One of our goals as health care professionals is to educate patients in the holistic approach to health. All factors of our “self” must come together for the self-actualization level that includes wellness (refer to Chapter 4, “Educating Patients,” for Maslow’s Hierarchy of Needs). Holistic medicine works for harmony and balance, or homeostasis, in all areas that make us who we are (Fig. 5-1). This includes our physical being, our mental or emotional self, and our social life and spirituality. Patients are ultimately responsible for maintaining this balance, we cannot do it for them, but we must help them learn to maintain wellness using natural means and prudent choices before they need medical intervention.

Figure 5-1 Circle of Life: The “whole” of a person is greater than and different from the sum of the parts.

Through all of our discussions of health, remember that disease is only one of the many parts of the person we are treating; we must consider the whole person. Medical science has always linked healthy minds to healthy bodies. Illness was originally thought to be evil spirits invading the mind and directing the body. Now we have scientific evidence that a healthy mind nurtures a healthy body and vice versa. Our mind and our body make up our total self; if the health of one is affected, it may be devastating to the whole self. The whole patient includes the following:

• Physical health and fitness

• Mental health and emotional stability

• Stress management

• Environmental and occupational safety

• Social supports

• Spiritual harmony

Many factors work together for holistic health. They include the following:

• Genetic endowment: Along with general appearance and other characteristics, we inherit our anatomy and physiology, metabolism, and immune system from our extended family. For example, how well our body resists communicable diseases depends on a strong and intact immune system. Some people never seem to catch a cold or flu, and others seem to attract every passing microorganism. Preventive measures (immunizations, Standard Precautions, and so forth) are a big factor, but so is the strength of our inherited immune system. Likewise, how we metabolize dietary fats, for example, has a strong relationship to whether or not we develop heart disease. How strong and well made our body is (anatomy) and how well it works (physiology) helps determine our general level of health and resistance to disease.

• Availability of health care (socioeconomic status): The world’s best medical technology will not help our patients if it is not available to them. Whether a patient can afford prevention measures or to seek help to relieve a medical problem depends largely on financial resources. When the decision is between food or shelter and health care, and the question is “Of all I must pay, which is most important?”, health care, particularly preventive care, may be a low priority. Wealthy patients with better education and better access to health care usually know the symptoms of illness, have regular physical examinations, and schedule diagnostic screenings to manage illness while it is still more likely curable. Financially stable patients usually maintain immunizations for childhood diseases, flu, pneumonia, tetanus, and hepatitis B. Many poorer patients with no access to health care do not have these options.

• Family dynamics: A calm, loving home protects us from many stresses and meets our love/belonging and safety/security hierarchical needs. A stormy, upsetting home life gives us no shelter from the stress of the outside world. Family exposure also teaches us how to respond to illness, forms our exercise and diet habits, and shows us how to react to stress.

• Culture: The food we eat, our reproductive philosophies, and how we care for our illnesses are all largely cultural and have an enormous impact on health. We have covered cultural factors in the health care setting, and as we work through this text we will see how diet and cultural approaches to health care affect long-term health.

• Environmental: Exposure to polluted air, water, soil, or foods stresses even the strongest immune system. Environmental exposure to strong, drug-resistant microorganisms challenges our resistance and may overpower otherwise good health.

• Emotional or physical stress: Extremely stressful situations or exposure to moderate stress over a long period measurably decreases the immune response and makes us susceptible to opportunistic disease. This is covered later in this chapter in “The Stress Factor.”

• Poor social habits: Smoking, alcohol and drug abuse, a sedentary lifestyle, and overexposure to sun versus good nutrition, exercise, and prudent living all strongly influence long-term health. Imprudent choices lead to STDs, traumatic injuries, early degenerative disease, and generally poor health, regardless of a strong inherited immune system.

Help-seeking mechanisms vary also and significantly affect health. Whether we seek help is very cultural and also varies with age, social class, and sex. Patients must recognize that something is wrong, realize that help is needed, and decide on a course of action. Many patients deny they have a problem if they have more pressing hierarchical needs (review Chapter 4, “Educating Patients,” for Maslow’s Hierarchy of Needs).

• Middle-aged and older adults ask for help more frequently than teenagers and young adults.

• Educated patients with better financial resources are more likely to recognize when they need care than members of lower socioeconomic groups with less education.

• Women ask for help more frequently than men, and mothers of young children are most likely of all to seek help.

• The patient’s perception of the illness is also a factor. He may wonder, “Is this a heart attack or indigestion?” Many do not recognize a problem unless the symptoms are identifiable or unusually uncomfortable or painful. Many wait with vague symptoms before asking for help.

• If the suspected disorder or symptom is not socially acceptable, patients may decide not to seek help. Patients may wonder, “Do I want anyone to know about this?” Many patients would rather not report symptoms that are potentially embarrassing. For example, consider the following for social acceptance: a vaginal discharge that may be a STD versus a breast lump; skin cancer versus possible Kaposi’s sarcoma; heart disease versus morbid obesity. Pride is associated with some disorders, such as those related to sports; for example, shin splints and tennis elbow. Patients are rarely reluctant to report these disorders.

• The age at which the symptoms appear may determine whether the patient or caregiver sees the symptom or sign as significant. For example, for whom would unexplained joint pain be a greater concern, an otherwise healthy 10-year-old or an 85-year-old with multiple health problems?

• For working adults, seeking help may depend on balancing available sick leave against the severity of the symptoms. Patients may weigh the options of treating themselves or going for help if they have no more sick days available.

• The day of week and the time of day also have an impact on reporting illnesses. Patients are more likely to seek help early in the week or early in the day and are least likely to report illness on Friday or the weekend or late in the evening (Fig. 5-2). Think of what this might mean for someone with unexplained chest pain.

All of the factors listed above help determine whether patients are likely to be ill and whether they ask for help with health care problems. If they do not come to us, we cannot offer our care. Once they recognize the need, we can begin to do those things for which we were trained.

THE NUTRITION GOAL: WE ARE WHAT WE EAT

The body needs fuel from a well-balanced diet to remain healthy, delay degenerative disorders, and resist communicable illnesses. This concept is so important that many health care agencies employ nutritionists and dietitians to help patients determine a diet to meet individual needs. This is particularly important for patients with severe nutritional disorders, or with disorders caused by poor eating habits. If there are no diet specialists on staff, referrals can be made to outside sources. If the problem is not complicated or does not require close professional management, patient education materials can be ordered or created to help instruct patients regarding a healthy diet.

Diet is one of the most important of the controllable factors influencing health. The term diet comes from the Greek word, meaning diata, “a way of life.” What and how we eat have such a profound affect on health that the importance of diet-related wellness throughout our lifetime cannot be overemphasized. Salt, fat, sugar, caffeine, and alcohol all significantly affect how well the body functions. Although hunger is certainly present in our country, most Americans are rarely truly hungry. However, many who can afford to eat well are obese, nutritionally deficient, or malnourished by poor diet choices; in fact, many of our most obese patients are technically malnourished. Diet-related heart disease, osteoporosis, cirrhosis, and eating disorders are more common in the United States than in most other developed nations in spite of the abundance of food, nutritional education in schools, and the constant exposure to diet theories. Patients need to know and understand the basics of good nutrition. It is human nature to eat only what we have always eaten or only what we like, unless we understand how important it is to our overall health and quality of life to vary our diet and to eat nutritious foods properly prepared.

Review your course work that includes the mechanics of metabolism and nutrition to refresh your memory of how the body uses nutrients to grow and heal. Remember these concepts as you help patients understand the importance of an appropriate diet and as you help the physician determine the patient’s nutritional status. Your clinical responsibilities may include many of the measurements used to assess a patient’s nutritional status. Height versus weight, fat to muscle ratio, and body mass index comparisons are reliable indicators of healthy food choices. A tool called a caliper measures skin fold thickness at various points on the body to determine subcutaneous (under the skin) fat deposits. Biochemical blood tests register levels of available nutrients in circulation. The nutritional history is also assessed in the physical examination with the physician’s inspection of the patient’s skin, hair, eyes, teeth, and muscle mass. To complete the analysis, a diet history helps determine how much patients understand about nutrition.

When all of the information listed above regarding the patient’s nutritional status is documented and evaluated, education and an appropriate diet can be arranged around the patient’s specific needs. Not everyone responds equally to the same procedures or medication, and the same is true of diets. Two people consuming the same diet respond according to their individual metabolism. One may lose significant weight; the other may simply maintain, neither gaining nor losing. If the health concern involves a nutritional imbalance, such as poor absorption of nutrients or the need for great weight loss, a dietitian or nutritionist should work with the patient. These situations will not respond to the latest best selling one-size-fits-all diet. In cases of morbid obesity, patients may be referred to a bariatrics specialist, a new field that concentrates on obesity and its related disorders. However, in cases that involve nothing more than poor or imprudent food choices, following the current accepted nutritional guidelines almost always leads to better health and more realistic weight regulation. Since the nutritional and dietary sciences constantly update recommendations to reflect new information regarding proper food choices, it is in everyone’s best interest to stay current of the latest dietary theories. Guidelines have been designed to ensure healthy food choices for most age groups, many cultural and ethnic backgrounds, and various diseases and disorders. All can be easily adapted for individual preferences and special needs (Box 5-1).

Box 5-1 Talking about Food

Determining your patient’s dietary status requires careful questioning about eating habits and other issues that affect proper nutrition. The following questions should help.

• How is your appetite?

• Are you eating more or less than your normal diet?

• Does food smell as good or taste as good as it used to?

• Do you have trouble swallowing?

• Does it sometimes feel that food just will not go down?

• Do you have frequent heartburn or indigestion?

• Do you eat out frequently? What do you usually order?

• Is it hard for you to purchase or prepare foods?

• Are there foods you cannot or will not eat?

• Have you ever followed a popular weight reduction diet recommended by a friend or advertisement?

• Are you taking diet supplements? Which ones and for what reasons?

Food Guide Pyramids

In 2005, the United States Department of Agriculture (USDA) updated the Food Guide Pyramid to reflect the newest nutritional information. The newer form of the previous pyramid is a good reference for anyone concerned with maintaining a healthy diet. The pyramid concept encourages building a diet with a base of whole grains and working to progressively smaller portions of vegetables, fruits, dairy products, and meats and meat products and includes a very small amount of the “other” group. These guidelines include an ideal balance of nutrients to provide for cell growth and repair and to supply enough energy to make it through the day. No major source of nutrients is neglected or eliminated, as all Recommended Dietary Allowances (RDAs) are covered by the guidelines. People who follow the recommendations maintain the nutrients necessary for good health. If portion size guides are followed, an ideal weight is more likely possible than if any vital group is neglected or avoided. Following some of the current fad diets that alter the pyramid balance may lead to weight loss, but studies are not complete regarding their affect on long-term health. Although studies are ongoing, and theories are constantly challenged, it appears that diets that encourage avoiding any of these nutrients ultimately fail to maintain either health or ideal weight.

More recently, in recognition of cultural diversity, food pyramids were designed for ethnic groups such as African American, Asian, and Native American. Pyramids also offer healthy food choices for older adults, children, and vegetarians. The World Health Organization (WHO) developed pyramids for other countries that offer the best nutrition based on foods locally preferred and regionally available. Within each group, and within each culture’s traditions, a healthy diet is possible by following the appropriate guidelines (Table 5-1).

Table 5-1

CULTURAL AND RELIGIOUS DIETARY PRACTICES

Group	Prohibitions	Preferences/Requirements
Catholics	Fast or abstain on certain holy days
Hindus	Range widely from prohibiting all meats and animal products to more lenient practices	Yogurt, beans/peas, prefer to balance hot with cold and sweet with sour
Islamic/Muslims	Pork, alcohol and its products (includes alcohol-based medications), shortening made from animal products, gelatin made from animal products
Jews	Pork, shellfish, and scavenger seafood (shrimp, crab, catfish), milk and meat dishes together, blood or bloody products, such as rare meat or blood sausage	Fish with fins and scales, Kosher products
Mainline Protestants	May forbid alcohol or tobacco, may fast for certain occasions
Mormons	Alcohol, tobacco, and stimulant beverages (colas, coffee, tea)
Seventh Day Adventists	Pork, shellfish, and certain other seafood, fermented beverages