Wellness: A Model of Holistic Health
The World Health Organization defines health as “a state of complete physical, mental, and social well being and not merely the absence of disease or infirmity.”1 “Well-being” and “wellness” have become common words in the popular media, but what does “wellness” really mean? Who gets to decide, i.e., you, your doctor, or your health insurance plan? And most importantly, what does it take to experience wellness and to achieve the coveted “complete well-being”?
The concept of wellness as a balanced state of physical, social, emotional, intellectual and spiritual health emerged in the 1950s2. Figure 1, below, provides one model for thinking about the many aspects of wellness- The Wellness Wheel. As you read this discussion, reflect on how well you feel in each segment of the Wheel! Then consider how your can give some extra attention to previously ignored areas of your wellness to help round out your health and experience improved well-being.
Although the Wellness Wheel is a useful model, I tend to think about wellness in each of the many facets of “Wellness” on a scale. For example: If “1” = Not Well, “5” = Partially Well, and “10” = Perfectly Wellness, where are you on the following facets of wellness?:
Let’s consider each facet of Wellness separately.
The condition of our physical body is most often equated to “health” and thus we reflexively think first about our physical health when considering “wellness” too. This reflex is in our best interests, because lifestyle factors, specifically tobacco use, diet and physical activity, and overuse of alcohol use remain the three leading causes of death.3 However, even when we know the healthy thing to do, putting it into practice can be a challenge. Remember, success is always at the end of a long road of failures- the key to success is to keep trying! Sometimes we need the support of a friend or family member, or other times we need more education about why change is good for us.
Healthful dietary patterns: The cornerstone of physical wellness. I am frequently asked, “What is the best diet?” Although ideally dietary patterns should be individualized, until proven otherwise, my default answer remains the Mediterranean diet. The characteristics of a Mediterranean diet include:4
- Lots of fruits, vegetables, bread and other cereals, potatoes, beans, nuts and seeds
- Olive oil as the major dietary fat, providing monounsaturated fat
- Dairy products, fish and poultry are consumed in low to moderate amounts, and red meat is eaten only occasionally and in small portions
- Eggs are eaten in moderation from none at all to four times a week. (Interesting in many cultures eggs take the place of other types of protein and are eaten less often for breakfast, and more often in place of meat in other meals of the day.)
- Wine, typically red wine, is consumed in low to moderate amounts, one to two drinks per day with meals
- The Mediterranean diet pattern also incorporates connections between physical health and other facets of Wellness, including enjoying eating outside in natural surroundings, and sharing food with friends and family over stories, support and laughter!
Why follow a Mediterranean diet pattern? Because the Mediterranean diet pattern is perhaps the best-studied and generally healthful dietary pattern globally. Eating a Mediterranean diet is associated with a lower risk of death from all-causes, including death from coronary heart disease, cardiovascular diseases, and cancer6-10. Perhaps even more shocking, estimates suggest that not following a Mediterranean diet is attributed with 60% of all deaths, 64% of deaths from coronary heart disease, 61% from cardiovascular diseases, and 60% from cancer in the total population! These findings are staggering, and are consistent with others suggesting that adopting a comprehensive healthful dietary patterns was associated with a 56% reduced mortality.11 Specific to diabetes prevention, a subgroup analysis in the recent PREDIMED trial demonstrated 40% fewer cases of type 2 diabetes in the group following a Mediterranean diet supplemented with extra virgin olive oil (smaller reductions were also measured in the group supplemented with walnuts). 12
All the science aside, who can’t daydream about the feelings of well-being that come with warm evenings, sitting outside on the cobblestone sidewalks enjoying a slow, savory meal shared with good company and lots of laughter? This, too, is part of the Mediterranean diet: how we eat is at least as important as what we eat.13
Physical Activity and Fitness
We all know being physical active (or at least not sedentary ) is important for our physical wellness. There is an increasing body of literature differentiating the importance of body composition from body weight. Increased lean muscle mass and reduced abdominal fat are measures of fitness, independent of total body weight14=16. From a wellness perspective, “fitness over fatness” resonates intuitively with many people because the total health of the individual is prioritized over individual measures. Offering an example of the connection between the difference facets of wellness, is the fact that physical activity also improves mood17-19. Positive changes occur in the brain when we exercise, including increases in the neurotransmitter serotonin (the pharmacologic target of numerous antidepressant medications) and in the number of dopamine receptors in the brain. Because dopamine is generated in times of pleasure and reward, physical activity does become a self-reinforcing habit once you get started!20 Even more fascinating, exercise may induce the generation of new connections (or synapses) in a region of the brain called the hippocampus. This process is called “neurogenesis” or the generation of new nerve pathways. Interestingly, neurogenesis is known to be suppressed in association with both depression and obesity, which helps to explain why it can be difficult to learn new things, or motivate to engage and create when people are depressed.21
Although inseparable, beyond physical wellness comes emotional wellness. Interestingly, in most of medicine, emotional wellness is equated to “mental health”. This mislabeling is typical of biomedicine. In the absence of an identifiable “emotional organ,” the brain, with its pathways and transmitters became the epicenter of biomedicine’s quest to affect emotions using medications. From this mechanistic construct, came the search for drugs to replace depression, grief and anxiety with blunted emotions by binding some receptors and blocking others. Needless to say, turning down the temperature on the oven when the timer goes off will only delay, not prevent, the dish from burning! This reductionist thinking has also influenced the delivery of “mental health” services around the world, and has resulted in a crisis in many US healthcare facilities. Sadly, the consideration of other approaches to emotional health, i.e., mindfulness training, physical activity, cognitive behavioral therapy, etc., rarely enter the conversation in mental health facilities burdened by more patients than time. Admittedly, acknowledging, processing, accepting and moving beyond one’s emotional states requires a lot more work, time and emotional energy!
Interestingly, the ancient texts of the discipline of Ayurvedic medicine identified an emotional center in the human body thousands of years ago, i.e. the heart chakra .22 Although biomedicine doesn’t locate the emotional center in the anatomical heart, we have all felt this truth as heart palpitations from anxiety, a “broken heart” from lost love or a “heart ache” from grief. Fortunately, some leaders in biomedicine have made advances in explaining the heart as our emotional epicenter. Some of the best examples of this research, and its practical application to improving emotional wellness, have been done by the HeartMath Institute in Boulder Creek, California, USA. HeartMath™ is a therapeutic approach that uses biofeedback to reprogram reactions to stressors (not unlike mindfulness meditation). HeartMath™ focuses attention on the heart, uses heart-centered breathing (described as extending the exhalation longer than the inhalation) and many other mind-body exercises which can be learned at home, and then practiced as needed, any place at any time.23 Their research suggests that people who practice HeartMath™ principles experience lower blood pressure and people with diabetes experience increased well-being from following the practices.24
Science aside, how do we know when we’ve achieved emotional wellness? I like to think you know you have achieved emotional wellness when you are not limited by stress, anxiety or fear to give and receive love. Although upon first read, many may consider “love” to be related to romantic love, but romantic love isn’t necessary for emotional wellness. Giving love may be as simple as extending a helping hand to someone in need, or smiling at a child. Similarly, receiving love may be as simple as allowing someone to help you, or accepting a compliment with grace. Not receiving very much love? Try giving some out. Love is an unlimited force and giving some away doesn't create a void, rather it helps create the space to accept love in return.Intellectual and Cognitive Wellness
Intellectual stress is a relatively modern phenomenon- historically the most difficult intellectual tasks consisted of where to find food and when to seek shelter from the weather- and family, community and social structures helped protect individuals and their clans to ensure survival. But today, we often feel we are on our own to survive and intellectual stressors bombard our day-to-day lives. Balancing checkbooks, learning new technologies, using “apps”, remembering passwords (each requiring its own combination of letters, numbers, symbols and security questions) all present new challenges and stressors. All of these tools, designed to make tasks “easier” have accumulated to become stressors in our day-to-day “life” The result is a major increase in cumulative screen time and less time being present with friends and family. The psychology literature now describes several distinct phenomena and psychological dysfunctions related to technology, and its over use25. Over use of technology and its collateral psychological effects can include:
- Reduced attention span: continuous partial attention and attention-deficit trait
- Inhibited creative thinking and cognition: digital fog and techno-brain burnout
- Overloaded unfocused activities: data smog and “frazzing” (frantic ineffectual multitasking)
- Addiction: on-line compulsive disorder
- Agoraphobia: fear of leaving the house and interacting with the outside world
Soon we will not even have to use a separate device to interact with technology, rather it will be inherent in our living environments, like our cars and homes, and in our accessories like glasses and clothing. So how do we balance the benefits of technology with its darker sides of brain-numbing distraction and impersonal relationships? A good start is to create time away from screens and devices with personal discipline around when to be “screened-in” and when to take “data fasts”. Dedicating time throughout the day to turn devices off or leave them at home or in the office not only creates more time to spend with real people (giving and receiving love) but also frees up mental space for self-reflection, personal creativity, quiet mental calm, and even thinking for yourself!Spiritual Wellness
Many equate spirituality with religion, and many people do find spirituality through their religious practices. However, generically, spiritual wellness is the quest for meaning and purpose in our lives through connection with something larger than our self. The goal of most spiritual practices is to find harmony and peace within one’s self and within our relationships with other entities, including humanity and our physical environment. Spirituality also guides how we approach our daily activities, i.e., ideally with compassion, self-giving, mindfulness, gratitude and love. Spiritual wellness is a highly individualized pursuit and each person must explore their own sense of meaning and purpose, in order to find practices that foster spirituality within their own lives. Yet, most spiritual practices share common tenants, including mindfulness, inter-dependency on one another, and non-violence.
The importance of spirituality has also undergone scientific inquiry. The University of Minnesota Center for Spirituality has probably done more than any modern U.S. university to help generate a literature base for the study of spirituality and the effects it has on personal health. Among their research findings, people who engage in daily spiritual activities experience more meaning in life, higher self-esteem, and a more positive overall mood.26 The “interventions” that get us here range from 8-week spiritual awareness programs,27 to spending more time in nature28, to attending church potlucks with your community.Social Wellness
Abraham Maslow, an early 20th century psychologist, is credited with first articulating the importance of the social setting in which we live as critical to the health of the individual. Maslow’s hierarchy of needs (Figure 2), first proposed in 1943, suggests human potential is realized systematically, by ascending different stages of personal and social security, eventually allowing individuals to “self-actualize” or create their lives with creativity and autonomy29. It isn’t surprising that humans are selfishly motivated to first meet their basic survival needs, i.e., food, water, shelter and security. Other values become lower priorities until these needs are met. Thus “higher” levels of development, i.e., creativity and self-actualization, are unattainable until basic needs are met . However, social wellness extends beyond our physical needs on the pyramid, and therefore is critical to “climbing” up the ladder.
Do you feel safe, secure and supported in your social sphere? There are numerous ways to give your social wellness some much needed attention, including making more time to spend enjoying activities with friends and family, but also reaching out to your neighbors and community to tell them they are not alone and to help assure their safety (which in turns does the same for you!). Although our virtual social networks provide us with the façade of social health and connection, they don’t help in a snowstorm, an emergency situation, or when you need someone’s physical shoulder to cry on. Some practical ways to help encourage social wellness are to make an effort to meet your neighbors, organize a block party or community event, participate with a local community center, create a block watch or contact list, and make a little extra time for family, church and other gatherings. Try to influence multiple facets of wellness simultaneously by stimulating healthful exchanges like walking clubs, community potluck meals, or shared spiritual practices like group meditation or prayer.Environmental Wellness
Environmental wellness refers to the importance of the health of our physical environment and the impact it has on the other facets of our personal wellness. For me, environmental wellness includes the natural environment since it is impossible to be physically, emotionally and spiritually well in the absence of fresh air, clean water, and the sense of spiritual greatness when one witnesses the natural beauty around us all. However, there are increasing concerns about the sustainability and accessibility of the natural environment as human impact and urbanization touch a growing percentage of the planet. Additionally, there are increasing concerns about the impact of pollutants and toxins in the environment and their impact on human health.
The exposure to and accumulation of chemicals in the body poses a serious threat to physical health. Indoor air pollution is an established contributor and trigger for asthma.30,31 Numerous cancers are linked to environmental exposure.32 Environmental chemicals such as persistent organic pollutants, phthalates, bisphenol A, and contemporary-use pesticides are known endocrine disruptors and have been linked to precocious puberty.33,34 Unfortunately, exposure is nearly ubiquitous. The Environmental Protection Agency has studied over 40 persistent pesticides and organic pollutants, including herbicides (atrazine), insecticides (organophosphorus, carbamate, pyrethrin and organochlorine), phthalate esters (butylbenzyl, di-n-butyl), phenols, polychlorinated biphenyls, and polycyclic aromatic hydrocarbons, and have found, for example, that 100% of sampled children had detectable levels of 3,5,6-trichloro-2-pyridinol (TCP) a known carcinogen, with reproductive and developmental toxicity, neurotoxicity, and acute toxicity.35
While the science of removing these substances from the body is beyond our scope here, the best practice is to minimize exposure. This means understanding the sources of potential toxicants and becoming educated on the risks of exposure and strategies to reduce it. The non-profit Environmental Working Group publishes numerous consumer guides to help with this, including an annual “Dirty Dozen Clean Fifteen shopper’s guide to organic produce” to help consumers prioritize consumption.36 More practically, environmental wellness also refers to our immediate environment- our homes, our workplaces and our neighborhoods. If our homes are filled with toxic chemicals, our workplaces filled with unhealthy food and emotional abuse, and our neighborhoods filled with roadway hazards, violence and/or lack spaces for community congregation and physical activity they will not foster personal or collective wellness. What can you do to make the environment in which you live a healthful, wellness-promoting one?
Let’s reconsider the Wellness Wheel and our scores on each of the facets of “Wellness”. Do your ratings remain the same as what you thought before reading this? Are you thinking about areas that need attention, support, or enrichment? Wellness is a multi-dimensional experience and “total well-being” is within the grasp of each of us. What will the path to total wellness look like for you?
In health, Ryan Bradley, ND, MPH
Ryan Bradley, ND, MPH is a naturopathic doctor, clinical researcher and epidemiologist in San Diego, CA. He is an Associate Professor and Assistant Director of Research at the National University of Natural Medicine in Portland, OR and an Assistant Professor in the Department of Family Medicine and Public Health at the University of California, San Diego.
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