Well now

What humans need to flourish

Plug “wellness” into a search engine and you’ll get 405 million hits — and a lot of advice. Everyone, from genuine experts to click-bait writers, has an opinion about what’s good for us.

We are told to strengthen our willpower, but indulge ourselves; exercise, but not too much; go vegetarian, but eat more meat; develop our social network, but indulge in more “me time”; have great sex, but not too much; safeguard our financial health, but spend our money on travel that leaves memories; keep our minds active, but empty our minds and meditate; volunteer; forgive; and be grateful.

“There’s been a lot of ‘expert speak’ on the concept of what it means to be well,” says associate professor of psychology and of medicine Catherine Heaney, PhD, who is leading a team at Stanford that has been working to define and measure wellness. “What there has been less of,” ​Heaney​ says, “is going to ordinary people and trying to get a sense of what being well means to them.”

People long for a sense of well-being. For thousands of years, everyone — from philosophers such as Aristotle, Epictetus and Buddha to the smooth-talkingest snake-oil salesmen — have tugged at the problem of what makes for a good life.

Researchers at UC-Berkeley’s Greater Good Science Center, for example, report six major underpinnings of happiness, one component of wellness: compassion, friendship, gratitude, forgiveness, exercise and mindfulness. Private foundations, including the Charles Koch Foundation, have taken an interest in funding well-being research. Even governments have gotten into the act. In 2008, a commission of economists assembled by Nicolas Sarkozy, the president of France, called for the development of broader measures of national well-being. Two years later, the United Kingdom did the same.

But what does it mean to be well? If we want to promote wellness for everyone, we have to, first, be able to say exactly what it is and, second, devise rigorous ways of measuring whether it is increasing or decreasing. Once we can measure it, we can begin to discover which factors promote it or diminish it. In this way, an ambitious Stanford project aims to tackle anew an age-old question.

The path to wellness

In 2014, the Stanford Prevention Research Center launched the WELL program — its ultimate goal, to improve the health and wellness of whole populations. WELL, the Wellness Living Laboratory, emphasizes research on overall health rather than the absence of disease. Funded by an unrestricted $10 million gift from the Amway Nutrilite Health Institute Wellness Fund, WELL proposes to identify what factors help people maintain health and wellness and to develop techniques to help people to change their lifestyles.

The center’s WELL for Life program is both an observational study and an interventional study. WELL will observe more than 30,000 people over many years and also test behavioral modification and other interventions to help people make health improvements such as quitting smoking, eating better or exercising more. The center’s health promotion arm, the Health Improvement Program, will enable the techniques to reach the wider population.

“This is an effort to change the world of medicine and health,” says John Ioannidis, MD, DSc, professor of medicine and of health research and policy, who directs the center. “It may sound very ambitious, but I see this as a way to refocus the key priorities of biomedical research.

“The vast majority of biomedical research has focused on treating diseases,” he says. “A much smaller part has focused on maintaining health and maybe some prevention efforts. But there’s very, very little research that has tried to look at the big picture — what makes people happy, resilient, creative, fully exploring their potential and living not only healthy, but more-than-healthy lives.”

Among the things the WELL team wants to know: Is wellness the same for everyone, or do factors like gender or age influence how we perceive it? For example, among young adults, wellness might revolve around finances, career and athleticism. But as we age, social connectedness and resilience to stress may become more important drivers of our sense of how well we feel.

“We want to determine not only what makes people feel that they have a higher level of wellness, but also interventions that would help it,” says Ioannidis. “So we want to ask not only what is the profile of someone who feels good about their life, but how can we make that profile better?

“And how can we intervene with simple means — things that we do in everyday life — not with drugs or devices or complex procedures in the hospital?”

“We know that a person’s ability to move more, to sit less and to eat healthfully are influenced by their environment. This includes social relationships, neighborhoods and public policy,” says Abby King, PhD, professor of medicine and of health research and policy, who studies what’s needed for healthy behavior change.

“It’s about helping people make connections between their own pursuit of well-being and their health,” explains Heaney. Maybe for some people, making a better life for their children is more motivating than reducing their risk of a heart attack in the distant future, she says.

Once a doctor knows what motivates patients, it may be possible to harness that in the service of patients’ well-being and physical health.

During the first five years, the 30,000 participants — 10,000 each in China, Taiwan and the United States — will supply mountains of personal health information, ranging from general health and lifestyle information to genetic and other biological markers, says Sandra Winter, PhD, director of WELL. And it’s likely WELL will expand to other countries in the future.

Each of the thousands of participants will periodically answer scores of questions such as, “During the last two weeks, did your diet, physical activity and sleep habits influence your well-being?” or “How confident are you that you can bounce back quickly after hard times?”

Listening well

How do you ask people meaningful questions about a concept as fuzzy as wellness? To create an accurate vocabulary of wellness, trained interviewers sat down with more than 100 people from Santa Clara County and listened to their stories. Demographically representative of this diverse area, the 100 included men and women, young and old, and a variety of ethnic groups. Similar efforts took place in China and Taiwan.

Tia Rich, PhD, WELL senior research assistant, interviewed half of the Santa Clara County participants. She asked them to talk about a time of peak wellness, a time of low wellness and, finally, their current state. In each case, she also asked them to describe all aspects of their life that they wanted to share regarding each level of wellness.

And then Rich listened. The conversations lasted anywhere from 30 minutes to two hours. “The process of listening to 50 people share their life stories was extremely meaningful. It was really an honor to be trusted in that way,” she says.

The domains of wellness

After transcribing the Santa Clara County interviews and sorting the responses almost line by line into categories, Heaney’s team identified 10 domains of wellness that people most commonly mentioned:

• Social connectedness
• Lifestyle behaviors
• Stress and resilience
• Emotional health
• Physical health
• Meaning and purpose
• Sense of self
• Finances
• Spirituality or religiosity
• Exploration and creativity

For these interviewees, having a social network was the single largest driver of wellness. Being integrated into a social network, having opportunities to receive support and companionship, feeling loved and feeling a sense of belonging, and also having others in your social network doing well is what most enhances wellness, said the interviewees. As one put it, “If my family is doing well, I will be doing well.”

But having a social network can be as much a burden as a comfort. “When people in your social networks are not doing well or when they act in ways that are socially undermining,” says Heaney, “that detracts from our sense of well-being.”

It’s important to manage our social connections so they contribute more than they detract. “It’s like the old saying,” she laughs, “When you’re a parent you can never be happier than your least-happy child.” So, ultimately, we need to find ways to support those we love while remaining somewhat stoic about their problems, so our own well-being doesn’t decline, too.

The second major domain was lifestyle behaviors such as eating well and getting plenty of sleep and exercise. People looked back on times when they were engaging in healthy behaviors as times of great well-​being, says Heaney.

As one interviewee reported, “I’d been outside all summer long just doing labor. I mean, sometimes you dig ditches, and sometimes you’re pruning Mrs. McGillicuddy’s pansies, whatever it is, you’re outside all day long, which really nourishes the animal, I’m here to say. And I remember my mother, for some reason we were driving along, and I said, ‘I’m at the peak of my physical health.’”

Wellness and resilience

The team also found that stress and resilience to stress were important factors in wellness. Major changes, such as a divorce or moving from another country, were especially likely to induce stress. But participants also spoke with pleasure about how well they had coped during a difficult time.

One interviewee said, “Even the worst of times, even the most difficult of times, there’s always been light and strength, and that is because I have a very rich inner life. And in the end, I have hope.”

Some people can adapt to the most dire of circumstances. In her book The Pursuit of Happiness, Carol Graham, PhD, an economist and a senior fellow at the Brookings Institution who studies happiness and well-being, reports that even though poor people around the world are less happy than the wealthy, some of the poorest often report high well-being.

Even those with serious illness may report a sense of well-being. “I was surprised by the extent to which people did not talk about illness,” Heaney says. People who had cancer might not even mention it in the context of their well-being. “Having an illness or not having illness was not what was important. What was more important was the experience of it and the extent to which a person felt like they were managing or coping.

“People would actually say, ‘Yeah, you know, a time of particularly high well-being for me was when I was diagnosed with heart disease,’ ” says Heaney. “And you’re like, ‘What?’ ” But they would then go on to say, ‘Yeah, because I learned how resilient I am. I learned how strong I am. I have come out of that a better person and I learned what matters to me.’ ”

The last five domains, which came up less often, included having a sense of meaning and purpose, which could encompass accomplishments or, alternatively, a sense of why we are here; a sense of self (a measure of confidence and self-esteem); financial comfort; spirituality; and, finally, exploring (or pioneering) and creativity.

Building the questionnaire

Using the 10 domains, Heaney and her team wrote 72 questions designed to probe people’s experiences of wellness. The questionnaire is already online for a small test group of WELL participants, and ultimately it will be available for all 10,000 U.S. participants.

Participants are asked, for example:
During the last two weeks, how often did you feel...
...that you were very capable?
...that you were interested in your daily activities?

To get at resilience, Heaney and her team included questions such as:
How confident are you that you can...
...bounce back quickly after hard times?
...adapt to change?
...deal with whatever comes your way?
...see the humorous side of problems?

The 72 questions have been translated for use in the China and Taiwan arms of the WELL study, field tested to make sure they have the same meaning in all three sites and modified to adjust for cultural or language differences. Additional modules may be added in each country to address determinants of wellness that are specific to that culture.  

While the questions themselves might vary a little from site to site, it remains to be seen how different the answers will be.

More broadly, each of the three WELL for Life sites will look a bit different, says Winter. “In the Bay Area, we’ve really been focusing on an online registry. In China, we are using a more traditional study approach in which people are going to come in in person, and we’ll gather physiological data such as BMI, height, weight, grip strength, plus blood samples and a battery of survey questions. And just as in Santa Clara, we’ll be following these people over time.” Meanwhile, the Taiwan arm of the study will add a biobank of tissue samples collected from all 10,000 participants.

Ioannidis says these tissues may reveal biological markers for wellness. “Just as we can monitor diabetes by looking at blood sugar levels,” he says, “is there some wellness biomarker that can tell us something about how one feels about one’s life? Are there biomarkers that indicate levels of wellness and that change as people’s levels of wellness increase or decrease?

“Of course, this is exploratory,” he says. “I cannot promise that we will have hundreds of biomarkers explaining everything about wellness, but it’s possible that some of them will be of interest.” That would be a huge step forward.

How confident are you that you can...
...overcome obstacles?
...stay focused under pressure?
...think of yourself as a strong and resilient person?
...manage any unpleasant feelings that you might have?
...not get disheartened by setbacks?

In a few years, the WELL project team may be able to help us answer questions like these with “very confident.”

Jennie Dusheck is a science writer for the medical school's Office of Communication & Public Affairs. Email her at dusheck@stanford.edu.

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