On the surface, defining "wellness behaviors" is easy—"eat your vegetables," "go out and play with your friends," "be nice to your sister," "smoking can be hazardous to your health," "Just Say No," "don't drink and drive"—these maxims and slogans all allude to well-known healthful behaviors. If people were to follow such advice regularly, they would certainly be healthier. It is, of course, not so simple. Western medicine, shaped by physicians, has dominated health care in the United States during the past century. Most physicians are remarkably service-oriented people who want nothing more than to make people healthy. However, they are trained in curing disease, not enhancing health. As a result, health care systems focus on curing disease rather than promoting health and preventing disease. Hospitals are able to transplant vital organs, create new skin for people with burns covering a majority of their bodies, reattach severed limbs, and perform other equally miraculous procedures. Unfortunately, they do an inadequate job of keeping people healthy.
This focus is changing, however. During the second half of the twentieth century, a body of research began to emerge that provides compelling evidence that lifestyle choices make a difference between health and disease, and between life and death. Michael McGinnis and William Foege have calculated that half the deaths in the United States are caused by lifestyle-related behaviors. Their work, and that of others, has shown that over 400,000 deaths could be saved by eliminating smoking; over 300,000 through regular exercise and good nutrition; 100,000 by responsible use of alcohol; 35,000 by eliminating firearms; 30,000 through safe-sex practices; 25,000 by safer driving; and 20,000 by eliminating drug abuse. To put these numbers in perspective, tobacco causes more deaths in the United States each year than all the foreign wars in the nation's history. Lifestyle factors contribute to all of the top fifteen diseases that cause deaths in the United States.
QUALITY OF LIFE
Wellness is certainly not just avoiding death, so counting the number of deaths that healthful lifestyles could save tells only part of the story. Practicing these behaviors also improves quality of life in terms of having more energy, fewer aches and pains, better sex, and enhanced self-esteem. Such elements of health are more difficult to measure, so most scientists focus their research on objective measures such as death and disease.
There is some controversy in the interpretation of much of the available data, especially in the areas of obesity and nutrition. For example, Jeremiah Stamler estimates that obesity alone causes 240,000 to 380,000 deaths each year, while Steven Blair argues that lack of exercise, not obesity per se, is the more important risk factor. There are also arguments about the amount of alcohol that is optimal. After decades of debate, many scientists now believe that up to four glasses of beer or wine per week may actually be more healthful than complete abstention from alcohol for those who are not alcoholics and do not suffer from conditions that can be aggravated by alcohol. The general public is also often confused by reports about the healthfulness of specific diets. Is butter or margarine more healthy? Is beta carotene good or bad? In fact, factors at this level of detail have only a minimal impact on health. The death rate in the United States and most developed countries could be cut in half if all people could be persuaded to not use tobacco or illegal drugs; to use alcohol in moderation or not at all; exercise on a regular basis; always wear a seat belt when driving; never drink and drive; not use firearms; get plenty of sleep; practice safe sex; and eat a diet high in vegetables, fruits, and whole grains, and low in fat, sodium, and sugar. Another 20 percent of deaths could be eliminated if everyone had affordable access to health care and was diligent about getting regular medical and dental checkups, getting immunizations when needed, and taking medication as directed.
SOCIAL FACTORS
The data gets more complex when other nations of the world are examined. It is safe to say that approximately half the deaths in developed nations of the world, and possibly one-third or more of the deaths in developing nations, are caused by lifestyle-related problems. Nevertheless, the smoking rate and consumption rate of high-fat foods is higher in some European nations, though the rate of heart disease is much lower than in the United States, and very low rates of heart disease are found in Asian nations like Japan and Korea despite very high rates of smoking. The low-fat, high-vegetable diets common in these countries explain part, but not all, of the difference in heart disease rates. Within the United States, people from Hispanic backgrounds tend to have lower rates of child mortality than people from other cultures, even among those who have similar income levels and health habits. The common characteristic of all of those groups is strong social connections through extended family and networks of friends.
Findings like these are beginning to make scientists speculate that social factors are very important in determining a person's health. At least three elements of our social environment impact our health. In 1980, Robert F. Allen explained the importance of people's peers in shaping health behaviors, as well as the futility of trying to change health and other behaviors without changing the norms of the group. For example, most children start smoking cigarettes and drinking alcohol through the influence of their friends, and when they quit they often lose those friends who choose to continue. Most people who exercise as adults started when they were kids, and they often did so to be involved in neighborhood or school sports to be with their friends.
The work of Barbara Israel, Kenneth McLeroy, Michael Marmot, and others has shown the protective effect that social support provided by social networks of family and friends can have on helping avoid problems that can threaten health, as well as the effect social factors have in helping people recover from illness more quickly. In his popular book, Love and Survival, Dean Ornish reviewed scientific literature that showed that men who feel loved by their wives, adults who had warm relationships with their parents, and people who have a warm integrated community of friends all have lower rates of disease and death. This work has led Ornish to speculate that social factors may be as important as physical factors in determining overall health. Finally, work by Michael Marmot and others has shown that socioeconomic status, both in absolute and relative terms, has a very significant impact on health.
Can people change the social factors in their lives? They cannot choose their parents or siblings, and birth circumstances often dictate socioeconomic status. However people can choose their spouse, and they do have an influence on their children. They can also choose their friends, and, through diligent effort, can work to shape the norms of friends, organizations, and communities to influence health in a positive way. This is, however, a formidable task.
So "wellness behavior" might not be the right term. "Wellness lifestyle" may be a more accurate term but "striving for optimal health" expresses the complex set of social and behavioral factors that impact health much better.
OPTIMAL HEALTH
Inspired by the work of Bill Hettler, and recognizing the scope and complexity of all the factors that impact health, the American Journal of Health Promotion has suggested that people think in terms of optimal health and the factors that impact optimal health. Optimal health may be defined as "a balance of physical, emotional, social, spiritual, and intellectual health." Spiritual health includes having a sense of purpose in life, the ability to give and receive love, and feeling goodwill and charity toward others. Intellectual health is related to learning and achievements in life, which can occur through school, work, hobbies, community service, or cultural pursuits. Emotional health refers to one's mental state of being and encompasses the stresses in a person's life, how one reacts to those stresses, and the ability to relax and enjoy leisure. Rather than strive for excellence in any one area, people can best achieve a state of health by striving to achieve balance in these five areas.
Behavior alone is not the sole determinant of lifestyle; a person's environment and opportunities also play major roles in health. People may focus on different areas of optimal health as they pass through different stages in their lives, because achieving optimal health is a lifelong process. This thinking goes beyond current science, but it may provide a framework for issues to be studied in the future.
Allen, R. F. (1980). Beat the System!: A Way to Create More Human Environments. New York: McGraw-Hill.
Marmot, M., and Wilkinson, R. G. (1999). Social Determinants of Health. Oxford: Oxford University Press.
McGinnis, M., and Foege, W. (1993). "Actual Causes of Death." Journal of the American Medical Association 270(18):2208.
Ornish, D. (1998). Love and Survival: The Scientific Basis for the Healing Power of Intimacy. New York: Harper Collins.
Stamler, J. et al. (1999). "Death from Obesity." Journal of the American Medical Association 282(21):2026.
U.S. Department of Health and Human Services (1996). Physical Activity and Exercise: A Report of the Surgeon General. Atlanta, GA: USDHHS, National Center for Chronic Disease Prevention and Health Promotion.
