The Unmentionables of Health: When Life Gets in the Way of Healthy Living

During the 2011 meeting of Health 2.0, an annual conference showcasing ways in which new technologies are transforming health and healthcare, Alexandra Drane, cofounder of Eliza Corporation, Danvers, Massachusetts, summarized her company's findings about "the unmentionables of health." 1 According to Drane, there is a general understanding of what it takes to maintain a healthy lifestyle. These factors include the following: Consuming a low-fat, high-fiber diet Getting at least seven hours of sleep each night Maintaining blood pressure under 140/90 Maintaining low cholesterol Obtaining current and timely healthcare screenings Having regular medical checkups Exercising 30 minutes per day However, Drane explains, even among healthcare professionals and advocates, our lives get in the way of the pursuit of these objectives as a number of challenges confront and take precedence over these more commonly recognized contributors to general health. Because these challenges are often deeply personal and rarely discussed within healthcare interactions, they have been described as the "unmentionables of health." They include such things as: Job stress Financial problems Caregiving Depression Sleeplessness Marital trouble In their survey of more than 1,200 individuals, Drane's group discovered that 95 percent admitted to having challenges with at least one of ten unmentionables. Of these, 37 percent conceded challenges with two to three unmentionables; an additional 40 percent described dealing with four to six unmentionables; and 17 percent of the surveyed sample acknowledged difficulties with seven to nine unmentionables. 1 When this data was compared against self-described health status, anticipated trends began to emerge. For example, among those who do not contend with any of the unmentionables, 16 percent reported excellent health with only 6 percent citing bad health. Among those with one to three unmentionables in their lives, the percentage of those with excellent health dropped to 10 percent while those with bad health rose to 18 percent. Among those with four to five unmentionables, only 4 percent reported excellent health, with 35 percent reporting bad health. Rephrased, people who report having four or five unmentionables are over five times more likely to report bad health, while people who say they have no unmentionables are over three times more likely to report excellent health. 1 These concepts will resonate with experienced O&P clinicians. While our scope of practice is officially limited to the management of O&P devices, we log a number of hours with our patients and often attain a level of familiarity in which many of the unmentionables of healthcare are shared and discussed. Further, we've seen from our experiences just how much financial concerns, caregiving, job stress, and marital trouble can affect an individual's ultimate health and well-being. While not confined to O&P-specific populations, the purpose of this article is to facilitate a better understanding of how these unmentionables may affect the general health and well-being of the patients we care for. Financial Stress In an article titled "Financial Stress and Its Physical Effects on Individuals and Communities," Laura Choi, with the Federal Reserve Bank of San Francisco, cited a 2008 Associated Press-AOL health poll in which it was observed that those dealing with significant debt were much more likely to report health problems. 2 Among the poll respondents, 27 percent of those reporting high debt stress said they had ulcers or digestive tract problems, compared to only 8 percent of respondents reporting low debt stress. Similarly, severe anxiety was reported by 29 percent of those with high debt stress compared to only 4 percent of those with low debt stress. 2 Given the increasing consumer costs associated with current healthcare trends and the disruption that major health events like an amputation or neurologic disorder can create within the workplace, financial strain can be observed frequently within the O&P patient population. In a recent metaanalysis of the relationship between personal unsecured debt and mental and physical health, Richardson et al. identify statistically significant relationships between elevated personal debt rates and the presence of mental disorders, depression, suicide attempts and completions, drinking problems, drug dependence, and neurotic disorders. 3 Further, several studies have suggested a dose-response effect in which greater debt levels are associated with more severe health difficulties. 3 If we confine our considerations to those of strictly physical health, correlations have been observed between elevated debt and self-rated physical health, long-term illness or disability, chronic fatigue, back pain, higher levels of obesity, and a reduced health-related quality of life as measured by the 36-Item Short Form Health Survey (SF-36). 3 Simply summarized, there is a clear relationship between financial health and physical health. Job Stress Job stress is an expensive problem. When the impacts of missed time, decreased productivity, and healthcare expenses are viewed collectively, the annual costs have been estimated at $200-350 billion in the United States. 4 The underlying neurochemical processes are generally understood. When an employee encounters an event that he or she perceives as harmful or threatening, it triggers the body's fight-or-flight response, inducing the secretion of various hormones that produce increases in pulse rate, blood pressure, and sweating. Over time, these reactions can lead to additional physical symptoms including stomach distress, headache, backache, and other musculoskeletal pain. 4 According to a recent meta-analysis of this topic, the strength of the relationship between job stressors and physical health appears to vary according to the type of stressor encountered at work. 4 Across the 79 studies included in their analysis, Nixon et al. observe that the strongest relationships with negative physical health symptoms were associated with organizational constraints, followed by role conflict, interpersonal relationships, and workload (Table 1). 4 In addition, while relationships were observed with all of the examined physical symptoms and the leading workplace stressors, the cumulative data supports the notion that certain physical symptoms were more strongly associated with each stressor (Table 1). 4 Gastrointestinal problems and sleep disturbances were the most commonly experienced physical symptoms linked to job stress, with each of these symptoms having a significant relationship with six of the seven occupational stressors examined. 4 Marriage Quality The connection between marriage quality and health is part of a larger body of research that has examined and confirmed strong links between social relationships and physical health. 5 Within this broader context, the relationship between marriage and improved health and longevity has long been suggested. However, more recent evidence has helped clarify that, just as a good marriage appears to be associated with improved physical health, a poor marriage appears to correlate with reduced physical health. 5-6 In one of the first studies to clarify this distinction, Bookwala surveyed 729 adults over the age of 50 who were currently in their first marriages. The average age of the sample was 60 (50-74 years) with an average marriage duration of 38 years. 6 Indeed, 99.6 percent of her study sample had been married for more than 20 years. 6 The study participants rated their marriage quality across five different indicators. Level of marital disagreement was assessed by taking a composite assessment of spousal disagreement on money matters, household tasks, and leisure-time activities. Positive spousal behaviors were a summation of six items that described caring and helpful behaviors that the respondent received from his or her spouse, such as "understands the way I feel about things." By contrast, negative spousal behaviors were a summation of six items that reflected uncaring or unhelpful behaviors that the respondent received from his or her spouse, such as the extent to which the spouse made unreasonable demands or argued with the respondent. Global quality was a single item rating from excellent to poor. Marital communication was a summation of four items that assessed the degree to which the respondent's spouse consulted with him or her during decision making. In addition to marriage quality assessment, subjects provided a wealth of information to quantify their physical health. Ratings of physical symptomology represented the frequency of such symptoms as headaches and backaches. Chronic health problems denoted a summation of the presence of 29 possible problems including asthma, urinary problems, and hypertension. Physical disability assessed ability with activities of daily living (ADLs) (such as bathing and dressing), and intermediate activities of daily living (IADLs) (such as the ability to lift and carry groceries or climb several flights of stairs). Perceived health was simply a single ordinal rating from the worst possible to best possible health. After controlling for variables known to directly influence physical health, such as age, education, gender, and depression, the study began to extract correlations within the collected data. All of the indicators of marriage quality were significantly correlated to one another. Similar correlations were found between all of the various health indicators. 6 Patterns of the relationship between marriage quality and physical health, which were also controlled for the effects of all the other variables in the model, began to emerge. For example, the presence of more physical symptoms was significantly predicted by higher reported levels of marital disagreement and negative spousal behaviors . 6 Similarly, chronic health problems, physical disabilities , and lower perceived health were all significantly associated with higher levels of negative spousal behaviors . 6 Restated, higher reported rates of negative spousal behaviors were found to be predictive of increased physical symptoms, chronic health problems, physical disabilities, and reduced perceived health. What's more, the apparent harmful effects of negative spousal behaviors on measures of physical health were more established than any of the measured positive marital characteristics. In fact, in this study, the positive aspects of marriage did not uniquely contribute to the physical health of the sample. 6 A bad marriage, it would appear, does more harm to physical health than a good marriage provides benefit. The correlations between marital quality and physical health outcomes are admittedly modest. However, in their meta-analysis of the topic, Robles et al. point out that small effects can have considerable practical significance as they exert their effects on a daily basis. Similar levels of correlation have been identified in meta-analytic reviews exploring the relationships between fruit and vegetable consumption and reducing the risk of coronary heart disease, exercise to prevent declines in health-related quality of life, and increased television viewing and the risk of cardiovascular disease. 5 Just as increasing consumption of fruits and vegetables and decreasing sedentary activity are considered important targets for improving public health, greater marriage quality is consistently related to better physical health, regardless of the study design, marital quality measure, and publication year. 6 Moreover, the consistent effects in longitudinal studies suggest that poor marital quality is a risk factor for poor health outcomes. 6 Caregiving The burdens associated with caregiving have shown themselves to be fairly constant across the spectrum of disease and disability in the individual being cared for. A representative study from China examined the health impacts on primary caregivers (PCGs) for elderly individuals. 7 The study defined a caregiver as a family member, relative, or friend who spent at least four hours per week providing unpaid assistance to a care recipient over the age of 64 in at least one ADL or IADL, such as feeding, dressing, grooming, bathing, toileting, transportation, housework, and taking medications. The authors identified 246 PCGs, most of whom shared a household with the recipient of their care (n=215), but some of whom resided in a separate household from the care recipient (n=31). For each PCG, it further identified two controls who did not serve as PCGs but were otherwise matched by demographics such as age and gender (NPCG). The health status of PCGs and NPCGs were obtained through telephone interviews, extracting the presence of diseases experienced over the past year, symptoms experienced during the past four weeks, and self-rated health compared with that experienced one year prior to the survey. The level of burden experienced by the PCGs was quantified using the standardized Zarit Caregiver Burden Scale. The matching of controls ensured similar socioeconomic backgrounds of the two groups. Among the PCGs, two-thirds were female and roughly half were over the age of 50. While trends differed between male and female caregivers, regression analysis revealed a more adverse health profile for PCGs. Male PCGs were four times more likely to have required an average of one or more visits to a physician per month and almost twice as likely to have required a hospital admission in the previous year. They were over two times more likely to have experienced asthma or a digestive ulcer, three times more likely to have arthritis, and over five times more likely to have lost at least five pounds over the past year. Collectively, they were twice as likely as NPCGs to have experienced two or more chronic illnesses over the past year. 7 Female PCGs fared no better. Over the previous year they were more than twice as likely as NPCGs to have required at least monthly physician visits or experienced a weight loss of at least five pounds. They had more than a twofold increase in their risk of osteoporosis, more than a threefold increase in their risk for arthritis, a fivefold increase in the likelihood of experiencing asthma, and a 17-fold increased risk of digestive ulcers. Collectively, they were more than their NPCG peers to have experienced two or more chronic illnesses over the past year. 7 Similar trends were seen in symptomologies. In the preceding month, male PCGs were more likely to experience headaches, stomachaches, and memory loss, and were twice as likely to report their health as worse than it was one year ago. Female PCGs reported elevated rates of headaches, dizziness, heart palpitations, stomachaches, and memory loss, and nearly two-and-a-half times more likely to report a decline in their general health over the past year. Further, greater levels of caregiver burden were found to correlate with elevated rates of both chronic illnesses and symptoms. 7 In summary, in addition to the elevated rates of depression and anxiety commonly associated with caregiving, there were a number of observed relationships with aspects of physical health, especially among female caregivers. Summary While we may generally appreciate many of the key contributors to physical health in ourselves and our patients, such as diet and exercise, there are a number of unmentionables, such as personal debt, job stress, marital problems, and caregiving, that can have striking effects on physical health and well-being. An appreciation of these unmentionables and their effects may allow an increased appreciation of the overall health challenges experienced by those around us. Phil Stevens, MEd, CPO, FAAOP, is in clinical practice with Hanger Clinic, Salt Lake City. He can be reached at philmstevens@hotmail.com . References Drane, A. 2011. Yet More and Different Unmentionables Panel. Presentation at the San Fransisco Health 2.0 Conference. www.health2con.com/tv/yet-more-and-different-unmentionables Choi, L. 2009. Financial Stress and Its Physical Effects on Individuals and Communities. Community Development Investment Review 5 (3):120-2. Richardson, T., P. Elliott, and R. Roberts. 2013. The relationship between personal unsecured debt and mental and physical health: A systematic review and metaanalysis. Clinical Psychology Review 33 (8):1148-62. Nixon, A. E., J. J. Mazzola, J. Bauer, J. R. Krueger, and P. E. Spector. 2011. Can work make you sick? A metaanalysis of the relationships between job stressors and physical symptoms. Work & Stress 25 (1):1-22. Robles, T. F., R. B. Slatcher, J. M. Trombello, and M. M. McGinn. 2014. Marital quality and health: A metaanalytic review. Psychological Bulletin 140 (1):140-87. Bookwala, J. 2005. The role of marital quality in physical health during the mature years. Journal of Aging and Health 17 (1):85-104. Ho, S. C., A. Chan, J. Woo, P. Chong, and A. Sham. 2009. Impact of caregiving on health and quality of life: A comparative population-based study of caregivers for elderly persons and noncaregivers. The Journals of Gerontology, Series A, Biological Sciences and Medical Sciences 64 (8):873-9.

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