# Presentation: 086366

## Richard Harvey, Ph.D.
VA National Center for Health Promotion & Disease Prevention

- VA National Center for Health Promotion & Disease Prevention

***WELLNESS!***

**Notes:**
Today let’s talk about wellness, not as an academic topic, but wellness for you- living a wellness lifestyle and feeling the results!

## WELLNESS

***                  ******	******	******A State of Enhanced Health***
*** ***
***An Integration of Body, Mind, & Spirit in Health and Well Being***

_**The Health Continuum**_
** **
-            Death ------------------Not Sick-----------------Enhanced Health

**Notes:**
Wellness is often thought of as an integration of body, mind, and spirit.  It is helpful to understand “health” as a continuum, with death at one end representing the absolute lack of health, and instead of simply not being sick as the top of the range, it is but the middle.  There is a whole other end of the continuum which might be called “enhanced health”.  Here we are talking about feeling really good- having abundant energy, peace of mind, and a joy for living.  So indeed, there is more to “health” than simply not being sick!

## What is Wellness?

- Wellness is a lifestyle.
- Good health habits- traditional and non-traditional
- Mostly in your head-
- 		A state of mind

**Notes:**
Wellness is more than just a state of being, it is a lifestyle.  It encompasses all the good health habits that we will be talking about, but it’s more than that.  It is also a state of mind.  That is, one has to fully embrace the healthy behaviors in one’s mind as being an integral part of oneself.  After all, one’s mind controls what one does.  Our attitudes, specific thoughts, and emotions all come together to govern our actions, and that applies as much to health behaviors as to anything else.

## Body Wellness

- Eat a wide variety of healthful, wholesome foods.
- Exercise your body.
- Control your weight.
- Get enough rest.
- Don’t Smoke.

**Notes:**
So what are healthy behaviors?  Here are some of them, and we’ll be talking in more detail about some of these later.  Eat a wide variety of healthful, wholesome foods.  We’re not talking about going on a “diet” here, but instead simply doing what this says.  Being physically active is extremely helpful for our well-being.  So is maintaining a healthy weight, which generally means a BMI between 18 and 25.  Americans are chronically under-rested and this isn’t a health habit that is often mentioned, but it should be.  Make time for sufficient sleep.  And we all know about not smoking.

## Mind Wellness

- Keep your mind active.
- Think positive thoughts.
- Minimize the stress in your life.

**Notes:**
How do we keep our mind healthy and vibrant?  Research on aging tells us not to let our mind become stagnant.  We should give ourselves mental challenges, make ourselves solve problems, read interesting books and materials, and do things to stimulate our thinking.  What else?  Thinking positive thoughts keeps one’s attitude and emotions positive as well.  And in turn, that energizes us and stimulates beneficial immune system responses.  Minimizing stress falls into much the same category.  Stress is a “hidden” risk factor for health, and minimizing felt stress is good for us, leaves us energy for creativity and other positive things, keeps our immune system strong, and is good for our health in general.

## Spirit Wellness

- Experience pleasure and beauty.
- Find meaning and purpose in your life.
- Allow yourself to experience the joy of living.

**Notes:**
What is this about?  If there were an agreed upon definition of “spirit” we would be a step ahead.  Failing that, it is agreed that aspects of one’s emotional functioning and general sense of security and belongingness are legitimate parts of overall wellness.  The ability to maximize one’s experience of pleasure and to appreciate and “feel” beauty enriches the life experience and enhances well-being.  Similarly, having a sense of meaning and purpose in one’s life provides a feeling of security, being grounded, and well-being.  Also, allowing oneself to experience a certain “joy of living” is a positive emotion that seems to come from positive thoughts and positive appraisal of one’s situation, place in life, and functioning therein.

## Why Wellness?

- I Feel Good!!
- I have Energy!
- I am Healthy!
- I have Joy!
- I have Contentment...

**Notes:**
So, what does wellness feel like?  Perhaps these things help describe the feeling.  Nice...

## Wellness-- Not?

**Any excuse will work...**
- I don’t know anything about healthy lifestyle.
- Its too much effort.
- Changing my habits adds too much stress to my already stressful life.
- There is no room in my life for that.

**Notes:**
We might ask “If wellness feels so good and is so good for our health, why doesn’t everyone practice wellness behaviors?”  Here are some possible reasons, bearing in mind that as humans we have naturally developed strong habits of taking the road of least resistance.  Also, the behavioral law of “immediacy” comes into play.  That behavior which gets immediately rewarded is the one that prevails.  For example, are we going to go ahead and eat that big piece of delicious chocolate cake in front of us, or push it away because eating it might make us gain more weight, and gaining weight might cause us some health problems 25 years from now?  Duh... (Go over these points with examples where possible)

## Wellness-- Not?

**Any reason will work...**
- I don’t have any support for changing anything.
- I am too tired.
- I just don’t want to...
- I just feel lazy.

**Notes:**
Here are more reasons that are based to some extent on the same principles.  Making health behavior changes is often quite an effort, and is definitely more difficult without support.  Of course, just feeling too tired from the grind of everyday life makes one reticent to take on additional projects, even if doing so would be beneficial.  Others are perfectly happy with the way things are in the present and simply don’t want to do anything different for any reason.  And feeling lazy relates to not wanted to put out the effort.  (examples would be helpful where possible)

## Making Changes...

**Making changes can be hard**
- We are almost always ambivalent.
- The same old routine is usually the easiest path to follow.
- Change takes effort & energy.
- Change takes focus.

**Notes:**
In addition to the energy it takes to make even one change in our health behavior, we are usually ambivalent about doing so.  “Should I or shouldn’t I?” keeps bouncing back and forth in our head until we are so confused and tired of hassling about it that we may elect to do nothing at all.  Change is inherently stressful, and of course people are reticent to induce more stress in their life, even if it is temporary and clearly for the best.  (Go over these points with examples where possible)

## Making Changes...

- Change is stressful.
- Without a firm plan of action, we get distracted and lose our inertia.
- Change is hard to maintain until enough time passes to get some reinforcement.
- Others may resist our changing.

**Notes:**
So yes, changing one’s health behavior may be difficult.  Here are some of the reasons.  As mentioned, change itself is stressful because it involves having to adapt to something new.  If we don’t have a good plan for what we are going to do, when we are going to do it, and how we are going to do it, we may just wallow around until we find some excuse to escape the stress, get distracted, or just lose the drive.  So there never was adequate focus.  Also, most health behavior changes take time for us to feel their positive effect, se we must persist until the reinforcement comes.  Also, when we  change something about ourselves it is stressful for our family members or others around us, so they may consciously or unconsciously resist and/or discourage us.  A great way to destroy our motivation...

## What to Do?

- Get your head around the matter.
- Make a list of the _pros_ and _cons_ of each proposed change you are considering.
- Talk the proposed changes over with a trusted friend until your decision is firm and well thought out.

**Notes:**
But we can change our health behaviors!  However, we have to pay some attention to doing so and “get our head around it”.  This is a matter of getting focused.  Then, do the things we talk about here.  (Examples would be helpful)

## What to Do?

- Make a firm plan about what to do and how to fit it into each day.
- Have a backup plan- Plan ahead to deal with interruptions to your plan.
- Set daily goals..... _every day_.

**Notes:**
More steps toward changing a health behavior here, relating to having a firm plan, a backup plan, and setting small achievable daily goals.  (Go over these, using examples where applicable)

## What to Do?

- Keep an ongoing record of your new behavior.
- Set up a reinforcement system, and reward yourself often.
- Tell others what you are doing, and ask for their support.

**Notes:**
Keeping a record of our new behavior helps us to stay on track and provides us some accountability if only just for ourselves, although it is probably best if it is posted where others may see it as well.  Because it takes a while for the rewards of a new behavior to be felt, it helps to provide some interim rewards for ourselves.  For example, if and only if we walk for exercise each day we let ourselves watch our favorite 
TV show that night.  If we walk at least five days during the week perhaps we buy ourselves a little something special or let ourselves eat a special meal.  Lastly, support from others is extremely helpful so it is good to actively seek support from others.

## What to Do?

- Frequently remind yourself of the benefits you will enjoy.
- “Positive affirmations”- tell your self you are doing well, and leave yourself positive notes!
- Banish negative thoughts.
- Take one step at a time.

**Notes:**
Here are some other steps that will help us establish and maintain a new health habit.  Going back over the benefits of making a change towards wellness helps keep us looking forward to those rewards, and motivates us to hang in there,  Talking to ourselves about how well we are doing, that we are worth the effort, and so on seems silly but is known to help keep us motivated.  Of course, negative thinking is never helpful, and has to go...  So as to avoid feeling overwhelmed, just taking one step at a time, one day at a time makes new wellness behaviors much easier to get in place.  (Go over these, using examples where applicable)

## Habits

- “Old habits die hard...”
- Make yourself aware of each instance of the habit in question.
- Keep a record of each instance.
- Establish consequences- negative for undesirable habits; positive for desirable ones, and enforce them upon yourself.
- Set up your environment to reinforce change.
- Post reminders
- Written daily schedule
- Get rid of old cues
- Get friends to ask you about it

**Notes:**
Here are some ideas about how to deal with old habits, which virtually all of our health habits are.  We have to make ourselves fully aware of our behavior in order to change it.  So keeping it in the front of your mind and actually recording it will help.  Having consequences for the behavior(s) in question will keep our awareness acute, and give us encouragement.  And we need to make our daily environment change-friendly.  Here are some suggestions on how to do that.

## Physical Activity

- At least 30 minutes daily of moderate exercise- longer is better
- Can be in several parts
- Any kind of physical activity will count
- Start out slowly- strength and endurance will build

**Notes:**
A bit more detail now about physical activity. At least 30 minutes on most or all days of each week is recommended for basic health.  However, in order to lose weight up to 90 minutes has been recommended, and 60 minutes to maintain prior weight loss.  In general more is better, up to a point.  However, physical activity is just as good done over several shorter periods rather than all at once.  People don’t have to become “gym rats” either, because virtually any kind of physical activity counts.  Other than the classic “check with your medical care provider before starting an exercise program” advice which applies to older individuals and those with known chronic diseases of certain sorts, people should start out slowly if they were not already very physically active and allow their endurance to build.  Some people have a tendency to really overdo it at first, end up sore, injured, and in pain, and then they quit. Not good.  So, easy does it...

## Physical Activity

- Becomes a daily routine
- Huge “feel good” benefits!
- Just do it... Get moving!

**Notes:**
Just like virtually all habits, the longer one engages in regular physical activity the more firmly engrained it becomes as a habit.  One of the encouraging things about regular physical activity is that it results in “feel good” benefits very quickly.  People feel more energy, mood improves, sleep improves, their body loosens up, and so on.  That reinforcement helps to maintain it.  However, it is still the case that early on it’s easy to get distracted and end up stopping before daily physical activity becomes a strong habit.  And perhaps getting started is the toughest part early on.  One simply has to make up one’s mind, make the necessary arrangements, and get going!

## Nutrition

- Moderation
- Balanced meals
- Eat slowly
- 4-6 small servings each day

**Notes:**
What about our diet?  There is a huge abundance of dietary advice, plans, and theories out there, some based on evidence, and some not.  Many are fad diets meant to sell books or particular products.  However, we do know some general principles for healthy eating.  Eating in moderation is one that the American public has been having more than a little trouble with.  But eating in moderation is a habit than can be shaped just like other health habits.  Eating a wide variety of healthful foods in balanced meals is advice that has stood the test of time.  Eating slowly is also good for us in that we tend to eat less and it makes the eating experience more enjoyable and less stressful to our body.  Eating 4-6 small servings spread out throughout the day also helps us learn moderation, keep our metabolism active, keep our blood sugar levels more constant, temper our hunger, and control our weight. 

## Nutrition

- Eat until satisfied- not stuffed...
- Lots of fruits, vegetables, &
- 	whole grains
- Feel better!
- Control weight!

**Notes:**
Eating in moderation can be learned by the aforementioned eating slowly, eating 5-6 small portions each day, and monitoring oneself while eating so that one stops eating when one reaches the point of satisfaction rather than the point of being stuffed.  This usually requires a person to actively keep this goal in mind while dining and to monitor hunger level.   Another well established principle is to eat lots of fruits, vegetables, and whole grains.  All told, these habits help to both control weight and to feel better than one would if one ate lots of junk food and ate until feeling stuffed.

## Mind and Spirit Health

**Positive attitude**
- Think positive thoughts- banish negative thinking from your head
- Set achievable goals
- Reward yourself
- Seek support and encouragement

**Notes:**
What about the well-being of our mind and spirit?  There are many things that will contribute to this.  Certainly positive thinking leads to positive feelings, a positive attitude, creativity, productivity, and energy.  Having goals that you can reasonably achieve and feel good about contributes to self esteem and self confidence.  Being able to reward yourself for doing a good job at something feels good and also contributes to self esteem.  And as we have mentioned previously, having the support and encouragement of others is very helpful to having peace of mind and feeling good about oneself, others, and one’s life in general.

## Mind and Spirit Health

**Pleasure**
- Makes life better
- Soothes the savage beast (stress)
- Plan for pleasure
- Experience everyday pleasures

**Notes:**
One thing we don’t talk about often enough is seeking and experiencing pleasure!  But the ability to let oneself experience pleasure and the amount of pleasure actually experienced clearly is part of one’s well-being and quality of life.  Pleasure helps to balance the unpleasant aspects of everyday life and reduces the stress we feel from the not-so-pleasant things we must endure.  One way to experience pleasure is to plan for it.  By that I mean make plans to do things that are pleasurable, such as socializing, playing golf or engaging in a hobby, going to a movie, having a special meal, or perhaps simply taking time out for relaxing.  But the other often ignored source of pleasure is to “Stop and smell the roses”.  There are many, many small sources of pleasure present in each day if we would only stop long enough to notice and enjoy them.  Examples of these might be taking a hot shower, sleeping, stretching, eating a certain flavorful food, talking with someone, sharing feelings, hearing a funny joke, looking at the bright sunshine, looking at pretty photographs or paintings, taking a walk, reading a book, watching a good TV show, completing a project, or a myriad of other daily occurrences.  The key is to make oneself stop and become fully aware of the pleasure in these events.  

## Mind and Spirit Health

**Your mind- you are in charge!**
- Just plain “Get the stinking out of your thinking”!!

**Notes:**
Now about our thinking.  The key to cognitive well-being is to get the “stinking out of our thinking”.  Put simply, this is done by stopping long enough to make yourself aware of any negative thoughts going on in your mind.  Once such thoughts are clearly identified, one can ask “Is this what I really want to be thinking?  “Am I making something out of nothing?”  Is this good for me?”  Then, you substitute more positive or counteractive thoughts in their place, and keep doing this process until the negative thoughts stay gone.  

## Mind and Spirit Health

**Experience Less Stress**
- Think differently
- Exercise regularly
- Eat healthy
- Practice relaxation

**Notes:**
All of the things we have talked about help lower the stress we feel.  The one thing newly mentioned here is to practice deep relaxation on a daily basis.   Research has confirmed the benefits of doing so.   There are relaxation recordings widely available in bookstores to help with this process.  Various forms of meditation also fall in this category. 

## Mind and Spirit Health

- Have a passion
- Help others
- Seek meaning and purpose in your life

**Notes:**
Here are some other suggestions for mind and spirit wellness.  One is to have a passion of some sort.  Having a passion might give you a reason to keep going when times are tough.  It can give you something to look forward to.  Similarly, helping others gives one a good feeling as well.  Everyone wants to feel useful and reaching out to help others is one way to do that.  Finally, some reflection on what the purpose and meaning in one’s life is can lead to peace of mind.  That may be accomplished through religious means for some, or just knowing that one’s life has some purpose for others.  Either way, coming to a conclusion about that generally takes some concerted and thoughtful consideration.

## Helping Clients With Change

- Be aware of the client’s stage of change, and counsel accordingly.  Goal is to move the stage forward.
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance

**Notes:**
As health care workers we can help our clients and patients with making health habit changes for the better.  The first step is to determine whether or not the person wants to or feels ready to make a change.  You have no doubt heard of the stages of change before.  There are different things to do that help at each stage.  At the precontemplation stage we can help by not pressuring the patient to change, but we can provide nonjudgmental information about the potential benefits of a change, and offer help when and if the patient desires it.  At the contemplation stage we can facilitate the patient’s thinking about the personal pros and cons in order to resolve their ambivalence, and help them think about what it would take to actually make the change.  The other stages involve more assistance with planning and providing support.  The main point, however, is to avoid pressuring a patient to change when he/she is not ready to do so.

## Health Behavior Change Counseling

- Patient-centered counseling strategies
- Partnership- driven by preferences and active participation of the client
- Respects the client’s decisions
- Absolutely non-coercive
- Non-argumentative
- Non-judgmental
- Empathetic
- Supportive

**Notes:**
When talking with a client/patient about health habit change, it is important to use “patient-centered” counseling strategies.  These are listed here and in the next couple of slides, and come at least partly from Miller and Rollnick’s Motivational Interviewing books.  The bottom line is to talk with the patient in a nonjudgmental fashion rather than at the patient.  The conversation must be a true partnership.  Coercion, judgmental statements, and argument have no place in helping people make changes in their behavior.  On the other hand, empathy and support are helpful.

## Health Behavior Change Counseling

- Provide both general and personally relevant information.
- Explore importance and confidence.
- Explore pros and cons.
- Develop discrepancy.

**Notes:**
Here are more patient-centered strategies.  Information that is personally relevant to the individual is helpful if it is communicated in an objective fashion.  We can explore how important a given behavior change is to the individual and ask what it would take for it to become more important.  The same goes for the person’s confidence in their ability to successfully change their behavior.  Exploring the pros and cons of a behavior change being considered helps to clarify some of the issues.  And we can help the individual look at the difference between where they are now and where they would like to be.  Doing that develops a discrepancy that may motivate change.

## Health Behavior Change Counseling

- Elicit self-motivational statements.
- Explore past successes.
- Solicit client-originated solutions to barriers.
- Support and reinforce self-efficacy.

**Notes:**
Here are others.  Whenever the opportunity presents itself, we should encourage statements that reflect the will to make a desirable change in behavior by reinforcing such statements with comments such as “That’s good that you are considering that”, “You do seem to have some good ideas about how you might do that”, or just nodding when such statements occur.  It is also helpful to ask about how the patient accomplished various things successfully in the past to look for strategies that might generalize to the present situation.  It is extremely important to have the patient come up with their own solutions rather than giving them your canned solutions, because people are much more likely to carry out what they thought of than what others came up with.  And we should support and reinforce the patient’s ability to succeed.

## Counseling Strategies

- Open-ended questioning
- Reflective listening
- Summarizing
- Accepting and rolling with resistance
- Affirming- verbally and non-verbally

**Notes:**
Also in talking with clients/patients in a patient-centered and motivational fashion, there are certain other techniques that are helpful.  The first three are generally well known interviewing techniques.  Accepting and rolling with resistance means understanding that patients will naturally be resistant to change at times and remaining supportive, helpful, and  completely nonjudgmental in the face of that resistance.  Statements like “I understand that this is hard for you.  It would be hard for me too.” are helpful here.  Affirming refers to the practice of acknowledging the validity of the patient’s concerns, and particularly subtly reinforcing movement in the positive direction through head nods and positive statements such as “That sounds pretty good” when the patient says something in favor of making a positive change in a health habit.

## Resources

- vaww.move.med.va.gov
- _[www.move.va.gov](http://www.move.va.gov/)_
- _[www.prevention.va.gov](http://www.prevention.va.gov/)_
- NCP VA Intranet website (VA employees only)
- www.motivationalinterview.org

**Notes:**
So there you have it.  Here are some online resources related to wellness.  The MOVE! weight management program’s VA intranet and internet sites offer lots of information about weight management.  Also helpful are the NCP’s intranet and internet sites with information about prevention in general with a section devoted to wellness, and finally, information about motivational interviewing. 

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