In addition to physical activity, diet is another relatively easy target
for increasing health and wellbeing of people living with chronic
conditions. Referring back to the link between depression and chronic illness noted above, using diet as a clinical target has proven effective in improving depression symptomology \citep{Opie2015,Parletta2019}.
An important dietary contributor to risk of future chronic
illness is alcohol consumption, which has been causally related to 60
medical conditions, including certain cancers (breast, mouth and liver),
epilepsy and haemorrhagic stroke \citep*{Room2005}. Shockingly, ~20% of
nursing home residents have been reported to be malnourished
internationally, although depending on the definition of malnutrition
prevalence ranges from 1.5% to 66.5% \citep*{Bell2015}. Suggested interventions for
reducing malnutrition included dietary supplements, encouraging active
participation in food choice and staff training programmes. These
findings are especially concerning when considering the increasingly
understood role of poor diet as a contributing factor to mental health
conditions [REF], which subsequently increases risk of further
ill-health [REF]. In recent years, research has demonstrated that
the Mediterranean diet may protect against chronic disease including
common mental disorders \citep{Lassale2019,Dinu2018}. Dietary and physical activity modifications
have also proven effective in reducing the progression of type 2
diabetes and cardiovascular disease in particular \citep{Greaves2011,Sofi2010}. \citet{Sofi2010} concluded from a systematic review and meta-analysis that a
greater adherence to a Mediterranean diet leads to a significant
reduction in cardiovascular incidence, cancer incidence or mortality and
neurodegenerative diseases. Importantly, randomised controlled trials
now demonstrate that adopting a Mediterranean diet independently reduces
cognitive decline in chronic conditions \citep{Martínez-Lapiscina2013,Valls-Pedret2015}. Intestinal microbiome also plays a key role in modulating the risk of disease development, including inflammatory bowel disease, obesity, type 2 diabetes, cardiovascular disease, and cancer. Dietary changes have shown to be effective in triggering changes in the microbiome within 24 hours, highlighting the importance of diet as a pathway through which health can be improved \citep{Singh_2017}. It is argued that targeting diet would be an effective opportunity to relieve the growing burden of mental and neurological disease \citep*{Owen_2017}.
It is noted however, that
simply providing information on modifications to health behaviours such
as level of physical activity and diet quality is not sufficient to
elicit behaviour change; the use of behaviour change theory or behaviour
change techniques is needed to initiate behaviour changes \citep*{Michie2009}. Simply put,
information is not transformation, and targeting the mechanisms through
which behaviour change can be achieved is vital. Interventions that
include self-monitoring and at least one other technique, such as goal
setting, goal review and feedback, are more successful than
interventions that do not adopt these strategies \citep{Michie2009}. Based on the upward
spiral theory of lifestyle change, increasing positive affect will
encourage adherence to a new behaviour change \citep*{Van2018}, mediated by increasing
HRV and social connectedness \citep*{Kok2010}. There is a need
to build positive psychological experiences in parallel with the ongoing
medical treatment to both increase treatment adherence and improve
health and wellbeing through other routes.
Another important factor influencing health and wellbeing of people
living with chronic conditions is sleep. Many chronic conditions are
associated with sleep-related problems, including sleep-related
breathing disorders, insomnia, sleep-related movement disorders and
sleep-related epilepsy \citep{Basnet2016,Dyken2012}. Critically, sleep quality is vitally important
for people living with chronic conditions as it can worsen their already
existing symptoms, for example, sleep quality has been shown to impact
on metabolic function of type 2 diabetes \citep{Lee2012}. More generally, comorbid
insomnia with a chronic condition is more severe and persistent than in
cases where insomnia is the only disorder \citep*{Ancoli-Israel2006}. Among an elderly population
with comorbid medical and mental illness, sleep is a useful predictor
for general physical and mental health-related quality of life status \citep{Reid2006}.
Sleep – in both the general population and among people with chronic
conditions – can be improved through physical activity \citep{Hartescu2015,Kredlow2015}. Alternative
forms of exercise such as Tai Chi are now being adopted and researched
to encourage greater physical activity \citep{Raman2013}. Other methods through which
sleep can be improved include music therapy, with research highlighting
benefits for both acute and chronic sleep disorders \citep*{Wang2014}. Massage,
acupuncture, natural sounds and music videos have also been reported to
be effective in health care settings \citep*{Hellström2011}. Environmental modifications may
also be another option for improving sleep, especially for those living
in care homes, and this opportunity is discussed further within the
section on the environment below.
In addition to positive health behaviours, the promotion of individual
strengths such as acceptance, optimism and resilience are likely to
promote health and wellbeing in people living with chronic conditions.
These strengths are developed through cognitive-behaviour therapy,
acceptance and commitment therapy and positive psychotherapy \citep{Hughes2017,Joyce2018} (Neenan, 2011).
Understandably, people living with chronic conditions have a much lower
level of resilience compared to healthy individuals although notably,
increased resilience among those living with a chronic condition is
associated with reduced psychological distress, and reduced symptoms of
anxiety and depression \citep{Keil2017,Winger2016}. Strikingly, a strong sense of coherence (or
SOC) is associated with a 30% reduction in mortality rate from
cardiovascular disease, cancer and all cause-related death \citep{Surtees2003}. SOC
reflects feelings of confidence that stimuli in the (internal and
external) environment are comprehensible, manageable and meaningful.
Common resilience-related protective factors that are employed by this
population include self-efficacy and adaptive coping \citep{Ghanei2016}. A recent study
involved administering a 6-week programme that incorporated mindfulness
and CBT techniques to build resilience in individuals living with
chronic physical conditions including heart disease and diabetes \citep*{Robinson2019}.
Findings emphasised positive experiences around well-being, condition
management, and social engagement. In another study, a mind-body
intervention involving dance and movement has also been shown to be
effective in improving resilience in people suffering from chronic pain \citep{Shim_2017}.
In summary, there is tremendous opportunity for improving the health and wellbeing of people living with chronic conditions by focusing on the individual. Traditional routes for improving physical health, such as physical activity, diet and sleep may now be considered as opportunities to support mental wellbeing, when combined with strategies for behaviour change. Treatments that build strengths, resilience, optimism and positive psychological attributes will provide useful strategies to promote health and wellbeing, as has been discussed previously [REF].