WHAT IS ‘WELLNESS’?

‘Wellness’ is a concept that has gained popularity in recent years but still has no rigorously developed definition, theory or philosophy. At a very simple level, wellness can be equated with health which, according to the World Health Organization, is ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO 1948). Wellness, however, can also be seen as distinct from health in that it is holistic and multidimensional. The notion of wellness includes not only physical, mental and social dimensions, but also emotional, cultural, spiritual, educational, sexual, occupational, financial, environmental, ethical and existential dimensions, with the assumption being that if any one of these dimensions is deficient, complete wellness cannot be achieved.

Wellness describes a quality of systems rather than isolated entities and, as such, it is dependent on relationships and must take into account both content and context. Because it describes systems, the notion of wellness can be applied to individuals as well as to communities, businesses and large-scale economies. The notion of wellness requires an ecological perspective that can be expanded to include the concepts of human security, corporate social responsibility, social justice, environmental impact and sustainability, together with subjective fulfilment and wellbeing.

In 1961, wellness pioneer Halbert Dunn defined wellness, in his book High-level wellness, as ‘an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable’ (Dunn 1961, p 4). He acknowledges that wellness is dependent on the relationship between individuals and their environment, stating that wellness ‘requires that the individual maintain a continuum of balance and purposeful direction within the environment where he is functioning’. He also stated that ‘wellness is a direction in progress toward an ever-higher potential of functioning’ (Dunn 1961, p 6).

More recently the [US] President’s Council on Physical Fitness and Sports proposed a uniform definition of wellness as ‘a multidimensional state of being describing the existence of positive health in an individual as exemplified by quality of life and a sense of well-being’ (Corbin & Pangrazi 2001). Yet another definition suggests that wellness is an ‘active process of becoming aware of and making choices toward a more successful existence’ (US National Wellness Institute 2009). Another proposed definition is:

This definition implies that the state of wellness allows the greatest flexibility to respond to situations and therefore provides the greatest resilience to stress and disease. Wellness in this context can be seen as the best preventative medicine. In this definition wellness is also seen as a state of consciousness that guides the quality of our relationships with the world and therefore cannot be viewed separately from the environment in which it occurs. Thus, if ‘health’ is ‘wholeness’, then wellness is the experience of an ever-expanding realisation of what it means to be whole (Cohen 2008a).

Travis and Ryan suggest that wellness is never a static state but rather a way of life, and that wellness and illness exist along a continuum: just as there are degrees of illness, there are also degrees of wellness. Travis and Ryan further see wellness as a choice, a process, a balanced channelling of energy, the integration of body, mind and spirit, and the loving acceptance of self (Travis & Ryan 2004).

If health and disease are considered to be at opposite ends of a spectrum, then it is possible to classify health into three broad areas: ill health (illness), average health and enhanced health (wellness) (Fig 12.1). The divide between ill health and average health is generally defined in Western medical terms, which classify diseases based on symptom patterns or other diagnostic parameters. Western medicine uses a bottom-up approach that aims to define and understand illness, and develop interventions such as drugs and surgery to treat or prevent the disease and control factors that reduce wellbeing (‘stressors’).

FIGURE 12.1 The illness–wellness spectrum (Cohen 2008a)

The divide between average health and enhanced health is less distinct. Enhanced health is more than just being disease-free:it assumes high levels of physical strength, stamina and mental clarity, as well as physical beauty and maximal enjoyment and fulfilment from life. This requires the holistic integration of multiple factors that determine physical, psychological, emotional, social, economic, environmental and spiritual health. In many Eastern philosophies, the idea of enhanced health can be extended to the concept of ‘perfect health’ or ‘enlightenment’, whereby a person is ‘at one with the universe’ and hence in a state of perfect bliss or ‘nirvana’ (Cohen 2003).

Moving up the spectrum from illness to wellness allows for greater flexibility of response and hence greater resilience; the best form of prevention is therefore to be as high on the spectrum as possible. Thus, while ‘stressors’ tend to reduce the ability to respond and create downward movement, upward movement can be facilitated by ‘blissors’, which create greater wellbeing. Throughout the spectrum, however, there is also a central axis that represents the core of our being. This central core, which may be termed the ‘soul’ or the ‘essence’, is an eternal and immortal aspect of the self that is naturally at one with the universe and blissful.

Bliss, or ‘ananda’ in Sanskrit, is considered by Vedic scholars to be the innermost level of the individual self, as well as the nature of the whole universe. It is the goal of the path to enlightenment and is found in the deepest experience of meditation and the innermost level of our being (Maharishi 1957–64). Bliss is also the ultimate aim of Eastern healing and spiritual practices, which adopt a top-down approach by attempting to elicit bliss through meditation and other practices that enhance wellbeing (‘blissors’) (Cohen 2008a).

The state of bliss can also be considered as the ultimate in achieving human potential. As the late anthropologist Joseph Campbell states:

This ‘state of total aliveness’ is what many people may consider to be ‘wellness’.

THE WORLD IN CRISIS

It seems that all people at some time have tried to tackle the question of how to live well in the world. This single question has driven many different areas of human endeavour and has led to innovations that have created new technologies and ways of living that have allowed human populations to expand exponentially (Meadows et al 1976).

The world is currently facing a series of crises that are challenging the financial system, the climate and the environment. Increased global terrorism, pandemics, environmental pollution, general toxicity and natural disasters are breaching national boundaries and threatening human security. We also currently live in a world where one-third of the world’s population is dying from diseases linked to malnutrition and starvation; another third is dying from obesity and diseases related to overconsumption; toxic chemicals are continuously being created and released into our environment and food supply, and people are becoming increasingly disconnected from their natural environment and one another.

Modern healthcare systems are also struggling to provide quality care to all in need, as the burden of illness-care reaches barely manageable proportions. It is becoming clear that the current illness-based medical model is not sustainable and is ill-equipped to meet the needs of the global population or deal with the consequences of an ageing population, increasing healthcare costs and an epidemic of lifestyle-related diseases such as obesity, diabetes, heart disease and cancer.

The disproportionate focus on illness has allowed unhealthy lifestyle practices to remain largely unchecked, thereby allowing them to expand across the globe to the point where they now represent the greatest threat to human health and survival. A 2005 report by the World Health Organization entitled Preventing chronic disease: A vital investment estimates that of the 58 million deaths in the world in 2005, 35 million (60%) were caused by chronic diseases such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes. The report goes on to suggest that 80% of premature heart disease, stroke and type 2 diabetes and 40% of all cancers are preventable, concluding that the main modifiable risk factors for these diseases are lifestyle-related and include unhealthy diets, physical inactivity and tobacco use (WHO 2005).

It has been predicted that, as a result of unhealthy lifestyles, for the first time in history the lifespan of the next generation in the United States could be shorter than that of their parents (Olshansky et al 2005). In a PriceWaterhouseCoopers (PWC) report on the future of healthcare entitled HealthCast 2020: Creating a sustainable future (PWC 2005), it is suggested that ‘There is growing evidence that the current health systems of nations around the world will be unsustainable if unchanged over the next 15 years’ (PWC 2005, p 2), while ‘preventive care and disease management programs have untapped potential to enhance health status and reduce costs’ (PWC 2005, p 4).

IN SEARCH OF WELLNESS

It is becoming increasingly evident that the fate of all people is ultimately linked and that as a global species we must find sustainable ways to live well in the world together. It could be viewed that humanity has reached a ‘tipping point’, bringing the possibility of either substantial hardship or a breakthrough into new ways of living and a new phase in human evolution. This new phase represents a culmination of thousands of years of human history, during which different philosophies, traditions and technologies have attempted to address the questions of life, ageing, illness and death.

The search for wellness is a common goal for all people. It can be understood as a conscious extension of the basic animal instinct to avoid pain that has its origins at the dawn of humanity when consciousness first became self-reflective (Cohen 2000). This search has influenced the evolution of medicine, which has seen the elaboration of two distinct yet complementary approaches: Eastern medicine, which is based on holistic thinking that maintains a cosmological and systems perspective outlining a philosophy of life; and Western medicine, which is based on a reductionist approach, emphasising controlled scientific experimentation and mathematical analysis (Cohen 2002).

The different health paradigms that aim to improve health and wellness have attempted to address the same issues in different ways. The principle of consilience suggests that there is an underlying unity of knowledge whereby a small number of natural laws may underpin seemingly different conceptual frameworks (Wilson 1999). Indeed there are general concepts and principles that seem to recur as themes across different healthcare paradigms.

WELLNESS AND FLOW

While it may be true that life depends on energy, living systems must remain ‘open’, as it is the flow of energy through them that maintains their integrity. The concept of ‘flow’ is a powerful one that provides a bridge between Eastern and Western thought. The concept of flow applies to both thermodynamic processes and systems theory, as well as to the cyclic thinking of Eastern medicine. The concept of flow has also been applied to subjective psychological states that involve the integrated functioning of mind and body. This concept has been developed by Mihalyi Csikszentmihalyi who describes flow as ‘a joyous, self-forgetful involvement through concentration, which in turn is made possible by a discipline of the body’ (Csikszentmihalyi 1992).

The state of flow occurs when perceived challenges exactly match the skills and capacity to respond. Such a state is therefore a ‘whole of consciousness’ phenomenon that requires the integrated action of both physiological and psychological processes, and hence the involvement of the entire being. In requiring ‘wholeness’, the ‘flow state’ is aligned with health and wellness, and engenders positive feelings that include:

• being completely involved in what we are doing — focused, concentrated

• a sense of ecstasy — of being outside and beyond everyday reality

• great inner clarity — knowing what needs to be done and how well we are doing it (introspective, realistic feedback)

• knowing the activity is able to be done — that our skills are adequate to the task

• a sense of serenity — having no undue concerns or worries about oneself, and a feeling of growing beyond the boundaries of the ego

• timelessness — being thoroughly focused on the present so that hours seem to pass by in minutes

• intrinsic motivation — whatever produces flow becomes its own reward (Csikszentmihalyi 2004).

The idea that positive psychological states and wellbeing require ‘open systems’ is recognised in everyday common language in the phrases ‘having an open heart’ or ‘open mind’. The concept of flow sustaining life is also a basic tenet of Chinese and other traditional medicine philosophies. A thermodynamic model that includes the concept of energy and flow can also be seen to include many parallels between Eastern and Western concepts and thus provide links between different conceptual systems (Fig 12.2).

FIGURE 12.2 Pictorial conceptualisation of wellness concepts from traditional Chinese medicine (Cohen 2008a)

For example, the process of flow leading to transformation and the maintenance of living systems parallels the concept of the five elements or phases of transformation that is common to Chinese medicine, Ayurvedic medicine and ancient Greek medicine (which considered quintessence as a fifth element in addition to air, water, fire and earth). The result of this transformation is represented by the concept of ‘yin’ and ‘yang’, which refers to interdependent yet mutually exclusive opposites and can be compared to the concept of ‘complementarity’ in quantum physics or the concept of homeostatic balance in physiology. The result of this balance leads to an increase or decrease in order as described by entropy or evolution, while the infinite nature of direct experience can be compared to the concept of ‘Tao’ or the mathematical concept of ‘absolute infinity’, both of which are defined as being inherently incomprehensible (Cohen 2002).

WELLNESS METRICS

Wellness is holistic and multidimensional, and involves content and context. As such it is both subjective and objective, and is difficult to quantify. As yet there are no agreed upon metrics by which wellness can be reliably measured, despite the existence of many potential indicators and proxy measures that may be applied to populations as well as individuals. Thus it is now possible to measure subjective states such as ‘quality of life’, ‘happiness’ and ‘wellbeing’ through instruments such as the Australian Quality of Life Index (Cummins et al 2008), as well as to use more objective and physiological measures such as anthropometric and biometric data. Objective indicators of wellness can also be obtained from tissue sampling and measuring biochemical, hormonal, genetic, haematological and toxological data, as well as by testing functional capacity and performance. Further indicators for wellness can be obtained from demographic, socioeconomic and epidemiological data, which can be used to appraise access to food, shelter, education, employment, healthcare and consumer goods, as well as to rate health risks, ecological footprint, morbidity, mortality and life expectancy (Cohen 2008a).

The multidimensional nature of wellness makes any single measure inadequate, and so attempts have been made to combine measures from the different domains. For example, the BankWest Quality of Life Index tracks Australian living standards across municipalities based on key indicators of the labour market, the housing market, the environment, education and health (Bankwest 2008).

In attempting to measure ‘full spectrum wellness’, Travis and Ryan adopt the concept of a ‘wellness energy system’, which implies a thermodynamic model and measures wellness in terms of inputs and outputs. They acknowledge that ‘we are all energy transformers, connected with the whole universe’, and that ‘all our life processes, including illness, depend on how we manage energy’ (Travis & Ryan 2004). These authors further describe 12 aspects of wellness, which include inputs provided by breathing, eating, and sensing, and outputs described as self-responsibility and love, transcending, finding meaning, intimacy, communicating, playing and working, thinking, feeling and moving. These 12 aspects of wellness are the basis for the wellness inventory: evolved from health-risk appraisal techniques to become the first computerised wellness assessment tool, this inventory aims to provide a measure of wellness across the 12 dimensions through a self-reported questionnaire.

Perhaps the most comprehensive attempt to create a metric for wellbeing is the ‘Happy Planet Index’, which uses both subjective and objective data in an attempt to measure the ecological efficiency with which countries achieve long and happy lives for their citizens. The Happy Planet Index is a composite measure that is calculated by multiplying life satisfaction by life expectancy and then dividing by ecological footprint. It therefore takes a thermodynamic approach to the wellness of populations by dividing outputs (the length and happiness of human life) by inputs (natural resources) (Marks et al 2009). The finding that the average scores across nations are low, that all nations could do better and that no country does well on all three indicators or achieves an overall high score on the index has led the Happy Planet Index to be considered currently as the (Un)Happy Planet Index (Marks et al 2009).