30) whereas beta-carotene or anti-oxidant-rich foods are. (31) (32) (33) Specific foods can enhance immunity. The lack of attention to diet in conventional healthcare may be a reflection of the lack of content in most health practitioner training courses. Nevertheless, if the effects attributable to healthy nutrition were attributable to a pharmaceutical then a doctor would probably be negligent for not knowing all about it and prescribing it widely. A high intake of fruit and vegetables, for example, is associated with half the incidence of cancer according to a review of over 200 studies.(34) Fibre is associated with a reduced risk of bowel cancer (35) particularly if that fibre has not been broken down by over-cooking. Cruciferous, or ‘winter vegetables’ like cabbage, broccoli and brussel sprouts are protective for bowel, lung, pancreas, breast and uterine tissue possibly because of effects on the metabolism and excretion of oestrogens.(36) The benefits of phytooestrogen and soy products are considerable for a range of uses such as the treatment of symptoms associated with menopause(37) (38) or to improve memory.(39) Fish oils are as much medicinal as they are nutritional with benefits for blood lipids (40) (41) the prevention of heart arrhythmias,(42) (43) the reduction of blood pressure, (44) and the thinning of blood. They are also now recognized as anti-depressants and help to protect joints from arthritis.

Connectedness:

‘Connectedness’ or social support is vitally important at any age or situation in life. Connectedness at home and school are particularly important for adolescents (45) to protect from depression, suicide, drug and alcohol abuse, teen pregnancy, crime and violence. Interestingly, contact between adolescents and adults is especially important at specific times of the day like meal times and when the adolescent arrives home from school. Social isolation has been shown to predispose to heart disease, cancer, depression, hypertension, arthritis, schizophrenia, TB and overall mortality.(46) All-cause mortality in socially isolated males was 2 to 3 times higher and in women were 1.5 times higher over 12 years follow-up.(47) With regard to heart disease, socioeconomic and occupational factors are independent risk factors (48) (49) but even when a person has well-established heart disease social support has a profound effect on recovery. For example, there was a fourfold increased in death rate following heart attack if the person is socially isolated and experienced high levels of stress.(50) Those over 65 years of age were 3-times more likely to die post-heart attack if they had poor social support as measured by the simple question which was, “can you count on anyone to provide you with emotional support (talking over problems or helping you to make a difficult decision)?”(51) So connectedness has an important role to play in the prevention and management of any disease at any part of the life-cycle and health practitioners have a significant part to play in providing that support or helping to encourage a patient’s seeking of it.

Environment:

Environment means much more than avoiding pollution in the air, water or earth, as important as they are. It also includes the number and types of chemicals we expose ourselves to, domestically and occupationally. It includes the radiation we are exposed to (52) and the social and sensory environment we make for ourselves. An overly noisy environment is associated with poorer health and higher stress.(53) Regular moderate doses of sunlight helps 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.(54) Global warming has implications for many mosquito born diseases. (55) Effects upon biodiversity have implications for other species, food sources and sustainability which are yet to be fully felt. (56) Obviously health practitioners cannot intervene on all these fronts but nevertheless can help to give some practical advice about many environmental issues as well as being community advocates, policy makers or researchers. We can be more conscious of the environment we make for ourselves and we can vote accordingly.

Using ESSENCE in practice

The ESSENCE model is designed to give a structure to lifestyle and holistic management. Without structure it is often difficult to set systematic, specific and achievable goals. Often it is good to work on one goal at a time and as individual behaviours become established then to move on to the next goal according to motivation and priorities. Many of the aspects of ESSENCE, such as making healthy dietary changes, may well need the support and engagement of others such as family members and friends.

by Dr. Craig Hassed

References

1. Hassed C, de Lisle S, Sullivan G, Pier C. Enhancing the health of medical students: outcomes of an integrated mindfulness and lifestyle program. Adv Health Sci Educ Theory Pract. 2008 May 31. [Epub ahead of print]
2. Hassed C. The ESSENCE of healthcare. Aust Fam Physician. 2005 Nov;34(11):957-60.
3. Hassed C. (2008) The Essence of Health: the seven pillars of wellbeing. Sydney, Random House.
4. Lehrer PM. Sargunaraj D. Hochron S. Psychological approaches to the treatment of asthma. Journal of Consulting & Clinical Psychology 1992;60(4):639-43.
5. Syme SL. Balfour JL. Explaining inequalities in coronary heart disease. Lancet 1997;350(9073):231-2.
6. Syme SL. Mastering the control factor. The Health Report, ABC Radio. Health Report transcript 9.11.1998. www.abc.net.au/rn
7. Eckert JK. Rubinstein RL. Older men’s health. Sociocultural and ecological perspectives. Medical Clinics of North America 1999;83(5):1151-72.
8. Ornish D., Brown S., Scherwitz L., et al. Can lifestyle changes reverse coronary heart disease? Lancet 1990;336:129-33.
9. Ornish D., Scherwitz L., Billings J., et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA 1998;280:2001-7.
10. Bunker SJ, Colquhoun DM, Esler MD et al. “Stress” and coronary heart disease: psychosocial risk factors. Med J Aust. 2003;178(6):272-6.
11. Linden W, Stossel C, Maurice J. Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Int Med 1996;156(7):745-52.
12. Koenig HG. Religion and medicine II: religion, mental health, and related behaviors. International Journal of Psychiatry in Medicine. 2001;31(1):97-109.
13. Townsend M. Kladder V. Ayele H. Mulligan T. Systematic review of clinical trials examining the effects of religion on health. Southern Medical Journal. 2002;95(12):1429-34.
14. Sullivan MD. Hope and hopelessness at the end of life. American Journal of Geriatric Psychiatry. 2003;11(4):393-405.
15. McCord G, Gilchrist VJ, Grossman SD et al. Discussing spirituality with patients: a rational and ethical approach. Ann Fam Med. 2004;2(4):356-61.
16. Dervic K, Oquendo MA, Grunebaum MF et al. Religious affiliation and suicide attempt. Am J Psychiatry. 2004;161(12):2303-8.
17. Bauman A. Updating the evidence that physical activity is good for health: an epidemiological review 2000-2003. J Science and Medicine in Sport 2004;7(1 supp):6-19.
18. Australian Institute of Health and Welfare 2001. Heart, Stroke and Vascular Diseases – Australian Facts 2001. National Heart Foundation of Australia, National Stroke Foundation of Australia (Cardiovascular Disease Series No 14). AIWH Cat No CVD 13. AIWH, Canberra 2001
19. Kampert J, Blair S, Barlow C, et al. Physical activity, fitness and all cause and cancer mortality. Annals of Epidemiology. 1996; 6: 542-7.
20. Maiorana A, et al., Combined aerobic and resistance exercise training improves functional capacity and strength in CHF. J Appl Physiol. 200;88:1565-70.
21. Berlin J, Colditz G. A meta analysis of physical activity in the prevention of coronary heart disease. American Journal of Epidemiology, 1990; 132: 612-28.
22. Tanasescu M et al. Exercise type and intensity in relation to coronary heart disease in men. JAMA;2002;2881994-2000.
23. Helmrich S, Ragland D, Paffenbarger R. Prevention of non- insulin dependent diabetes mellitus with physical activity. Medicine and Science in Sports and Exercise. 1994; 26: 649-660.
24. Colditz G, Cannuscio C, Grazier A. Physical activity and reduced risk of colon cancer. Cancer Causes and Control. 1997; 8: 649-667.
25. Thune I, Lund E. The influence of physical activity on lung cancer risk. International Journal of Cancer. 1997; 70: 57-62.
26. Thune I, Lund E. The influence of physical activity on lung cancer risk. International Journal of Cancer. 1997; 70: 57-62.
27. Friedenreich CM, McGregor SE, Courneya KS et al. Case-control study of lifetime total physical activity and prostate cancer risk. Am J Epidemiol. 2004;159(8):740-9.
28. Dunn AL, Trivedi MH, Kampert JB et al. Exercise treatment for depression Efficacy and dose response. Am J Prev Med. 2005;28(1):1-8.
29. Byrne A, Byrne DG: The effect of exercise on depression, anxiety and other mood states: a review. J Psychosom Res 1993;13(3): 160-170.
30. Hennekens, C.H. Lack of effect of long term supplementation with beta carotene on the incidence of malignant neoplasms and cardiovascular disease. NEJM 1996;334(18):1145–49.
31. Omenn, G.S. et al. Effects of a combination of beta carotene and Vitamin A on lung cancer and cardio vascular disease. New England Journal of Medicine. 1996;334(18):1145-1149.
32. Shekelle, R.B. et al. Dietary vitamin A and the risk of cancer in the Western Electric study. Lancet 1981;2(8257):1186–90.
33. Kushi LH, Folsom AR, Prineas RJ et al. Dietary antioxidant vitamins and death from coronary heart disease in postmenopausal women. N Engl J Med. 1996;334(18):1156-62.
34. Block, G. et al. Fruit vegetables and cancer prevention : a review of the epidemiological data. Nutr Cancer 1992;18:1-29.
35. Peters U, Sinha R, Chatterjee N, et al. Dietary fibre and colorectal adenoma in a colorectal cancer early detection programme. Lancet 2003;361(9368):1491-5.
36. Grubbs, C.J. et al. Chemoprevention of chemically induced mammary carcinogenesis by indole-3-carbinol, Anticancer Res 1995;15(3):709-16.
37. Chiechi LM, et al. The effect of a soy rich diet on the vaginal epithelium in post menopause: a randomised double blind trial. Maturitas 2003;45(4):241-6.
38. Wilcox G., Wahlqvist, M.L. et al. Oestrogenic effects of plant foods in postmenopausal women, BMJ 301, pp 905 – 6
39. File SE, Jarrett N, Fluck E, et al. Eating soya improves human memory. Psychopharmacology 2001;157(4):430-6.
40. Jeppesen J et al. Triglyceride concentration and ischemic heart disease: an eight year follow up in the Copenhagen Male Study. Circulation 1998;97(11):1029-36.
41. Kristof Vanschoonbeek et al Fish oil consumption and reduction of arterial disease. Nutr. 2003;133:657-660.
42. de Lorgeril M, Salen P. Alpha-linolenic acid and coronary heart disease. Nutr Metab Cardiovasc Dis. 2004;14(3):162-9.
43. McLennan PL, et al Dietary fish oil prevents ventricular fibrillation following coronary artery occlusion and reperfusion. Am J Heart 1988;116(3):709-17.
44. Geleijnse JM et al. Blood pressure response to fish oil supplementation:meta regression analysis of randomised trials. J Hypertension 2002;20(8):1493-99.
45. Resnick MD, Bearman P, Blum R et al. Protecting adolescents from harm; findings from the National Longitudinal Study on Adolescent Health. JAMA 1997;278(10):823-32.
46. Pelletier K. Mind-body health: research, clinical and policy applications. Am J Health Promot 1992; 6(5):345-58.
47. House J., Landis K, Umberson D. Social relationships and health. Science 1988;241:540-5.
48. Lantz PM, House JS, Lepkowski JM et al. Socioeconomic factors, health behaviours, and mortality: results from a nationally representative prospective study of US adults. JAMA 1998;279(21):1703-8.
49. North FM. Syme SL. Feeney A. et al. Psychosocial work environment and sickness absence among British civil servants: the Whitehall II study. American Journal of Public Health. 1996;86(3):332-40.
50. Ruberman W. et al. Psychosocial influences on mortality after AMI. N Engl J Med 1984;311:552-59.
51. Berkman L. et al. Emotional support and survival after AMI: a prospective, population-based study of the elderly. Annals of Internal Medicine 1992;117:1003-9.
52. Henshaw D.L. Does our electricity distribution system pose a serious risk to public health? Medical Hypotheses. 2002;59(1):39-51.
53. Topf M. Hospital noise pollution: an environmental stress model to guide research and clinical interventions. Journal of Advanced Nursing 2000;31(3):520-8.
54. Hassed C. Are we living in the dark ages? The importance of sunlight. Australian Family Physician 2002;31(11):1039-41.
55. Russell, R.C. Mosquito-borne arboviruses in Australia: the current scene and implications of climate change for human health. International Journal for Parasitology 1998;28(6):955-69.
56. Ostfield, R.S. Keesing F. The function of biodiversity in the ecology of vector-borne zoonotic diseases. Canadian Journal of Zoology 2000;78(12):2061-2078.