research paper on lifestyle

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• Am J Lifestyle Med
• v.12(6); Nov-Dec 2018

Lifestyle Medicine: The Health Promoting Power of Daily Habits and Practices

There is no longer any serious doubt that daily habits and actions profoundly affect both short-term and long-term health and quality of life. This concept is supported by literally thousands of research articles and incorporated in multiple evidence-based guidelines for the prevention and/or treatment of chronic metabolic diseases. The study of how habits and actions affect both prevention and treatment of diseases has coalesced around the concept of “lifestyle medicine.” The purpose of this review is to provide an up-to-date summary of many of the modalities fundamental to lifestyle medicine, including physical activity, proper nutrition, weight management, and cigarette smoking cessation. This review will also focus specifically on how these modalities are employed both in the prevention and treatment of chronic diseases including coronary heart disease, diabetes, obesity, and cancer. The review concludes with a Call to Action challenging the medical community to embrace the modalities of lifestyle medicine in the daily practice of medicine.

‘The strength of the scientific literature supporting the health impact of daily habits and actions is underscored by their incorporation into virtually every evidence-based clinical guideline . . .’

An overwhelming body of scientific and medical literature supports the concept that daily habits and actions exert an enormous impact on short-term and long-term health and quality of life. 1 This influence may be either positive or negative. Thousands of studies provide evidence that regular physical activity, maintenance of a healthy body weight, not smoking cigarettes, and following sound nutritional and other health promoting practices all profoundly influence health. The strength of the scientific literature supporting the health impact of daily habits and actions is underscored by their incorporation into virtually every evidence-based clinical guideline stressing the prevention and treatment of metabolically related diseases. 2 - 18 A sampling of the guidelines and consensus statements from various prestigious medical organizations is found in Table 1 . All of these statements emphasize lifestyle habits and practices as key components in the prevention and treatment of disease.

Sampling of Guidelines That Incorporate Lifestyle Recommendations for the Threat or Prevention of Chronic Disease.

Despite the widespread recognition of the important role of lifestyle measures and practices as a key component of the treatment of metabolic diseases, scant progress has been made in improving the habits and actions of the American population. For example, in the Strategic Plan for 2020 released by the American Heart Association, it was stated that only 5% of the adult population of the United States practice all of the positive lifestyle measures known to significantly reduce the risk of developing cardiovascular disease (CVD). 14

The power of positive lifestyle decisions and actions is underscored by multiple randomized controlled trials and a variety of cohort studies. For example, the Nurses’ Health Study demonstrated that 80% of all heart disease and over 91% of all diabetes in women could be eliminated if they would adopt a cluster of positive lifestyle practices including maintenance of a healthy body weight (body mass index [BMI] of 19-25 kg/m 2 ); regular physical activity (30 minutes or more on most days); not smoking cigarettes; and following a few, simple nutritional practices such as increasing whole grains and consuming more fruits and vegetables. 19 The US Health Professionals Study showed similar, dramatic reductions in risk of chronic disease in men from these same positive behaviors. 20 In fact, if individuals adopted only one of these positive behaviors, their risk of developing coronary artery disease (CAD) could be cut in half.

For decades physicians have emphasized the importance of practicing “evidence-based medicine.” Yet when it comes to incorporating the vast amount of evidence supporting positive health outcomes from lifestyle practices and habits, the medical community has been relatively slow to respond. This, despite the fact that virtually every physician would agree with the premise that regular physical activity, weight management, sound nutrition, and not smoking all result in significant health benefits.

The purpose of the current review is to provide a summary of the literature underscoring the benefits of positive health promoting habits and to present some strategies and guidelines for implementing these actions within the practice of medicine and issue a call for increased emphasis on lifestyle medicine among physicians.

What Is Lifestyle Medicine?

I had the privilege of editing the first, multi-author, academic textbook in lifestyle medicine. 21 In fact, this textbook, published in 1999, coined the term lifestyle medicine , which we defined as “the discipline of studying how daily habits and practices impact both on the prevention and treatment of disease, often in conjunction with pharmaceutical or surgical therapy, to provide an important adjunct to overall health.”

While there have been a number of different constructs concerning these disciplines and many investigators have made important contributions to components of lifestyle medicine such as nutrition, physical activity, weight management, smoking cessation, and so on, it is clear that the field is now going to coalesce around the term lifestyle medicine . For example, the American Heart Association changed the name of one its Councils from the “Council on Nutrition, Physical Activity and Metabolism” to the “Council on Lifestyle and Cardiometabolic Health” in 2013. 22 In addition, both the American College of Preventive Medicine and the American Academy of Family Practice have established working groups and educational tracks in the area of lifestyle medicine. Circulation , a major academic journal from the American Heart Association, published a series of multiple articles titled “Recent Advances in Preventive Cardiology and Lifestyle Medicine.” Representatives from a variety of organizations including the American Academy of Pediatrics, the American College of Sports Medicine, the Academy of Nutrition and Dietetics, the American Academy of Family Practice, and the American College of Preventive Medicine sent representatives to a working group that established the first summary of competencies physicians should possess to practice lifestyle medicine, which was published in the Journal of the American Medical Association . 23

Importantly, a new health care organization has been formed called the “American College of Lifestyle Medicine” (ACLM), which is devoted to providing a professional home for individuals who wish to emphasize lifestyle medicine in their practices. 24 This organization has doubled its membership each year for the past 5 years. ACLM has also spawned initiatives to develop curricula and encourage education of medical students in the area of lifestyle medicine. ACLM has also supported the development of Lifestyle Medicine Student Interest Groups at medical schools and has developed criteria for lifestyle medicine certification. 25 The goal of this organization is ultimately to establish certification boards in lifestyle medicine. Lifestyle medicine has also become an international movement with the development of the Lifestyle Medicine Global Alliance. 26

In addition, a peer-reviewed academic journal has been established, the American Journal of Lifestyle Medicine , 27 to provide a forum for individuals interested in exchanging academic information in this growing field.

There are multiple reasons why the term lifestyle medicine seems particularly appropriate for this discipline. First, the field is focused on lifestyle and its relationship to health. Second, it is clearly medicine based on the wide range and large volume of evidence supporting the health benefits of daily habits and actions.

The Power of Lifestyle Habits and Practices to Promote Good Health

Multiple daily practices have a profound impact on both long-term and short-term health and quality of life. This review will focus on 5 key aspects of lifestyle habits and practices: regular physical activity, proper nutrition, weight management, avoiding tobacco products, and stress reduction/mental health. This initial section will focus on general considerations related to each of these lifestyle habits and practices. In the subsequent section, this information will be applied to specific diseases or conditions.

Physical Activity

Physical activity is a vitally important component to overall health and both prevention and treatment of various diseases. Regular physical activity has been specifically demonstrated to reduce risk of CVD, type 2 diabetes, the metabolic syndrome, obesity, and certain types of cancer. 18 The important role of physical activity in these conditions has been underscored by its prominent role in evidence-based guidelines and consensus statements from virtually every organization that deals with chronic disease. In addition, there is strong evidence that regular physical activity is important for brain health and cognition as well as reduction in anxiety and depression and amelioration of stress. 16

The recently released 2018 Physical Activity Guidelines Advisory Committee Scientific Report emphasizes that increased physical activity carries multiple individual and public health benefits. 18 This report also catalogs that physical activity contributes powerfully to improved quality of life by improving sleep, general feelings of well-being, and daily functioning. The report emphasizes that some of the benefits of physical activity occur immediately and most of the benefits become even more significant with ongoing and regular performance of moderate to vigorous physical activity.

In addition, physical activity has been shown to prevent or minimize excessive weight gain in adults as well as reducing the risk of both excess body weight and adiposity in children. 28 Physical activity decreases the likelihood that women will gain excessive weight during pregnancy, making them less likely to develop gestational diabetes. 29 Physical activity may also decrease the likelihood of postpartum depression.

Physical activity has also been demonstrated to lower the risk of dementia and improve other aspects of cognitive functioning. Importantly, as the population in the United States continues to grow older regular physical activity has been shown to decrease the likelihood of falls 30 and fall-related injuries and assist in the preservation of lean body mass. 31

Other conditions that regular physical activity improves are osteoarthritis and hypertension. 18 All in all, the multiple benefits of regular physical activity make it one of the key considerations that should be recommended to all children and adults as part of a comprehensive lifestyle medicine approach to health and well-being.

Numerous studies have shown that physicians’ own physical activity behavior predicts the likelihood that they will recommend physical activity to their patients. Unfortunately, it has been estimated that less than 40% of physicians regularly counsel their patients on the importance of increasing physical activity. The low level of prescription among physicians, as well as the recognized benefits of regular physical activity in health, stimulated the American College of Sports Medicine to launch the “Exercise is Medicine®” (EIM) initiative. This initiative is designed to encourage primary care providers and health providers to design treatment plans that include physical activity or to refer patients to evidence-based exercise programs with qualified exercise professionals. EIM also encourages health care providers to assess and record physical activity as a vital sign during patients’ visits. The initiative further recommends concluding each visit with an exercise “prescription.” 32

Nutrition plays a key role in lifestyle habits and practices that affect virtually every chronic disease. There is strong evidence for a role of nutrition in CVD, diabetes, obesity, and cancer, among many other conditions. 33 Dietary guidelines and consensus statements from a variety of organizations have recognized the key role for nutrition, both in the prevention and treatment of chronic disease. 4 , 6 , 8 These consensus statements are very similar to each other in nature and consistently recommend a dietary pattern higher in fruits and vegetables, whole grains (particularly, high fiber), nonfat dairy, seafood, legumes and nuts. 34 Guidelines further recommend that those who consume alcohol (among adults), do so in moderation. The guidelines are also consistent in recommending diets that are lower in red and processed meats, refined grains, sugar sweetened foods, and saturated and trans fats. All the guidelines also emphasize the importance of balancing calories and also regular physical activity as strategies for maintaining a healthy weight and, thereby, further reducing the risk of chronic diseases.

Dietary guidance over the past 2 decades has moved from specific foods and nutrients to a greater emphasis on dietary patterns. The emphasis has also shifted to the critical aspect of providing practical advice for implementing recommendations. 9 This latter emphasis recognizes that despite consistent guidelines and nutrition recommendations for many decades, a distinct minority of Americans are following these guidelines. For example, in the area of hypertension <20% of individuals with high blood pressure follow the DASH Diet. 35 It is also estimated that <30% of adults in the United States consume the recommended daily number of fruits and vegetables. 34

The 2015-2020 Dietary Guidelines for Americans focused on integrating available science and systematic reviews, scientific research, and food pattern modeling on current intake of the US population to develop the “Healthy U.S. Style Eating Pattern.” 8 This approach allowed blending recommendations for an overall diet including constituent foods, beverages, nutrients, and health outcomes, while allowing for flexibility in amounts of food from all food groups to establish healthy eating patterns that meet nutrient needs and accommodated limitations for saturated fats, added sugars, and sodium. This approach also allowed for the potential nutritional areas of public health concern. Utilizing this approach to Dietary Guidelines for Americans 2015-2020 indicated the following:

Within the body of evidence higher intakes of vegetables and fruits consistently have been identified as characteristic of healthy eating patterns: whole grains have been identified as well, although slightly less consistently. Other characteristics of healthy eating patterns have been identified with less consistency including fat free or low fat dairy, seafood, legumes and nuts. Lower intakes of meats including processed meats, poultry, sugar sweetened foods (particularly beverages), and refined grains have also been identified as characteristics of healthy eating patterns.

Despite the multiple known benefits of proper nutrition, most physicians feel they have inadequate education in this area. In one survey, 22% of polled physicians received no nutrition education in medical school, and 35% polled said that nutrition education came in a single lecture or a section of a single lecture. 36 The situation does not improve during medical residency. More than 70% of residents surveyed felt they received minimal or no education on nutrition during medical residency. In the United States, 67% of physicians indicate they have nutritional counseling sessions for patients. However, this education was largely focused on the ill effects of high sodium, sugars, and fried foods. It is noteworthy that only 21% of patients feel they received effective communication in the area of nutrition from their physician. 36

Issues related to healthy nutrition permeate virtually every condition where lifestyle medicine plays a role and will be treated in detail under each specific condition.

Weight Management

In many ways overweight and obesity represent quintessential lifestyle diseases. These conditions serve as significant public health problems in the United States and other countries throughout the world. 37 In the United States, the prevalence of overweight (BMI ≥ 19-25 kg/m 2 ) has been estimated at approximately 70%, while obesity (BMI ≥ 30 kg/m 2 ) is estimated at 36%, and severe obesity (BMI ≥ 35 kg/m 2 ) at 16%. 38 These rates are significant since even small amounts of excess body weight have been associated with many chronic diseases including CVD, diabetes, some forms of cancer, 39 muscular skeletal disorders, arthritis, 40 and many others. The cornerstone of obesity treatment relies on lifestyle measures that contribute to balancing energy to prevent weight gain or creating an energy deficit to achieve weight loss. These lifestyle factors including both physical activity and nutrition are cornerstone modalities to achieve these results.

Tobacco Products

Overwhelming evidence exists from multiple sources that cigarette smoking significantly increases the risk of multiple chronic diseases including heart disease and stroke, diabetes, and cancer. Early in the 20th century in the United States, cigarette smoking was more prevalent in men than women. 41 However, women have rapidly caught up with men. The health risks of smoking in women are the equivalent of men. Substantial benefits in the reduction of risk of both CVD and cancer accrue in individuals who stop smoking cigarettes. These benefits occur over a very brief period of time. 42

After years of significant decreases in cigarette smoking, the prevalence of cigarette smoking has appeared to level off in recent years with approximately 15% of individuals currently smoking cigarettes. 43

It should be noted that secondhand smoke also increases the risk of multiple chronic diseases, since secondhand smoke contains numerous carcinogens and may linger, particularly in indoor air environments, for a number of hours after cigarettes have been smoked. 44

Stress, Anxiety, and Depression

Stress is endemic in the modern, fast-paced world. It has been estimated that up to one third of the adult population in the United States experiences enough stress in their daily lives to have an adverse impact on their home or work performance. Anxiety and depression are also very common. Lifestyle measures, such a regular physical activity, have been demonstrated to provide effective amelioration of many aspects of all three of these conditions. 45 , 46

Interestingly, in the past decade positive psychology has also emerged as a significant component of lifestyle medicine. 47 This field has demonstrated that positive approaches to psychological issues such as gratitude, forgiveness, and other strategies can play a very important role in stress reduction and amelioration of both anxiety and depression.

Obtaining adequate amounts of sleep has also been demonstrated to be an effective strategy in all these conditions, which proved so troublesome to many individuals. 48

Lifestyle Medicine Approaches in the Treatment and Prevention of Chronic Diseases

Lifestyle medicine modalities have been demonstrated in multiple studies to play an important role in both the treatment and prevention of many chronic diseases and conditions. This section will explore some of the most common diseases or conditions where lifestyle modalities have been studied.

Cardiovascular Disease

Daily lifestyle practices and habits profoundly affect the likelihood of developing CVD. Many of these same practices and habits also play a role in treating CVD. 1 - 4 , 9 , 14 - 16

Numerous studies have demonstrated that regular physical activity, not smoking cigarettes, weight management, and positive nutritional practices all profoundly affect both CVD itself and also risk factors for CVD. 49 , 50 Numerous epidemiologic studies have shown that positive lifestyle decisions such as engaging in at least 30 minutes of physical activity on most days; not smoking cigarettes; consuming a diet of more fish, whole grains, fruits, and vegetables; and maintaining a healthy body weight can reduce the incidence of CHD by over 80% and diabetes by over 90% in both men and women. 19 , 20

Between 1980 and 2000, mortality rates from CHD fell by over 40%. 51 CVD, nonetheless, remains the leading cause of worldwide mortality, and in the United States, it results in over 37% of annual mortality. 51 Approximately half of the reduction in CVD deaths since 1980 can be attributed to reduction in major lifestyle risk factors such as increasing physical activity, smoking cessation, and better control of blood pressure and cholesterol. Unfortunately, increases in obesity and diabetes have moved in the opposite direction and could jeopardize the gains achieved in other lifestyle risk factors, unless these negative trends can be reversed. 51

In the past decade a number of important initiatives have been undertaken and comprehensive summaries published linking overall life strategies to reductions in cardiovascular risks. In 2012, the American Heart Association (AHA) released its National Goals for Cardiovascular Health Promotion and Disease Reductions for 2020 and beyond. 14 This important document also introduced the concept of “primordial prevention” (preventing risk factors from occurring in the first place) into the cardiology lexicon as well as introducing the concept of “ideal cardiovascular health.” Daily lifestyle measures were central to both these new concepts. In 2013, the American Heart Association and American College of Cardiology (ACC) jointly issued Guidelines for Lifestyle Management to Reduce Cardiovascular Risk, 52 which also emphasized lifestyle measures to reduce the risk of CVD or assist in its treatment if already present.

Unfortunately, a distinct minority of Americans are following the recommendations from the AHA to achieve “ideal” cardiovascular health. Ideal cardiovascular health was defined as achieving appropriate levels of physical activity, consuming a healthy diet score, maintaining a total blood cholesterol of <200 mg/dL, maintaining a blood pressure of <120/<80 mm Hg, and a fasting blood glucose of <100 mg/dL (the cholesterol, blood pressure, and glucose parameters were all defined as “untreated” values). In the AHA document, it was noted that less than 5% of adults in the United States fulfill all 7 criteria for achieving ideal cardiovascular health. 14

Metrics for Cardiovascular Health

Overweight and obesity represent significant risk factors for cardiovascular disease. Guidelines developed by a joint effort from The Obesity Society (TOS), AHA, and ACC 53 were designed to help physicians manage obesity more effectively. Key recommendations include enrolling overweight or obese patients in comprehensive lifestyle interventions for weight loss delivery and programs for 6 months or longer.

Increased levels of moderate or vigorous intensity physical activity have been repeatedly shown to lower the risk for cardiovascular disease. Compared with those who are physically active, the risk of coronary heart disease (CHD) in sedentary individuals is 150% to 240% higher. 54 Unfortunately, only about 25% of Americans engage in enough regular physical activity to meet minimum standards of the Centers for Disease Control and Prevention of at least 150 minutes/week of moderate intensity aerobic exercise or at least 75 minutes of vigorous exercise and muscle strengthening activities at least 2 days/week. 18

The greatest reduction in risk for CHD appears to result from those engaging in even modest amounts of physical activity compared with the most physically inactive. Even relatively small amounts of increase in physical activity could potentially result in a significant decrease in CHD for a large portion of the American population. Both the 2008 Physical Activity Guidelines for Americans and the 2018 55 Physical Activity Guidelines Advisory Committee Scientific Report 18 recommend similar levels of physical activity as an important component of the reduction of risk for CHD.

There is no question that diet plays a significant role in overall strategies for cardiovascular risk reduction. 56 , 57 This fact is recognized by numerous scientific statements and documents from the American Heart Association including the AHA 2020 Strategic Plan 14 as well as the AHA/ACC Guidelines for Lifestyle Management 52 and the 2006 AHA Nutrition Guidelines. 56 All these recommendations are similar and include consumption of increased fruits and vegetables, consuming at least 2 fish meals/week (preferably oily fish), consuming fiber-rich grains, and restricting sodium to <1500 mg/day and sugar sweetened beverages ≤450 kcal (36 ounces) per week. The AHA Dietary Guidelines recommend plant-based diets such as the DASH Diet 35 (Dietary Approach to Stop Hypertension), as well as the Mediterranean-style diets. 58 Definitive evidence-based guidelines for overall dietary health are summarized in the Dietary Guidelines for Americans 2015-2020 Report. 8

Smoking and Use of Tobacco Products

Overwhelming evidence from multiple sources demonstrates that cigarette smoking significantly increases the risk of both heart disease and stroke. This evidence has been ably summarized elsewhere 59 and is incorporated as a recommendation for every AHA document including the 2020 Strategic Plan. The good news is that risk of CHD and stroke diminish rapidly once smoking cessation occurs. It should also be noted that secondhand smoke also increases the risk of CHD. It has been estimated that 1 nonsmoker dies from secondhand smoke exposure to every 8 smokers who die from smoking. 60

Hypertension

Hypertension represents a significant risk factor for CHD and is the leading risk factor for stroke. The recently released 2017 Guidelines for the Prevention and Detection, Evaluation and Management for High Blood Pressure in Adults from the AHA and the ACC defines normal blood pressure as <120 mm Hg/<80 mm Hg, and hypertension as systolic >120 mm Hg and diastolic high blood pressure as >80 mm Hg. 3 The new criteria are found on Table 2 . Using these criteria, more than 40% of the adult population in the United States has high blood pressure. Recommendations for treating high blood pressure, particularly in the lowest categories, involve a number of lifestyle medicine modalities such as increased physical activity, weight loss (if necessary), and improved nutrition including a salt reduction to <1500 mg/day. 3

2017 Blood Pressure Guidelines From the American Heart Association and American College of Cardiology.

Dyslipidemias

In 2013, the ACC and AHA issued “Guidelines for the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Disease in Adults.” 6 These guidelines recommend an increased use of statin medications to reduce atherosclerotic cardiovascular disease (ASCVD) both in primary and secondary prevention and recommended the discontinuation of the use of specific low-density lipoprotein and high-density lipoprotein treatment targets. Within these guidelines for treating blood lipids, it was acknowledged that lifestyle is the foundation of ASCVD risk reduction efforts. This includes adhering to a heart healthy diet, regular exercise, avoidance of tobacco, and maintenance of a healthy body weight.

Diabetes and Pre-Diabetes

Dramatic increases in diabetes have occurred around the world in the past 2 decades. Lifestyle medicine modalities to prevent or treat diabetes focus on nutrition therapy, physical activity, education, counseling, and support given the great importance given to the metabolic basis of the vast majority of individuals who have either pre-diabetes or diabetes. 61 The International Diabetes Federation estimates that 387 million adults in the world live with type 1 or type 2 diabetes. Tragically, almost half of these individuals do not know they have these diseases. It is estimated that the number of individuals living with diabetes will increase to 392 million people by 2035.

In the United States in 2011-2012, the estimated prevalence of diabetes was 12% to 14%. 62 There is a higher prevalence in adults who are non-Hispanic-Black, non-Hispanic-Asian, or Hispanic. The proportion of people who have undiagnosed diabetes has decreased between 3.1% and 5.2% during this period of time. The prevalence of pre-diabetes has been reported to be between 37% and 38% of the overall US population. Consequently, 49% to 52% of the US population has either diabetes or pre-diabetes. 63

Pre-Diabetes

Multiple lifestyle interventions play critically important roles in preventing pre-diabetes from turning into diabetes. The strongest evidence comes from the Diabetes Prevention Program (DPP), which demonstrated that an intensive lifestyle intervention in individuals with pre-diabetes could reduce the incidence of type 2 diabetes by 58% over 3 years. 64 Other studies that have supported the importance of lifestyle intervention for diabetes prevention include the Da Qing Study, where 43% reduction in conversion from pre-diabetes to diabetes occurred at 20 years, 65 and the Finnish Diabetes Prevention Study, which showed also a 43% reduction in conversion of pre-diabetes to diabetes at 7 years and a 34% reduction at 10 years. 66

The 2 major goals of the DPP in the lifestyle intervention arm were to achieve a minimum of 7% weight loss and 150 minutes of physical activity/week at a moderate intensity such as brisk walking. These goals were selected based on previous literature suggesting that these were both feasible and could influence the development of diabetes. Both these goals were largely met in the DPP.

The nutrition plan in DPP focused on reducing calorie intake in order to achieve weight loss if needed. The recommended diet was consistent with both Mediterranean and DASH eating patterns. Conversely, sugar sweetened beverages and red meats were minimized since they are associated with the increased risk of type 2 diabetes. 63 The 150 minutes/week of moderate intensity physical activity was achieved largely through brisk walking, which also contributed to beneficial effects in individuals with pre-diabetes.

Education and support in the DPP was provided with an individual model of treatment rather than a group-based approach including a 16-session core curriculum completed in the first 24 weeks including sections on lowering calories, increasing physical activity, self-monitoring, maintaining healthy lifestyle behaviors, and psychological, social, and motivational challenges. 63

Recent evidence has also suggested that breaking up sedentary time (such as screen time) further decreases the risk of pre-diabetes being converted to diabetes.

Lifestyle modalities are a cornerstone for diabetes care. These modalities include medical nutrition therapy (MNT), physical activity, smoking cessation, counseling, psychosocial care, and diabetes self-management education support. 66

There are many different ways of achieving the nutritional goals. Individuals with diabetes should be referred for individualized MNT. MNT promotes healthful eating patterns emphasizing a variety of nutrient-dense foods at appropriate levels with the goal of achieving and maintaining healthy body weight; maintaining individual glycemic, blood pressure, and lipid goals; and delaying or preventing complications of diabetes. There is not one ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. A variety of eating patterns are acceptable for the management of diabetes including the Mediterranean, DASH, and other plant-based diets. All of these have been shown to achieve benefits for people with diabetes. 67

Weight management, if necessary, and reduction of weight are important particularly for overweight and obese people with diabetes. Weight loss can be attained in lifestyle programs that achieve 500 to 750 kcal daily reduction for both men and women adjusted to the individual based on body weight. For many obese individuals with type 2 diabetes, weight loss >5% is necessary in order to achieve beneficial outcomes for glycemic control, lipids, and blood pressure, while sustained weight loss of >7% is optimal.

Regular physical activity is also vitally important for the management of diabetes. People with diabetes should be encouraged to perform both aerobic and resistance exercise regularly. 68 Aerobic activity bouts should ideally be at least 10 minutes, with a goal of 30 minutes/day or more on most days of the week. Recent evidence supports the concept that individuals with diabetes should be encouraged to reduce time spent being sedentary in activities such as working at a computer, watching TV, and so on, or breaking up sedentary activities by briefly standing, walking, or performing light physical activity. Research trials have demonstrated strong evidence for A1C lowering value of exercise in individuals with type 2 diabetes. The ADA Consensus Report indicates that prior to starting an exercise program medical providers should perform a careful history to assess cardiovascular risk factors and be aware of atypical presentation of CAD in patients with diabetes. Health care providers should customize exercise regiments to individuals’ needs. 67

In many ways obesity represents the quintessential lifestyle disease. 34 Obesity is the result of energy imbalance, since energy expenditure and energy intake are key factors in the energy balance equation. 61 Thus, both nutritional and physical activity components of lifestyle intervention are critically important to both short-term weight loss and also long-term maintenance of healthy body weight.

It is currently estimated that 78 million individuals in the United States are obese. This represents 36% of the population. 37 More than 70% of individuals in the United States are overweight (BMI ≥ 25 kg/m 2 ), including obese (BMI ≥ 30 kg/m 2 ) and severely obese (BMI ≥ 35 kg/m 2 ). While it may seem simple that either decreased caloric intake or increased physical activity may contribute to weight loss, in fact the process is complicated. As emphasized in the Consensus Statement on Obesity from the American Society of Nutrition, metabolism consists of multiple factors including percent body fat, other issues related to metabolism, and a host of environmental factors. 69

At any time, approximately 50% to 70% of obese Americans are actively trying to lose weight. Sustained weight loss of as little as 5% to 10% is considered clinically significant, since it reduces risk factors for a variety of chronic diseases such as diabetes and heart disease. Both the Diabetes Prevention Program and the Look AHEAD Trial 70 showed that weight loss of 7% in obese individuals resulted in significant improvement in risk factors for both heart disease and diabetes. Nutrition represents a cornerstone of treatment for overweight and obesity. 71 Dietary treatments for disease have been called MNT. This therapeutic approach has been used in a variety of medical conditions, but there is particularly strong proof that MNT improves waist circumference, waist-to-hip ratio, fasting blood sugar, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and blood pressure.

Typical nutritional interventions for weight loss in obese individuals involve sustaining an average daily caloric deficit of 500 kcal. Energy recommendations also include that intake should not be <1200 calories/day for male or female adults in order to maintain adequate nutrient intake.

A variety of evidence-based diets have been demonstrated to assist in healthy weight loss. These include the Mediterranean diet, the DASH diet, and the Healthy U.S. Eating Style Pattern. It has also been demonstrated that macronutrient composition of a weight loss plan (eg, low fat vs low carb, etc) do not achieve different results in studies lasting longer than one year.

The Weight Loss Guidelines jointly issued by the US Preventive Services Task Force, the American Heart Association, the American College of Cardiology, the Obesity Society, and the Academy of Nutrition and Dietetics all recommend a multidisciplinary team approach to managing obesity. 53 These approaches include physical activity counseling, MNT, as well as a structured approach to behavioral change utilizing problem solving and goal setting as well as self-monitoring. Most evidence suggests that effective weight loss programs should last at least 6 months and have a minimum of 24 counseling sessions.

There is a prevalent misconception that maintenance of weight loss is virtually impossible. In both the Diabetes Prevention Program and the Look AHEAD Trial, however, individuals who completed the initial 16-week program and then were followed on a monthly basis for the next 3 to 4 years were able to maintain 90% of the weight that they initially lost. The National Weight Control Registry, which is a registry of over 10 000 individuals who have lost at least 50 pounds and kept it off for at least 1 year, also demonstrated that key components of lifestyle measures such as regular attention to monitoring nutritional intake as well as regular physical activity (on average 60 minutes/day) were key components of how these individuals were able to maintain initial weight loss. 72

It has been argued that physical activity alone is not a powerful tool for initial weight loss. However, abundant evidence supports the concept that regular physical activity is a key component of long-term maintenance of weight loss. Regular physical activity also plays an important role in preservation of lean body mass, which is a key component of maintaining adequate metabolism to support maintenance of weight loss. 28 As already indicated, regular physical activity also conveys a host of health enhancing benefits in addition to its role in weight loss and weight management.

Lifestyle measures play a critically important role both in the prevention of cancer and treatment of individuals who have already established cancer. Moreover, lifestyle measures play a very important role in the ongoing health of cancer survivors. These facts are underscored by the joint statement issued by the American Cancer Society, the American Diabetes Association, and the American Heart Association on preventing cancer, CVD, and diabetes. 15

Cancer is a generic term that represents more than 100 diseases, each of which has a different etiology. Nonetheless, lifestyle measures can play a critically important role in virtually every form of cancer. In 2016, an estimated 1 685 210 new cases of cancer were diagnosed in the United States and 595 690 people died from the disease. 73 Worldwide it has been estimated that the number of new cancers could rise by as much as 70% over the next 2 decades. Approximately 70% of deaths from cancer will occur in low- and middle-income countries. 74

Cancer is no longer viewed as an inevitable consequence of aging. In fact, only 5% to 10% of cancers can be classified as familial. Thus, most cancers are associated with multiple environmental factors including lifestyle issues. For example, the importance of nutrition was emphasized more than 35 years ago by Dahl and Petro. They estimated that approximately 35% (10% to 70%) of all cancers in the United States could be attributable to dietary factors. 75 In 2007, the World Cancer Research Fund and American Institute for Cancer Research (WCRF/AICR) evaluated 7000 studies and concluded that diet and physical activity were major determents of cancer risk. 76 Thus, on a global scale, 3 to 4 million cancer cases could be prevented each year from more positive lifestyle habits and actions. 76

The relationship of obesity to cancer is also very strong. 77 This relationship is based not only on hormonal changes associated with obesity but also a variety of other physiologic mechanisms. Adipocytes, which compose the predominant cell in body fat, have been historically thought to be simply passive storage vessels. It is now clear, however, that adipocytes secrete a variety of metabolically active substances that promote inflammation, insulin resistance, and a variety of other factors, all of which may promote cancer cell growth. The AICR and IARC (International Agency for Research on Cancer) have concluded that there is sufficient evidence to link 13 human malignancies to excess body fatness. 78 Excess body fatness is now the second leading preventable cause of cancer, behind only cigarette smoking. 79 The AICR also reported in 2017, that, unfortunately, only 50% of Americans are aware that obesity promotes cancer growth, so there is an important educational issue to combat, as well. 80

Individuals who are overweight or obese should follow standard cancer screening guidelines. Intentional weight loss lowers cancer risk and improves survival. Individuals with cancer should avoid excess weight gain or, if already overweight or obese, should attempt to lose weight to improve prognosis. The typical program for safe and effective weight loss involves both regular physical activity and caloric restriction. These programs may need to be modified given the unique aspects of each cancer.

General nutrition guidelines for cancer prevention and treatment are very similar to those for healthy eating, in general. However, some modifications may be necessary to protect against certain cancers or treat various side effects of cancer therapy, such as excessive weight loss. In general, lifestyle nutrition measures for cancer prevention involve increasing the consumption of foods that have been shown to decrease the cancer risk, which include whole grains, vegetables, fruits, and legumes. In addition, individuals should decrease consumption of foods associated with increased cancer risk such as processed meat (including ham and bacon), red meat such as beef, pork and lamb, and decrease alcoholic beverages and salt preserved foods. Individuals should eat a healthy diet rather than relying on supplements to protect against cancer.

Physical activity also plays a key role in the association of lifestyle risk to cancer. 81 , 82 Although specific biologic mechanisms linking physical activity to cancer reduction remain unknown, there is growing evidence supporting the role of physical inactivity in various cancer diagnoses. According to the World Cancer Research Fund International, 20% of cancer cases in the United States could be prevented through physical activity, weight control, and consumption of a healthy diet. 83 In addition, a pooled analysis of 12 prospective cohort studies involving 1.4 million participants in the United States and Europe demonstrated an association between higher levels of leisure time physical activity and risk reduction of 13 different cancer types. 84

Among those cancers linked to inactivity, colon, breast, and endometrial cancers are the most studied. 85 The link between physical activity and breast cancer may be through reducing levels of sex hormones and increasing concentrations of sex hormone binding globulin proteins. 86 The relationship between exercise and decreased endometrial cancer risks may have similar mechanisms. 87 The relationship between physical activity and decreased colon cancer risk may be due to immune function modulation reduction in intestinal transit time, hyperinsulinemia, and inflammation. 88 Despite these postulated underlying factors, the biological link between physical activity and reduced colon cancer risk is not well understood.

There are multiple physical activity guidelines that not only have been demonstrated to reduce the risk of cancer, but may also be employed as a treatment tool for cancer populations. Safety is the key consideration in physical activity for cancer survivors. Guidelines for physical activity and cancer have been issued both by the American Cancer Society 89 and the AICR. 90 While a detailed explanation of these guidelines is beyond the scope of this review, the interested reader is referred to these guidelines for more specific detail.

Dementia/Cognition

Maintaining cognitive function is vital to maintaining quality of life, functional independence, and is an important component of the aging process. As life expectancy continues to increase in developed countries, the number of individuals over the age of 65 will undoubtedly increase dramatically over the next 15 to 20 years. 16 It has been estimated that there are currently 47 million people with dementia worldwide and this is projected to increase to 75 million individuals in 2030 and 131 million individuals by 2050. 16

There is a strong linkage between brain health and cardiovascular health. This central fact is underscored by the Presidential Advisory from the AHA and American Stroke Association (ASA) on “Defining Optimal Brain Health in Adults.” 16

Lifestyle measures play a central role in the recommendations from the AHA/ASA for maintaining healthy cognition throughout a lifetime. Modifiable risk factors that may compromise brain health are also associated with poor cardiovascular health such as uncontrolled hypertension, diabetes mellitus, obesity, physical inactivity, smoking, and depression. Each of these conditions has been shown to be potentially ameliorated, at least to some degree, by positive lifestyle measures. For this reason, the AHA and ASA have identified 7 metrics to define optimal brain health including nonsmoking, physical activity at goal levels, a healthy diet consistent with current guideline levels, and a body mass index of <25 kg/m 2 . 16 In addition, the AHA and ASA recommend 3 ideal health factors including an untreated blood pressure of <120/<80 mm Hg, untreated cholesterol <200 mg/dL, and fasting blood glucose of <100 mg/dL.

Virtually all of these factors are affected by positive lifestyle decisions, making cognition and reducing the risk of dementia strongly linked to lifestyle factors. Furthermore, it is important to stress that while many of the manifestations of the spectrum ranging from diminished cognition to dementia occur in individuals in their 50s, 60s, and beyond, paying attention to these risk factors should occur throughout a lifetime, thus enhancing the importance of lifestyle measures in maintaining positive brain health.

A variety of dietary habits have also been shown to decrease the risk of cognitive decline and risk of dementia. These include Mediterranean style diets (MST) and the Dietary Approach to Stop Hypertension (DASH) diet. 91 A combination of MST and DASH (the so-called MIND diet) has also been observed to be associated with decreased risk of dementia with aging. All of these diets are plant based as their principle sources of energy and involve a high intake of grains and cereals, fruits, vegetables, legumes, nuts, olive oil, and fish as fat sources. In addition, a recent study demonstrated that consumption of cocoa, both in individuals over the age of 60 with maintained cognition and also mild cognitive impairment, may improve levels of cognition. 92 , 93 A number of studies have shown that regular physical activity is associated with improved cognition. 16

Anxiety, Depression, and Stress Reduction

Anxiety, depression, and stress are all endemic in the modern, fast-paced world. Lifestyle interventions have been demonstrated to play an effective role in ameliorating all three of these conditions.

Within all of the mental health disorders, anxiety is the most common. 94 The overall prevalence of anxiety disorders has been reported at more than 30%. Regular physical activity has been demonstrated in multiple studies to lower anxiety levels. While the state of anxiety has been shown to be reduced immediately after performing a single bout of exercise, the anxiolytic effect of treating the trait of anxiety appears to require a training period of at least 10 weeks. The exact level of physical activity has not been determined. However, most studies employ the general guidelines of 30 minutes of moderate intensity physical activity/session.

Depression is also quite common with a lifetime prevalence of significant depression of approximately 10% in the US population. 95 Even in the absence of significant depressive disorder, symptoms of depression can negatively influence health and quality of life. Physical activity has been repeatedly shown to decrease symptoms of depression. Typical levels of physical activity employed once again have involved at least 30 minutes of moderate intensity physical activity performed on a regular basis.

Stress is endemic in our modern world. 96 While exact prevalence figures for stress are difficult or impossible to determine, most people experience at least moderate stress in their daily lives. It has been estimated that up to one third of individuals experience enough stress in their daily life to decrease their performance at either work or home. While a certain level of stress may be protective, excessive stress may be harmful through a variety of physiologic and psychological effects.

A variety of approaches to ameliorate stress have been studied and found effective. These include the relaxation response and other mind-body therapies. Certainly, these mind-body therapies play an important role in the delivery of lifestyle medicine. One other aspect of modern psychological therapy that has gained increased prominence in the past decade is positive psychology involving modalities and concepts such as gratitude and forgiveness, which may help reduce stress.

Lifestyle Medicine and Pediatrics

A detailed discussion of lifestyle medicine in the pediatric population is beyond the scope of this review. However, it should be noted that many of the conditions that manifest themselves in adulthood have their roots in childhood. In particular, there has been a dramatic increase in the prevalence of overweight and obesity in children 97 and a corresponding increase in the prevalence of type 2 diabetes. Dyslipidemia 98 and hypertension 99 have also increased in prevalence in the pediatric population.

There is emerging evidence that many of the conditions now increasing in prevalence in children may actually begin in utero. 100 The same types of lifestyle measures that are applicable both for the prevention and treatment of chronic disease in adults are also very relevant to children. Good information on physical activity in children can be found in the recently revised Physical Activity Guidelines for Americans. 18 Nutritional guidance may also be found in the 2015-2020 Dietary Guidelines for Americans. 8 Since many of the lifestyle medicine modalities employed in adults are highly relevant to families, issues related to physical activity, nutrition, and weight management should be addressed in the family setting.

Conclusions

There is no longer any serious doubt that daily habits and practices profoundly affect the short-term and long-term health and quality of life. Increased physical activity, proper nutrition, weight management, avoidance of tobacco, and stress reduction are all key modalities that can lower the risk of chronic disease and improve quality of life. Despite the overwhelming evidence that these practices have a profound impact on health, the medical community has been slow to respond in addressing these modalities and in encouraging patients to make positive lifestyle changes. This represents a significant missed opportunity since more 75% of Americans see a primary care doctor every year. Employing the principles of lifestyle medicine in the daily practice of medicine represents a substantial opportunity to increase the value of proposition in medicine by improving outcomes for patients, while controlling costs. 101 The time has come to employ the vast body of evidence in lifestyle medicine and encourage positive lifestyle medicine not only for our patients but also in our own lives.

Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Rippe is the editor in chief, American Journal of Lifestyle Medicine , and editor of Lifestyle Medicine (CRC Press). He is also founder and director, Rippe Lifestyle Institute, a research organization that has conducted multiple studies in physical activity, nutrition, and weight management.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval: Not applicable, because this article does not contain any studies with human or animal subjects.

Informed Consent: Not applicable, because this article does not contain any studies with human or animal subjects.

Trial Registration: Not applicable, because this article does not contain any clinical trials.

• Research article
• Open access
• Published: 29 September 2022

A healthy lifestyle is positively associated with mental health and well-being and core markers in ageing

• Pauline Hautekiet   ORCID: orcid.org/0000-0003-3805-3004 1 , 2 ,
• Nelly D. Saenen 1 , 2 ,
• Dries S. Martens 2 ,
• Margot Debay 2 ,
• Johan Van der Heyden 3 ,
• Tim S. Nawrot 2 , 4 &
• Eva M. De Clercq 1  

BMC Medicine volume  20 , Article number:  328 ( 2022 ) Cite this article

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Studies often evaluate mental health and well-being in association with individual health behaviours although evaluating multiple health behaviours that co-occur in real life may reveal important insights into the overall association. Also, the underlying pathways of how lifestyle might affect our health are still under debate. Here, we studied the mediation of different health behaviours or lifestyle factors on mental health and its effect on core markers of ageing: telomere length (TL) and mitochondrial DNA content (mtDNAc).

In this study, 6054 adults from the 2018 Belgian Health Interview Survey (BHIS) were included. Mental health and well-being outcomes included psychological and severe psychological distress, vitality, life satisfaction, self-perceived health, depressive and generalised anxiety disorder and suicidal ideation. A lifestyle score integrating diet, physical activity, smoking status, alcohol consumption and BMI was created and validated. On a subset of 739 participants, leucocyte TL and mtDNAc were assessed using qPCR. Generalised linear mixed models were used while adjusting for a priori chosen covariates.

The average age (SD) of the study population was 49.9 (17.5) years, and 48.8% were men. A one-point increment in the lifestyle score was associated with lower odds (ranging from 0.56 to 0.74) for all studied mental health outcomes and with a 1.74% (95% CI: 0.11, 3.40%) longer TL and 4.07% (95% CI: 2.01, 6.17%) higher mtDNAc. Psychological distress and suicidal ideation were associated with a lower mtDNAc of − 4.62% (95% CI: − 8.85, − 0.20%) and − 7.83% (95% CI: − 14.77, − 0.34%), respectively. No associations were found between mental health and TL.

Conclusions

In this large-scale study, we showed the positive association between a healthy lifestyle and both biological ageing and different dimensions of mental health and well-being. We also indicated that living a healthy lifestyle contributes to more favourable biological ageing.

Peer Review reports

According to the World Health Organization (WHO), a healthy lifestyle is defined as “a way of living that lowers the risk of being seriously ill or dying early” [ 1 ]. Public health authorities emphasise the importance of a healthy lifestyle, but despite this, many individuals worldwide still live an unhealthy lifestyle [ 2 ]. In Europe, 26% of adults smoke [ 3 ], nearly half (46%) never exercise [ 4 ], 8.4% drink alcohol on a daily basis [ 5 ] and over half (51%) are overweight [ 5 ]. These unhealthy behaviours have been associated with adverse health outcomes like cardiovascular diseases [ 6 , 7 , 8 ], respiratory diseases [ 9 ], musculoskeletal diseases [ 10 ] and, to a lesser extent, mental disorders [ 11 , 12 ].

Even though the association between lifestyle and health outcomes has been extensively investigated, biological mechanisms explaining these observed associations are not yet fully understood. One potential mechanism that can be suggested is biological ageing. Both telomere length (TL) and mitochondrial DNA content (mtDNAc) are known biomarkers of ageing. Telomeres are the end caps of chromosomes and consist of multiple TTAGGG sequence repeats. They protect chromosomes from degradation and shorten with every cell division because of the “end-replication problem” [ 13 ]. Mitochondria are crucial to the cell as they are responsible for apoptosis, the control of cytosolic calcium levels and cell signalling [ 14 ]. Living a healthy lifestyle can be linked with healthy ageing as both TL and mtDNAc have been associated with health behaviours like obesity [ 15 ], diet [ 16 ], smoking [ 17 ] and alcohol abuse [ 18 ]. Furthermore, as biomarkers of ageing, both TL and mtDNAc have been associated with age-related diseases like Parkinson’s disease [ 19 ], coronary heart disease [ 20 ], atherosclerosis [ 21 ] and early mortality [ 22 ]. Also, early mortality and higher risks for the aforementioned age-related diseases are observed in psychiatric illnesses, and it is suggested that advanced biological ageing underlies these observations [ 23 ].

Multiple studies evaluated individual health behaviours, but research on the combination of these health behaviours is limited. As they often co-occur and may cause synergistic effects, assessing them in combination with each other rather than independently might better reflect the real-life situation [ 24 , 25 ]. Therefore, in a general adult population, we combined five commonly studied health behaviours including diet, smoking status, alcohol consumption, BMI and physical activity into one healthy lifestyle score to evaluate its association with mental health and well-being and biological ageing. Furthermore, we evaluated the association between the markers of biological ageing and mental health and well-being. We hypothesise that individuals living a healthy lifestyle have a better mental health status, a longer TL and a higher mtDNAc and that these biomarkers are positively associated with mental health and well-being.

Study population

In 2018, 11611 Belgian residents participated in the 2018 Belgian Health Interview Survey (BHIS). The sampling frame of the BHIS was the Belgian National Register, and participants were selected based on a multistage stratified sampling design including a geographical stratification and a selection of municipalities within provinces, of households within municipalities and of respondents within households [ 26 ]. The study population for this cross-sectional study included 6054 BHIS participants (see flowchart in Additional file 1 : Fig. S1) [ 27 , 28 , 29 , 30 , 31 ]. Minors (< 18 years) and participants not eligible to complete the mental health modules (participants who participated through a proxy respondent, i.e. a person of confidence filled out the survey) were excluded ( n  = 2172 and n  = 846, respectively). Furthermore, of the 8593 eligible participants, those with missing information to create the mental health indicators, the lifestyle score or the covariates used in this study were excluded ( n  = 1642, 788 and 109, respectively).

For the first time in 2018, a subset of 1184 BHIS participants contributed to the 2018 Belgian Health Examination Survey (BELHES). All BHIS participants were invited to participate except for minors (< 18 years), BHIS participants who participated through a proxy respondent and residents of the German Community of Belgium, the latter representing 1% of the Belgian population. Participants were recruited on a voluntary basis until the regional quotas were reached (450, 300 and 350 in respectively Flanders, Brussels Capital Region and Wallonia). These participants underwent a health examination, including anthropological measurements and completed an additional questionnaire. Also, blood and urine samples were collected. Of the 6054 included BHIS participants, 909 participated in the BELHES. Participants for whom we could not calculate both TL and mtDNAc were excluded ( n  = 170). More specifically, participants were excluded because they did not provide a blood sample ( n  = 91) or because they did not provide permission for DNA research ( n  = 32). Twenty samples were excluded from DNA extraction because either total blood volume was too low ( n  = 7), samples were clothed ( n  = 1) or tubes were broken due to freezing conditions ( n  = 12). Twenty-seven samples were excluded because they did not meet the biomarker quality control criteria (high technical variation in qPCR triplicates). This was not met for 3 TL samples, 20 mtDNAc samples and 4 samples for both biomarkers. For this subset, we ended up with a final number of 739 participants. Further in this paper, we refer to “the BHIS subset” for the BHIS participants ( n  = 6054) and the “BELHES subset” for the BELHES participants ( n  = 739).

As part of the BELHES, this project was approved by the Medical Ethics Committee of the University Hospital Ghent (registration number B670201834895). The project was carried out in line with the recommendations of the Belgian Privacy Commission. All participants have signed a consent form that was approved by the Medical Ethics Committee.

Health interview survey

The BHIS is a comprehensive survey which aims to gain insight into the health status of the Belgian population. The questions on the different dimensions of mental health and well-being were based on international standardised and validated questionnaires [ 32 ], and this resulted in eight mental health outcomes that were used in this study. Detailed information on each indicator score and its use is addressed in Additional file 1 : Table. S1. Firstly, the General Health Questionnaire (GHQ-12) provides the prevalence of psychological and severe psychological distress in the population [ 27 ]. On the total GHQ score, cut-off points of + 2 and + 4 were used to identify respectively psychological and severe psychological distress.

Secondly, we used two indicators for the positive dimensions of mental health: vitality and life satisfaction. Four questions of the short form health survey (SF-36) indicate the participant’s vital energy level [ 28 , 33 ]. We used a cut-off point to identify participants with an optimal vitality score, which is a score equal to or above one standard deviation above the mean, as used in previous studies [ 34 , 35 ]. Life satisfaction was measured by the Cantril Scale, which ranges from 0 to 10 [ 29 ]. A cut-off point of + 6 was used to indicate participants with high or medium life satisfaction versus low life satisfaction.

Thirdly, the question “How is your health in general? Is it very good, good, fair, bad or very bad?” was used to assess self-perceived health, also known as self-rated health. Based on WHO recommendations [ 36 ], the answer categories were dichotomised into “good to very good self-perceived health” and “very bad to fair self-perceived health”.

Fourthly, depressive and generalised anxiety disorders were defined using respectively the Patient Health Questionnaire (PHQ-9) and the Generalised Anxiety Disorder Questionnaire (GAD-7). We identified individuals who suffer from major depressive syndrome or any other type of depressive syndrome according to the criteria of the PHQ-9 [ 37 ]. A cut-off point of + 10 on the total sum of the GAD-7 score was used to indicate generalised anxiety disorder [ 31 ]. Additionally, a dichotomous question on suicidal ideation was used: “Have you ever seriously thought of ending your life?”; “If yes, did you have such thoughts in the past 12 months?”. Finally, the BHIS also includes personal, socio-economic and lifestyle information. The standardised Cronbach’s alpha coefficients for the PHQ-9, GHQ-12, GAD-7 and questions on vitality of the SF-36 ranged between 0.80 and 0.90.

Healthy lifestyle score

We developed a healthy lifestyle score based on five different health behaviours: body mass index (BMI), smoking status, physical activity, alcohol consumption and diet (Table 1 ). These health behaviours were defined as much as possible according to the existing guidelines for healthy living issued by the Belgian Superior Health Council [ 38 ] and the World Health Organisation [ 39 , 40 , 41 ]. Firstly, BMI was calculated as a person’s self-reported weight in kilogrammes divided by the square of the person’s self-reported height in metres (kg/m 2 ). BMI was classified into four categories: underweight (BMI < 18.5 kg/m 2 ), normal weight (BMI 18.5–24.9 kg/m 2 ), overweight (BMI 25.0–29.9 kg/m 2 ) and obese (BMI ≥ 30.0 kg/m 2 ). Due to a J-shaped association of BMI with the overall mortality and multiple specific causes of death, obesity and underweight were both classified as least healthy [ 42 ]. BMI was scored as follows: obese and underweight = 0, overweight = 1 and normal weight = 2.

Secondly, smoking status was divided into four categories. Participants were categorised as regular smokers if they smoked a minimum of 4 days per week or if they quit smoking less than 1 month before participation (= 0). Occasional smokers were defined as smoking more than once per month up to 3 days per week (= 1). Participants were classified as former smokers if they quit smoking at least 1 month before the questionnaire or if they smoked less than once a month (= 2). The final category included people who never smoked (= 3).

Thirdly, physical activity was assessed by the question: “What describes best your leisure time activities during the last year?”. Four categories were established and scored as follows: sedentary activities (= 0), light activities less than 4 h/week (= 1), light activities more than 4 h/week or recreational sport less than 4 h/week (= 2) and recreational sport more than 4 h or intense training (= 3). Fourthly, information on the number of alcoholic drinks per week was used to categorise alcohol consumption. The different categories were set from high to low alcohol consumption: 22 drinks or more/week (= 0), 15–21 drinks/week (= 1), 8–14 drinks/week (= 2), 1–7 drinks/week (= 3)and less than 1 drink/week (= 4).

Finally, in line with the research by Benetou et al., a diet score was calculated using the frequency of consuming fruit, vegetables, snacks and sodas [ 43 ]. For fruit as well as vegetable consumption, the frequency was scored as follows: never (= 0), < 1/week (= 1), 1–3/week (= 2), 4–6/week (= 3) and ≥ 1/day (= 4). The frequency of consuming snacks and sodas was scored as follows: never (= 4), < 1/week (= 3), 1–3/week (= 2), 4–6/week (= 1) and ≥ 1/day (= 0). The diet score was then divided into tertiles, in line with the research by Benetou et al. [ 43 ]. A diet score of 0–9 points was classified as the least healthy behaviour (= 0). A diet score ranging from 10 to 12 made up the middle category (= 1), and a score from 13 to 16 was classified as the healthiest behaviour (= 2).

All five previously described health behaviours were combined into one healthy lifestyle score (Table 1 ). The sum of the scores obtained for each health behaviour indicated the absolute lifestyle score. To calculate the relative lifestyle score, each absolute scored health behaviour was given equal weight by recalculating its maximum absolute score to a relative score of 1. The relative lifestyle scores were then summed up to achieve a final continuous lifestyle score, ranging from 0 to 5, with a higher score representing a healthier lifestyle.

Telomere length and mitochondrial DNA content assay

Blood samples were collected during the BELHES and centrifuged for 15 min at 3000 rpm before storage at − 80 °C. After extracting the buffy coat from the blood sample, DNA was isolated using the QIAgen Mini Kit (Qiagen, N.V.V Venlo, The Netherlands). The purity and quantity of the sample were measured with a NanoDrop spectrophotometer (ND-2000; Thermo Fisher Scientific, Wilmington, DE, USA). DNA integrity was assessed by agarose gel electrophoresis. To ensure a uniform DNA input of 6 ng for each qPCR reaction, samples were diluted and checked using the Quant-iT™ PicoGreen® dsDNA Assay Kit (Life Technologies, Europe).

Relative TL and mtDNAc were measured in triplicate using a previously described quantitative real-time PCR (qPCR) assay with minor modifications [ 44 , 45 ]. All reactions were performed on a 7900HT Fast Real-Time PCR System (Applied Biosystems, Foster City, CA, USA) in a 384-well format. Used telomere, mtDNAc and single copy-gene reaction mixtures and PCR cycles are given in Additional file 1 : Text. S1. Reaction efficiency was assessed on each plate by using a 6-point serial dilution of pooled DNA. Efficiencies ranged from 90 to 100% for single-copy gene runs, 100 to 110% for telomere runs and 95 to 105% for mitochondrial DNA runs. Six inter-run calibrators (IRCs) were used to account for inter-run variability. Also, non-template controls were used in each run. Raw data were processed and normalised to the reference gene using the qBase plus software (Biogazelle, Zwijnaarde, Belgium), taking into account the run-to-run differences.

Leucocyte telomere length was expressed as the ratio of telomere copy number to single-copy gene number (T/S) relative to the mean T/S ratio of the entire study population. Leucocyte mtDNAc was expressed as the ratio of mtDNA copy number to single-copy gene number (M/S) relative to the mean M/S ratio of the entire study population. The reliability of our assay was assessed by calculating the interclass correlation coefficient (ICC) of the triplicate measures (T/S and M/S ratios and T, M and S separately) as proposed by the Telomere Research Network, using RStudio version 1.1.463 (RStudio PBC, Boston, MA, USA). The intra-plate ICCs of T/S ratios, TL runs, M/S ratios, mtDNAc runs and single-copy runs were respectively 0.804 ( p  < 0.0001), 0.907 ( p  < 0.0001), 0.815 ( p  < 0.0001), 0.916 ( p  < 0.0001) and 0.781 ( p  < 0.0001). Based on the IRCs, the inter-plate ICC was 0.714 ( p  < 0.0001) for TL and 0.762 ( p  < 0.0001) for mtDNAc.

Statistical analysis

Statistical analyses were performed using the SAS software (version 9.4; SAS Institute Inc., Cary, NC, USA). We performed a log(10) transformation of the TL and mtDNAc data to reduce skewness and to better approximate a normal distribution. Three analyses were done: (1) In the BHIS subset ( n  = 6054), we evaluated the association between the lifestyle score and the mental health and well-being outcomes (separately). These results are presented as the odds ratio (95% CI) of having a mental health condition or disorder for a one-point increment in the lifestyle score. (2) In the BELHES subset ( n  = 739), we evaluated the association between the lifestyle score and both TL and mtDNAc (separately). These results are presented as the percentage difference in TL or mtDNAc (95% CI) for a one-point increment in the lifestyle score. (3) In the BELHES subset ( n  = 739), we evaluated the association between the mental health and well-being outcomes and both TL and mtDNAc (separately). These results are presented as the percentage difference in TL or mtDNAc (95% CI) when having a mental health condition or disorder compared with the healthy group.

For all three analyses, we performed multivariable linear mixed models (GLIMMIX; unstructured covariance matrix) taking into account a priori selected covariates including age (continuous), sex (male, female), region (Flanders, Brussels Capital Region, Wallonia), highest educational level of the household (up to lower secondary, higher secondary, college or university), country of birth (Belgium, EU, non-EU) and household type (single, one parent with child, couple without child, couple with child, others). To capture the non-linear effect of age, we included a quadratic term when the result of the analysis showed that both the linear and quadratic terms had a p -value < 0.1. For the two analyses on TL and mtDNAc, we additionally adjusted for the date of participation in the BELHES. As multiple members of one household participated, we added household numbers in the random statement.

Bivariate analyses evaluating the associations between the characteristics and TL, mtDNAc, the lifestyle score or psychological distress as a parameter of mental health and well-being are evaluated based on the same model. The chi-squared tests (categorical data) and t -tests (continuous data) were used to evaluate the characteristics of included and excluded participants. The lifestyle score was validated by creating a ROC curve and calculating the area under the curve (AUC) of the adjusted association between the lifestyle score and self-perceived health. Adjustments were made for age, sex, region, highest educational level of the household, country of birth and household type.

In a sensitivity analysis, to evaluate the robustness of our findings, we additionally adjusted our main models separately for perceived quality of social support (poor, moderate, strong) and chronic disease (suffering from any chronic disease or condition: yes, no). The third model, evaluating the biomarkers with the mental health outcomes, was also additionally adjusted for the lifestyle score.

Population characteristics

The characteristics of the BHIS and BELHES subset are presented in Table 2 . In the BHIS subset, 48.8% of the participants were men. The average age (SD) was 49.9 (17.5) years, and most participants were born in Belgium (79.5%). The highest educational level in the household was most often college or university degree (53.3%), and the most common household composition was couple with child(ren) (37.7%). The proportion of participants in different regions of Belgium, i.e. Flanders, Brussels Capital Region and Wallonia, was respectively 41.1%, 23.3% and 35.6%. For the BELHES subset, we found similar results except for region and education. We noticed more participants from Flanders and more participants with a high educational level in the household. The mean (SD) relative TL and mtDNAc were respectively 1.04 (0.23) and 1.03 (0.24). TL and mtDNAc were positively correlated (Spearman’s correlation = 0.21, p  < 0.0001).

We compared (1) the characteristics of the 6054 eligible BHIS participants that were included in the BHIS subset with the 2539 eligible participants that were excluded from the BHIS subset (Additional file 1 : Table S2) and (2) the 739 participants from the BHIS subset that were included in the BELHES subset with the 5315 participants that were excluded from the BELHES subset (Additional file 1 : Table S3). Except for sex and nationality in the latter, all other covariates showed differences between the included and excluded groups. On the other hand, population data from 2018 indicates that the average age (SD) of the adult Belgian population was 49.5 (18.9) with a distribution over Flanders, Brussels Capital Region and Wallonia of respectively 58.2%, 10.2% and 31.6% and that 48.7% were men. The distribution of our sample according to age and sex thus largely corresponds to the age and sex distribution of the adult Belgian population figures. The large difference in the regional distribution is due to the oversampling of the Brussels Capital Region in the BHIS.

Bivariate associations evaluating the characteristics with TL, mtDNAc, the lifestyle score or psychological distress as a parameter of mental health are presented in Additional file 1 : Table S4. Briefly, men had a − 6.41% (95% CI: − 9.10 to − 3.65%, p  < 0.0001) shorter TL, a − 8.03% (95% CI: − 11.00 to − 4.96%, p  < 0.0001) lower mtDNAc, lower odds of psychological distress (OR = 0.59, 95% CI: 0.53 to 0.66, p  < 0.0001) and a lifestyle score of − 0.28 (95% CI: − 0.32 to − 0.24, p  < 0.0001) points less compared with women. Furthermore, a 1-year increment in age was associated with a − 0.64% (− 0.73 to − 0.55%, p  < 0.0001) shorter TL and a − 0.19% (95% CI: − 0.31 to − 0.08%, p  = 0.00074) lower mtDNAc.

Mental health prevalence and lifestyle characteristics

Within the BHIS subset, 32.3% and 18.0% of the participants had respectively psychological and severe psychological distress. 86.7% had suboptimal vitality, 12.0% indicated low life satisfaction and 22.0% had very bad to fair self-perceived health. The prevalence of depressive and generalised anxiety disorders was respectively 9.0% and 10.8%, respectively. 4.4% of the participants indicated to have had suicidal thoughts in the past 12 months. Similar results were found for the BELHES subset (Table 3 ).

Within the BHIS subset, the average lifestyle score (SD) was 3.1 (0.9) (Table 4 ). A histogram of the lifestyle score is shown in Additional file 1 : Fig. S2. 16.6% were regular smokers, and 4.9% reported 22 alcoholic drinks per week or more. 29.7% reported that their main leisure time included mainly sedentary activities, and 18.6% were underweight or obese. 29.2% were classified as having an unhealthy diet score. The participants of the BELHES subset were slightly more active, but no other dissimilarities were found (Table 4 ). The ROC curve shows an area under the curve (AUC) of 0.74, indicating a 74% predictive accuracy for the lifestyle score as a self-perceived health predictor (Additional file 1 : Fig. S3).

Healthy lifestyle and mental health and well-being

Living a healthier lifestyle, indicated by having a higher lifestyle score, was associated with lower odds of all mental health and well-being outcomes (Table 5 ). After adjustment, a one-point increment in the lifestyle score was associated with lower odds of psychological (OR = 0.74, 95% CI: 0.69, 0.79) and severe psychological distress (OR = 0.69, 95% CI: 0.64, 0.75). Similarly, for the same increment, the odds of suboptimal vitality, low life satisfaction and very bad to fair self-perceived health were respectively 0.62 (95% CI: 0.56, 0.68), 0.62 (95% CI: 0.56, 0.68) and 0.56 (95% CI: 0.52, 0.61). Finally, the odds of having depressive disorder, generalised anxiety disorder or suicidal ideation were respectively 0.57 (95% CI: 0.51, 0.63), 0.63 (95% CI: 0.57, 0.69) and 0.63 (95% CI: 0.55, 0.72) for a one-point increment in the lifestyle score.

The biomarkers of ageing

After adjustment, living a healthy lifestyle was positively associated with both TL and mtDNAc (Table 6 ). A one-point increment in the lifestyle score was associated with a 1.74 (95% CI: 0.11, 3.40%, p  = 0.037) higher TL and a 4.07 (95% CI: 2.01, 6.17%, p  = 0.00012) higher mtDNAc.

People suffering from severe psychological distress had a − 4.62% (95% CI: − 8.85, − 0.20%, p  = 0.041) lower mtDNAc compared with those who did not suffer from severe psychological distress. Similarly, people with suicidal ideation had a − 7.83% (95% CI: − 14.77, − 0.34%, p  = 0.041) lower mtDNAc compared with those without suicidal ideation. No associations were found for the other mental health and well-being outcomes, and no associations were found between mental health and TL (Table 6 ).

Sensitivity analysis

Additional adjustment of the main analyses for perceived quality of social support, chronic disease or lifestyle score (in the association between the mental health outcomes and the biomarkers of ageing) did not strongly change the effect of our observations (Additional file 1 : Tables S5-S7). However, we noticed that most of the associations between severe psychological distress or suicidal ideation and mtDNAc showed marginally significant results.

In this study, we evaluated the associations between eight mental health and well-being outcomes, a healthy lifestyle score and 2 biomarkers of biological ageing: telomere length and mitochondrial DNA content. Having a healthy lifestyle was positively associated with all mental health and well-being indicators and the markers of biological ageing. Furthermore, having had suicidal ideation or suffering from severe psychological distress was associated with a lower mtDNAc. However, no association was found between mental health and TL.

In the first part of this research, we evaluated the association between lifestyle and mental health and well-being and showed that living a healthy lifestyle was positively associated with better mental health and well-being outcomes. Similar trends were found in previous studies for each of the health behaviours separately [ 11 , 12 , 46 , 47 , 48 ]. Although evaluating these health behaviours separately provides valuable information, assessing them in combination with each other rather than independently might better reflect the real-life situation as they often co-occur and may exert a synergistic effect on each other [ 24 , 25 , 49 ]. For example, 68% of the adults in England engaged in two or more unhealthy behaviours [ 25 ]. Especially, smoking status and alcohol consumption co-occurred, but half of the studies in the review by Noble et al. indicated clustering of all included health behaviours [ 24 ].

To date, the number of studies evaluating the combination of multiple health behaviours and mental health and well-being in adults is limited, and most of them use a different methodology to assess this association [ 50 , 51 , 52 , 53 , 54 , 55 , 56 ]. Firstly, differences are found between the included health behaviours. Most studies included the four “SNAP” risk factors, i.e. smoking, poor nutrition, excess alcohol consumption and physical inactivity. Other health behaviours that were sometimes included were BMI/obesity, sleep duration/quality and psychological distress [ 50 , 53 , 54 , 56 ]. Secondly, differences are found in the scoring of the health behaviours and the use of the lifestyle score. Whereas in this study the health behaviours were scored categorically, studies often dichotomised the health behaviours and/or the final lifestyle score [ 50 , 52 , 53 , 56 ]. Also, two studies performed clustering [ 54 , 55 ]. Health behaviours can cluster together at both ends of the risk spectrum, but less is known about the middle categories. This is avoided by using the cluster method where participants are clustered based on similar behaviours. On the other hand, a lifestyle score can be of better use and more easily be interpreted when aiming to compare healthy versus unhealthy lifestyles, as was the case for this study.

Despite these different methods, all previously mentioned studies show similar results. Together with our findings, which also support these results, this provides clear evidence that an unhealthy lifestyle is associated with poor mental health and well-being outcomes. Important to notice is that, like our research, most studies in this field have a cross-sectional design and are therefore not able to assume causality. Therefore, mental health might be the cause or the consequence of an unhealthy lifestyle. Further prospective and longitudinal studies are warranted to confirm the direction of the association.

Healthy lifestyle and biomarkers of ageing

How lifestyle affects our health is not yet fully understood. One possible pathway is through oxidative stress and biological ageing. An unhealthy lifestyle has been associated with an increase in oxidative stress [ 57 , 58 , 59 ], and in turn, higher concentrations of oxidative stress are known to negatively affect TL and mtDNAc [ 60 ]. In this study, we showed that living a healthy lifestyle was associated with a longer TL and a higher mtDNAc. Our results showed a stronger association of lifestyle with mtDNAc compared with TL. TL is strongly determined by TL at birth [ 61 ]. On the other hand, mtDNAc might be more variable in shorter time periods. Although mtDNAc and TL were strongly correlated, this could explain why lifestyle is more strongly associated with mtDNAc. However, we can only speculate about this, and further research is necessary to confirm our results.

Similar as for the association with mental health, in previous studies, the biomarkers have been associated with health behaviours separately rather than combined [ 62 , 63 , 64 , 65 ]. To our knowledge, we are the first to evaluate the associations between a healthy lifestyle score and mtDNAc. Our results are in line with our expectations. As TL and mtDNAc are known to be correlated [ 60 ], we would expect similar trends for both biomarkers. In the case of TL, few studies included a combined lifestyle score in association with this biomarker. Consistent with our results, in a study population of 1661 men, the sum score of a healthier lifestyle was correlated with a longer TL [ 66 ]. Similar results were found by Sun et al. where a combination of healthy lifestyles in a female study population was associated with a longer TL compared with the least healthy group [ 67 ]. Also, improvement in lifestyle has been associated with TL maintenance in the elderly at risk for dementia [ 68 ], and a lifestyle intervention programme was positively associated with leucocyte telomere length in children and adolescents [ 69 ]. These results suggest that on a biological level, a healthy lifestyle is associated with healthy ageing. Within this context, a study on adults aged 60 and older showed that maintaining a normal weight, not smoking and performing regular physical activity were associated with slower development of disability and a reduction in mortality [ 70 ]. Similarly, midlife lifestyle factors like non-smoking, higher levels of physical activity, non-obesity and good social support have been associated with successful ageing, 22 years later [ 71 ].

Mental health and well-being and biomarkers of ageing

Finally, we evaluated the association between the biomarkers of ageing and the mental health and well-being outcomes. The hypothesis that biological ageing is associated with mental health has been supported by observations showing that chronically stressed or psychiatrically ill persons have a higher risk for age-related diseases like dementia, diabetes and hypertension [ 23 , 72 , 73 ]. Important to notice is that, like our research, the majority of studies on this topic have a cross-sectional design and therefore are unable to identify causality. Therefore, it is currently unknown whether psychological diseases accelerate biological ageing or whether biological ageing precedes the onset of these diseases [ 74 ].

Our results showed a lower mtDNAc for individuals with suicidal ideation or severe psychological distress but not for any of the other mental health outcomes. Evidence on the association between mtDNAc and mental health is inconsistent. Women above 60 years old with depression had a significantly lower mtDNAc compared with the control group [ 75 ]. Furthermore, individuals with a low mtDNAc had poorer outcomes in terms of self-rated health [ 76 ]. In contrast, Otsuka et al. showed a higher peripheral blood mtDNAc in suicide completers [ 77 ], and studies on major depressive syndrome [ 78 ] and self-rated health [ 79 ] showed the same trend. Finally, Vyas et al. showed no significant association between mtDNAc and depression status in mid-life and older adults [ 80 ]. These differences might be due to the differences in study population and methods. For example, the two studies indicating lower mtDNAc in association with poor mental health both had an elderly study population, and one study population consisted of psychiatrically ill patients. Next to that, differences were found in the type of samples, mtDNAc assays and questionnaires or diagnostics. The inconsistency of these studies and our results calls for further research on this association and for standardisation of methods within studies to enable clear comparisons.

As for TL, we did not find an association with any of the mental health and well-being outcomes. Previous studies in adults showed a lower TL in association with current but not remitted anxiety disorder [ 81 ], depressive [ 82 ] and major depressive disorder [ 73 , 83 ], childhood trauma [ 84 ] suicide [ 77 , 85 ], depressive symptoms in younger adults [ 86 ] and acculturative stress and postpartum depression in Latinx women [ 87 ]. Also, in a meta-analysis, psychiatric disorders overall were associated with a shorter leucocyte TL [ 88 ]. However, other studies failed to demonstrate an association between TL and mental health outcomes like major depressive disorder [ 89 ], late-life depression [ 90 ] and anxiety disorder [ 91 ]. Again, this could be due to a different method to assess the mental health outcomes, a different study design, uncontrolled confounding factors and the type of telomere assay. For example, a meta-analysis showed stronger associations with depression when using southern blot or FISH assay compared with qPCR to measure telomere length [ 92 ].

Strengths and limitations

An important strength of this study is the use of a validated lifestyle score that can easily be reproduced and used for other research on lifestyle. Secondly, we were able to use a large sample size for our analyses in the BHIS subset. Thirdly, by assessing multiple dimensions of mental health and well-being, we were able to give a comprehensive overview of the mental health status. To our knowledge, we are the first to evaluate the associations between a healthy lifestyle score and mtDNAc.

Our results should however be interpreted with consideration for some limitations. As mentioned before, the study has a cross-sectional design, and therefore, we cannot assume causality. Secondly, for the lifestyle score, we used self-reported data, which might not always represent the actual situation. For example, BMI values tend to be underestimated due to the overestimation of height and underestimation of weight [ 93 ], and also, smoking behaviour is often underestimated [ 94 ]. Also, equal weights were used for each of the health behaviours as no objective information was available on which weight should be given to a specific health behaviour. Thirdly, there is a distinct time lag between the completion of the BHIS questionnaire and the collection of the BELHES samples. The mean (SD) number of days is 52 (35). This is less than the period for suicidal ideation, assessed over the 12 previous months, but there might be a more limited overlap with the period for assessment of the other mental health variables, such as vitality and psychological distress, assessed over the last few weeks, and depressive and generalised anxiety disorders, assessed over the last 2 weeks. Fourthly, due to a non-response bias, the lowest socio-economic classes are less represented in our study population. This will not affect our dose–response associations but might affect the generalisability of our findings to the overall population. Finally, we do not have data on blood cell counts, which has been associated with mtDNAc [ 95 ].

In this large-scale study, we showed that living a healthy lifestyle was positively associated with mental health and well-being and, on a biological level, with a higher TL and mtDNAc, indicating healthy ageing. Furthermore, individuals with suicidal ideation or suffering from severe psychological distress had a lower mtDNAc. Our findings suggest that implementing strategies to incorporate healthy lifestyle changes in the public’s daily life could be beneficial for public health, and might offset the negative impact of environmental stressors. However, further studies are necessary to confirm our results and especially prospective and longitudinal studies are essential to determine causality of the associations.

Availability of data and materials

The dataset used for this study is available through a request to the Health Committee of the Data Protection Authority.

Abbreviations

Area under the curve

Body mass index

Confidence intervals

Generalised Anxiety Disorder Questionnaire

General Health Questionnaire

Inter-run calibrator

• Mitochondrial DNA content

Patient Health Questionnaire

Relative operating characteristic curve

Short Form Health Survey

• Telomere length

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Acknowledgements

We are grateful to all BHIS and BELHES participants for contributing to this study.

The HuBiHIS project is financed by Sciensano (PJ) N°: 1179–101. Dries Martens is a postdoctoral fellow of the Research Foundation—Flanders (FWO 12X9620N).

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PH drafted the paper. PH, NS, MD and ED set up the design of the study. NS, DM, JvdH, TN and ED reviewed and commented on the manuscript. All authors read and approved the final manuscript.

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Additional file 1: text s1..

TL, mtDNAc and single copy-gene reaction mixture and PCR cycling conditions. Table S1. The mental health indicators with their scores and uses. Table S2. Comparison of the characteristics of the 6,054 eligible BHIS participants that were included in the BHIS subset compared to the 1,838 eligible participants that were excluded from the BHIS subset. Table S3. Comparison of the characteristics of the 739 participants from the BHIS subset that were included in the BELHES subset compared to the 5,315 participants that were excluded from the BELHES subset. Table S4. Bivariate associations between the characteristics and telomere length (TL), mitochondrial DNA content (mtDNAc), the lifestyle score or psychological distress. Table S5. Results of the sensitivity analysis of the association between lifestyle and mental health. Table S6. Results of the sensitivity analysis of the association between lifestyle and the biomarkers of ageing. Table S7. Results of the sensitivity analysis of the association between mental health and the biomarkers of ageing. Fig. S1. Exclusion criteria. The BHIS subset consisted of 6,055 BHIS participants and the BELHES subset consisted of 739 BELHES participants. Fig. S2. Histogram of the lifestyle score. Fig. S3. Validation of the lifestyle score. ROC curve for the lifestyle score as a predictor for good to very good self-perceived health. The model was adjusted for age, sex, region, highest educational level in the household, household composition and country of birth.

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Hautekiet, P., Saenen, N.D., Martens, D.S. et al. A healthy lifestyle is positively associated with mental health and well-being and core markers in ageing. BMC Med 20 , 328 (2022). https://doi.org/10.1186/s12916-022-02524-9

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Association between healthy lifestyle practices and life purpose among a highly health-literate cohort: a cross-sectional study

• Nobutaka Hirooka 1 ,
• Takeru Kusano 1 ,
• Shunsuke Kinoshita 1 ,
• Ryutaro Aoyagi 1 &
• Nakamoto Hidetomo 1  

BMC Public Health volume  21 , Article number:  820 ( 2021 ) Cite this article

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The national health promotion program in the twenty-first century Japan (HJ21) correlates life purpose with disease prevention, facilitating the adoption of healthy lifestyles. However, the influence of clustered healthy lifestyle practices on life purpose, within the context of this national health campaign remains uninvestigated. This study assessed the association between such practices and life purpose, in line with the HJ21.

We performed a nationwide cross-sectional survey on certified specialists in health management. Participants’ demographic information, lifestyle, and purpose in life were measured using a validated tool. The cohort was median-split into two groups based on their clustered health-related lifestyle score. The values for health-related lifestyle and purpose were compared between the two groups and the correlation between health-related lifestyle and purpose in life was measured.

Data from 4820 participants were analyzed. The higher-scoring health-related lifestyle group showed a significantly higher life purpose than the lower group (35.3 vs 31.4; t  = 23.6, p  < 0.001). There was a significant association between the scores of clustered healthy lifestyle practices and life purpose ( r  = 0.401, p  < 0.001). The higher-scoring health-related lifestyle group achieved a higher life purpose than the lower-scoring group. This association between healthy lifestyle practices and life purpose denotes a positive and linear relationship.

Conclusions

Our results suggest that individuals who have a better health-related lifestyle gain a higher sense of life purpose. In other words, a healthy lifestyle predicts a purpose in life. Our findings posit that examining the causal relationship between healthy lifestyle and purpose in life may be a more efficient approach toward health promotion.

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Several studies have investigated the implications of life purpose, and literature has shown that a strong sense of purpose in life was positively associated with positive health outcomes [ 1 , 2 , 3 , 4 , 5 , 6 ]. Thus, having a sense of purpose in life is a vital component of human life. Due to a rapidly aging society in Japan, a national health promotion program in the twenty-first century—Health Japan twenty-first century (HJ21)—considers purpose in life as one of the major target goals of health promotion [ 7 ].

Purpose in life is defined as “a self-organizing life aim that stimulates goals” [ 1 ] and is known to promote healthy behaviors and give life meaning [ 8 , 9 ]. Ikigai is a Japanese word for what is considered an important factor for achieving better health and a fulfilling life [ 10 ]. Ikigai is defined as something to live for, exemplifying the joy and the goal of living [ 11 ]. Although Ikigai may not be fully comparable to purpose in life, it does contain the respective concept and plays a cardinal role in yielding positive health-related outcomes [ 12 ].

Notably, health outcomes associated with life purpose or Ikigai include physical [ 1 , 12 , 13 ] and mental health [ 3 , 13 ], quality of life [ 4 ], disease mortality [ 1 , 12 ], and longevity [ 12 ]. Possessing a strong sense of purpose in life has been associated with a lower risk of mortality and cardiovascular diseases [ 1 ] (relative risk: 0.83 and 0.83, respectively). The study concluded that purpose in life tends to yield health benefits. One of the mechanisms considered in the literature was the benefits associated with a healthy lifestyle. People who have adopted a higher purpose in life tend to follow healthier lifestyle practices, which may decrease the incidence of non-communicable chronic diseases, such as cardiovascular diseases or cancer.

Healthcare personnel are responsible for the health of their patients. Studies have shown that healthcare personnel are more likely to encourage healthy lifestyle behaviors among their patients if they engage in such behaviors themselves. Our study population comprises certified specialists in health management who routinely provide advice on health to individuals in their community. Investigating the relationship between lifestyle and purpose in life among healthcare personnel, our target population, is therefore of great scientific interest.

There is a hierarchy of causality among chronic diseases. Non-communicable diseases, such as diabetes, stroke, cancer, and coronary artery disease, have risk factors. In the case of risk factors, such as hypertension, smoking, dyslipidemia, hyperglycemia, studies typically signified proximal causes [ 14 , 15 ]. A healthy lifestyle is a central causality for these risk factors and thus basic lifestyle should be considered a fundamental and proximal risk factor for the aforementioned non-communicable diseases. Studies also highlight that healthy lifestyle practices prevent many similar chronic diseases [ 16 , 17 ], and that intervening to promote healthier lifestyle decreases mortality due to non-communicable diseases [ 18 , 19 ]. Hence, the notion that health benefits are brought through a healthy lifestyle may be supported if the lifestyle strongly correlates with purpose in life.

In this context, however, research exploring the association between purpose in life and healthy lifestyle practices remain scarce. Moreover, existing literature usually considers a single health behavior in relation to purpose in life. To determine the relationship between purpose in life and clustered health-related lifestyle—the fundamental and proximal cause of many health outcomes—the potential benefits of purpose in life towards disease prevention and health must be deciphered.

This study aimed to investigate the association between health-related lifestyles, in line with the HJ21, and purpose in life, measured with a validated tool to better understand the relational mechanisms.

Study design

The design was a cross-sectional study on a cohort of nationwide certified specialists in health management. We surveyed health-related lifestyles similar to those in the questionnaire used for the HJ21. Our questionnaire is based on the one of the oldest national health surveys around the world, the National Health and Nutrition Survey conducted by Japanese Government [ 20 ]. This survey is the oldest of all national health examination surveys currently conducted worldwide and serves as a comprehensive database for risk factors related to non-communicable diseases in Japan. The survey includes questions on demographic data and health-related habits, such as physical activity and exercise, nutrition and diet, smoking, stress, and alcohol intake. Purpose in life was measured with a validated tool in Japanese using the purposeful life scale (Ikigai-9) [ 21 ]. The ethics committee of the Saitama Medical University approved the study (ID: 896, 2018).

Participants

Study participants were certified specialists in health management who actively pursued professional growth provided by the Japanese Association of Preventive Medicine for Adult Disease [ 22 ]. This certification is sponsored by the Ministry of Education, Culture, Sports, Science and Technology, Japan. We excluded specialists who did not actively engage in continuing education or health promotion activities. These specialists are expected to engage the community and the society they live in to promote health and wellbeing. Specialists in health management are certified in multiple processes of study. Candidates study various aspects within the course, including health promotion, lifestyle-related diseases, mental health, nutrition, environment and health, physical activity and exercise, emergency medicine, life support, and health care system. To register, candidates must pass the final written examination. The Japanese Association of Preventive Medicine for Adult Disease encourages specialists to participate in numerous activities by facilitating health promotion workshops, speeches, and activities after registration. Among these individuals who met our inclusion criteria ( N  = 9149), 4820 agreed to participate in the survey.

Variables and measurements

Variables measured in this study were demographic characteristics; health-related habits, including physical activity and exercise, nutrition and diet, smoking, stress, and alcohol intake; and purpose in life. There were eleven health-related lifestyle questions, of which five were two-scaled (“Intention to maintain ideal weight,” “Exercise,” “Alcohol intake,” “Manage lifestyle to prevent disease,” and “Smoking”). For these items, a score of “1” was assigned for an unhealthy lifestyle and a score of “4” was assigned for a healthy lifestyle. The rest of the six health-related habits (“Reading nutritional information labels,” “Maintaining a balanced diet in daily life,” “Intention for exercise,” “Stress,” “Rest,” and “Sleep”) were to be answered on a four-point scale, from “4” (most favorable) to “1” (least favorable). Finally, we added the values of each answer to the questions on the health-related lifestyle of the participants as their clustered health-related lifestyle scores. To measure purpose in life, we used the Ikigai-9 scale, a validated tool to quantify purpose in life. The Ikigai-9 is a psychometric tool that measures across the dimensions of (1) optimistic and positive emotions toward life, (2) active and positive attitudes towards one’s life, and (3) acknowledgement of the meaning of one’s existence [ 23 ]. The Ikigai-9 scale consists of nine questions on various aspects of life purpose and each question must be answered on a five-point scale, from “1” (Strongly disagree) to “5” (Strongly agree). These variables and measurements were previously described elsewhere [ 24 ]. Considering the variables, age, weight, height, BMI, volume of alcohol intake, and purpose in life scores were numeric. Sex, healthy lifestyle, smoking, alcohol intake, and stress comprised either binary or ordinal data.

Descriptive statistics (i.e., mean, standard deviation, range) were used to describe participants’ characteristics. The cohort was divided into two groups (i.e., a higher and lower group, with a cut-off using the median score) based on the clustered health-related lifestyle scores. The correlations between age and lifestyle score and between age and purpose in life score were analyzed. The difference in the Ikigai-9 score between the two clustered health-related lifestyle score groups was investigated. Further, the effect size of the difference in Ikigai-9 score between the two groups was calculated with using Cohen’s d . The association between the clustered health-related lifestyle score and the Ikigai-9 score was also analyzed as a bivariate correlation and a correlation coefficient was calculated to see whether the health-related lifestyles accounted for life purpose. A multiple regression analysis was performed to determine the association between the clustered health-related lifestyle score and the purpose in life score, after controlling for age. All statistical tests were two-tailed and the software IBM SPSS Statistics (Version 26.0. Armonk, NY) was used for the analysis.

The demographic and health-related lifestyle characteristics of the study participants are shown in Table  1 . In total, 4820 certified specialists in health management were included in the analysis. There were 3190 women (66.2%) and 1630 men (33.8%). The mean ( SD ) age of all study participants was 55.4 (±12.2) years. The majority of the participants (85.0%) were non-obese and “intended to keep ideal weight” and “maintain a healthy lifestyle (82.6% and 89.2%, respectively) to prevent lifestyle-related disease,” such as obesity, metabolic syndrome, and cardiovascular disease. We also found that more than 80% of the study participants “read nutritional information labels” and more than 90% “maintained a balanced diet in daily life.” Regarding exercise and physical activity, more than 80% of the study participants “intended to exercise” and approximately 64% of them achieved the recommended levels. These findings reflected a low rate of obesity among the participants, which was 15.0% in the study. While most of the participants reported resting and sleeping adequately, the rate of taking on stress was high (74.4%). The descriptive analysis of the Ikigai-9 scores confirmed that it was normally distributed, based on the histogram and P-P plot.

Table  2 shows the demographics and healthy lifestyle practices for both the higher and lower clustered health-related lifestyle score groups. We found consistent favorable results in all measured health-related habits in the higher clustered health-related lifestyle score group. There was a significant difference in the scores of purpose in life between the higher group and the lower clustered health-related lifestyle score group ( t  = 23.6, p  < .0001). In the higher group, the average score of purpose in life was 35.3 (95% CI; [35.1–35.5]), while for the lower group, the average score for purpose in life was 31.4 (95% CI; [31.2–31.7]). The differences in the Ikigai-9 purpose in life scores of the two groups and its effect sizes (Cohen’s d) were 3.8 (95% CI; [3.5–4.2]) and 0.68, respectively. Moreover, there was a significant association between the clustered health-related lifestyle score and purpose in life score, r  = .401, p  < .001. The significance remained after controlling for age. Correlation between age and both lifestyle and purpose in life were significant (Pearson r  = 0.29 and 0.15, respectively; both p  < .05).

We found that the higher-scoring clustered health-related lifestyle group showed a statistically significant higher purpose in life than the lower-scoring clustered health-related lifestyle group. The study also highlighted a significant positive association between the clustered health-related lifestyle score and the Ikigai-9 score. To the best of our knowledge, this study was the first to show that a strong sense of purpose in life correlates with clustered health-related lifestyles in the context of a national health campaign. Several studies indicate a positive relationship between purpose in life and health-related lifestyles [ 1 , 25 , 26 , 27 ]. Furthermore, many publications reveal a correlation between a single healthy habit and purpose in life. Therefore, our findings—that affirm a positive relationship between purpose in life and clustered health-related lifestyle—are consistent with previously reported results and help broaden the evidence of this association.

Exploring the mechanistic link of purpose in life with a healthy lifestyle may help us understand this relationship. While studies highlight the positive relationship between purpose in life and health-related lifestyle, a few studies’ results are inconsistent with our findings. For example, an existing prospective study did not observe a positive association between purpose in life and healthy sleep patterns [ 28 ]. In other studies, the purpose of life was not associated with smoking [ 29 , 30 ]. Notably, the mechanistic link between health-related lifestyle and purpose in life has not been well examined. Hooker et al. proposed a hypothesized model linking purpose in life with health [ 31 ]. They summarized the relationship between life purpose and health outcomes by utilizing the concept of self-regulation. In the model, they proposed that life purpose influenced health through three self-regulatory processes and skills: stress-buffering, adaptive coping, and health behaviors. Health-related lifestyle, one of the self-regulatory processes, is the result of individuals setting goals, monitoring their progress, and using feedback to modify their lifestyle [ 31 ]. Thus, a purpose provides the foundation and motivation for engaging in a healthy lifestyle. Kim et al. also suggested that sense of purpose in life enhances the likelihood for engagement in restorative health-related lifestyle practices (e.g., physical activity, healthy sleep quality, use of preventive health care services) from cardiovascular disease to the indirect effect of behavior [ 32 ].

There is an alternative explanation for the mechanistic link between purpose in life and health-related lifestyle. A reverse causality model suggested that engaging in healthy lifestyle practices could predict a greater purpose in life [ 31 , 33 ]. Our results denoted that the group with a higher score in purpose in life performed healthier lifestyle practices and behaviors (Table 2 ), which can be supported by either of the hypothesized models. Age statistically significantly influenced both lifestyle and purpose in life in this study, while gender did not. However, age did not change overall relation between lifestyle and purpose in life. This infers that age may act as a moderator on the association. Further research is needed to clarify the mechanism and the directionality of the association, including any modifying factors. The mechanism to explain the causal relationship between life purpose and healthy lifestyle practices helped prepare for healthy aging by preventing diseases, increasing health longevity, and imbuing a health-oriented drive, which are the major goals of the HJ21.

Additionally, the difference in life purpose scores between the two groups (35.3 vs 31.4), shown in Table 2 , should be further explored, whilst we found a statistically significant difference and a correlation between healthy lifestyle practices and purpose in life. Rather than being a single concept, purpose in life has several elements and a more comprehensive construct. The majority of measurement tools concerned with meaning in life assess two distinct concepts: coherence and purpose [ 34 ]. Coherence is a sense of comprehensibility, or one’s life “making sense,” which is descriptive and value-neutral. Purpose means a sense of core goals, aims, and direction in one’s life, which is more evaluative and value-laden in concept. Ikigai is the Japanese concept meaning a sense of life worth living. The Ikigai-9 scale used in this study has three constructs for measuring the purpose in life; (1) optimistic and positive emotions toward life, (2) active and positive attitudes towards one’s life, and (3) acknowledgement of the meaning of one’s existence. The scale seems to measure more similarly to the purpose; however, the total score does not distinguish between the association of specific constructs and healthy lifestyle practices. Thus, further methodological sophistication regarding the evaluation of a specific concept encompassed within life purpose needs to be reached. This aspect broadens our understanding of purpose in life and its relation to health. This particular cohort of certified specialists shared many features of high health literacy through the process of professional development and certification, combined with life-long learning and activities related to their role as health management specialists. Further, health-related lifestyle practices mean that the certified specialists were far healthier than the national average. These characteristics represent an individual’s health literacy. Health literacy is considered to be an individuals’ capacity to obtain and understand basic health information and services and to make appropriate health-related decisions based on this information [ 35 ]. Therefore, health literacy is directly associated with disease mortality [ 36 ], overall health status [ 37 ], disease prevention [ 38 , 39 ], and health behaviors. These can be attributed to purpose in life [ 2 ].

Thus, health literacy and health-related lifestyle appear to have a similar relationship with disease prevention and better health outcomes. The mediating effect of health literacy on the relationship between healthy lifestyle and life purpose should be investigated. Such inquiries in a prospective cohort study can better explain the mechanism of the causal link between purpose in life, health-related lifestyle, and health literacy.

Limitations

There are several limitations to this study. First, all the measurements were self-reported, which can be a source of bias. Second, while the survey questionnaires are widely used in national health promotion, they have not been fully validated. Third, the real-life meaning of purpose in life has not been determined yet. The Ikigai-9 score, one of the tools used to measure the life purpose score, was validated in a small and limited population; however, the instrument may not capture it holistically. This limitation was implicated by the previously reported systematic review. Furthermore, Zheng et al. found variability in the strength of correlation among the questionnaire for quality of life, part of which included questions regarding a purposeful life [ 40 ]. Lastly, the correlational analysis did not include an adjustment for confounding factors other than age. Hence, little is known about factors influencing the relationship between a healthy lifestyle and purpose in life. We need to establish other potential influencing factors and determine which variables have mediating, moderating, and confounding effects on purpose in life to understand the causal relationship between healthy lifestyle practices and life purpose [ 41 ]. This exploration proposes a promising model for future intervention programs.

Despite these limitations, this study has several strengths. First, the study sample size, N  = 4820, was large and distributed throughout Japan. This aspect of the study increases generalizability. According to the previous review, numerous studies on purpose in life focused on older adults [ 42 ], whereas only a few were concerned with younger or middle-aged adults. In the present study, the majority of the participants were younger and middle-aged adults. Second, previous studies used relatively simple questions or did not employ validated tools to measure purpose in life. However, we used a validated tool, Ikigai-9, in this study. This aspect allows the study results to increase the reliability and validity of the measurement of purpose in life and also hold applicability in other studies. Lastly, study participants were certified specialists in health management who have shown high health literacy. This inclusion criterion provides guidance on improving healthy lifestyle practices through health literacy as an approach to health promotion.

In conclusion, a healthy lifestyle was found to be positively associated with purpose in life among a cohort of highly health-literate professionals. Healthcare personnel who receive specific training for health management may play important roles in promoting a population’s health and wellbeing. However, the mechanism to explain the relationship between purpose in life and health-related lifestyle remains unknown. Therefore, causal relations between improving healthier lifestyles and increasing purpose in life should be tested.

Availability of data and materials

The datasets used in the current study are available from the corresponding author upon reasonable request.

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All authors contributed to the study conception and design. Material preparation and data analysis were performed by Nobutaka Hirooka, Takeru Kusano, and Shunsuke Kinoshita. Nobutaka Hirooka, Shunsuke Kinoshita, and Ryutaro Aoyagi collected the data. Nobutaka Hirooka, Takeru Kusano, and Hidetomo Nakamoto interpreted the analysis. The first draft of the manuscript was written by Nobutaka Hirooka and all authors commented on drafted versions of the manuscript. All authors read and approved the final version of the manuscript.

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Hirooka, N., Kusano, T., Kinoshita, S. et al. Association between healthy lifestyle practices and life purpose among a highly health-literate cohort: a cross-sectional study. BMC Public Health 21 , 820 (2021). https://doi.org/10.1186/s12889-021-10905-7

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Sustainable lifestyles: towards a relational approach

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The concept of sustainable lifestyles is said to have reached the limits of its usefulness. As commonly understood, it impedes an effective response to our increasingly complex world, and the associated societal challenges. In this context, the emerging paradigm of relationality might offer a way forward to renew our current understanding and approach. We explore this possibility in this study. First, we systematize if, and how, the current dominant social paradigm represents a barrier to sustainable lifestyles. Second, we analyze how a relational approach could help to overcome these barriers. On the basis of our findings, we develop a Relational Lifestyle Framework (RLF). Our aim is to advance the current knowledge by illustrating how sustainable lifestyles are a manifestation of identified patterns of thinking, being, and acting that are embedded in today’s “socioecological” realities. The RLF revitalizes the field of sustainable lifestyle change, as it offers a new understanding for further reflection, and provides new directions for policy and transformation research.

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Introduction

Sustainable lifestyles are of vital importance for social and ecological transformation towards sustainability (IPCC 2014 ; IGES 2019 ; Akenji and Chen 2016 ; Gilby et al. 2019 ). Sustainable lifestyles make reference to the possibility that human and other life can flourish on the planet forever (Ehrenfeld 2008 ). However, major changes are necessary to achieve this goal, as lifestyles are said to be difficult to alter. Moreover, even if there is a willingness to live sustainably, many people fail to make the necessary changes (Mont and Power 2010 ; Van Vliet et al. 2005 ).

It is increasingly understood that sustainable lifestyles are not a simple matter of changing habits and behaviors. Instead, they require deep, systemic changes that presuppose new ways of living, communicating, feeling, and thinking (Gilby et al. 2019 ; Bengtsson and Akenji 2010 , Lorek 2010 ; Rijnhout and Lorek 2012 ; Gifford et al. 2018 ; Mao et al. 2019 ).

Nonetheless, the term ‘sustainable lifestyles’ is commonly used interchangeably with ‘behavioral change’, to refer to pro-ecological, frugal, altruistic, and equitable behaviors in all areas of life, including diet, energy use, mobility, or political orientation and engagement (Corral-Verdugo 2012 ; DeYoung 1993 ; Schultz 2001 ; Rijnhout and Lorek 2012 ; IGES 2019 ). Moreover, common sustainable lifestyle frameworks separate the personal from the structural and the cultural dimension and/or address them hierarchically (e.g., Akenji and Chen 2016 ). Although it is understood that behavior is not separate from its context, sustainable lifestyles are often treated as a linear problem in which misbehavior can be fixed. In addition, they are often framed as individual endeavors, and their potential is thus marginalized due to a lack of influence and scale (Paech 2012 ; WBGU 2011 ). These misconceptions, we will argue, overlook the possibility of driving deep, systemic changes towards a flourishing future, as they are based on an outdated paradigm that is also reflected in the current scientific approaches.

Dominant social paradigms underlie deep, systemic structures, mechanisms and changes (Meadows 1999 ; Wamsler et al. 2018 ; Kagan 2010 ; Ives et al. 2019 ; Fischer and Riechers 2019 ) and can thus be both a barrier to or driver of sustainable lifestyles. They not only influence us personally (e.g., via our motivation, values, attitudes, psychological make-up), but also shape our structures (e.g., economic, infrastructural, institutional) and cultural contexts and associations (e.g., narrative frames and cultural norms) (Akenji and Chen 2016 ; Gilby et al. 2019 ; Gifford 2011 ; Schösler and Hedlund de Witt 2012 ; Shove et al. 2012 ; Sorin 2010 ; Lakoff 2014 ; Wahl 2016 ; Escobar 2017 ; Orr 2002 ).

Thomas Kuhn ( 1996 [1962]) gave the term ‘paradigm’ its contemporary meaning, defining it as a set of practices that provide model problems and solutions for a community of researchers. On this basis, Pirages and Ehrlich ( 1974 :23) wrote that paradigms are “… the socially relevant part of a total culture. Different societies have different dominant social paradigms.”

Hence, political, economic, and social systems, as well as the tools we use (i.e., electronic devices, vehicles, and machinery), are a reflection of society’s dominant paradigm (Wahl 2016 ; Orr 2002 ). Accordingly, lifestyles are particularly interesting to investigate in regards to paradigms, because—as we will explore in this article—they are a manifestation of each of these aspects.

Although we know that dominant social paradigms can be a barrier to, or a driver of sustainable lifestyles, the relationship between them has not been sufficiently investigated. The current theoretical efforts can be divided into psychologically-grounded, culturally-grounded, or structurally-grounded approaches. Psychologically-grounded approaches theorize causal relations between inner worlds and behaviors. Examples include the Theory of Planned Behavior (Ajzen 1991 ) and its extension, the reasoned-action approach, which offers an integrative framework to predict and change human social behavior (Fishbein and Ajzen 2010 ). Other examples are the Value Belief Norm Theory (Stern and Dietz 1994 ), the Needs-Opportunities-Ability model (Gatersleben and Vlek 1998 ; OECD 2002 ) and the New Environmental Paradigm (Dunlap 2008 ). Culturally-grounded approaches focus on social norms and behaviors. Examples include narrative frames and the communication of cultural norms (Nisbet and Mooney 2007 ), and social marketing (Thaler and Sunstein 2008 ). Structurally-grounded approaches theorize about how (infra-)structural measures cause behavior change (Akenji and Chen 2016 ). Examples include the provision of car sharing services, the availability of organic and fair trade foods and goods, or renewable energy. Yet, none of these approaches investigate the underlying paradigm and its relation to sustainable lifestyles.

The Integrative Worldview Framework (Hedlund‐de Witt 2012 ), which comes closest to addressing the relationship between paradigm and lifestyles, focuses on worldviews. Hedlund Dewitt draws the distinction between worldviews and paradigm as follows: “While a paradigm tends to define what is valid and what is not for the whole of the ideological constellation of a given time and place, the worldview concept, in contrast, potentially aims to explicate and acknowledge the existence of different viewpoints” (Hedlund-de Witt 2012 :20). This approach therefore addresses worldviews, which may differ for each individual (Pirages and Ehrlich 1974 ), in contrast to the notion of the paradigm as elaborated here, which addresses the “total culture” (Pirages and Ehrlich 1974 :23).

Against this background, this article aims to explore the theoretical linkage between paradigms and sustainable lifestyles by showing how the current dominant social paradigm, which we refer to as a mechanistic paradigm, may hinder sustainable lifestyles. We will then discuss how an emerging paradigm, which we refer to as a relational paradigm, may offer more effective pathways toward understanding and achieving sustainable lifestyles.

Accordingly, our study is based on a three-step methodology: First, we systematize the existing literature to identify if, and how, the mechanistic paradigm correlates with barriers to sustainable lifestyles ( The mechanistic paradigm and its implications for sustainable lifestyles ). Second, we analyze how a relational paradigm can help overcome common barriers by exploring and systematizing relational patterns ( How a relational paradigm can help overcome common barriers to sustainable lifestyles ). Based on the results, we then develop and discuss a conceptual framework that delineates a relational approach to sustainable lifestyles ( Discussion ). The resultant Relational Lifestyle Framework (RLF) underlines that sustainable lifestyles are a manifestation of patterns of thinking, being, and acting that are embedded in socioecological realities. It reframes sustainable lifestyle change and argues that relational lifestyles are a more comprehensive framing. It advances the current knowledge and revitalizes the field of sustainable lifestyle change by opening new policy pathways, offering a new frame for reflection, and giving directions for future transformation research and practice.

The mechanistic paradigm and its implications for sustainable lifestyles

In this section, we analyze how the dominant social paradigm may hinder sustainable lifestyles. We begin with a brief overview of its characteristics ( What is the dominant social paradigm ) and then exemplify how it might foster or hamper sustainable lifestyles ( How does the mechanistic paradigm hinder sustainable lifestyles? ).

What is the dominant social paradigm?

The dominant social paradigm, which structures society’s beliefs and perceptions of the modern world (Kilbourne et al. 2002 ), can also be referred to as the mechanistic paradigm. It is considered to be endemic to Western and industrialized civilization (Kilbourne et al. 2002 ). As the name suggests, the basic idea is that the world functions as a machine (Peitgen et al. 1994 ). It assumes that if one has full knowledge of the exact state of a given object at a point in time, and knows the interactions informing that state, then its future state could be reasonably determined as a result of prediction. This assumes that the act of observation itself can be independent of the factors considered to influence phenomena. The mechanistic paradigm is rooted in modernity, emerging out of the Scientific Revolution (14–sixteenth centuries), the Renaissance (14–seventeenth centuries), and the Enlightenment (starting in the eighteenth century). Modernism offered a secular understanding of the world in which individuals were understood as individualistic, materialistic, and competitive (Peat 2002 ; Lent 2017 ). One of its outcomes was the conquest of nature (Swilling 2019 ). Although postmodernism questions and critiques modernity, it fails to confront the systemic nature and root causes of the current challenges, due to its “relativism and its antipathy to integrated knowledge and meta-level understanding” (Bhaskar et al. 2016 :2). The ideas of modernity therefore continue to dominate in many parts of the world (Nicholson and Dupré, 2018 ).

The mechanistic paradigm is characterized by rationalism, reductionism, empiricism, dualism, and determinism—approaches which are said to be inadequate to address the complex systemic challenges of sustainability (Capra and Luisi 2014 ; Corral-Verdugo 2012 ; Escobar 2017 ; Haraway 2016 ; O’Brien 2020 ; Wahl 2016 ). Three common patterns that are endemic to this way of understanding the world have been identified (Redclift and Sage 1994 ; Rees 1999 ; Capra and Luisi 2014 ):

Pattern 1: Humans are separate from and above nature.

Pattern 2: Humans are able to control nature.

Pattern 3: Nature is a machine, and can be known and addressed by reducing it to its parts

In the following, we exemplify how these three patterns hinder sustainable lifestyles.

How does the mechanistic paradigm hinder sustainable lifestyles?

In the following, we exemplify six requirements for supporting sustainable lifestyle approaches, together with policies and practices, and point out how a mechanistic paradigm might impact these.

Sustainable lifestyle policies and practices require motivation (Akenji and Chen 2016 , 15). The dualistic framing of humans and nature as two separate aspects of reality (pattern 1) presents humans as distinctly different from the nonhuman world. Hence, there is little motivation to preserve the nonhuman (Du Plessis 2012 ; Schultz 2001 ). Research on the ‘connectedness to nature scale’, for example, suggests that the perception of a connection to the more-than-human world is predictive of the motivation to engage in responsible environmental behavior (Mayer and McPherson 2004 ).

Sustainable lifestyle policies and practices require a perception of behavioral control (Fishbein and Ajzen 2010 ). Understanding oneself as separate from the larger world (pattern 1) can result in a sense that individual actions are insignificant, and hence one might not even try to change, as it does not seem to matter (O’Brien 2020 ). This sense of insignificance and meaninglessness is a common symptom of postmodernity and is said to result from the separation between the individual and the greater whole (Freinacht 2017 ; Alexander 2010 ).

Sustainable lifestyle policies and practices require sufficiency (Hickel 2020 ; Paech 2012 ). Although sufficiency, which can be described as a reduction in consumption, is considered to be the least desirable way forward (Folkers and Paech 2020 ), many studies have shown that economic growth cannot be totally decoupled from ecological impacts; sufficiency should, therefore, supplant growth as an overarching economic goal (Raworth 2018 ). However, the idea that humans are able to control nature, and that nature is a machine that can be known by reducing it to its parts (patterns 2 and 3) evokes a hierarchy of power, leading to a mentality of ‘me versus’ instead of ‘me and’. It therefore fosters competition rather than co-creation (Capra and Luisi 2014 ). When individual existence is based on competition, a sustainable lifestyle is associated with scarcity, renunciation, and constraints, along with feelings of being regulated and limitations on individual freedom (Verlie 2017 ).

Sustainable lifestyle policies and practices require deep, systematic change (Lorek 2010 ). The idea that humans are able to control nature (pattern 2), and that nature is a machine that can be known by reducing it to its parts (pattern 3) means that there is a strong reliance on business-as-usual technological fixes that emphasize consistency (changing one mode of development for another more sustainable one) and efficiency (IPCC 2014 ; Schäpke and Rauschmayer 2014 ). The idea here is that through better technology, nature can be controlled ad infinitum. Climate engineering is one example. Climate engineering tries to control climate change using new technologies without addressing its underlying causes. Sustainable lifestyle policies and practices that focus on changing technology, without questioning the underlying patterns are unable to create systemic change. They merely support the status quo (Gilby et al. 2019 ) and therefore do not create circumstances that support sustainable lifestyles.

Sustainable lifestyle policies and practices require valuing personal and planetary wellbeing. When humans are thought to be separate from nature (pattern 1), personal health and social and ecological health appear unrelated. For example, recent theories point to the possible loss of a connection to people and places, and an overarching narrative, which may result in addiction, depression, and a decrease in personal wellbeing (Hari 2019 ; Schaef 1988 ; Alexander 2010 ). The lack of a connection fosters a tendency to care for personal health first and foremost, with no regard for any social and environmental consequences (Verlie 2017 ; Sonu and Snaza 2015 ). There is insufficient consideration of how to merge planetary boundaries with personal and societal wellbeing (Gilby et al. 2019 ; Büchs and Koch 2019 ). Movements, such as Degrowth (Folkers and Paech 2020 ), Minimalism (e.g., Fields Millburn and Nicodemus 2011 ), and Voluntary Simplicity (e.g., Elgin 1977 ; Shaw and Newholm 2002 ) emphasize the personal freedom and wellbeing that comes with living a life of less consumption, and link sustainable development with notions of quality of life. Yet, the connection between quality of life and reduced material consumption still runs counter to mainstream ideas within the current paradigm (Gilby et al. 2019 ).

Sustainable lifestyle policies and practices require valuing social and ecological justice (Klein 2014 ; Walsh et al. 2020a , b ; Swilling 2019 ). The separation of humans from nature (pattern 1) often encompasses a separation between the individual and the collective, contributing to both social and ecological injustice. Although their inseparability is increasingly discussed and recognized by sustainability experts, they are mostly thought of as different phenomena without due consideration to their underlying and interrelated systemic and historical conditions (Schönach 2016 ; Mercure et al. 2016 ).

How a relational paradigm can help overcome common barriers to sustainable lifestyles

The relational paradigm represents a shift from a mechanistic understanding of the world to a holistic, interconnected, living systems understanding (e.g., Capra 1997 ; Kumar 2002 ; Raskin et al. 2002 ). It is not a new paradigm, Footnote 1 but rather a rediscovery, by scholars of the western, industrialized world, of lines of thinking that can be found in Eastern mysticism and religious traditions, in the work of Western thinkers such as Baruch Spinoza (Naess 1977 ) and Alfred North Whitehead ( 1978 ), as well as in deep ecology (e.g., Naess 1977 ), ecofeminism (e.g., Plumwood 1993 ), and Indigenous philosophies (e.g., Salmon 2000 ). It is reinforced by recent scientific discoveries, such as quantum physics and ecology (as pointed out by Walsh et al. 2020a , b ).

Moreover, there is a growing body of sustainability science literature that addresses relational approaches with respect to their potential for sustainability transformations. Illustrations include relational ontologies as leverage points (West et al. 2020 ), relational values for pro-environmental behaviors and wellbeing (Thiermann and Sheet 2020 ; Jax et al. 2018 ; Helne and Hirvilammi 2015 ; Schulz and Martin-Ortega 2018 ) or relational epistemologies for ecosystems research (Hertz et al. 2020 ; Mancilla Garcia et al. 2020a , b ) and sociotechnical change (Chilvers and Longhurst 2015 ).

At the same time, there are communities that are based on a relational paradigm or way of living. Notably, many indigenous cultures have a longstanding history of engaging in knowledge production practices that emphasize more-than-human relational ontologies (Todd 2016 ). For instance, the Kogi, an indigenous ethnic group in northern Colombia, acknowledge that everything is interconnected, and live according to this understanding (Buchholz 2019 ). Another example is the philosophy found in sub-Saharan Africa, in which the two most important concepts are Ubuntu and Ukama. Ubuntu refers to relational humanness, and Ukama means the relatedness of everything (Murove 2009 ). Similarly, the Latin American philosophy of Buen Vivir refers to the right way of living, or Good Living, and relationality is one of the four principles that defines this way of living and being (Akosta 2015 ).

The following Sects ( Pattern I: from separation to interconnection , Pattern II: from human agency to intra - action with the more - than - human , Pattern III: from individuals to dividuals , Pattern IV: from control to emergence , Pattern V: from mind - body dualism to embodiment , Pattern VI: from individual well - being to relational well - being , Pattern VII: from meaninglessness to meaningfulness ) analyze how a relational paradigm could help overcome the barriers to sustainable lifestyles identified above ( The mechanistic paradigm and its implications for sustainable lifestyles ). We identify seven key patterns based on an extensive literature review by Walsh et al. ( 2020a , b ), which analyzes the relational paradigm in terms of its ontological, epistemological, and ethical dimensions. We then discuss how the identified patterns may influence sustainable lifestyles by drawing on examples of how they affect policies and practices.

Pattern I: from separation to interconnection

The relational paradigm considers that humans and nature are linked. It views the world as an interconnected, complex, and adaptive socio–ecological system that is constantly in flux (Walsh et al. 2020a , b ). Humans are a part of nature and co-create with the more-than-human world (Abram 2010 ) instead of merely using nature for their benefit. According to Spretnak:

“all entities in the natural world, including us, are thoroughly relational beings of great complexity, who are both composed of and nested within contextual networks of dynamics and reciprocal relationships. We are made entirely of relationships, as is the whole of the natural world” (Spretnak 2011 :4).

The interconnection between humans and the more-than-human world implies that the divide between nature and culture is socially and historically constructed. This has led to what has been called a postnatural ontology of the Anthropocene (Küpers 2020 ), also referred to as ‘natureculture’ (Haraway 2003 ). From this perspective, nature and culture, or social and ecological, are not two separate interacting systems, but rather one autopoietic (self-maintaining and reproducing) system, in which humans are one participant among many others. Feeling and understanding the connection to the more-than-human world might lead to caring more for the general wellbeing of the whole system and marginalized groups within that system (Plessis 2012 ), since one part cannot be healthy if the whole is not healthy. This highlights that various forms of social and ecological injustice are interrelated. It is, therefore, necessary to align human developmental models with justice frameworks, and the healthy development of natural systems, instead of equating human development with economic and technological progress (Plessis 2012 ; Pirages and Ehrlich 1974 ).

A further consequence of seeing oneself as interconnected with both humans and nonhumans is that it may foster empowerment. Although sustainable lifestyles are contextualized as part of a sustainable future (WBGU 2011 ; Buenstorf and Cordes 2008 ; World Watch Institute 2008 ), they are often marginalized as they are considered to be an inefficient driver for sustainability transformations. “The notion of people as active agents of change towards sustainability is by no means widely accepted and conflicts with some of the current, dominant belief systems and worldviews” (Wamsler et al. 2020 :234). When the individual is seen as just that, the person remains isolated from the rest of the world, and sustainable actions seem insignificant and insufficient (O’Brien 2020 ; Wahl 2016 ).

However, when one sees oneself as an inherent and equal part of the world, personal lifestyle choices are not a private act, but instead may produce unexpected social dynamics (Draper 2013 ; O’Brien 2020 ). As any human is always part of a system that he or she influences and that is influenced by the person, the concept of sustainable lifestyles needs to move away from the idea of being an individual endeavor towards having systematic relevance. For example, a common discussion when trying to live a sustainable lifestyle is whether social issues matter in the face of climate change, based on the argument that the ecological foundation matters more than the social. Others argue that the root cause lies in economic or other systems and structures. Yet, understanding the relational nature of things, that the social and the ecological are not separate from each other, and addressing the relation between these aspects across personal, collective and system levels, is important (Walker et al. 2015 ; Smartt Gullion 2018 ). From this perspective, sustainable lifestyles are not either a social or an ecological endeavor, but “socioecological”.

Pattern II: from human agency to intra-action with the more-than-human

The physicist–philosopher Karen Barad ( 2007 ) takes the idea of interconnection a step further and argues that agency is not possessed by individual things or beings but emerges through relationships. Her approach, which is referred to as ‘agential realism’, is derived from understanding the inseparability of subjects and objects, and recognizes the ways humans invariably participate in the nonhuman world. By dissolving the subject-object dichotomy, the phenomena of unsustainability, as manifested in climate change for example, is not merely human-induced, but can be understood as co-produced by carbon and humans (as well as other more-than-human forces and entities) (Verlie 2017 ). Together, these constitute entanglements of human and nonhuman materiality. This entanglement results in what Barad refers to as intra-action (Barad 2007 ). We become-with carbon by being affected by carbon’s agency in less tangible and measurable ways (Haraway 2016 ).

Clearly, living a sustainable lifestyle includes sustainable actions, such as reducing one’s carbon footprint, but it does not end there. The relational paradigm acknowledges that because we are always intra-acting with the world, our influence is much broader. At the same time, we cannot fully predetermine or control our actions. We can, therefore, also create unanticipated consequences (diffractions) with the world, rather than upon the world (Haraway 2016 ; Verlie 2017 ; Barad 2007 ). For example, a simple climate action such as recycling can have unanticipated consequences, as Verlie ( 2017 ) describes. The latter author points out how one of her students started recycling to live a more sustainable lifestyle, but her determination made her increasingly aggressive towards her housemates who did not share her dedication. So-called ‘climate killjoy subjectivity’ (killing joy through the way people engage with the climate crisis) can be the outcome. This illustrates the influence and limitations of human agency and decenters the human, acknowledging that sustainable lifestyles are co-produced with other beings, systems, and forces (Pickering 1995 ; Latour 2005 ; Barad 2007 ; Abram 2010 ; Bennett 2010 ).

This recontextualization of the human as part of, rather than as dominating the human-Earth system is expressed in Küpers’ ( 2020 ) desire to rename the Anthropocene (meaning the ‘human epoch’) as the Ecocene, which decenters the human and acknowledges a relational approach. Decentering the human and attending to what we might be able to intra-act and become-with increases our capacities to respond to unsustainability (O’Brien 2016 ). Instead of working upon the world, humans work with the world and foster the capacity to respond to unsustainability in previously unthought ways. Sustainable lifestyles are, in this understanding, no longer approached from a normative viewpoint, based on exclusive human agency (as follows from human exceptionalism); rather, they follow from the perspective that we are a species living in conjunction with our kin, intra-acting with other agents, instead of controlling them (Verlie 2017 ).

Barad ( 2007 ) argues for the inseparability of ethics (acting), ontology (being), and epistemology (knowing) as a tri-partite constellation, also referred to as ethico-onto-epistemology, that does not presuppose subject-object and nature-culture binaries (Barad 2007 ; Escobar 2017 ; Kassel et al. 2016 ; Walsh et al. 2020a , b ). We use the following definitions (based on Walsh et al. 2020a , b ): ontologies describe what is taken to be real; epistemologies describe how we come to know the world; and ethics describe what is right and wrong. Sustainable lifestyles that are based on a relational paradigm thus demand ethical, ontological, and epistemological transformations.

Pattern III: from individuals to dividuals

Identities come into being “through relationships which are ever changing and constituted at multiple scales” (Neely and Nguse 2015 :141). Humans are and become-with their environment (Faber and Stephenson 2011 ), and the environment constitutes part of the mind (Clark and Chalmers 1998 ). Gregory Bateson saw the idea of a separate individual as a root cause of our multiple crises and argued that humans are essentially symbiotic with their environment (Bateson 2002 ). To facilitate a shift in perspective that helps to understand oneself as being and becoming through relationships, individuals can be conceived of as dividuals (Wahl 2016 ).

Moreover, identities and the boundaries between them are sociomaterially and performatively reconfigured. They can be understood as superpositionalities: emerging “through the ongoing interference of natural cultural waves (such as gender and climate change); superpositionalities are momentarily articulable sociomaterial relational locations which are both situated and dynamic” (Verlie 2017 :12). The concept of superpositionality implies that economic, social, physiological, emotional, or ecological positionalities result in dynamically configured power hierarchies (Barad 2007 ; Haraway 2016 ; Verlie 2017 ). These hierarchies cannot be erased but are instead constantly reconfigured through intra-action. The concept of intersectionality applies this perspective to the burgeoning literature on intersectional identity politics (Verlie 2017 ). It implies not only the social and political context, but also the historical context, as well as the unique experiences of an individual.

Understanding that dividuals are superpositionalities helps us attune to how we are all a “wave of possibility” (O'Brien 2020 :26) informed by dominant sociomaterial (Verlie 2017 ) or socioecological (see Pattern I: from separation to interconnection ) configurations of power. This may offer an even stronger frame for empowerment towards sustainable action (O’Brien 2016 ). When moving towards a sustainable lifestyle, seeing oneself as a dividual explains why sometimes, despite one’s best intentions, actions fail. The dividual that attempts to make the change is subject to the constraints of their environment. This frame also better-addresses injustices, and the fact that they have emerged from multilayered, systemic, environmental, and institutionalized influences. It therefore removes the blame from the individual and shifts it towards a personal and collective endeavor to overcome injustices. Research shows that approaches that focus less on the individual, and more on the collective, group and mutual support make change more likely (Darnton 2008 ; Sustainable Consumption Roundtable 2006 ; McLoughlin et al. 2019 ). Collective approaches to injustice are therefore a key component for sustainable lifestyles, whilst at the same time they support individual capacities and agency for transformation (cf. Pattern II: from human agency to intra - action with the more - than - human ).

By perceiving oneself as a dividual, relational values emerge that are conducive to a sustainable lifestyle. Values define what leading a good life means (Hedlund-de Witt 2012 ). Relational values are increasingly studied in the context of sustainability (e.g. Klain et al. 2017 ; Thiermann and Sheet 2020 ; Jax et al. 2018 ; Helne and Hirvilammi 2015 ; Schulz and Martin-Ortega 2018 ), and this shift illustrates that valuing the more-than-human world only for its functionality rather than its intrinsic worth, may lead to overexploitation. In simple terms, it is, for example, easy to cut down a tree when considering only its monetary as opposed to its intrinsic value.

Pattern IV: from control to emergence

Intra-action results in emerging phenomena that can be reinterpreted as a materio-culture or a socio-nature (Arias-Maldonado 2015 ). Emergence is a process by which a whole becomes greater than the sum of its parts. New and often unpredictable properties of the whole emerge out of the intra-actions of its individual elements and are irreducible to them. A molecule, a cell, a human being, a community, and the planet can each be understood as an emergent phenomenon (Wahl 2016 ). These living systems are not static configurations of components; they are rather continual flows of matter and energy whose form is maintained over time.

On the one hand, this perspective links a living system closely to metabolic and developmental processes. On the other hand, it raises the question of whether life itself is an emergent phenomenon. Maturana and Varela ( 1987 ) refer to life as structural couplings that create autopoiesis, defined as the self-making by which one brings forth a world. From this point of view a system is not static, but instead is constituted through patterns of relationships and interactions that emerge. The latter do not emerge randomly, but are based on structural couplings that stabilize over time. Synergetic relationships, for example, create new system properties through cooperative interactions. The process of emergence shapes sustainable lifestyles, for instance if we consider phenomena such as rebound or spillover effects. Rebound effects, for example, show that energy efficiency in one area may lead to increased energy use in another area. Spillover effects show that improving one area, such as eating vegan food, may lead to improvements in another area, such as only purchasing organic food. These phenomena emerge from a complex, dynamic process that is uneven and contingent, meaning that what unfolds cannot be fully controlled (Küpers 2020 ). Hence, developing an understanding of the phenomenon of emergence also helps to overcome the belief that humans are meant to dominate and control the nonhuman world, and to understand why we should always consider how and why (human and nonhuman) agents are affected and influenced by an individual decision (Swilling 2019 ). From the perspective of a mechanistic paradigm, the agent who takes sustainable action is presumed to be an autonomous, independent entity that acts upon the world rather than one that acts and emerges with it (Dürbeck et al. 2015 ; Verlie 2017 ). From a relational perspective, humans and unsustainability do not pre-exist, but are co-emergent. This offers a broader context for understanding and advancing individual sustainable actions.

An example that illustrates this point is meat consumption. Consuming meat can harm our own health, animals, and the environment. Therefore, the interpretation might be that a sustainable lifestyle involves not eating any meat, independent of the context and any alternative ways to produce and consume food. However, how we become-with these animals needs to be considered (Haraway 2003 ). The question then becomes: what would a sustainable lifestyle look like that decenters the human and recognizes nonhuman agency? The answer is not a clear-cut, one-size-fits-all response (as is often given by sustainable lifestyles informed by a mechanistic paradigm). It is rather the ability to learn to listen and understand nonhuman agents, and to create unanticipated, creative, context-specific, different actions (diffractions) with these agents (Verlie 2017 ).

Pattern V: from mind–body dualism to embodiment

Ever since Descartes observed, “I think therefore I am,” the mind and body have been considered as separate entities (Hedlund-de Witt 2012 ; Lange 2018 ). The mind is understood as observing the world, independent of the body and the context. In the mid-twentieth century, philosophers like Edmund Husserl and Maurice Merleau-Ponty pointed out that the self, including the mind, cannot exist in an abstract sense (Sterling 2003 ). Instead, it is derived from the experience of phenomena, and experience fundamentally depends on our body and our emotions. The field of constructivist developmental psychology, for example, conceptualizes individuals as constructing knowledge through their interaction with the world (e.g., Kohlberg 1984 ; Loevinger 1977 ). The body is the starting point of experience (Pelluchon 2019 ; Toadvine 2019 ). Merleau-Ponty’s phenomenological approach views sensing and perceiving as not merely confined to the realm of matter and ideas, but as having expressive qualities (Küpers 2014 ). Living, embodied beings are constantly exchanging with the environment, continually co-creating together (Küpers 2020 ). Barad ( 2007 ) supports this notion that objectivity is contextual and embodied. She emphasizes that lived and embodied experience are crucial to addressing complex sustainability challenges (Barad 2007 ; O'Brien 2016 ).

Through embodied awareness, humans can learn to acknowledge their relations to other human and nonhuman agents through relearning to sense, listen, perceive, and respond in caring ways (Küpers 2020 ). Care for the nonhuman, in return, has been shown to increase personal wellbeing (Jax et al. 2018 ). When the body is understood as the starting point of experience, inter-being becomes apparent, because nourishment of the whole being connects the person’s body with other bodies (air, food, sunlight, etc.) (Pelluchon 2019 ). Seeing the world as nourishment implies that “we insist on the conditions of existence that are at once biological, social, and environmental, ceasing to separate man from nature” (Pelluchon 2019 :2). This helps articulate an ecology that emerges from the experience of the human condition, which offers a little-explored path to taking sustainable action (Pelluchon 2019 ). It implies an ethics that focuses on the self as constituted by its relations to other beings, in which care for others becomes care for oneself (Groenhout 2004 ).

Understanding embodiment as a form of knowing the world sets it apart from the dominant form of knowing-that, which Vervaeke refers to as propositional knowing (Vervaeke 2013 ). Propositional knowing is the knowing that is found in making conceptual maps. Although helpful, over-reliance on such maps can be misleading as they reduce reality (i.e., the map is not the territory). According to the systems theorist Nicholas Taleb, phenomenological knowledge is more likely to be anti-fragile than propositional knowledge (Taleb 2013 ). This does not imply that propositional knowledge should be abandoned, however. Instead, if it is enriched through phenomenological knowledge, it opens up space for more creative and applicable ideas to emerge.

For example, reducing carbon emissions can be a challenge for individuals. Here, it is helpful to rely on propositional knowledge that points out the increase in atmospheric carbon, and its consequences. Nevertheless, we are likely to be more willing to act if we also experience the effects of a rise in carbon emissions, in the form of, for example, climate hazards, climate grief, or climate anxiety. Allowing and combining different forms of knowledge and associated emotions can, therefore, be a more efficient catalyst for sustainable action.

Pattern VI: from individual well-being to relational well-being

The mechanistic paradigm focuses on the wellbeing of the individual as a part that is disconnected from the greater whole. As noted above, the result is that sustainable living is often associated with a decrease in wellbeing due to it being framed around negative consequences such as discomfort, inconvenience, and sacrifice (Vertugo 2012 ). Yet research shows that the opposite is often true. Many scholars show that sustainable lifestyles are closely linked to wellbeing (Ericson 2014 ; Brown and Kasser 2005 ; Amel et al. 2009 ). They are increasingly highlighting how individual wellbeing can mutually benefit ecological and collective wellbeing, rather than being incompatible with it (e.g., Brown and Kasser 2005 ; Jacob et al 2009 ).

For example, human wellbeing is closely related to two factors: a sense of autonomy and a sense of belonging. Both are equally important (Hüther 2013 ). This is supported by research showing that health and wellbeing are strongly dependent on social foundations and the associated social paradigm (Aknin et al. 2019 ; Helliwell et al. 2017 ). For example, poor social relationships are linked with a mortality risk that is similar to tobacco and alcohol use, and have a more significant impact on wellbeing than physical inactivity and obesity. Similarly, environmental factors play a key role in developing and regulating the immune system, gene expression, and brain function (Gallon 2020 ).

Bacteria and other gut microorganisms influence physiological processes, but they also affect our psychological wellbeing (Lorimer 2020 ; Spretnak 2011 ). Researchers have investigated the importance of intestinal flora. From the moment we are born, we are populated by billions of living things. Bacteria colonize our skin and the interior of our body, and interact with us physically and psychologically. Studies show that the composition of the bacteria in our intestines, our so-called microbiome, influences how we feel, and our characteristics. And, vice versa, our moods have a significant influence on our intestinal flora (e.g., Tasnim et al. 2017 ; Spretnak 2011 ).

Social and environmental factors then underpin personal wellbeing, as it emerges through interactions. Recent studies have therefore shifted the focus from subjective to relational wellbeing (e.g., Jax et al. 2018 ; White 2015 ). A sustainable lifestyle based on a relational paradigm recognizes that personal health and wellbeing are interconnected to social and ecological wellbeing. Health issues are then not merely thought of as a personal matter, but instead become a socio-ecological one. If, for example, we suffer from phosphorus deficiency, the solution may not be to take supplements, instead it might require exploring soil health, and a shift toward regenerative agriculture.

Pattern VII: from meaninglessness to meaningfulness

A lack of meaning can lead to unsustainable behaviors such as compulsive consumption and is thus key to understand sustainable lifestyles (Hari 2019 ; Zerach 2016 ). Some authors refer to the root cause of our current multiple crises as a meaning crisis (e.g., Schmachtenberger 2019 ; Vervaeke 2019 ). Merleau-Ponty’s analysis of sense-making explains why meaning-making matters for a sense of wellbeing. The former term is closely associated with meaning-making, and is often used interchangeably. Even simple organisms make sense of the world by transforming it into an environment with salience, meaning, and value (Thompson and Stapleton 2008 ). If sense-making is an inherent part of each autonomous being, not being able to make sense of the world can decrease wellbeing. This is acknowledged in research that refers to eudaemonic, rather than hedonic wellbeing, which considers that a sense of meaning is an essential constituent of wellbeing in general (Stone and Mackie 2013 ). In the context of sustainable lifestyles, a shift from hedonic wellbeing (focused on subjective feelings) to eudaemonic wellbeing (focused on meaning) might also lead to a shift from more to less resource-intensive consumption patterns (Brown and Kasser 2005 ).

Two centuries ago, Nietzsche pointed out that modernity led to a sense of meaninglessness. Today, various philosophical and sociological analyses have explored the connection between meaninglessness and psychological disorders (e.g., Hari 2019 ; Alexander 2010 ; O’Brien 2016 ). These analyses point out that the experience of meaninglessness can result from various factors, such as a lack of embodiment through displacement (Alexander 2010 ), a loss of connection to others (humans and nonhumans) (Hari 2019 ), or neglecting the metaphysical (O’Brien 2020 ).

An underlying thread is that the mechanistic paradigm cannot fully explain subjective experience and the subject’s relation to the greater whole, with negative consequences for our sustainable lifestyle approaches. In other words: the established frame does not capture the full picture.

As we lack an overarching frame to make sense of the world, we find what some call a war on sense-making, in which individuals try to impose their own frame onto the world (Vervaeke 2013 ). A collective frame or narrative that reflects multiple truths, while at the same time offering an overarching perspective might be a key sustainability challenge (e.g., Wahl 2016 ; Lent 2017 ; Freinacht 2019 ). The relational paradigm helps to provide a collective frame by acknowledging the importance of individual autonomy and the person’s interconnection to the greater whole, while overcoming the dualism of subjectivity and objectivity. It gives meaning by enhancing the integration between the individual’s subjective experience and actions toward sustainability and relating them to the world at large. This can be especially important for sustainability pioneers who may feel that their actions are insignificant. Moreover, it fosters a broader sense of self by engaging emotional, symbolic, and more contextual understandings of sustainability (Lange 2019 ). As O’Brien observes, a relational paradigm widens the frame and “introduces meaning into what might otherwise be considered a meaningless world” (O’Brien 2016 :7). A relational paradigm may thus contribute to a sense of meaning for the individual in general and explain, more broadly, why, sustainable lifestyles matter.

In the previous section, we presented seven patterns of a relational paradigm, and how each one might contribute to overcome challenges of sustainable lifestyles. We do not see these seven patterns to be an exhaustive list, but rather an exemplification of the importance of moving towards a relational approach. Building on these insights, in this section, we discuss the possible implications of changing our understanding of sustainable lifestyles, and propose a framing that lays the foundation for further research and operationalization. In this context, we briefly address the epistemological challenges that we faced during the research process.

Towards a relational approach to sustainable lifestyles: the relational lifestyle framework

By adopting a relational paradigm to investigate sustainable lifestyles, we draw upon Haraway’s idea of diffraction. Diffraction creates something new by looking at it through a different lens. Haraway ( 1997 :14) first articulated the notion as a metaphor for inquiry and a critical method, “where inference patterns can make a difference in how meanings are made and lived”.

On this basis, the knowledge that emerges from our work highlights that sustainable lifestyles are co-constituted by ethico-onto-epistemologies and socioecological realities. Four dimensions, namely epistemology, ethics, ontology (described in Pattern II: from human agency to intra - action with the more - than - human ), and socioecology (described in Pattern I: from separation to interconnection and Pattern III: from individuals to dividuals ) are viewed through a new lens. These dimensions capture the intra-action, mutual dependence, and co-constituency that dissolve the binaries of inner and outer, personal and social, or natural and cultural. Positionalities are, then, not represented as something ‘out there’ or ‘external’, but instead as an inherent, constitutive part of various phenomena (see Pattern V: from mind - body dualism to embodiment ). They are constituted in relation to each other, indicating that changes in one might change the other (see Pattern IV: from control to emergence ): wellbeing in one dimension relates to wellbeing in other dimensions (see Pattern VI: from individual well - being to relational well - being ). Such a new understanding gives meaning to sustainable lifestyles (see Pattern VII: from meaninglessness to meaningfulness ), as it captures a sense of co-creation and flow between the different dimensions, and shows that all four dimensions are subject to an ongoing, nonhierarchical, nonlinear, dynamic process of intra-action.

Accordingly, we propose to refer to sustainable lifestyles as relational lifestyles. Why? Because both the language and the frames we use are closely related to paradigms (Ives et al. 2019 ; Lakoff 2014 ). As Smartt Gullion ( 2018 :29) points out, “Paradigms by definition determine how we frame reality”, and, as Ives et al. ( 2019 ) note, language can be seen as an expression and reinforcement of paradigms. The term ‘sustainability science’ implies the pursuit of maintenance. Our study shows that the term ‘sustainable lifestyles’ is both outdated and inaccurate; while it is enough to sustain the status quo, it is insufficient to move beyond and support sustainable transformation (e.g., Wahl 2016 ). Sustaining the status quo does not give a sense of direction or orientation.

Moreover, the term ‘sustainable lifestyles’ originates in mechanical ontologies that characterize a lifestyle with reference to fixed properties, and supports a type of thinking that focuses on the stability of entities and systems. As shown in our study, this hinders a flourishing future. In contrast, the term ‘relating’ points to a deeper desire, as it appeals to a shared sense of belonging. It moves away from merely answering living-how (sustainably) questions, and marks a shift towards living-with as an epistemological, ethical, and ontological task that is composed of not just new lifestyles, but new conceptions of what it means to live well. In the following, we refer to the proposed new understanding and framework as the Relational Lifestyle Framework (RLF).

Epistemological challenges

Although our initial intention was to develop a relational framework as a practical tool that is supported by a figure, because a growing number of scholars are calling for the use of relational frameworks in the social and natural sciences, as there is little rigorous, in-depth and/ or detailed advice regarding how empirical research can be conducted (Mannion 2019 ; Smartt Gullion 2018 ), we decided to abandon this goal during the research process. One reason was that the relational paradigm questions the linear model of causality, and therefore causations can rather be seen as probabilities in which certain characteristics relate to a change in another characteristic (Smartt Gullion 2018 ). These intertwined entities make it difficult to identify clear cause-and-effect relationships, and the idea that a specific tool can be used to lead to relational lifestyles becomes questionable. Additionally, as Latour points out, “tools are never ‘mere’ tools ready to be applied: they always modify the goals you had in mind” (Latour 2005 :143). By offering a practical tool or figure, we risked offering a simplistic conceptualization that narrows one’s understanding (Mancilla Garcia et al. 2020a ). Moreover, relational epistemologies question the idea that tools can be used to represent reality without acknowledging the entanglement of the researcher who is co-creating the knowledge (e.g. Latour 2005 ).

We therefore suggest that the proposed RLF should not be seen as a tool with specific prescriptions and instructions, but instead as a proposition that “triggers conditions of emergence” (Springgay 2015 :78). Rather than generating data, it aims to construct new propositional knowledge (see also Pattern V: from mind - body dualism to embodiment ). As Barad ( 2007 :91) points out, “practices of knowing are specific material engagements that participate in (re)configuring the world”, and the understanding of sustainable lifestyles that is created has material consequences (Barad 2007 ) that can improve related policies and practice. The RLF then allows effects that would not have been obtained by other frameworks (Latour 2005 ). It is not a representation of a complex reality, but an enactment of it (Latour 2005 ). Thus, the RLF offers a more encompassing framing that can help to better-cope with the complexity of sustainable lifestyles. While it is beyond the scope of this article to describe how to cultivate a relational paradigm in different settings and contexts, the RLF represents a starting point for changing our conversations, discourses, and approaches to support relational lifestyles through research, policy and practice.

Sustainable lifestyle concepts that are grounded in a mechanistic paradigm are no longer useful, and are preventing an effective response to our complex and dynamic world. We argue that our novel relational framing is a new conceptual approach that has the potential to transform research, policy, and practice.

The proposed RLF scales in depth, rather than breadth. It encompasses people’s inner worlds, which is critical for sustainable lifestyles and transformation (Gilby et al. 2019 ; Wamsler et al. 2021 ). At the same time, it recognizes the need to scale up and out, as it acknowledges the importance of both inner and outer dimensions of transformation. In this respect, it contributes to the branch of transition studies that “posit[s] a profound cultural, economic, and political transformation of dominant institutions and practices” (Escobar 2015 :454), rather than the branch that narrowly focuses on socio-technical (e.g., Grin et al. 2010 ), and techno-industrial (e.g., Perez 2016 ) transitions. The former focuses on postdevelopment, non-neoliberal, post/noncapitalist, biocentric, and postextractivist futures (Swilling 2019 ), and is aligned with approaches such as commoning (Bollier and Helfrich 2015 ) and degrowth (D’Alisa et al. 2015 ).

It is important to note that the relational paradigm is not a simple substitute for the mechanistic paradigm; rather it should be understood as a container for a new story to emerge. A mechanistic approach may still be useful, especially when considering domains with a clear objective, and quantitative goals, such as carbon emission reductions. Understanding intra-action and carbon’s agency on our actions should not stand in the way, or function as an excuse for an excessive carbon footprint. Nor should it misdirect responsibility, or be an excuse for inaction. Instead, our framing opens up new opportunities for creative solutions to emerge that address existing challenges. As Capra and Luisi ( 2014 :79) note, “the emphasis on relationships, qualities, and processes does not mean that objects, quantities, and structures are no longer important.”

In sum, our proposed RLF translates the relational paradigm into a comprehensive understanding of lifestyles. It helps to conceptualize multiscalar lifestyle patterns, and to overcome the distinction between inner and outer or micro, meso, and macro registers of experience (Smartt Guillon 2018 ). Lifestyles then are not only concerned with individual behavior but instead are a manifestation of identified patterns of thinking, being, and acting that are embedded in today’s “socioecological” realities. We acknowledge that it will take some time to recognize the benefits, as we are all immersed in the current social paradigm. However, it is a starting point that may help to ignite a new discourse. It can thus contribute to the transformation of lifestyles, which is required for a just socioecological transition towards a caring and flourishing society.

We acknowledge that all of the authors of this study come from the western, industrialized part of the world and hence have a limited understanding of cultures in which the dominant social paradigm differs. This article particularly addresses the problems that result from the dominant social paradigm in western industrialized societies, and does not presuppose that everyone equally contributes to associated sustainability challenges (such as high carbon footprints).

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Acknowledgements

The research was supported by two projects funded by the Swedish Research Council Formas: (i) Mind4Change (grant number 2019-00390; full title: Agents of Change: Mind, Cognitive Bias and Decision-Making in a Context of Social and Climate Change), and (ii) TransVision (grant number 2019-01969; full title: Transition Visions: Coupling Society, Well-being and Energy Systems for Transitioning to a Fossil-free Society). In addition, we thank the two anonymous reviewers whose critical feedback helped to improve and clarify this manuscript.

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Böhme, J., Walsh, Z. & Wamsler, C. Sustainable lifestyles: towards a relational approach. Sustain Sci 17 , 2063–2076 (2022). https://doi.org/10.1007/s11625-022-01117-y

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