Live Better by Building on the Six Pillars of Health

Getting healthy requires tending to six interconnected components of well-being: nutrition, exercise, sleep, stress, substance use, and personal connections.

BY SEAN CAPTAIN ILLUSTRATIONS BY MUTI

“Everything Everywhere All at Once” is not only an Oscar-favorite movie. It’s an excellent description of how our personal health works. Sleep reduces stress, which lowers the risk of diabetes. The company we keep affects how much we drink. And vigorous exercise improves nearly every aspect of health. All our activities are interconnected and work together to determine our overall health.

In the early 2000s, health researchers began recognizing the now-obvious truth that the choices we make and actions we take determine how well and how long we live. A key eyeopener was a study titled simply, “Actual Causes of Death in the United States, 2000.” It showed that half of all deaths—including from heart disease, cancer, and strokes—were due to lifestyle choices, especially around diet, exercise, and smoking. Around 2010, the American College of Lifestyle Medicine (ACLM) translated these and other findings into six interconnected pillars that support a healthy body and mind: nutrition, physical activity, restorative sleep, stress management, avoidance of risky substances, and social connection.

“The idea is, what can we do with our day-today life that can impact our disease, either progression or prevention? And that’s where these six pillars come in,” says Beth Frates, MD who is Director of Lifestyle Medicine and Wellness in the Department of Surgery at Massachusetts General Hospital and President of the ACLM.

To better understand these six pillars, we spoke with six leading experts in their fields: Layne Norton, Ph.D. (nutrition), Francis Neric, MS, MBA (exercise), Eti Ben Simon, Ph.D. (sleep), Josh Briley, Ph.D. (stress), Professor Ken Leonard, Ph.D. (substances), and Dr. Frates (social connection). They explain the latest science about why we get sick and suggest concrete, achievable actions to become healthier.

Take Charge of Nutrition

Managing calories is like managing money. As long as you stay within your budget, you have flexibility on how you spend, says nutrition expert Layne Norton, PhD, founder of the health and wellness company Biolayne. Norton allows himself a measured amount of ice cream most days. But Norton is a mountain of lean muscle who works out for two to three hours daily. When it comes to losing weight (the most-popular nutrition goal, he says), most of us don’t have a good sense of our budget. “When we do studies on nutrition, we find that the majority of people underestimate their calorie intake by about 30 to 50 percent,” he says.

Tedious as it may sound, it can be very enlightening to do some calorie counting (there are handy apps for that) and even spend a week weighing the food you eat to understand how big the portions really are. “I’ll tell people, the most I ever learned about nutrition was the first week I ever tracked anything,” says Norton, (Calorie counts on labels aren’t terribly accurate, he says, but they give a relative indication of your consumption.)

While being aware of what you put in your body is important, balance is key. A helpful, healthy habit can quickly turn into an obsession or symptom of disordered eating. So, if you choose to calorie count, do so with care, and be sure to reach out to your doctor if you notice an unusual level of fixation starting to occur.

There are food choices that not only control calories but also boost overall health. Norton can’t say enough about fiber, and not just because it helps you poop. Fiber also binds to and removes LDL cholesterol—the major risk factor for atherosclerotic cardiovascular disease—as well as carcinogens and other toxins. Plus, fiber is really filling: You’ll feel satiated with fewer calories. Norton recommends consuming at least 15 grams of fiber per 1000 calories you eat. (For reference, a slice of whole wheat bread has about 2 grams, and a cup of broccoli has about 5.)

Protein is another satiating food—very filling for the number of calories you get. Protein intake, combined with resistance training, is especially important as we age to stave off a loss of skeletal muscle mass and strength called sarcopenia. “As far as animal sources of proteins go, focus on lean proteins, except for maybe some fatty fish,” says Norton. You can get sufficient protein as a vegetarian or vegan, although it requires more work. “Certainly on a percalorie, per-gram of protein basis, it’s hard to argue that animal protein is not higher quality in terms of bioavailability, digestibility, and its effects on muscle protein synthesis,” he says. To get enough protein without too many calories, vegetarians or vegans should include protein isolates (extracts from whole foods), such as whey (for vegetarians), soy (a moderate amount won’t affect hormones), or combined pea and corn protein, he says. Norton recommends eating at least 1.6 grams of protein for every kilogram of body weight but says there’s no downside to eating more.

One food type Norton cautions against is saturated fats due to their tendency to increase LDL cholesterol. But Norton doesn’t believe in prohibiting foods outright. Even the occasional donut is OK, he says, going back to the budgeting analogy. “[If] I’m gonna have a donut, I recognize it’s not as satiating, but I’m desiring an experience,” he says. “And I understand that means I’m going to have to reallocate funds somewhere else, meaning maybe you’re not gonna get the pasta tonight. Maybe you’re gonna have a salad.”

Up Your Exercise

Weight loss is also one of the main goals of exercise, but there are limits, says Francis Neric, associate vice president of certification and credentialing at the U.S. Registry of Exercise Professionals. “Eighty percent of weight loss is from diet, and 20 percent of the weight loss is from exercise,” he says. “So, the exercise, what it does is keeps you motivated, and it keeps you accountable.” It also builds muscle mass, which is what the majority of people want. For some, that means bulking up, but it doesn’t have to.

“For female clients who do a lot of resistance training [like weightlifting], they aren’t looking like Arnold Schwarzenegger,” says Neric. “They’re actually becoming much more defined, and they’re able to perform at a high level.” Building strength is key to remaining independent in our later years, giving people stability to avoid falls, and staving off sarcopenia and osteoporosis. (Special gear and exercises can also strengthen proprioception, the awareness of our body’s position and movement.)

There are many ways to exercise. “[For] somebody who is generally healthy, the biggest bang for your buck is high-intensity interval training,” says Neric. HIIT “gives you a little bit of benefit for aerobic endurance. It also increases your muscle strength.” But you may want to specialize. If strength is your main goal, you should go lighter on the aerobics, he says. If you want to be a great runner, go easy on the resistance training. The minimum requirements are different, too. For aerobics, it’s five times per week, says Neric. For resistance training, it’s at least twice. That said, the American College of Sports Medicine recommends that everyone gets at least 5 days per week of moderate-intensity activity or 3 days per week of vigorous activity—for at least 30 minutes in either case.

While there are sophisticated ways to gauge your performance, such as VO2 max (the volume of oxygen the body absorbs and uses during exercise), there are good ballpark assessments, like the talk test. “When you’re working out at a high enough intensity, you can only spurt out a few words together,” says Neric. “If you can have a full-blown conversation, you’re not exercising hard enough.” For resistance training, he advocates the 2 for 2 rule: You can increase the weight after you can perform two more repetitions in your last set for two weeks in a row.

You don’t have to figure all this out on your own. Whether working one-on-one or with a group (which is great for solidarity), a professional trainer can guide you through your goals—and make sure you don’t hurt yourself. Selecting a trainer is a lot like finding a therapist, says Neric. “It’s just like being able to find somebody who understands who you are and is meeting your needs and meets you where you are,” he says. A trainer helps you set realistic goals (you won’t lose 30 pounds in a month), and they won’t overpromise. Also, beware of people who overwhelm you with technical jargon, says Neric.

He advises taking a close look at education and certifications. “I’m not gonna call out any organizations, but there are some where you can just go have an open book test, or you just pay for a credential,” he says. It’s important instead to look for people with credentials from accredited programs—ones that are certified in the U.S. by the National Commission for Certifying Agencies (NCCA) or internationally by meeting the International Standards Organization (ISO) 17024 requirements. (You can look up a trainer’s certifications at usreps.org)

Exercise only works in conjunction with nutrition, says Neric. “When [you] were in high school, you could eat whatever you wanted as long as you exercised. As you get older, especially when you hit 30 and 40, that’s not the same,” says Neric. “You can’t outwork a bad diet.”

Optimize Your Sleep

While your body needs a good workout, it also needs a good lie-down. But sleep isn’t passive. “It’s during sleep, and especially during deep sleep, when hundreds of thousands of brain cells all of a sudden decide to sing together in this amazing feat of coordination,” says Matt Walker, founder of the UC Berkeley Center for Human Sleep Science and author of the book Why We Sleep, in his eponymous podcast. If you don’t allow your brain sufficient sleep (seven to nine hours for a young, healthy adult, and up to 11 for teens), things deteriorate quickly, says Walker’s colleague, research scientist Eti Ben Simon. The effects are clear when people sleep for just six hours, then perform tests of vigilance and alertness.

“They would report not feeling sleepy,” she says. “But then when you look at their performance, they’re still doing worse relative to themselves on seven hours of sleep.” To test yourself, try a brief online Psychomotor Vigilance Test (PVT)—like one hosted by Sleep Disorders Center Florida.

Research by Ben Simon and Walker shows that poor sleep also impairs our ability to regulate emotions, increasing the risk of stress, irritability, and depression. After just one sleepless night, “you see that the region of the brain that is in charge of processing emotions, the amygdala, can be up to 60 percent more active,” says Ben Simon. If you pull an all-nighter, go easy on yourself—and others—the next day. Conversely, anxiety hurts sleep by keeping the body in the fight-or-flight mode, causing frequent awakenings and diminished deep sleep (the most important stage for regulating emotions).

Sleeping better requires paying attention to substances. Ben Simon advises cutting caffeine off by noon. Even then, up to a quarter of it still sloshes about your bloodstream at midnight. Alcohol blocks REM, the main dreaming stage of sleep, which helps us process emotions and consolidate memories. Ben Simon suggests ending drinking at least six hours before sleep. In lieu of that, taking a nap the next day can provide some REMcatchup. (She’s generally a proponent of naps but cautions that ones lasting more than 20 minutes are followed by 10-15 minutes of grogginess.) THC, the psychoactive component of cannabis, also disrupts REM sleep. Low doses of CBD, the other key ingredient in pot, rev you up. But higher doses (over 50mg) may help sleep, though there isn’t enough data to prove that.

Sleeping pills such as Zolpidem (Ambien) or benzodiazepines like Clonazepam (Klonopin), simply sedate the mind (as does alcohol). “There is a lot of...electrical dance that’s happening during sleep, and that’s not always mimicked by sleeping pills,” says Ben Simon. Supplements of melatonin, a hormone that initiates the sleep process, can help people over 60, whose natural melatonin levels can drop by up to 50 percent. (She recommends a gradual-release version, such as the melatoninmimicking drug Ramelteon.) But studies don’t show benefits in younger people. Learning new behaviors through psychological treatment, especially cognitive behavioral therapy, is the best remedy for long-term sleep problems such as insomnia.

A good bedtime routine helps everyone. Start by turning the lights down about an hour before bedtime, as darkness triggers melatonin release. Screens aren’t necessarily bad if you filter out the melatonin-blocking blue light component by shifting them to a warm tone, enabling dark mode (white text on black), or wearing blue light-blocking glasses. Otherwise, screens are OK, “as long as you’re not reading anything too suspenseful or arousing,” she says, such as aggravating social media. Ben Simon also advocates relaxing activities, such as meditating, stretching, or journaling. Light exercise like yoga is fine if doesn’t warm you up. (The body needs to cool about two to three degrees Fahrenheit before sleep.) Eating can also warm you up, but a snack to stave off hunger is fine. “It’s kind of the Goldilocks region of not too hot and not too cold, not too full and not too hungry,” she says.

Reduce Stress

Stress is a killer. A 2012 study in the UK found that people with high levels of stress had a 21 percent increased risk of death from all causes, with a 22 percent higher risk for cardiovascular disease and a 9 percent higher risk for cancer. (And none of these 68,222 people suffered from a diagnosed mental illness like anxiety or depression.)

This is just one of many studies showing that stress can kill you.

When stress is high, you go into fight or flight mode as if in mortal danger. “Your body pumps more resources to the extremities than to the torso, so digestion is affected, heart rate goes up, cortisone production is increased because your body needs those sugars to escape the bear that’s trying to kill you,” says clinical psychologist Josh Briley, a spokesman for the American Institute of Stress. Blood vessels constrict, raising blood pressure, and the extra glucose in your system raises the risk of developing diabetes. The recognized symptoms of stress hint at how widespread the damage to the body is. In addition to blushing, sweating, or grinding teeth, the unpleasantries may include muscle pain and spasms, frequent colds, and other infections, seeming allergic reactions, constipation, and excessive farting. People under stress also tend to wreck other components of health by smoking, eating poorly, and not exercising.

Stress isn’t always bad, though. “Stress can improve your performance,” says Briley. “[It] can help you think more clearly.” It’s natural, for instance, to feel stressed before you speak in front of a crowd, and that stress can focus the mind. But it’s unhealthy to feel stressed afterward, he says, especially if you criticize yourself with worries that you didn’t speak well, that you were boring, that people didn’t like you.

Such negative thinking prolongs and exacerbates stress and can lead to anxiety disorder and depression. Signs of danger, says Briley, include snapping at your partner or children, pulling away from friends and family, constantly griping or venting around others, and having poor sleep and diet. “That’s when it’s time to seek professional help,” he says. Briley doesn’t advocate a particular type of therapy. “More important than trying to find a cognitive behavioral therapist, or somebody who’s trained in EMDR or something like that, is finding somebody that you feel comfortable opening up to,” he says.

But some of the best treatments are DIY, and things you should be doing already for optimal health. “One of the best ways to deal with pentup energy from stress is to exercise,” says Briley. An intense cardio workout is best if your body can handle it. Briley used to run three to five miles a day. “I just poured all of it into that workout, and I was exhausted. But I wasn’t keyed up and stressed anymore,” he says. If that’s too much for you, though, the key thing is to get some regular exercise, says Briley, such as walking. In addition, “sleep is very restorative to your mind and body,” he says. “And so that increases your resilience to handle stress and all those situations.”

Maintaining solid relationships helps you gain others’ perspective to appreciate if you are overreacting and understand that you are not alone. “If you’re stressed out about something, and you think, ‘Man, I’m the only one worried about this,’ you run the risk of crossing from stress into anxiety,” says Briley. A changed mindset allows you to focus on how to solve a problem rather than magnifying it into a catastrophe or blaming yourself. “You can say that was a stupid thing to do; you can say, I screwed that up,” he says. “But don’t personalize it and make it a trait about yourself.”

Eliminate or Minimize Harmful Substances

There are many addictive and harmful substances, but the harm and potential for abuse vary wildly. There’s no case for smoking a drug—be it tobacco, cannabis, or anything else. “The substance that causes the most deaths and the most expensive in our society is tobacco—hands down,” says Professor Ken Leonard, director of the University at Buffalo Clinical and Research Institute on Addictions. He means smoking tobacco, which the CDC estimates causes more than 480,000 deaths (or about one in five) in the U.S. each year. But the second-greatest cause of harm (killing 140,000 people) is alcohol—something that most of us can use safely, with moderation. So substances fall into two groups: Those you might be able to use safely and those that are never a good idea. The latter includes some drugs that doctors prescribe. “The people who research pain suggest that opiates do not have real good effectiveness in the long term,” says Leonard. “But [patients] continue to need opiates...and doctors are reluctant to take them off.”

The possibly safe group is pretty tiny, including alcohol, perhaps cannabis (if you don’t smoke it), and maybe hallucinogens like magic mushrooms—at least in a clinical setting to treat ailments like depression. For cannabis that you eat, “I don’t think we’re near understanding what’s a safe level,” says Leonard, including the risks of THC vs CBD. Research on mushrooms is also scant, he says, but notes that people tend only to take them occasionally, “and that would seem to mitigate a lot of the potential health problems, as long as they’re taking them in a protected environment,” he says. “I don’t think I’d want to walk around New York City after taking some mushrooms.”

Alcohol is much better understood. The National Institute on Alcohol Abuse and Alcoholism has some straightforward measures for excessive use. For women: more than three drinks on any day or more than seven drinks per week. For men, it’s four and 14 drinks. But alcoholism is more than a numbers game. The AUDIT test, which you can take online at auditscreen.org, asks about other factors, including whether you can ever stop drinking, if you drink in the morning, or if you have felt guilt or remorse after drinking. “You begin to think that there’s a problem when it begins to be an organizing principle in people’s life,” says Leonard. Are you really looking forward to that next drink? Are you drinking every day? Do you need a drink to prepare yourself before you go out? The same questions could hold true for cannabis, as well.

Some people may need professional help to curb addiction. The most effective therapies are motivational interviewing and cognitive behavioral therapy (including a version called relapse prevention). Opiate addictions, however, always require the medication buprenorphine (aka naloxone or Suboxone). There are also some medications for severe alcoholism: disulfiram (Antabuse), acamprosate (Campral), and naltrexone (Revia).

Luckily, many people can deal with substance abuse on their own, says Leonard. Mindfulness practices like meditation, selfhelp tools, like the book Sober for Good, and (as in so many other cases) exercise are all excellent remedies. “I think moderate to high intensity is probably better at generating that positive feeling,” says Leonard. But if all you are up for is a walk, that still helps. Your relationships also play a key role. “Take a good hard look at your friends,” he says. “And if they’re just drinking buddies, and that’s all you do with them, then you need to expand your friend network and find friends that you can do interesting and joyful things with that don’t involve alcohol or cannabis or other drugs.”

Foster Social Connections

Companionship shores up the other pillars of health. It provides solidarity and encouragement in exercise groups. It provides a reality check and understanding for people with runaway anxiety, and it can provide healthy activities as alternatives to getting drunk or high. “The Connection Prescription,” a 2017 summary of research studies, pulled together oodles of findings on the possible health benefits of social connection. One study indicated that low social interaction was as harmful as smoking 15 cigarettes per day. Another showed that people with diabetes in a peer support group had better blood glucose control. And another found that social connection may increase the lifespan of women with breast cancer. “We knew that there was something protective about being connected to people,” says Dr. Beth Pegg Frates, who was one of the authors, noting that such research dates back to the 1970s. How can socializing potentially affect so many aspects of our health?

Some studies found that support groups for people with illnesses help them manage fears and develop strategies to feel better. But one physiological mechanism may be the “love hormone” oxytocin. It’s central to childbirth—stimulating labor, milk production, and bonding between mother and child. But oxytocin is produced by all types of intimacy, from lovemaking to petting your dog. And it’s an essential product of social interaction. Oxytocin lights up several parts of the brain, improving mood and memory. It has sedating and anti-anxiety effects that can lower heart rate, blood pressure, and levels of cortisol (the primary stress hormone), dampening the amygdala response that revs up emotions. Some research indicates that it can lower blood glucose levels, too.

Several studies show that being married helps people live longer. “I don’t want people to read this and then say, ‘Oh, I’m not married, or I don’t have a partner, or I just had a fallout, and I no longer have a relationship, so I’m doomed,’” says Frates, explaining that close friendships or connections to family members can also be powerful.

It’s best to find what psychologist and author Robert Brooks, Ph.D. calls a “charismatic adult.” That’s someone “who really knows you, understands you. And after you’re with them, you feel energized,” she says. “You are not afraid of discussing any topic with this charismatic adult.” Sometimes you are also the charismatic adult for that person, but not always. You may fill the role for other people instead.

Deep relationships take time to form and effort to maintain. Life changes like moving or falling out with friends can force us to start anew. But even without a deep connection, any level of human contact is a health booster—even making chitchat with and saying thank you to a grocery-store checker or a barista. “Having just a little interaction, a little gratitude...these little acts of kindness can be very valuable and ultimately add up,” says Frates. Learning people’s names at stores or restaurants and exchanging pleasantries provides a basic level of friendship. Classes, including exercise classes, are another way to foster connections, even if they don’t yield deep friendships. “I like the idea of volunteering, and I like the idea of soup kitchens,” says Frates. “I like the idea of food pantries and coming back with the same group that’s serving. And then you have a mission.”

Frates recommends reaching out to a friend or loved one at least once a day, even if for just a few minutes. “You want to have interactions that make you feel alive, that make you feel creative, that make you feel even curious to learn more,” she says. “These would be positive social connections.”