Integrative approach to lifestyle management: Implications for public health research & practice in the context of SDG-3

Abstract

In the last 100 years, the communicable diseases have been replaced by non-communicable diseases as the leading cause of deaths across the world. Periodically, the communicable disease outbreaks continue to pose a challenge to the public health systems. Change in human behaviors and lifestyles are recognized as risk factors for the public health challenges we face today, which significantly affect wellbeing and quality of life. Healthy lifestyles are critical to not only controlling diseases, but also to promote good health and wellbeing. Modern Medicine has provided evidence-based approaches to lifestyle management, but there are challenges to implementing them effectively. The traditional disciplines such as Ayurveda, Yoga and Meditation are showing promise as complementary approaches to further community wellbeing. A new perspective and a model is proposed by the author called ‘Integrative Lifestyle” which is informed by the evidence in the space of modern and traditional approaches to lifestyle management. The article describes the elements of the model, highlights the emerging evidence and implications for public health practice and research. The efforts by Government of India and its collaborators to promote integrative approaches is worthy of emulation and should be backed by sufficient investments into implementation research and population wide scale up for accelerating SDG-3 outcomes related to health and wellbeing.

1. Background

1.1. Changing landscape of health status and Sustainable Development Goal - 3

Over the last 100 years, paradigm shifts have been observed in disease epidemiology and health profile of populations worldwide. Before World War Two, the average life expectancy globally was under 30 years of age, and infectious diseases were the dominant cause of deaths. Today, the average life expectancy is over 65 years and non-communicable diseases have emerged as the leading cause of deaths [1]. As people continue to live longer due to advances in public health, vaccine and drug discovery, medical diagnostics and treatments, the critical parameters such as quality of life, wellbeing and patient satisfaction continue to remain a challenge today [2].

Advances that have prolonged longevity of life have not necessarily translated into improvements in human wellbeing and quality of life. Sustainable Development Goal (SDG) 3 that focuses on ‘Health’ also brought into the forefront, the ‘Wellbeing’ agenda, announcing the goal of ‘Health and Wellbeing for all’ by 2030 [3].

To add to the complexity, COVID-19 pandemic has slowed down the progress toward SDGs across the world, and even reversed the progress in many countries. Prior to COVID-19 pandemic, we have observed epidemic outbreaks such as SARS, EBOLA and others quickly translating into pandemics. Thus, communicable diseases continue to remain a challenge to the public health and global health community today in addition to the non-communicable diseases.

1.2. Critical influence of ‘Lifestyles’ in today's health and wellbeing scenario

Both the non-communicable diseases and communicable disease pandemics are influenced by lifestyles and human behaviours. Changing food habits, sedentary and stressful lifestyles, excess use of substances, increase in travel, changing work and family systems as a result of globalization and unmoderated urbanization, etc. are some of the risk factors that are implicated [4,5].

In the context of non-communicable diseases, while efforts are directed toward better control and management of the disease conditions, their prevention through adequate lifestyle modification has not received the same attention until recently. Evidence points toward slow progress in lifestyle change at population level due to many reasons: lack of simple and effective interventions and tools; and lack of models for people engagement and motivation in lifestyle and behaviour change with [6]. Lack of provider and health systems readiness to deal with lifestyles effectively is yet another critical area to be addressed [7,8].

In the context of pandemic management, human behaviors and lifestyles are still not a part of the prevention strategy as much as few others such as vaccines and others. Responsible behaviors to arresting human to human transmission once the outbreak has occurred are advocated through interventions such as face mask, isolation, quarantine, etc. However what behaviors and practices potentially give rise to an outbreak, and how they can be prevented from occurring at first place, is not something that is discussed adequately. There is scope for more research in this space so as to avert huge economic losses and damage that is incurred during pandemics [5,9].

1.3. New look at ‘lifestyle management’ and its scope in today's context

In this backdrop, the global health community has an opportunity to take a fresh look into lifestyle management in today's context. Lifestyles as a part of health interventions and strategy targeting sustainable health and wellbeing, will need to satisfy the following characterstics:

• •Be able to target all dimensions of health and wellbeing (physical, intellectual, emotional, spiritual, and social),
• •Be able to translate into responsible human behaviors individually and collectively,
• •Be simple and effective for adoption by the populations

To achieve these needs, the author proposes a new lens to look at lifestyle management through integrating traditional approaches with evidence-based approaches offered by Modern Medicine.

2. Integrative Health and Wellbeing Lifestyle

The term ‘Integrative Health and Wellbeing Lifestyle’ represents a lifestyle that integrates approaches to lifestyle management provided by Modern Medicine (i.e., Lifestyle Medicine) with those of Ayurveda, Yoga and Meditation with an aim of improving health and wellbeing holistically (Fig. 1).

Fig. 1.

Four-pronged approach of Integrative Lifestyle. Source: Centre for Integrative Health and Wellbeing www.cihw.in.

2.1. Rationale for integrative approaches to lifestyle management

Standard definitions of ‘Health’, ‘Wellbeing’ and ‘Quality of Life’ incorporate dimensions beyond just a bio-medical domain. They include both ‘objective’ and ‘subjective’ traits which range across physical, mental, emotional, vocational, spiritual, and social dimensions [10]. Lasting health outcomes and quality of life is best achieved when interventions are targeted at all these dimensions. Recognizing the limited impact of biomedical approaches on wellbeing, people have explored traditional approaches and solutions [11].

Complementary medicine, where a non-mainstream medicine is practiced along with mainstream medicine, or Alternate medicine, where non-mainstream medicine substitutes mainstream medicine, are commonly used terms for a long time now [12]. Data shows that more than 40% of population in the U.S is following one or other of these approaches. When asked for reasons for choosing integrative health, they responded that these approaches are client centric, holistic and offers autonomy to clients. Particularly natural products, meditation, yoga, Ayurveda, Tai-chi, and others are increasingly sought after in this regard [11]. While there have been strong criticisms with regards to scientific validity of these approaches in the past, the scenario is changing today.

Integrative health refers to integrating conventional and non-conventional disciplines in a systematic and scientific way, that will best address the health, wellbeing, and quality of life, and is attracting attention by mainstream care providers, researchers, and the policy [12].

In the space of lifestyle medicine, we have emerging evidence as to how lifestyles can impact both prevention and management of chronic diseases. Ayurveda school of thought has established programs and personalized prescriptions for lifestyles and dietary practices. Yoga and Meditation have attracted attention in the recent past for their effects on physical, emotional, and spiritual benefits. Together, they form four prongs of ‘Integrative Lifestyle’, the details of which are discussed in the next section.

2.2. Components of integrative lifestyle

2.2.1. Lifestyle as medicine

More than 80% of chronic disease conditions can be prevented through adoption of few healthy practices as part of one's lifestyle [13]. Prevention of four unhealthy practices is the focus of lifestyle medicine: unhealthy diets, inadequate physical activity, tobacco and alcohol use.

Whole plant-based foods, leafy vegetables, fruits, and whole grains, while minimizing animal based products and processed foods are recommended [13]. WHO recommends 150 min of moderate to intense physical activity per week which can vary with age, gender, and other factors. Evidence also suggests that physical activity should include aerobic exercises as well as activities to improve strength, balance and stretching [14]. The effects of tobacco and alcohol on health are well documented and their prevention is an integral part of lifestyle education. In the recent past, managing stress and sleep as well as positive relationships are also recognized as important elements of lifestyle education as advocated by American college of lifestyle medicine [15].

2.2.2. Ayurveda

While lifestyle medicine provides standard interventions, there is also a growing recognition that lifestyle education has to be personalized and contextual [16]. The school of Ayurveda which is one of the oldest schools of medicine, has always laid emphasis on lifestyles and disease prevention through personalized approach. The theory and science of Ayurveda recognizes that each has a unique mind-body constitution that is inherent to the individual, referred to as ‘Prakruti’ (meaning: inherent nature). Any deviation from the original constitution (referred as ‘Vikruti’), is what gives rise to a disease process; and this deviation is primarily a result of altered lifestyles and practices that are not conducive to one's original constitution [17]. High emphasis is given to staying alert and making changes to food habits, mental and physical activity, sleep pattern, and other aspects of lifestyles in alignment with changes in time, place, and seasons. ‘Panchakarma’ meaning five practices are the detoxification and body cleansing procedures which are suggested at regular intervals to set right the altered constitution. They have shown to contribute to improved behaviors and practices [18]. In the recent years, there is interest in researching the effects of Ayurveda lifestyle and management on chronic diseases [19,20].

2.2.3. Yoga and Meditation

Yoga and Meditation are increasingly adopted as a way of life by people all over the world in the recent times. It refers to the body of knowledge and practices, which when practiced in a systematic way can facilitate alignment (harmony) between the body, mind, and spirit. Yoga and Meditation are widely researched today to explore their effects on mind and body. Evidence has indicated their complementary role in regulation of blood pressure, blood sugar, neurocognitive benefits, stress management, emotion, and sleep regulation [[21], [22], [23]]. Yoga movement is a worldwide phenomenon today and many schools of yoga in India and outside are coming together in a collaborative manner to increase awareness and adoption of this simple age-old practice that has wide range of benefits.

Today, two practices of Meditation amidst others i.e., Heartfulness and Mindfulness are adopted by millions of people across the world. Heartfulness meditation is a modified and simplified form of ancient Raja Yoga system, while Mindfulness meditation has its roots in the Vipassana system of meditation. The Mindfulness meditation helps practitioners to relax and become more aware of one's thoughts and actions to achieve self-regulation of mind. The Heartfulness meditation practice helps its practitioners to achieve mindfulness states and goes beyond mindfulness to facilitate opening of deeper states of consciousness. Though the heart-based practices are offered to help practitioners achieve their spiritual objectives, and to become socially responsible beings, the recently conducted studies are also indicating positive effects in managing stress, sleep, physical and psychological wellbeing [24,25]. Yoga and Meditation practices when adopted as part of one's lifestyle, have potential to expand consciousness and influence behaviors appropriate for sustainable development [10].

3. Integrative lifestyle: implications for public health policy and research

3.1. Public health policy: strengthening prevention agenda

Today the health systems are more focused on managing illnesses than preventing them. The agenda of disease prevention and health promotion is well articulated in the policies but continue to suffer poor implementation on the ground. However recent initiatives with regards to strengthening prevention agenda and wellbeing is praiseworthy. India's flagship national program ‘Ayushman Bharat’ is aiming to build over 150,000 health and wellness centers across the country to augment focus on wellbeing [26]. Amongst them, 12,500 centers are dedicated to promoting traditional approaches to wellness and called AYUSH wellness centers that [27]. Several pilot initiatives and recommendations to operationalize wellness initiatives through yoga and other programs are underway [28]. In the west too, high impetus is provided to enhance focus on lifestyles in controlling chronic diseases. American College of Lifestyle Medicine has established fellowships and trainings to strengthen providers' competencies in this direction [29]. While these are good areas to begin with, more efforts are needed in implementation which can result in triggering desired population impact. Policy may have to recognize few critical areas and address them to facilitate effective implementation on the ground.

3.1.1. Interdisciplinary nature of ‘integrative lifestyle’ and ‘wellbeing’

The multidimensional nature of integrative lifestyles demands that the doctors, from both conventional and traditional systems, as well as other providers such as nurses and counsellors must come together as a team. Effective trainings will not only improve their skills and capacities, but also will clarify their roles and responsibilities. Clearly defined protocols, standard operating procedures will ensure smooth flow of the clients and effective interactions with the providers. Even in AYUSH clinics as part of Indian public health systems, the role of AYUSH providers in lifestyle change and wellbeing were not adequately emphasized for a long time until recently. However, the scenario is changing and now, there is greater impetus to promote AYUSH practice and research [30].

3.1.2. Convergence of various stakeholders

Efforts to impact lifestyles and wellbeing will need stakeholders outside of the health systems to play their part, such as the yoga institutions and certified meditation trainers. Local mapping of stakeholders and engaging them formally after defining roles and terms of reference, can have greater impact. Institutions such as Heartfulness Institute, SVYASA, Patanjali Yogapeeth have branches and trainers all over the world. They have active collaboration with the AYUSH ministry, Government of India [31] which may be utilized to give impetus to the ‘Wellbeing’ agenda. The collaboration with grassroot organizations may result in wider reach and impact, that can be through adequate coordination and engagement.

3.1.3. Empowering and motivating communities

Evidence is strongly pointing to the need to motivate and empower communities to sustain healthy behaviors and lifestyles [6]. While people will access health systems at times of need when they are sick, the same is not true for prevention services. People need be highly self-motivated and aware to prioritize prevention services and lifestyle change. Local leaders, village level committees, women, self-help, and youth groups, as well as institutions such as schools and universities, corporations, and residential committees, need to be encouraged and supported to lead the well-being activities locally. Appropriate behavioral change and motivational strategies must be integral part of interventions.

3.2. Integrative health: implications for future research

At a global level, the research in the space of integrative health is inadequate, and there is a dire need to step up investments in this space. In the recent years, there is a steady increase of research in few areas – yoga, meditation, Ayurveda, or Chinese medicine. Most of the existing studies are not of adequate strength, scale, and rigor. Several very effective treatment regimens have been documented and practiced in Ayurveda for thousands of years, especially for non-communicable diseases and cancers, and they need to be validated critically and brought to the mainstream. The efforts within the Government of India to set up AYUSH Mission to promote research and practice in integrative health through various collaborations deserves appreciation. Memorandum of Understanding (MOU) is signed with foreign countries to promote education, research, and dissemination of AYUSH practices. Studies have shown the potential of local traditional health practices in enhancing self-reliance of the community [32]. Can traditional health practices be effectively integrated within existing primary health care systems? How will that impact population health and wellbeing is an area that needs to be explored further.

Exploration should continue to provide more options to people, while minimizing side effects and costs. Particularly lifestyle change interventions require attention through mixed methods and implementation research approaches to examine their effectiveness as well as feasibility for scale and sustainability. The interventions have to be reviewed as part of existing health systems and public health programs [27,33]. Specific research questions for both clinical and public health research are listed at the end of the manuscript as an annexure (Table 1).

Table 1.

Key questions for future research in the space of integrative health and integrative lifestyles.

Clinical Research

Public Health Research

1.What level and dose of integration can achieve optimal control and thereby reduce the burden on patients of excess administration of therapeutics, diagnostics and out of pocket expenses? 2.In cases that are not amenable for cure, such as advanced cancers or severe dementia, what is the level of quality of life and wellbeing that can be enhanced through integrative approaches? How can we minimize the burden on care givers and families who attend to them? 3.Even in the context of pandemics such as covid-19 that is attracting much attention and investments for clinical and vaccine trials, the exploration within the domain of traditional disciplines should invite same level of attention if not more.

1.What is the level of effect of various integrated approaches on disease prevention and health promotion with respect to health in general or diseases in particular? 2.How do we best integrate different disciplines and offer them to populations through the existing primary health infrastructure? 3.Can implementation research explore the tools, technology and methods to provide integrated health services that are effective, easy to implement and scale up, both within the public and private sector. 4.Behavioural studies should explore the messages, tools and process to effectively influence individuals and the community to make healthy choices and prioritize prevention services. 5.What infrastructure and training requirements will facilitate effective provisioning of integrative medicine treatment, health promotion and prevention services. 6.What are the population level indicators that will best measure the impact of integrative approaches to health, for monitoring and planning purposes? 7.How do we best integrate prevention and curative services in both public and private sector, without losing on quality and patient centeredness?

More experiments are required to integrate local or native disciplines with the modern medicine. Rigorous controlled and randomized experimental studies should be explored. As a beginning, a systematic documentation of all existing integrative options for current problems we are facing, should be attempted that can be the reference for prioritizing and planning future studies. This is something that every country should make a sincere effort as there are locally, contextually, and culturally available integrative approaches to health and wellbeing.

Efforts by the Indian government in bringing Yoga, Ayurveda and Meditation on the forefront through International Yoga events, establishment of All India Institute of Ayurveda, collaboration with ICMR for furthering research, signing of MOUs with foreign countries to promote education and research, establishment of health and wellness centers for accelerating prevention efforts are good examples in recent times. At the same time, there are doubts and skepticism by the practitioners of conventional medicine for lack of sufficient evidence that needs to be carefully examined and addressed. Collaboration with professional bodies and the public for facilitating transmission of right knowledge is important as part of public health efforts to promote greater adoption and sustenance. Collaborative and objective attempts to undertake high level scientific studies will help to strengthen policy and program implementation.

‘Integrative Lifestyle’ brings together the science and practice of Lifestyle Medicine, Ayurveda, Yoga and Meditation, and seem to have potential to achieve holistic wellbeing. Empowering communities to drive the ‘lifestyle change’ movement, collaboration with widely dispersed wellbeing programs such as those offered by Heartfulness Institute and its collaborators are critical at this juncture to trigger a self-sustaining global ‘Wellbeing’ movement. With few years left to realize the SDGs, global and country level effort should accelerate research, policy, and action toward scaling up integrative approaches to health and wellbeing.

Source of funding

None.

Author contribution

The corresponding author (KJ) was involved in conceptualisation, literature review, drafting, editing and finalising the manuscript.

Conflicts of interest

None.