Lifestyle modification for mental health and well-being

Abstract

Background:

Unhealthy life-style leads to mental ill-health and poor quality of life and is the major determinant of a wide range of lifestyle disorders. The aim was to 1) review the work relating to life style modification for promoting mental health and 2) Present recommendations on life-style modification for mental health and wellbeing.

Material and Methods:

The work on life style changes for promotion of mental health was retrieved from the scientific literature and critically reviewed.

Conclusions:

Recommendations on ‘Life-style modification for mental health and wellbeing’ are presented. 20 specific components of healthy life style included are: Routine, time management, prayer, basic activities, reading newspaper, study/work, exercise, recreation/ relaxation/ talent promotion, education, cognitive activities, social networking, guidelines for behavior, peer group, social group, marriage/family, life skills, physical health, health education, mobile use, and digital media. The lifestyle modification package is comprehensive and geared to promote mental health and well-being.

INTRODUCTION

Unhealthy life style leads to mental ill health and poor quality of life and is the major determinant of a wide range of life-style disorders such as type 2 diabetes mellitus (T2DM), hypertension, cardiovascular disease, cerebrovascular disease, obesity, and fatty liver, which lead to increased suffering, disability, and even death. In addition, life-style diseases result in major financial burden to the person, his family, and the state. It has been noted that mental health professionals have significantly under-estimated the importance of life-style factors: (a) as contributors to the etiology and treatments for multiple psycho-pathologies, (b) for fostering individual and social well-being, and (c) for preserving and optimizing cognitive functions.[1] Besides, because of aggressive marketing by pharmaceutical companies, there has been a growing tendency among mental health professionals for non-pharmacological measures, such as life-style modification, for maintenance of mental health, reducing stress, and the prevention, exacerbation, and treatment of disorders, both mental and physical. Thus, there is a pressing need to focus on modification of life style for promoting mental health and well-being.

This paper has reviewed the work relating to life-style modification in promoting mental health. Thereafter, guidelines for a ‘Healthy life style’ for mental health and well-being have been put forward.

REVIEW OF LITERATURE

Mental health and well-being

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Mental health is an integral and essential component of health. It is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively, and is able to make a contribution to his or her community.[2] Good mental health is a sense of well-being, confidence, and self-esteem. It enables one to fully enjoy and appreciate other people in day-to-day life and in one’s environment. When a person is mentally healthy, he/she can form positive relationships, use one’s abilities to reach one’s potential, and deal with life’s challenges.[3] Subjective well-being refers to how one evaluates one’s life and specific domains and activities in one’s life.[4] The specific domains include variables such as life satisfaction and marital satisfaction, depression and anxiety, and moods and emotions.

Life-style behaviors

A number of life-style behaviors have been reported to affect mental health of people. These are given below.

1. Routine

   Everyone is expected to have a routine. This routine should synchronize with the routine of nature, that is, the day–night cycle, the circadian rhythm. Many biological processes of the body are in harmony with the circadian rhythm. The importance of creating a routine, incorporating life-style recommendations, has been highlighted. Health benefits include the ability to manage stress more effectively, sleep better, eat healthier, and exercise regularly, all of which promote mental health and well-being.[5] Furthermore, observational research shows that individuals in good health engage in highly routine health behaviors.[6]

   Some examples of abnormal routine in the community leading to adverse health consequences are mentioned below.

   • ‘Workaholism’: Excessive and compulsive working is the disease of modern age. Affected persons enjoy their work so much that they keep on working beyond duty hours and also on holidays. India is among the top ten workaholic countries in the world.[7] Workaholism adversely affects health and well-being and leads to conflicts between work and family life.[8] Workaholism was significantly associated with the presence of stress-related illness.[9]

   • ‘No routine’: This is being increasingly seen in young people in the metropolis, who live alone, and in the elite class, who have no domestic responsibilities, especially during summer vacations. They have no definite time to sleep, to wake up from sleep, to bathe and groom, and to take food. Lack of regular routine life and activities results in anxiety and mental distress.[10]

   • Obesogenic behavior: Most children gain weight during summer vacation, when schools are closed, because of time being less structured during the day.[6]

   • ‘Nothing to do’ syndrome: During the COVID-19 pandemic, the routine was affected. While many adjusted by making positive changes in their routine, others had serious problems. They could not go to school or to work, so they had ‘nothing to do’, which caused immense stress and increased use of mobile.[11] The mental health of people was seriously compromised, and there was emergence of new psychiatric symptoms and morbidities.[12]

   • Night shifts: Night shift work has become highly prevalent in the society. Doctors, nurses, and other hospital staff may have to do regular night duties for days together. In many call centers, the employees need to target customers only at night because of the difference in the time zone. Adverse health effects of chronic night work, including development of T2DM and cardiovascular disease across diverse populations, have been reported. These are mediated by the system’s primary marker melatonin and other downstream molecules.[13]

2. Time Management

   In a fast-moving world, time management is crucial and the path to success. Many people are able to draw out their priorities, plan and manage their time nicely, and move forward. On the other hand, there are others, who are inept at managing their time and have high levels of stress. Activities can be categorized as urgent and/or important on a continuum. Attending to only the most urgent while neglecting the important and vice versa can have negative effects on mental health. For example, a person has to take his wife for medical checkup for a nodule in the breast (suspected cancer) or has the important duty to pursue and fix the marriage of his daughter, who is 30 years old, but has not been able to find the time for the same for more than a year, and he did not take leave from his work for the same. Thus, ‘goal setting’ is needed for an individual’s long-term priorities.

   There is robust evidence to support the role time management for promoting mental health. A meta-analysis of 32 empirical studies reported that the increased use of time management behaviors is significantly related to better health, lower levels of stress, and higher levels of job satisfaction.[14]

3. Sleep

   Adequate good-quality night sleep is a must for everyone. Sleep has many restorative functions which go toward maintaining good mental health. Age and genetic factors affect need for sleep.[15] The National Sleep Foundation has made recommendations on sleep requirements across the lifespan.[15] Most adults need about 7–9 hours of sleep per night. People over 65 may require only 7–8 hours of sleep at night to function optimally. There are short sleepers requiring less than 6 hours and long sleepers needing 12 or more hours. Presence of illness (physical and mental) greatly influences sleep patterns.[15]

   Recent evidence suggests that sleep deprivation not only impairs the ability to consolidate previously learned tasks but also adversely affects the capacity to acquire new information.[15]

   Substantial adverse health consequences, both short and long term, of sleep disruptions have been reported. The short-term consequences of sleep disruption in children are behavioral problems and impairment in cognitive functioning. In adolescents, an adverse impact on psycho-social health, school performance, and risk-taking behaviors has been noted. In healthy adults, increased stress responsivity, somatic pain, reduced quality of life, emotional distress and mood disorders, and deficits in cognition, memory, and performance deficits are encountered. The long-term effects of sleep disruptions comprise hypertension, dyslipidemia, cardiovascular disease, weight-related issues, metabolic syndrome, and T2DM.[16] A landmark systematic review and meta-analysis study, which included 65 studies from 25 articles, involving 1,550,524 participants and 86,201 cancer cases, reported an association between short sleep duration and cancer risk among Asians,[17] and colorectal cancer.[16,17] Although with respect to colorectal cancer, the findings were not consistent in the dose–response meta-analysis.[17]

   All-cause mortality is increased in men with chronic sleep disruptions.[16] Long-term sleep disruption may also worsen the symptoms of a variety of gastrointestinal disorders; a bidirectional interplay between sleep disruption and gastrointestinal disorders has been noted.[16] In children and adolescents with underlying medical conditions, there is decline in the health-related quality of life.[16]

   Disturbed sleep, insomnia, and hypersomnia are risk factors for the development of psychiatric illness, especially mood disorders (depressive and anxiety disorders) in primary care settings.[15] It is worth noting that individuals who have difficulty sleeping or insomnia during times of stress have significant chances of developing depression in later life.[15]

   Fatigue and workplace sleepiness witnessed in modern industrial society are consequences of insufficient or disrupted sleep. On the highways are a serious safety hazard, which results in numerous accidents and adverse mental and physical health outcomes.[18]

   Oversleeping is also harmful. Both short sleepers and long sleepers are at increased risk of all-cause mortality.[19]

   Thus, it is evident that adequate good quality is needed for maintenance of mental health and preventing serious consequences.

4. Bathing, personal hygiene and grooming

   The human body needs to be cleaned every day. Poor hygiene leads to infections.

   Grooming has a great significance in a civilized world. When a person meets another person/group of persons, the first impression is from the way the person is dressed up. Grooming alone reflects a lot about the person. Indian society has unwritten codes for dressing in different situations. The dress code prescription is more stringent for women. Rural folk are expected to be more traditional than the urban class.

   Of late, intolerance to the violation of dress codes has been witnessed. For example, Blossoms School prohibits parents coming in nightwear to drop their kids. The Director said “Parents coming dressed in payjamas is an embarrassment for both the students and the school.”[20] In Chennai, women in jeans and capris were banned from driving test.[21] The Allahabad High Court refused to allow a suspended Muslim policeman to keep a beard while in service, saying it violates the official order of the Director General of Police, and he could not seek protection under Article 25 of the Constitution, which deals with freedom of religion.[22] A lawyer wearing ‘Jeans-Pant’, who to the Gauhati High Court for appearing in an anticipatory bail matter, was ‘decourted’ from the Court campus. The Court also ordered to bring the matter to the notice of Chief Justice as well as the State Bar Councils.[23] The Resident Welfare Association of Himsagar Society of Greater Noida Society, on June 14, 2023, banned lungis and nighties by issuing a notice titled “Dress code for walking in the premises of the society”.[24]

   In conclusion, socially appropriate grooming is linked to good mental health.

5. Prayer and participation in religious activities

   Prayer is a method of communication with what one believes to be the supreme spiritual being (God). The purpose of prayer is manifold: to thank God for all that he has given, get unconditional and trusted support, get forgiveness and permission for repentance, get support when carrying out difficult tasks, and get blessings to tide over crisis. Besides, daily prayer repeatedly reminds the person to follow the path of truthfulness and righteousness.

   Most people have a religion and celebrate the main religious festivals. In society, a person who prays is generally considered to be a good person, so many people visit temples and enhance their social image by praying. In a fast-moving world, time spent on praying has declined. According to the YouGov-Mint Millennial survey, 70–80% Indians (Muslims/Christians, 80%; Hindus 70%) offer daily prayers.[25]

   The desirable effect of prayer on mental health in students was confirmed in controlled study.[26] The beneficial effects of regular prayer on the mind have been studied in Phillopino Christian Youth.[27] Prayer guided many respondents in their decisions and life choices; evoked human virtues, such as gratitude, patience, and honesty; was critical to cognitive appraisal of stressful events; and served as a coping resource.

   It is important to mention that excessive praying results in introversion, increases schizoid tendencies, and can be an early symptom of psychosis. In addition, it can lead to neglect of other important areas of functioning such as work and family.

   Thus, praying is good for mental health provided it is practiced with moderation.

6. Physical Exercise

   Exercises are of 4 types.[28]

   1. Aerobic or endurance: Exercise which increases oxygen consumption, for example, jogging, running, skipping, swimming, cycling, sports, and dancing

   2. Strength: Muscle strengthening exercise

   3. Flexibility: Increases the flexibility of joints

   4. Neuromotor exercise: Involving balance, agility, and coordination.

Each one has different benefits. Aerobic exercise has been found to have maximum health benefits. Daily physical exercise is necessary as per the dictum ‘use it or lose it.’

Health benefits, immediate, short-term, and long-term, from different forms of regular exercise in persons in the general population have been established by randomized and non-randomized trials and meta-analysis.[29] Exercise enhances mental health by improvement in sleep, self-esteem, subjective well-being, health-related quality of life, cognitive functions,[30] and improved sexual performance[31] and reduction in anxiety, depression, negative mood, and suicide attempts.[32] Physical benefits of exercise are also many, including improvement in cardiometabolic risk factors.[29]

Physical inactivity (not exercising) is one of the major risk factors for non-communicable diseases (NCDs).[33] The study conducted by WHO researchers on 168 countries reported that in 2016, more than a quarter (27.5%) of all adults were not getting enough physical activity to stay healthy. India was in the top third of inactive countries. At least 34% (men 22%, women 48%) of India’s population is insufficiently active.[34]

Thus, WHO agreed to a relative 10% reduction in the prevalence of insufficient physical activity by 2025 and 15% by 2030 as one of the nine global targets to improve the prevention and treatment of NCDs.[35]

‘Stationery Running’ as an aerobic exercise has been used by Sharma and colleagues in a series of studies in healthy subjects and in patients with depression, schizophrenia, tension-type headache, and so on with beneficial results.[36,37] ‘Stationery Running’ is especially friendly to Indian women as it can be done indoors.

Sports and outdoor games have additional benefits as they instill competitive spirit and feelings of mastery, improve self-esteem, and sublime aggressive tendencies.

Dance is a feasible alternative to traditional physical activity. Dancing is fun and also a talent, so dance intervention facilitates access to physical activity. Additional benefits include providing relief of physical tension, anxiety, and aggression, while decreasing cognitive and kinesthetic confusion, defining and consolidating the body image, and illuminating the ego. Dance also increases the capacity for interaction and increases pleasure, fun, and impulsiveness.[38,39]

Exposure to nature and physical activity are known separately to have positive effects on physical and mental health. There is now research evidence to suggest that ‘green exercise’, exercise done in natural setting, has greater health benefits because of the synergistic effects.[40]

Recommendations on physical exercise

The WHO Global Action Plan on Physical Activity (2018–30)[41] provides for a selection of policy options targeting different settings and population groups that can be adapted and tailored to local contexts in all countries and has provided guidelines for adults and older people, children, adolescents, and pregnant and post-partum women. Adults should do at least 150 minutes of moderate-intensity physical activity throughout the week or do at least 75 minutes of vigorous-intensity physical activity or an equivalent combination of both.

For additional health benefits, adults should increase their moderate-intensity physical activity to 300 minutes per week or equivalent. Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.[41] The American College of Sports Medicine (ACSM) recommends a program of regular exercise that includes cardiorespiratory, resistance, flexibility, and neuromotor exercise training beyond activities of daily living to improve and maintain physical fitness and health. The ACSM recommends that most adults engage in moderate-intensity cardiorespiratory exercise training for ≥30 min·d on ≥5 d·wk for a total of ≥150 min·wk, vigorous-intensity cardiorespiratory exercise training for ≥20 min·d on ≥3 d·wk (≥75 min·wk), or a combination of moderate- and vigorous-intensity exercise to achieve a total energy expenditure of ≥500–1000 MET·min·wk.[42]

Intensity of exercise: The maximum achievable heart rate (MAHR) during exercise can be calculated by the formula 220-age (in years). For moderate-intensity physical activity, the target heart rate should be between 64% and 76% of MAHR, while for vigorous-intensity physical activity, the target heart rate should be between 77% and 93%. The talk test is a simple way to regulate the intensity of exercise. During moderate-intensity exercise, the ability to talk, but not sing, is retained but not during vigorous-intensity exercise.[43]

• 7. Yoga and spirituality

  Yoga as a way of life was practiced by the gurus (yogis) in medieval times for the development of an integrated personality. The yogis were ‘super humans’ living in huts in forests and leading an ascetic life free from worldly pleasures. Patanjali Yoga (Asthanga Yoga) prescribes eight steps[44] to be practiced sequentially. The first two, ‘Yama’ and ‘Niyama’, are guidelines for behavior. Yama comprises five observances with regard to interaction with society: Satya (truthfulness), Ahimsa (non-violence), Asteya (non-stealing), Brahmacharya (self-restraint), and Aparigraha (non-hoarding). Niyamas are individual observances for promotion of mental health and comprise Saucha (purity), Santosh (contentment), Tapas (penance), Swadhyaya (self-examination), and Ishwarpranidhyana (surrendering to higher principles of life). It may be appreciated that these guidelines incorporate principles of spirituality. ‘Asanas’ involve a variety of postures and coordination exercises, ‘Pranayam’ involves breathing exercises, ‘Pratiyara’ is contemplation, ‘Dharana’ is about focusing attention and lastly, and ‘Samadhi’ is deep meditation (bliss or enlightenment).

  Beneficial effects of Yoga have been widely reported both in the normal state to promote mental health and in a wide range of disorders [anxiety disorders, neurotic illnesses, substance use disorders, psychosomatic disorders (e.g., hypertension, asthma, arthritis etc.), and personality disorders].[45,46,47] The effect of Pranayama (controlled breathing) in anxiety disorder has been demonstrated in controlled studies.[48,49,50] Of late, modules have been developed for treatment of a wide range of mental disorders, older adults, care-givers, and stress reduction and relaxation.[51] However, in view of high proportion of drop outs,[47,52,53,54] reports of development of severe dysphoric episode, dissociative states, depersonalization syndrome, attempted suicide, severe depression, schizophrenic breakdown, in vulnerable populations, and precipitation of overt psychotic episodes with over meditation,[47,52,53] caution needs to be exercised. Recently, the impediments to evidence-based research on Yoga therapy in psychiatric patients have been described.[55]

  Yoga has been much hyped in our country and abroad as a panacea for all ailments. June 21 has been declared as the ‘International Day of Yoga’ by the United Nations and International community. Non-professional therapies, such as yoga, may have positive placebo effects which may wane as the therapy loses its popularity. Thus, specific yogic techniques, after suitable modification and robust research, may be recommended for promoting mental health and well-being but not as Yoga per se. For example, ‘Psychophysiological therapy’ for ‘Yoga’, ‘controlled breathing’ for ‘pranayam’, ‘relaxation’ for savasana’, and ‘deep relaxation’ for ‘meditation’.

• 8. Education and cognitive exercise

  Education, whether formal or informal, provides information on various issues. Regular news update via the newspaper or television provides information on a wide range of key areas ranging from health, disease, education, jobs, legislations, security, schemes, politics, and so on, which increases the person’s fund of knowledge and social intelligence. One can make suitable changes in one’s life style and adopt better ways to deal with life situations. Education has been shown to have protective effects on mental health, which are higher among women and rural residents. They are mediated through better physical health, improved health behavior and knowledge, and an increase in women’s empowerment.[56]

  In current times, proficiency in Hindi, the national mother tongue; English, the international mother tongue; and the regional language is desirable. Bilingualism has been reported to contribute to cognitive reserve and decrease the risk of Alzheimer’s dementia.[57]

  Life-style enrichment with cognitive stimulating activities should continue throughout life. It promotes growth of neurons and synapses, increases cognitive reserve, and decreases dementia risk[58] (58, Wu et al. 2023). For many people, their work in itself provides an adequate dose of cognitive stimulation. Some professionals, like doctors and lawyers never retire, keep working; others may become inactive after retirement. Women homemakers are generally disadvantaged as mostly they have very limited cognitive stimulation after they leave school/college.

• 9. Work

  Everyone should work if health allows. The advantages of working are many: earning money, getting an identity, using one’s mind and body, learning, and socialization. The primary work of children is to study. While too much work is stressful, too little or no work is also disadvantageous as it promotes laziness, boredom, and cognitive idleness. Government Offices in India have 8 hours of work schedule, with half to one hour break for lunch between 1 and 2 pm.[59] There is provision for weekly offs on Sundays, gazetted and restricted holidays, and other leaves (casual, earned leave, commuted leave, compensatory, medical leave, etc.).[60] Leaves are necessary to meet the demands of personal needs.

  Recently, Narayana Murthy, co-founder of Infosys, suggested that young Indians work for at least 70 hours/work per week on the pretext that he started work at 70 hours a week and then worked for 85–90 hours/week until 1994,[61]; which received strong criticism. Clearly, such a recommendation cannot be accepted as it would be a human rights violation.

  Karma yoga involves performing one’s duties for a higher principle of life, without any attachment to the results.[40] Incorporating ‘karma yoga’ philosophy increases engagement in work, which increases the chance of getting the fruits because of better performance.

  With improvement in socioeconomic status, there is a growing tendency in many people to view ‘work’ as ‘harassment’ and ‘no work’ as ‘privilege’. People would like to work only when they are paid for it. If not, they would prefer to either pay for the work or manage without the work. ‘Nothing to do Syndrome’ is fast emerging. It was much evident during the COVID-2019 pandemic, when it caused immense stress, leading to increased use of mobile by people.[11]

• 10. Recreation

  “All work and no play makes Jack a dull boy”. After a day’s work, recreation or pursuing a talent helps greatly in de-stressing by providing an alternative means of pleasure and cognitive stimulation.

• 11. Mobile use

  Mobile use has become the order of the day as most people find it difficult to survive without a mobile. Those who have no access to mobile are to some extent handicapped. The main purpose of a mobile is instant communication; other uses such as photography, videography, banking business, and social media are ancillary.

  Harmful effects of mobile are many ranging from headache, fatigue, impaired concentration, memory disturbances, sleeplessness, hearing problems, facial dermatitis, sensation of warmth within the auricle and behind or around the ear,[62] Internet addictions, online porn, shopping, gaming, and gambling.[63] The WHO’s International Agency for Research on Cancer has classified the electromagnetic fields produced by mobile phones as possible carcinogenic to humans.[64]

  In 2009, a CBSE issued a strong advisory to all the Heads of schools affiliated to CBSE to restrict the use of mobiles in schools by children and teachers.[65] However, with the COVID-19 pandemic, the use of digital media increased manifold. Mobile teaching continued even after the cessation of the pandemic. Many schools send notices and homework to children on WattsApp. It is common to witness children having textbooks/storybooks on mobile. A large number of scientific meetings and conferences are being organized on mobile/computer. The impact of digital media has been so great that many people do not think it wise to send hard copies of circulars. Mobile culture has resulted in deterioration of language and spelling of people. Excessive use of mobile results in harmful effects of screen exposure. Besides, it is at the cost of other important activities like physical exercise.

  These developments have prompted restrictions on mobile use. The gram sabha of the village of Bansi, Yavatmal district, in Maharashtra, banned the use of mobile phones by kids and teenagers younger than 18 years and imposed a fine of Rs 200 for anyone caught in breach of the same.[66] The Union Ministry banned PubG game in India to safeguard the interest and rights of citizens.[67] The Zee Group banned the use of mobile in all its offices.[68] However, the Medicines and Healthcare products Regulatory Agency (MHRA) said that a total ban on mobile phones is impossible to enforce and recommended restricted use in hospitals.[69]

  Talking on phone while walking/moving increases the exposure of radiation.[70] Keeping mobile phone in the front pocket for only 4 hours/day for 1 year can lead to male infertility. Electromagnetic radiation (EMR) emitted by mobile phones increases the scrotal temperature and results in reduced motility and structural anomalies of spermatozoa, which appears to be associated with the duration of mobile phone use.[71] The practice of keeping phone in the front pocket or near the abdomen by women reduces ovarian reserve, a term used to describe the number of eggs available for fertilization. Women who use laptops on their laps also have decreased fertility, most likely due to the heat generated by the device.[72] Keeping a mobile in bra may increase the risk of developing breast cancer.[73] Besides, EMF radiation exposure during pregnancy is associated with miscarriages and fluctuations in the fetal temperature and heart rate variability as well as infant anthropometric measures.[74] In consideration of the potential harm by mobile use, the National Cancer Institute has put a fact sheet on its web page on ‘Cell Phones and Cancer Risk’ and suggested measures to reduce radiation exposure.[75]

• 12. Digital media

  The computer is a vital tool for many different jobs and activities. Inappropriate/overuse of computer can cause muscle and joint pain; overuse injuries of the shoulder, arm, wrist, or hand; and digital eyestrain (computer vision syndrome).[76] Symptoms of computer vision syndrome include eye discomfort and fatigue, dry eye, blurry vision, and headache.

• 13. Family and marriage

  In a civilized society, marriage fulfills the sexual and other needs of the person. Everyone should marry, if feasible, when one attains the marriageable age. Delayed marriage/unmarried state/living alone can be problematic and lead to a wide range of mental ill-health and psychosocial problems. Marriage provides a family. The institution of family provides for many of the basic needs of the person. It is imperative to pay attention to the needs of the family. A happy family promotes mental health.

• 14. Social Group: Social Networking

  A person’s social group comprises his friends, neighbors, relatives, work mates, and others. The social group is the primary support system in times of distress. Social networking promotes mental health and well-being. Social isolation increases the risk of long-term mental illness and depressive symptomatology.[77] In older adults, social isolation is significantly associated with increased risk (25%) for premature mortality from all causes[78] and thus is a major public health challenge. Stable availability of a confidant in late life contributes to emotional well-being.[79] Older men and women with stable availability of a family or friend confidant have been reported to consistently score lowest on depressive symptoms (with lower scores in women), the gain of a confidant resulting in a decrease of depressive symptoms (greater with family confidant). In addition, the loss of a family confidant has been found to be associated with an increase in depressive symptoms over time.

• 15. Peer group

  “Bird of a feather flock together”. A healthy peer group is an asset. It provides guideline for behavior and also support when needed.

• 16. Values

  Thoughts (cognitions) are the main determinants on one’s behavior. What to do or not to do depends on our thoughts/values of what is right or wrong. The sources of values are conscience (superego), religion (moral values), parents, teachers, elder siblings, peers, friends, Yoga (Yama and Niyama), spirituality (human values), legislations, The Universal Declaration of Human Rights 1948,[80] and so on. UDHRs have 31 recommendations on human behavior. Ideally, there should be concurrence between values as conflicts lead to stress.

• 17. Life Skills

  1. Coping with stress

     Optimal stress motivates one into action and is desirable, but excessive stress can impair performance and can trigger or exacerbate psychopathology; so it necessary to keep stress within manageable limits. Coping with stress entails two components. Emotion-focused coping targets the unpleasant emotions associated with the stressor by techniques such as relaxation training or by aerobic exercise,[81] seeking emotional support from a confidant[79] or by invoking a coping style.[82] Three positive coping styles, problem solving, utilizing social support, and looking for silver lining, and three negative ones, avoidance, self-blame, and wishful thinking, have been validated. Problem-focused coping is targeted at solving the problem(s) arising from the stressful life event. It involves six steps: 1) identify and define the problem, 2) generate possible solutions, 3) evaluate alternatives, 4) decide on a solution, 5) implement the solution, and 6) evaluate the outcome.[83]

  2. Assertion behavior is the socially appropriate verbal and motor expression of any emotion other than anxiety.[84]

  3. Communication skills: Proficiency in communication, written and oral, in the Hindi/regional and English language is helpful in asserting and solving many problems.

  4. Emotional intelligence comprises a set of four related abilities, perceiving, using, understanding, and managing emotions,[85] and helps one to relate well to people.

  5. Recognizing people:

     Small bits of behavior of a person give information about the person’s character, whether he is honest/dishonest, trust-worthy/untrustworthy, helpful/unhelpful, and so on. Many persons have the skills to recognize people and adapt accordingly. Others, who do not, may lament later when they are betrayed.

  6. Being a ‘Responsible’ person, a responsible father, husband, son, student, teacher, friend, employer, employee, citizen, and so on.

  7. Self-help skills: Managing one’s affairs, for example, tidying room, belongings, washing, cooking, and so on.

  8. Financial budgeting: Many people are always short of money, may over-spend or take loan, and have no savings; others could be too miserly, ignoring important expenditures. It is more important to learn how to spend money than to earn it.

• 18. Obesity

  In 1997, a WHO expert committee classified a body mass index (BMI) of 25.0–29.0 kg/m² as overweight, 30–34.9 kg/m² as obesity, and ≥35 kg/m² as morbid obesity.[86] Thereafter, a debate ensued about the validity of cut-off points for determining overweight and obesity in Asian populations. The reviewed scientific evidence suggested that Asian populations have different associations between BMI, percentage of body fat, and health risks than do European populations.[87] Guidelines for Asian Indians were later revised by a Prevention and Management of Obesity and Metabolic Syndrome group. The revised guidelines categorize overweight as a BMI of 23.0–24.9 and obesity as BMI ≥25,[88] which are lower than those laid down by WHO in 1997.

  Obesity is a complex phenomenon, and its risk factors are numerous and mutually interactive.

  The ‘Health of the Nation 2023’ study has found a 50% increase in the prevalence of obesity and an 18% increase in dyslipidemia among Indians between 2019 and 2022.[89] The range of the prevalence of abdominal obesity across states has been found to be 23.9–65.4% in women and 1.8–28.2% in men.[90]

  The increasing prevalence of abdominal obesity, particularly in middle-aged women, is understandable as for most Indian women, especially home-makers, the priority is domestic work, not exercise. Obesity is also a mental health issue for many as fat women and men are not considered beautiful/handsome. Besides, obesity is linked to eating too much bad food and sedentary life style. There is a pressing to address the same.

• 19. Physical Health

  In the past few decades, rapid economic development and an increasing western way of living have resulted in alarming prevalence of life-style diseases among Indians.[91] The literature review mentions the high rates of major cardiovascular risk factors such as pre-hypertension, subnormal high-density lipoprotein levels, overweight/obesity, high dietary salt, high cholesterol, and triglyceride in the country. The prevalence of metabolic syndrome (a state of central obesity, high blood pressure, insulin resistance, and dyslipidemia) ranges from 23.2 to 41.1%⁹ in some regions of the country.[92] The five major risk factors of non-communicable diseases are tobacco use, physical inactivity, harmful use of alcohol, unhealthy diets, and air pollution.[29] It is high time preventive measures be instituted by adopting healthy life style.

• 20. Eating Behavior

  The gastric emptying time for 0–90% of solid food is 4 hours,[93] so a person should take meals every 4.25 hours, which would come to 4 times a day. Thus, four meals a day is universally accepted. Persons with T2DM are sensitive to changes in blood glucose, so they may take meals five times a day.

  Many people take meals only 2–3 times a day because of non-availability of healthy, tasty, hot food or because of being involved in work. They suffer from hunger stress and take coffee/tea and biscuits, which suppresses hunger and allows them to continue working. However, they suffer from slow and progressive malnutrition.

  Many homemaker women take only 2–3 meals/day. They take only tea/water in the morning, followed by lunch at around 11 am, a cup of tea in evening, and then dinner at night. As a consequence, many have acidity and frequently use antacids. Antacids, H2 blockers, and proton pump inhibitors adversely affect the ability to break down food. Excessive use of the same has been linked to reduction in absorption of nutrients, vitamin B12, vitamin D, magnesium, calcium, iron, folic acid, and zinc.[94]

  In earlier days, the dictum was ‘everyone must eat everything’ to prevent deficiencies.

  Contrary to this, a new behavior is being witnessed in young people, especially in the elite class: 1) They have no fixed times for eating, and the kitchen is always open. 2) They have food fads and generally do not like home food, so they order food from the Internet or go out to eat and drink. 3) The food eaten more often is junk food (pizza, burger, sugary drinks, etc.). 3) Most of them get pocket money, so they can pay for food. 4) Mothers often do not make evening snacks and do not object to outside food. Rather, they may be happy as they can also eat the purchased food.

• 21. Food

  Healthy food

  WHO has provided guidelines on a healthy diet.[95] It includes fruits, vegetables, legumes (e.g., lentils and beans), nuts, and whole grains. Energy intake (calories) should be in balance with energy expenditure. Total fat should not exceed 30%, and free sugars should be limited to 5–10% of total energy intake. Saturated fats should be less than 10%; transfat should be less than 1%, with higher intake of unsaturated fats; and salt intake should be restricted to 5 g/day.

  Unhealthy food

  Foodborne botulism caused by consumption of improperly canned, preserved, or fermented food is a rare but potentially fatal disease.[96] Growth of Clostridium sporogenes PA 3679 has been reported in Home-Style Canned Quick Breads.[97]

  Processed and ultra-processed food (UPF):

  Any food that has been altered in some way during preparation is processed food. Food processing can be as basic as freezing, canning, cooking, and preserving. If food is wrapped in plastic and has at least one ingredient that is not found in a standard home kitchen, then it is UPF.[98] Heavily processed foods often have high levels of sugar, salt, and transfat and are calorie dense but lack nutritional value, are micronutrient-deficient, and low in fiber. To make it worse, they are pre-chewed and addicting.[98] Much of it is familiar to us as ‘junk food’. UPFs are designed to be highly profitable, convenient, and hyperpalatable, often through food additives such as preservatives, colorings, and flavorings.[98] They nearly always have a health claim on the packet, for example, useful for weight loss. Indirect processes such as deceptive marketing, bogus court cases, secret lobbying, and fraudulent research are employed by corporations to promote them and extract money.[98]

  Research has shown a direct connection between consumption of trans fat (trans fatty acids) and a host of serious ailments (cardiovascular diseases, breast cancer, shortening of pregnancy period, risk of preeclampsia, disorders of nervous system and vision in infants, colon cancer, T2DM, obesity, and allergy). It recommended that it should be zero in diet.[99] There is evidence that persons who consumed the greatest amounts of artificial sweeteners (Cyclamate, Saccharin, Aspartame) are slightly more likely to develop cancer.[100] Concerns have been raised that some artificial sweeteners might increase obesity. Thus, WHO has recommended against the use of non-sugar sweeteners to reduce the risk of unhealthy weight gain.[101]

  During the refining process of oils, they are heated to high temperatures, resulting in their degradation and generation of toxic substances. Besides, refined oils are particularly high in PUFAs, degrade easily, and therefore should be avoided for frying and cooking.[102]

  A large-scale study has shown that higher consumption of UPFs was associated with higher risks of cardiovascular, coronary heart, and cerebrovascular diseases.[103] Besides, those who did not gain weight had high risks of dementia and inflammatory bowel disease.[98] The risk increases with quantity of UPF consumed. UPF is causing a parallel pandemic of obesity and malnutrition.[98] In India, 97.3% of obese children were fast food users, of which 42 (14.4%) consumed fast food daily.[104]

  Non-vegetarian food

  Of late, concerns have been expressed about the safety of non-vegetarian food. Research has tied red meat (such as bacon, hot dogs, sausage, and salami) to increased risk of T2DM, cardiovascular disease, and certain cancers.[105] This is because meat products are loaded with saturated fats.[106] Thus, non-vegetarians have a shorter life span.[106]

  Meat-borne diseases caused by meat-borne zoonotic bacterial pathogens are a serious threat to public health.[107] Higher levels of mercury have been reported in fresh water than in sea water. Nevertheless, the saltwater fish like tuna, mackerel, and shark pose more serious health threat to humans who eat them.[108] Game meat purchased online from Sainsbury’s stores had high lead levels.[109]

  Vegetarians consume a lesser amount of proteins. This protects them from the problems related to a high protein diet, such as osteoporosis and kidney failure.[106] Besides, a vegetarian diet is rich in vegetables, fruits, legumes, and grains and has a high level of antioxidants such as vitamins E and C and carotene. However, deficiency of vitamin B12 is common in vegetarian diet as B12 is solely derived from animal sources. A lactovegetarian diet provides for vitamin B12 and other fat-soluble items from dairy products.

  United Nations recommends more plant-based foods to reduce an individual’s annual carbon footprint by up to 2.1 tons with a vegan diet or up to 1.5 tons with vegetarian diets. One should eat only what is needed as this would not only save money but also make us healthier and protect our precious resources for future generations.[110]

  Ancient Indian texts have stated that the type of diet affects development of one’s personality.[111] Tamsic personality has been linked to performing activities in ignorance without considering the consequences. On the other hand, Rajasavic activities are enacted to gratify one’s desires. In contract, the Sattvic person acts with a sense of duty without attachment to the results. A Sattivic diet helps to maintain internal harmony in the body as well as in the mind and includes fresh seasonal fruits, green vegetables, wholesome grains, cow’s milk, and ghee.[111] It is thus clear that a lacto-vegetarianism promotes the development of a Sattvic personality, so it should be preferred.

• 22. Social Drugs:

  Tobacco use and harmful use of alcohol are risk factors for non-communicable diseases.[33] It is pertinent to mention alcohol is always harmful. Recently, Dr Atul Goel, Director General Health Services, New Delhi, issued an advisory to doctors to refrain from serving and drinking alcohol in medical conferences and CMEs.

  Bhang is made from leaves of buds of Cannabis Sativa plant. Bhang is part of the Hindu ancient tradition and custom in India. Bhang is not covered under the Narcotic-Drugs and Psychotropic Substances Act, 1985, so its use is legal in the country. It is a favorite recreational drug of many people and consumed as pellets or Thandai during the Holi festival. Bhang use is not without risks. Intoxication, delirium, dependence, induced anxiety disorder, amotivation syndrome, cognitive impairment, flashbacks, adverse psychomotor effects affecting driving, low birth babies when consumed by women during pregnancy, and psychosis in vulnerable persons have been reported.[112]

RECOMMENDATIONS ON LIFESTYLE MODIFICATION FOR MENTAL HEALTH AND WELL-BEING

1. Routine

   • A person should have a set routine. The routine should incorporate time for basic activities (sleep, bathing and grooming, feeding), prayer, physical exercise/sports, work/study, cognitive stimulation, recreation/indoor games/talent promotion, socialization, and other important activities.

   • Routine should be balanced with optimal space for major activities.

   • Separate routines for week days and Sundays/holidays/leave days should be made.

   • Sundays, holidays, and leaves should be utilized for fulfilling one’s personal needs (e.g., medical consultation), family and social responsibilities, attending social functions like marriages, condolence meetings, and other important activities.

     A balanced routine ensures that the major needs are met with results in productivity and promotes mental health and well-being.

2. Time Management

   • The routine of a person should not only have routine items but also include important and urgent items. The latter can usually be categorized on a scale, ranging from minimally to most important/urgent. Time should be managed accordingly.

   • Often, one is involved in only urgent items (preparing reports of urgent meetings, completing working within deadlines, etc.), which may continue for days/weeks and years, and neglects the very important ones, for example, settlement of marriage of daughter or consulting a doctor for his wife for a nodule in breast. This is very stressful. Thus, one should take leave to do important things for which one is not able find time.

   • ‘To Do’ Calendars, Daily, weekly and yearly, are helpful

   • Goal setting, with ~25% extra time for spillover, is recommended as all the time is not under the full control of a person.

   • Utilization of one’s leaves is necessary to ensure good mental health of self and family.

   • Women must take the full maternity leave and men paternity leave.

   • When urgent needs arise (e.g., accident of child), one must take leave, even if it has to be leave without pay.

   • One cannot possibly accept every responsibility/invitation. “Say no” politely when the work seems to be impossible or too taxing for you. One may ‘Request for more time’ if the set time limit is unrealistic.

     Note: Being ‘on duty and on leave’ at the same time is unhealthy and must not be practiced.

3. Prayer

   10–15 minutes prayer on daily basis gives solace as well as reminds one to follow the “Right path”. One may spend more time in praying and on religious festivals as per social norms and availability of time.

4. Basic activities

   1. Sleep:

      • 8 (7–9) hours good-quality night sleep is optimal; so it should be ensured. If one has to remain awake at night because of some life situation, the very next day, it should be compensated.

      • Note: Erratic sleep timings, sleeping during the day, sleeping too much, sleep deprivation(s) or being on the computer/mobile for long hours at night or working in “Call centers”, where one is supposed to work during the night and sleep during the day, should be avoided.

   2. Personal Care:

      • This includes urinating, defecating, bathing, grooming, and other related activities, which should be done daily at the scheduled time.

      • Grooming should be socially, culturally, and gender appropriate. Indian culture is mindful of dressing style. Various unwritten dress codes have been laid down for home, outside home, school, work place, social functions, and special occasions for boys/men and girls/women.

   3. Feeding:

      • One should take four solid meals a day: breakfast, lunch, evening tea with snack, and dinner at 4.25 hourly intervals. The stomach empties ~4.25 hours after a solid meal and ~2 hours after a liquid meal. Diabetics may take five meals, every 3.5 hours, because they are sensitive to changes in blood sugar levels.

      • Availability of healthy should be ensured at periodic intervals.

      Note:

      Tea, coffee, and biscuits do not satisfy hunger but may lead to malnutrition in the long run. Unavailability of healthy food leads to hunger stress and eating of unhealthy food like fast food. Skipping lunch by tea breaks or eating frequently or remaining hungry for long periods leads to acidity, so they should be avoided.

5. Newspaper

   Daily reading of newspaper, Hindi/Regional and English, should be ensured.

6. Study/Work

   • Everyone should work if health allows. 6.5 to 8 hours is optimal. There should be provision for ‘Lunch Break’ (half to 1hour), ‘Weekly Holidays,’ and emergency and other leaves.

   • ‘Adjustment for age’ is needed because the capacity to work decreases after the age of 20 at the rate of ~1%/year due to declining health and family responsibilities.

   • Unhealthy life style must be addressed.

   • The ‘Karma yoga’ philosophy, work is worship (duty), and not attaching work to the fruits should be adopted. This decreases work stress and increases the chances achieving the goal.

   Note:

   The main sources of stress for employees are denial of leave, inability to meet unrealistic targets, long hours of work, excessive travel, and too much time away from family. These may be sorted as best as possible; else, one may quit or take a job which is less demanding.

   Husband and wife working in different cities, with children staying with one parent or grandparent for long periods, is to be discouraged.

   Too much work/‘Workaholism’/‘All rest, no work’ is harmful.

7. Exercise

   • Exercise must be done in addition to activities of daily living.

   • The exercise program should be modified according to an individual’s habitual physical activity, health status, and age.

   • Elderly need all four types of exercise, supervised by a physiotherapist.

   • Daily exercise is strongly recommended to ensure regularity.

   • Some exercise is better than no exercise.

   • Use stairs, rather than lift.

   • Walk/cycle to work and other places if there are no time or other constraints.

   Aerobic exercise:

   Brisk walking, jogging, swimming, and cycling sports are examples. Aerobic exercise permits the greatest increase in energy expenditure with the least fatigue and has maximum health benefits.

   • Adults should do ≥30 minutes/day on 5 days/week (a total of ≥150 minutes/week) of moderate-intensity activity or ≥20 minutes/day on 3 days/week (a total of ≥75 minutes/week) of vigorous-intensity exercise/week or a combination of moderate and vigorous-intensity exercise. For additional benefits, one can do ≥300 minutes of moderate-intensity exercise per week.

   • For moderate-intensity exercise, the heart rate should be between 64 and 76% of MAHR [220-Age (years)], while for vigorous-intensity exercise, the heart rate should be between 77 and 93% of MAHR. The talk test is a simple way to regulate the intensity of exercise. During moderate-intensity exercise, the ability to talk, but not sing, is retained, but not in vigorous-intensity exercise.

   • The total energy expenditure should be of ≥500–1000 MET·min·wk. 40 minutes or 4km brisk walking/jogging, playing lawn tennis for 20 minutes or swimming for 30 minutes, and ‘stationery running’ or cycling for 40 minutes/day would suffice.

   • Exercise in a group or combining it with music makes it more user-friendly.

   • One should exercise at the same time everyday so that the exercise harmonizes with the biological rhythms.

   • Dancing and sports have additional benefits, so they should be preferred over other types of exercise.

   Muscle strengthening exercises:

   • Exercise involving major groups of muscles may be done on 2–3d·wk.

   Neuromotor exercise:

   • Exercises involving balance, agility, and coordination exercises are helpful.

   • A series of flexibility exercises for each the major muscle-tendon groups (a total of 60 s per exercise) on ≥2 d·wk for maintaining a joint range of movement are recommended.

   Yogic techniques:

   • They are beneficial but should be undertaken only after consulting a mental health professional and a yoga guru with respect to the specific technique, frequency, and duration of practice.

8. Recreation/Relaxation/Talent promotion

   After the day’s work, there should be at least 1 hour of recreation/relaxation/indoor games in the form of music, viewing television, and indoor games. Everyone should pursue at least one talent.

9. Education

   In a civilized society, everyone should be educated up till at least class 10; there is no upper limit.

   Education, formal/informal, should continue throughout life to increase one’s fund of knowledge. Everyone should know about the major laws of the country. Knowledge on both rights and the duties is important. The newspaper provides information on a wide range of topics.

10. Cognitive activities

    One should spend some time in activities that stimulate the brain. Reading the newspaper, teaching one’s children, having in-depth discussions on specific, playing games (chess, cards), writing articles, books, singing, playing instrumental music, and so on are user-friendly activities.

    Note: Non-working women and men whose job does not entail cognitive activities should pay more attention.

11. Social networking

    One should find time to develop and maintain a social network comprising friends, workmates, neighbors, relatives, and so on.

12. Guidelines for behavior

    Thoughts, of what is right or wrong, that is, the ‘values’, are the main determinants on one’s behavior. The sources of these are from the conscience (superego), called ethics, people [parents/teachers/peers/friends, religion (moral values)], legislation, Patanjali Yoga, and The 31 articles of The Universal Declaration of Human Rights (1948).

    Yama and Niyama are the first two limbs of Ashtanga (8-limbed) Patanjali Yoga. ‘Yama’ is about how one should interact with others in the society. It comprises five observances: Satya (truthfulness), Ahimsa (non-violence), Asteya (non-stealing), Brahmacharya (self-restraint), and Aparigraha (non-hoarding). Niyamas are individual observances for promotion of mental health and comprise Saucha (purity), Santosh (contentment), Tapas (penance), Swadhyaya (self- examination), and Ishwarpranidhyana (surrendering to higher principles of life). Yama and Niyama incorporate principles of spirituality. They focus on high moral standards, control of instincts, simplicity (not running after money), introspection, learning by penance, and finally submitting to the great power (God).

    There is a lot common in values derived from different sources.

    • All sources of values are important. With maturity, one should decide upon which ones to adopt.

    • Conflicts between values should be resolved by discussion.

    • It is good to follow the values advocated by one’s religion.

    • One should follow the law of the country.

    • It would be difficult for the common man, who has a family life and is soaked in worldly pleasures, to follow Yama and Niyama in toto. Nevertheless, the same may be incorporated as much as possible into one’s life style.

    • Human values such as having compassion for others, helping people in need if one can,

      not inflicting harm on the weak (poor, unprivileged, children, women, elderly), and not confiscating other’s rights can never be ignored.

    • Some other guidelines are:

      • Control over instincts: Oral (healthy food in moderation; no tobacco, alcohol), aggression (none, verbal nor physical), and sexual: Sex only with spouse in moderation;

      • Healthy competition; work hard with perseverance as and when required; work is duty (worship);

      • Satisfaction; no greed for power/wealth/status;

      • Learn by others and your own mistakes;

      • Truthfulness as much as possible; introspect before pointing a finger at others;

      • Submit yourself to the will of God.

13. Peer Group

    “Bird of feather flock together”. A healthy peer group is an asset. It provided guidelines for behavior and also provides support when needed.

14. Support Group

    • Build support groups by socializing, providing psychosocial (be a confidant) help by listening to your friends/neighbors/work mates and others, in times of distress; and instrumental support to them by actually helping them to carry out specific tasks (e.g., taking them to the hospital) to solve their problem.

    • Utilize the support group when in needed.

    • It is good to have 2–4 confidants, one at home, one at work place, and two from among friends in the community so that one can confide in those who are not biased.

15. Happy Marriage/Family

    • Everyone should marry after attaining the age for marriage, if it is feasible to do so.

    • The ideal age for marriage is 21–29 years so that the first baby can take birth before 30 years of age of the mother.

    • Efforts should be paid to keep family happy.

      Note: Marriage should not be deliberately/unnecessarily delayed as the purpose of marriage is also to provide a family.

16. Life skills

    Like skills enumerated below can be sharpened by paying attention and proper guidance.

    1. Coping with stress:

       Some stress is desirable as it motivates one into action. Excessive stress can be counterproductive by causing distress and may trigger/exacerbate mental illness.

       Coping with stress entails two components: emotion-focused and problem-focused.

       The unpleasant emotions (anxiety, sadness, dysphoria, restlessness, etc.) resulting from the stressor can be dealt with by relaxation, meditation, aerobic exercise, emotional support from a confidant, or invoking a particular cognitive style.

       Problem-focused coping solves the problem(s) arising from the stressful life event. It involves six steps: 1) identify and define the problem, 2) generate possible solutions, 3) evaluate alternatives, 4) decide on a solution, 5) implement the solution, and 6) evaluate the outcome. Problems are thus solved by self (internal locus of control) or by utilizing available social support external locus of control.

       • It is necessary to keep stress within manageable limits by adopting a healthy life style.

       • Having one or more confidant/confidante (friend/relative/workmate/neighbor) is a big support. A good practice would be to confide with a confidant at home about a problem at work place and with one at work place about a problem at home so that there is no bias.

       • Positive coping styles include problem solving, utilizing social support and looking for silver lining, internal locus of control, and advanced preparation for anticipated stress (such as elective surgery, marriage, etc.).

       • Managing stress by ‘internal locus of control’ is better than ‘external locus of control’.

       Note: Avoidance, exaggerated self-blame, only wishing/praying that all will be well, increased use of tranquillizers/alcohol, may make matters worse, so are maladaptive.

    2. Assertion:

       Assertion is the expression of any emotion/problem, other than anxiety, in a socially appropriate manner, verbally, in writing or by action. Assertive behavior is crucial to mental health.

    3. Communication:

       Communication can be oral or written in the Hindi/regional or English language. It should be in the language preferred by the respondent. Healthy communication means using the right words, in the right way, with the right emotional display, along with social etiquettes. Proficiency in communication is a great asset. It solves many problems of life.

       1. One should be apt in communicating both positive and negative information/emotions.

    4. Emotional intelligence:

       The ability to perceive and understand other’s emotions and accordingly regulate one’s emotions and express the same is a skill which helps to relate well people.

    5. Recognizing people:

       Small pieces of behavior give information about a person’s character, whether he is honest/dishonest, trust-worthy/untrustworthy, helpful/unhelpful, and so on.

       • One should recognize people by observing and analyzing their behavior and adapt accordingly.

    6. Responsibility:

       Being a responsible person (father/husband/son/daughter/student/teacher/friend, employer/employee/citizen) is a positive character trait, so it should be cultivated.

    7. Self-help skills:

       Managing one’s affairs: For example, tidying room, belongings, washing, and cooking.

    8. Financial Budgeting

       Many people are always short of money, may over spend or take loan, and have no savings; others could be too miserly. There are others who are ‘filthy rich’.

       • It is more important to learn not only to earn but also how to spend the money.

       • A good budget includes regular, ~50%; rainy day (emergency), ~25%; and happy future (car, house, marriage, etc.), ~25%, expenditure.

       • Ideally, one should neither give nor take loan. However, if one must give loan, it should preferably be considered as a donation; that is, one should not expect the person to return it.

       • Rules for buying/giving goodies to children should be laid down.

       • If one is wealthy, one may spend on ‘spiritual activities’ (e.g., free education, medical treatment) rather than on vices (e.g., sex, alcohol, etc.)

17. Physical Health

    1. Body weight

       People can be categorized on the basis of body mass index (BMI) (weight in Kg/height in meter)² as underweight (<18.5 kg/m²), normal or lean (18.5–22.9 kg/m²), overweight (23.0–24.9 kg/m²), and obese (≥25 kg/m²).

       • BMI should be 18.5–22.9 kg/m²; diabetics should be in the low normal range, that is, ≤20 kg/m².

    2. Food

       • Food should be healthy, tasty with variety, fresh, preferably hot, and unrefined.

       • Health food includes fruits, vegetables, legumes (e.g., lentils and beans), nuts, and whole grains.

       • Energy intake (calories) should be in balance with energy expenditure.

         Total fat should not exceed 30%, and free sugars to be limited to 5–10% of total energy intake. Saturated fats should be less than 10%; transfat less than 1%, with higher intake of unsaturated fats; and

       • Salt intake should be restricted to 5 g/day.

       • Cooking should be with natural unrefined oils, for example, mustard oil or rape-seed oil. A limited amount of ghee may be used for cooking.

       • All four grains, wheat, gram, maize, and millet, should be consumed.

       • Soya bean, spinach, and wall nuts are recommended for specific health benefits.

       • Vegetable salad should be consumed twice a day as it is a rich source of water-soluble vitamins and prevents constipation.

       • A ‘Lacto-vegetarian diet’ with all major seasonal vegetables is recommended.

       Note:

       Processed and UPFs [e.g., pizza, burgers, hot chips, sugary drinks (sports, energy and soft drinks], artificial sweeteners, Haldiram cookies), chocolate, sweets (mithai), cakes and biscuits, processed meat (e.g., sausages, bacon, ham, salami and pâtés), and tinned food should NOT be consumed. Refined oils should not be used for cooking, and it should not involve deep frying/roasting. Drinking from package bottles of mineral water should be avoided as 90% are contaminated with plastic particles and contain high levels of bromate, potential carcinogen.

    3. Social drugs:

       Alcohol, tobacco products, including pan, and bhang should NOT be consumed.

    4. Prevention of common illnesses

       Diarrhea, anemia, upper respiratory tract infection, viral fever, malaria, dengue fever, etc., are common.

       • Prevent common diseases by consuming healthy food, taking precautions during change of season, and handling pests (flies and mosquitoes) appropriately by hygiene and sprays and other ways.

18. Health Education

    A person should have knowledge of common illnesses, their early symptoms, how to prevent them, and when to consult a health professional for treatment.

19. Mobile/Smart phone use

    Judicious use of mobile gives the advantages of the mobile with no or minimum health hazards.

    • One should choose a mobile phone model that has a low ‘specific absorption rate’, which refers to the amount of radio frequency radiation absorbed by body tissues.

    • One should use a landline phone if one is available.

    • Use a mobile for instant communication. Phone calls should be kept short; a hands-free kit may be used. Other uses are ancillary, so it should be restricted.

    • A mobile phone should not be kept close to or on one’s body when it is switched on.

    • Talking on phone while walking/driving is not to be done.

    • Keep it in a bag in the outer pocket.

    • Do not study from mobile; study from hard copies.

    • Study the safety instructions issued and follow them.

20. Digital Media

    • Limit excessive use of digital media (computer/laptops) to protect your health.

    • Buy a printer and use hard copies to limit use of digital media.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.