Positive Health Online

World Health Organisation Director-General Margaret Chan, in her 2010 Global Status Report[1] says that "the epidemic of 'non-communicable diseases', like cardiovascular disease, diabetes, cancer, obesity and respiratory disease, extends far beyond the capacity of lower-income countries to cope and that in the absence of urgent action, the rising financial burden of these diseases will reach levels that are beyond the capacity of even the wealthiest countries in the world to manage."

In the United Kingdom, National Health Service expenditure rose between 1996 and 2006 from £55 billion to £107 billion.[2] Examining the obesity component of this problem, in the Department of Health White Paper 'Healthy Lives, Healthy People'[3] it is estimated that the cost to the NHS in England of obesity in 2007 was £4.2 billion and is predicted to rise to £6.3 billion by 2015. This is largely due to the need for investment in super sized 'bariatric equipment' for hospitals and ambulances which includes doubled sized beds, wheelchairs, operating tables and winching systems for the lifting of people who have become too heavy to be moved in and out of their beds by nurses. However, the cost of new equipment is just the tip of the iceberg, as obesity is causally linked to cancer, heart disease, diabetes, arthritis, vascular disease and depression, with all their associated co-morbidities. The future would look very bleak indeed if not for the huge amount of positive data which is streaming out now in relation to the efficacy of lifestyle interventions to effect both primary and secondary prevention of these illnesses.

Chan reports on the relative causal links in all non-communicable illness of physical inactivity, tobacco use, harmful use of alcohol and unhealthy diets. Hitherto, whilst there has been broad agreement about their link in the cause of illness there has been much scepticism that change in the lifestyle of those who are already ill, advocated for example by the UK's Bristol Cancer Help Centre (now Penny Brohn Cancer Care), could materially alter the outcome of major illness once pathology had developed. However, evidence grows daily that lifestyle change can be effective to reverse illness once developed, and in the USA the Mutual of Omaha Insurance company have stated that cardiac patients on the Dr Dean Ornish intensive lifestyle programme are costing them on average $30,000 per year less in the first year of treatment than their counterparts who are not making healthy lifestyle changes! All healthy lifestyle programmes support smoking cessation and the limited use of alcohol and recreational drugs, and the studies below show a selection of lifestyle studies where changes in diet, mental state and exercise levels have had a profound effect on either disease risk, aetiology or progression.

Review of the Recent Evidence for the Primary and Secondary Prevention of Illness

Primary Prevention of Cancer

• Norat et al (2005) confirmed that colorectal cancer risk is positively associated with high consumption of red and processed meat and report an inverse association with fish intake;[4]
• Ornish et al, (2008) showed that participation for three months in comprehensive lifestyle changes (of diet, exercise, daily exercise, emotional support and relaxation) increase telomerase activity by up to 30% and consequently improve telomere maintenance capacity in human immune-system cells.[6] The enzyme telomerase governs the integrity of the telomeres at the end of our genes which hold the strands of the genetic material together. (Telomeres are likened to the plastic aglet on the tips of our shoelaces that stop the laces from un-ravelling). Loss of integrity of the telomeres has been linked to the genetic mutations which cause cancer. This research followed the findings that telomerase becomes shortened in women with stress and was further built upon by researcher Dusek (2008) who discovered that meditation alone significantly increases telomerase activity. These findings are also of significance in terms of the prevention of premature ageing;
• Phipps et al,  (2011) who investigated body size, physical activity and risk of breast cancer concluded that despite biological and clinical differences, triple-negative and ER(+) breast cancers are similarly associated with Body Mass Index and recreational physical activity in postmenopausal women.[5]

Secondary Prevention of Cancer

• Ornish et al (2005)  examined the effects of intensive lifestyle changes on men with early prostate cancer. After 1 year on the programme, none of the men in the experimental group underwent conventional treatments compared to six in the control group. PSA (prostate specific antigen) levels decreased by 4% in the experimental group compared to a 6% increase in the control group. Prostate cancer cell growth was inhibited almost eight times as much in the experimental group compared to the control group. Dr Ornish states that "These results indicate that intensive lifestyle changes may affect the progression of early low grade cancer;"[7]
• Pierce et al (2007) in the San Diego Study showed a doubling of survival at 9 years into a prospective study of women who both adopted a healthy eating pattern and started a daily exercise routine, regardless of their starting weight. This great survival advantage was not seen in either women who only ate healthily or in those who only exercised.  The authors conclude that: "The strong protective effect observed suggests a need for additional investigation of the effect of the combined influence of diet and physical activity on breast cancer survival."[8] UK oncologist Professor Karol Sikora has stated that there is no conventional treatment for breast cancer with this survival benefit and that this intervention happens at a fraction of the cost.

Primary Prevention of Cardiovascular Disease

• Davidson, (2010) in the 'Don't worry be happy' study examined whether higher levels of positive affect are associated with a lower risk of coronary heart disease (CHD) in a large prospective study with 10 years of follow-up and found that 'increased positive affect was protective against 10-year incident CHD', suggesting that preventive strategies may be enhanced not only by reducing depressive symptoms but also by increasing positive affect;[9]
• He et al, (2007) made a meta analysis of studies linking fruit and vegetable intake and the incidence of cardio-vascular disease. Their finding was that in this meta-analysis of prospective cohort studies increased consumption of fruit and vegetables from less than 3 to more than 5 servings/day is related to a 17% reduction in cardiovascular disease (CHD) risk, whereas increased intake to 3-5 servings/day is associated with a smaller and borderline significant reduction in CHD risk. These results provide strong support for the recommendations to consume more than 5 servings/day of fruit and vegetables;[10]
• Maruthur (2009)  who studied adults with untreated pre-hypertension or stage I hypertension showed that those who added the healthy vegetable based Dietary Approaches to Stop Hypertension 'DASH diet' to established lifestyle recommendations for blood pressure control (i.e. sodium reduction, weight loss, and increased physical activity), observed reductions of 12% to 14% in estimated CHD risk;[11]
• Hamer (2008) studied the relationship between walking and prevention of CVD and death finding that "Walking is inversely associated with clinical disease endpoints and largely support the current guidelines for physical activity";[12]
• Smith et al, (2007) showed a significant reduction of CHD risk in diabetics who walk every day concluding that "walking a mile or more per day may provide strong protection from all-cause and non-CHD CVD mortality in older adults with diabetes";[13]
• Strazzullo (2009) studied the link between salt consumption and stroke and CVD finding that: "High salt intake is associated with significantly increased risk of stroke and total cardiovascular disease." These results support the role of a substantial population reduction in salt intake for the prevention of cardiovascular disease.[14]

Secondary Prevention of Cardiovascular Disease

• Ornish et al (1996) showed for the first time that intensive lifestyle change could reverse the narrowing of coronary arteries and the progression cardiovascular disease concluding that "Regression of coronary atherosclerosis occurred in the experimental group. In contrast, in the control group, coronary atherosclerosis continued to progress and there were more than twice as many cardiac events.[15]This highly significant finding has now led to widespread implementation of the Ornish model in the USA with Medicare now paying for the demonstration project;
• Van Dixhoorn and White (2005) showed that intensive supervised relaxation practice enhances recovery from an ischaemic cardiac event and contributes to secondary prevention stating that 'Learning relaxation is an important ingredient of cardiac rehabilitation, in addition to exercise and psycho- education;[16]
• Pischke and Ornish (2007) found that cardiovascular patients at risk for heart failure with an LVEFV40%, can make changes in lifestyle to achieve similar medical and psychosocial benefit to patients with an LVEFN40%;[17]
• Levitan et al, (2009) investigated the 'DASH' diet finding that: The Dietary Approaches to Stop Hypertension (DASH) diet effectively reduces blood pressure and heart failure, and that  in 36,019 participants 37% had a lower rate of heart failure after adjustment for age, physical activity, energy intake, education status, family history of myocardial infarction, cigarette smoking, postmenopausal hormone use, living alone, hypertension, high cholesterol concentration, body mass index.[18]

Primary Prevention of Diabetes

• Qin (2010) studied by systematic review the interaction of obesity and physical inactivity on the aetiology of diabetes. The results show that obesity and physical inactivity interact on an additive scale. This means that prevention of either obesity or physical inactivity not only reduces the risk of diabetes by taking away the independent effect of this factor, but also by preventing the cases that were caused by the interaction between both factors.[19]

Secondary Prevention of Diabetes

• Gillies (2007) compared lifestyle and pharmacological interventions in reducing the rate of progression to Type 2 Diabetes in people with impaired glucose tolerance showing that 'lifestyle interventions seem to be at least as effective as drug treatment'.[20]

Linking State of Mind with Health-Defining Behaviour and Behavioural Change
Whilst the Chan WHO report[1] shows the causal link between physical inactivity, tobacco use, harmful use of alcohol and unhealthy diets, it does not identify the link between these behaviours and the mental states of individuals. Neither does it describe how to work with the mental state of individuals in order to produce sustainable change in health-defining behaviour. The Department of Health Report (2011) No Health Without Mental Health[21] points out that currently 22.8% of the UK's NHS expenditure (circa £24.5 billion) is spent on care of the mentally ill (compared to 15.9% for cancer and 16.2% for cardio-vascular disease) and that the wider economic costs of statutory service provision, lost productivity at work and reduced quality of life are estimated to cost a further £105.2 billion each year, (which equals approximately one sixth of total government expenditure)! This report identifies the link between "good mental health and better physical health, reductions in health damaging behaviour, greater educational achievement, improved productivity, higher incomes, reduced absenteeism and presenteeism at work, less crime, more participation in community life, improved overall functioning and reduced mortality." Here the holistic nature of health is well described and it becomes clear that to change the incidence of the major disease of our time and halt the epidemic of non-communicable lifestyle related illness, we must work to improve mental health and well-being by improving the self-esteem and motivation of individuals in order to develop the 'fully engaged scenario' envisaged by Wanless (2002).[22]

Chan makes it clear "the warning remains stark" and that her report predicates the need "to launch a more forceful response to the growing threat posed by non-communicable disease". The alarming rises in incidence of these diseases that she quotes globally puts health on an equally threatening trajectory to that of global warming and it is clear that we must address the interacting states of body and mind and harness the individual will of individuals as well as the political will of governments to change our health status and long-term health risks. It is now abundantly clear that the key to this 'forceful response' is widespread implementation of low-cost supported self-help programmes which change the health-defining behaviour of individuals which simultaneously greatly improve their quality of life!

Dr Dean Ornish states that the key to his success in motivating and sustaining healthy change is to create a positive healthcare community of people working together to achieve health and happiness. He believes that of all the elements of his programme, the closeness and trust generated within group work settings provide the element of love and intimacy which is missing from so many people's lives, vital as over 35% of adults now live alone, prone to isolation and depression. He creates momentum towards change by emphasizing to people the positive benefits of changing rather than creating fear about not changing. Dr Rosy Daniel has worked now for ten years to create a health coaching model known as 'Health Creation (HC)'[23] to provide a skilled preventive healthcare workforce to help guide and catalyse healthy change in individuals and organizations. Along with developing the proactive healthcare knowledge base, the Bath Spa University based training of HC Mentors (who focus on the health and well-being of individuals) and HC Consultants (who focus on organisational health and well-being) is based upon developing the key reflective listening skills and vital motivational interviewing skills described by Rollnick and Miller[24] which provides the crucial momentum for change.

This health coaching has become an integral part of the Postgraduate Diploma course for doctors, nurses and other medical graduates studying Integrative Medicine at the new British College of Integrative Medicine[25] where Dr Daniel is Director. Many of the students have commented that being required to apply the practice of integrative healthcare to themselves has been the most important part of their course, as they have had to wrestle with and overcome their personal  barriers to healthy change through the six-month health coaching process. In this way it is clear that they will make far more effective health care professionals, becoming effective role models with real integrity and positive experience to share with the people they care for.

Inspired by the enormously significant results of Dean Ornish and others cited above, Dr Rosy Daniel has now launched the 'Regenerative Health Programme'[26] for those with all types of lifestyle non-communicable disease who would like to embark upon and intensive lifestyle programme in a Bath-based positive health community. The key ingredients are fitness coaching, nutritional therapy, emotional healing, yoga therapy and long-term support through a walking club, dance and singing groups, emotional support group plus yoga and meditation classes. All are welcome to join the programme whether mentally, physically or life challenged but again, there will be efforts to bring health care professionals into this programme, so that the positive effects will be experienced personally and then rolled out far more quickly as a result for the benefits of the community. This initiative is supported with interest by the NHS Director of Occupational Health for the South West region of the UK, who is watching with keen interest to see if the UK research results of this programme will match those achieved by other lifestyle researchers!

References
1. Chan, M. Global Status Report on Noncommunicable Disease. World Health Organisation. 2010.
2. Boyle, I. Overview of the health and social care expenditure in England.  Publ. London School of Economics and Political Science. 2010.
3. Department of Health Report  'No Health Without Mental Health'. 2011.
4. Norat T et al, (2005) Meat, Fish, and Colorectal Cancer Risk: The European Prospective Investigation into Cancer and Nutrition, JNCI J Natl Cancer Inst 97 (12): 906-916. 15 June 2005.
5. Phipps AI, Chlebowski RT, Prentice R, et al. Body size, physical activity, and risk of triple-negative and estrogen receptor-positive breast cancer. Cancer Epidemiol Biomarkers Prev. 20 (3): 454-63. Mar 2011.
6. Ornish D et al. Increased telomerase activity and comprehensive lifestyle changes: a pilot study. The Lancet Oncology, Volume 9, Issue 11, Pages 1048 - 1057. 2008.
7. Ornish et al. Intensive lifestyle changes may effect the progression of prostate cancer. Journal of Urology, Vol 174, 1067-1070. 2005.
8. Pierce J et al. Greater Survival After Breast Cancer in Physically Active Women With High Vegetable-Fruit Intake Regardless of Obesity.  J Clin Oncol. 25(17): 2345-2351. June 10 2007.
9. Davidson K. Don't worry, be happy: positive affect and reduced 10-year incident coronary heart disease: The Canadian Nova Scotia Health Survey Eur Heart J 31 (9): 1065-1070. 2010.
10. Van Dixhoorn Jan, White, Adrian.  Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. European Journal of Cardiovascular Prevention & Rehabilitation 12 (3): 193-202. June 2005.
11. Maruthur N et al. Lifestyle Interventions Reduce Coronary Heart Disease Risk: results From the PREMIER Trial, Circulation. 119:2026-2031. 2009.
12. Hamer M. Walking and primary prevention: a meta-analysis of prospective cohort studies. Br J Sports Med  42:238. 2008.
13. Smith TC, Wingard DL, Smith B, Kritz-Silverstein D, Barrett-Connor E. Walking decreased risk of cardiovascular disease mortality in older adults with diabetes. J Clin Epidemiol. 60(3):309-17. Mar 2007.
14. Strazzullo P. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ. 339:b4567. 2009.
15. Ornish D et al. Intensive lifestyle changes for reversal of coronary heart disease. JAMA,  Vol 280, No 23. Dec 16 1996.
16. He FJ Nowson CA Lucas, M. MacGregor GA. Increased consumption of fruit and vegetables is related to a reduced risk of coronary heart disease: meta-analysis of cohort studies. J Hum Hypertens. 21(9):717-28. Sep 2007.
17. Claudia R. Pischke et al. Lifestyle changes and clinical profile in coronary heart disease patients with an ejection fraction of =40% or >40% in the Multicenter Lifestyle Demonstration Project. Eur J Heart Fail 9 (9): 928-934. 2007.
18. Levitan E et al. Consistency with the DASH Diet and Incidence of Heart Failure. Arch Intern Med. 169(9):851-857. 2009.
19. Qin L, Knol MJ, Corpeleijn E, Stolk RP. Does physical activity modify the risk of obesity for type 2 diabetes: a review of epidemiological data. European Journal of Epidemiology 2010;25(1):5-12. 2010.
20. Gillies CL, Abrams KR, Lambert PC et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ 334: 299-307. 2007.
21. Department of Health White Paper: Our strategy for public health in England: Healthy lives, healthy people. 2010.
22. 1 Wanless D. Securing Our Future Health: Taking the Long-Term View of 2002' Department of Health. 2002.
23. Health Creation, Bailbrook Hosue, Bath, www.healthcreation.co.uk Tel: 01225-745757.
24. Rollnick S. and Miller WR  What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325-334. 1995.
25. British College of Integrative Medicine - www.integrativemedicine.com.uk 01225-319131
26. Regenerative Health Programme - www.drrosydaniel.org 01225-745766