What Does It Mean to be Healthy?
Giving “health” a precise definition is challenging. Health encompasses mental health, spiritual health, financial health, and physical health. These four pillars are areas that interventions can target to increase overall health and wellbeing at an individual level unique to each person.
The World Health Organization defines health as “a state of complete physical, mental, and social well-being… not merely the absence of disease or infirmity.” Indeed, the focus on health should include more than the absence of disease. Health should include feeling “good” in one or multiple areas – such as feeling good enough to lift weights, hike with a friend, or play with kids in the backyard. Health should also be preventative and proactive, not only reactive to a diagnosis or symptom.
Physical health can be viewed through several different lenses. First, it is possible to categorize health according to each body system, viewing each component of the body as its own entity with specific needs and regulation. Alternatively, the body can be viewed wholistically – as a whole unit, made up of components that are intricately linked and necessary for the function of each system. In this perspective, interventions aimed at one target can also have consequences for others, creating a snowball effect of beneficial outcomes.
Physical health is built upon four pillars that can be targeted for increasing health and wellness:
- Nutrition and food
- Physical activity
- Stress management
Nutrition and food
Physical health is largely determined by the diet and is arguably one of the most important determinants of health. A healthy, balanced diet can keep body systems operating efficiently throughout life, whereas an unhealthy body can cause deleterious effects early in life that can be a struggle to manage for decades. Maintaining a healthy weight was previously thought to be based off a simple equation: calories in should equal calories out. To lose weight, the equation becomes calories in should be less than calories out or expended. However, research has demonstrated that this picture is more complicated. It is now understood that both the quality and quantity of calories consumed are important.
One way to assess the quality of calories is to evaluate the nutrient density. Nutrient dense foods provide relatively high nutrition for a relatively low caloric value. Most fruits and vegetables are high nutrient-dense foods. Choosing foods that are nutrient dense can help increase health through increased nutritional value and increased satiety. On the other end of the spectrum are energy dense foods. These foods provide a relatively large number of calories while offering very little in terms of nutrition. Energy dense foods include sugar-rich, highly processed foods. For example:
|High Nutrient Dense Foods||High Energy Dense Foods|
Instead of viewing a particular food as bad, considering where a food falls on the spectrum between energy dense to nutrient dense may help make food-related decisions less daunting. This is especially helpful with foods that provide a lot of calories but also are high in nutrients. This includes foods like nuts and avocados that are relatively high in fat but still provide many important nutrients. Whereas these foods may once have been avoided due to their relatively high calorie count, they can be considered moderately nutrient dense due to the presence of healthy fats and other essential micronutrients.
Dietary choices are one of the primary modifiable lifestyle factors that can influence the risk of developing non-communicable diseases including hypertension, hypercholesterolemia, overweight/obesity, and inflammation, as well as cardiovascular disease (CVD), type 2 diabetes, and cancer.1 Consuming a diet that contains whole-food, plant-based, nutrient dense foods but also includes treats and energy dense foods in moderation can be a great way to improve health. This approach also tends to be more sustainable long term.
Components of healthy diet
Whole grains and fibers
Increased whole grain intake has been linked to a reduced risk of coronary heart disease, stroke, cardiovascular disease, and cancer.1 Additionally, whole grains contain fiber, which has been associated with improved insulin sensitivity and lower:2
- Blood pressure
- LDL cholesterol levels
- Breast cancer risk
- Rates of CVD and premature death
Fiber that is not digestible in humans can provide food to gut bacteria, working as prebiotics. This fuels gut bacteria, producing beneficial short chain fatty acids and other fermentation metabolites.3 Prioritizing whole grains over processed and refined grains will help deliver more vitamins, protein, and fiber, and is associated with decreased rates of CVD.2 The current USDA dietary guidelines recommend consumption of six ounce equivalents of grains per day for a 2,000 calorie diet, with more than half coming from whole grains.
Fruits and vegetables
Fruits and vegetables are nutrient dense food groups that are a good source of dietary fiber, promote satiety, and positively effect gastrointestinal function, cholesterol levels, and glycemic control.1 They are also a good source of phytochemicals, which exert many beneficial effects on the body including antioxidant activity.1 Green leafy vegetables likely have the most beneficial effects but consuming a variety of fruits and vegetables of varying colors will maximize intake of phytochemicals, antioxidants, and vitamins.2
Most Americans consume more than enough dietary protein, but maintaining proper intake of protein is especially important during aging to maintain lean body mass and preserve bone mass.1 Dietary protein comes from both animal and plant sources, each with advantages and disadvantages. While most animal sources of protein provide all essential amino acids, they also tend to be higher in saturated fat which has been linked to cardiovascular disease, dyslipidemia, and certain cancers including colorectal cancer.1 Studies have also found a dose-response relationship between red meat intake and risk of all-cause mortality, such that risk increases as consumption increases.2 However, in moderation, animal protein can fit into a balanced diet that focuses on whole, unprocessed protein sources.
Plant-based proteins include legumes, soy products, nuts, and seeds, and typically do not contain all essential amino acids. However, consuming complementary protein sources can help overcome this problem. Legumes are high in soluble fiber, protein, iron, B vitamins, and minerals and have a low glycemic index, meaning they do not cause a sharp spike in blood glucose levels upon consumption.2 Additionally, consumption of legumes four time per week was associated with reduced coronary artery disease and CVD risk, decreased recurrence of colorectal polyps, increased longevity, improved blood glucose control and better weight management compared to consuming them less than once a week.2
Fats play important roles in the body, including providing energy, acting as signaling molecules, and serving as a structural component in cellular membranes.1 Fats can be unsaturated or saturated, each with distinct properties and effects on health. Saturated fats are solid at room temperature and generally less healthy. Trans fat is a type of saturated fat that is industrially produced and very detrimental to health, specifically increasing LDL cholesterol while reducing HDL cholesterol.1 On the other hand, unsaturated fats contain a double bond, changing the biochemical properties. Both monounsaturated (one double bond) and polyunsaturated (more than one double bond) fatty acids are liquid at room temperature and are considered healthier than saturated fats. Unsaturated fats are associated with reduced risk of CVD and mortality.1
Within the polyunsaturated fatty acid category, omega-3 and omega-6 fatty acids are extremely important, and some are considered essential as they cannot be produced by the body. The omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) exert several beneficial effects on body systems including protecting against cardiovascular disease, preventing cognitive decline, reducing inflammation, sustaining muscle mass, and improving insulin resistance.1 Oily fish are a good source of DHA and EPA, and some nuts, seeds, and plant oils can also provide alpha-linolenic acid, an omega-3 fatty acid.1 Omega-3 and omega-6 fatty acids are also important precursors to endocannabinoids, as part of the endocannabinoid system that manages the response to stress and modulates the immune system. Maintaining an adequate balance of omega-3 to omega-6 fatty acids can affect the risk of cancer, obesity, allergy, and inflammatory disorders.2 The recommended ratio of omega-3 to omega-6 fatty acids ranges from 1:1 to 1:4, but the actual ratio found in the Standard American Diet falls near 1:15-1:17, largely skewed towards omega-6 – which may be harming metabolism and contributing to the development of diseases.4
Water is essential for survival. It provides hydration, maintains fluid balance, and carries micronutrients and electrolytes.1 It can also be a source of micronutrients and can positively impact health when it is consumed in place of sugar-sweetened beverages.2 Teas and other herbal infusions can also contribute to hydration status although coffee is considered a mild diuretic.1
Limiting consumption of sugar-sweetened beverages including soda, energy drinks, and juice can help protect against the development of hypertension, type 2 diabetes, and obesity-related cancer as the risk increases with each additional serving.2 While artificially sweetened beverages may seem like a healthier option, they also increase the risk of type 2 diabetes, albeit less so than sugar-sweetened beverages. Additionally, exposure to artificially sweetened beverages in utero or during early childhood may increase the risk of obesity in adulthood.2 Ultimately, water is the best choice for hydration and avoiding liquid calories.
Sodium and spices
Sodium is vital to water balance and regulating blood pressure, but too much dietary sodium can result in increased blood pressure, endothelial inflammation, and arterial stiffness which contributes to the development of CVD.5 The current Dietary Guidelines recommend that consumption of sodium be less than 2,300 milligrams per day. One option to lower sodium intake is to replace sodium used in food preparation with various spices. Many spices have beneficial effects on health including turmeric, cinnamon, and rosemary. Learning to utilize herbs and spices can contribute to a healthy diet not only by replacing sodium and therefore lowering intake, but also because of their rich polyphenol and antioxidant content.
There is no shortage of information on diets that can be found with dramatic claims about the possible results that may be achieved in a relatively short time frame. These fad diets may provide fast results, but they can be detrimental to long-term health. For example, contestants who competed on a reality television weight loss show not only regained a significant amount of weight, but up to six years after their televised weight loss demonstrated significant changes. Compared to baseline they were burning fewer calories than expected, demonstrated decreased thyroxin, a form of thyroid hormone important in metabolism, and decreased leptin levels, which play a role in satiety and caloric intake.6 Fad diets are also often missing entire groups of foods, like fruit, which can cause a lack of essential nutrients.
A healthy weight loss diet should aim for weight loss of one to two pounds per week, resulting in a 500-1,000 calorie deficit per day. This can be achieved through reducing caloric intake, expending more calories through physical activity, or a combination of both. The diet should meet micronutrient needs for vitamins and minerals, as well as macronutrient needs including healthy fats, plant-based proteins, and complex carbohydrates. Eliminating or reducing processed and fried foods, added sugars, sugar-sweetened beverages, and alcohol can greatly improve health and aid in weight loss efforts. Focusing on organic foods as much as possible can also help decrease the toxic burden on the body. The selected diet should also be sustainable long-term, with the goal of losing weight the same way it will be kept off.
Another component to consider when it comes to diet is the source of the food consumed. In a busy, modern world, people have become far removed from their food and its source. In recent years, movements have begun to try to address this distance, including the slow food movement and a push for farm-to-table production of food. Further complicating the issue of choosing healthy food is soil quality. Despite the best efforts to choose local, organically grown produce, the produce available in stores or markets may not be as healthy as it was 50 years ago. Due to farming practices over the past decades, the soil has become depleted of essential nutrients, resulting in less nutritious foods.
The one-size-fits-all approach to diet has been changing in recent years to match the unique needs of individuals. In this personalized nutrition approach, dietary plans and recommendations are tailored to the individual based on their specific needs as determined by their genetics. Nutrigenetics is the field of study looking to determine the types of nutritional requirements prescribed by an individual’s DNA sequence. This field is predicted to grow exponentially in coming years and could be a significant scientific advance in reducing disease burden related to diet and nutrition.
Focusing on singular foods can easily become overwhelming and may distract from the goal: to eat a well-rounded, balanced diet that meets the body’s needs. Evaluating dietary patterns can be more helpful in this regard. Dietary patterns provide a broader set of guidelines in terms of the proportions, variety, and combinations of foods and nutrients in the diet. A few prominent dietary patterns have emerged through epidemiological studies and have been evaluated for their effects on health.
The Standard American Diet (SAD), or Western diet, is high in processed foods, sugar, salt, saturated and trans-fat, and red meat while being relatively low in fruits and vegetables, fiber, and whole grains.1 This combination puts stress on many body systems resulting in conditions such as dyslipidemia, obesity, metabolic syndrome, cancer, and cognitive decline. Modern life is fast-paced and convenient foods have grown to meet the demands. Sometimes it is necessary to have a little help getting through the day, but relying on fast food long-term has proven to be very unhealthy.3 Additionally, the ultra-processed food and drinks common in the SAD are hyper-palatable and can negatively affect the gut microbiota, as early as childhood, which in turn impairs the immune system.3 The SAD also promotes the growth and colonization of pathological bacteria in the gut, which contributes to dysbiosis.3
Conversely, the Mediterranean diet (MedDiet) is high in healthy fats, including polyunsaturated fatty acids, fiber, fruits and vegetables, lean protein, and whole grains while being low in sugar and processed foods. Olive oil serves as the primary fat consumed in the MedDiet, and low-fat yogurt, cheese, and fermented dairy products are consumed in moderation.1 Fish, poultry, and eggs are the primary sources of protein.1 It also includes a focus on being cognizant of the sustainability and eco-friendliness of how foods are sourced, cooked, and eaten, as well as the lifestyle considerations including physical activity, adequate rest, and a strong sense of community.1
The MedDiet has been associated with several beneficial effects including cardiovascular and cerebrovascular diseases, cancer, glycemic control, and cognitive function.1 The high intake of polyphenols from fruits, vegetables, tea, olive oil, and wine typical of the MedDiet pattern was correlated with a 36 percent reduced risk of hypertension as well as improvements in inflammatory biomarkers related to atherosclerosis.1 The MedDiet also positively impacts the gut microbiota by reestablishing beneficial groups while decreasing harmful species.3
The Dietary Approach to Stop Hypertension (DASH) is similar in many respects to the MedDiet. The DASH diet contains very similar foods but is specifically focused on reducing sodium intake and therefore may be more restrictive than the Mediterranean dietary pattern. It emphasizes consuming a wide array of vegetables and fruits as well as fat-free or low-fat dairy, whole grains, and various protein sources, while limiting consumption of added sugars, sodium, and alcohol.1 The DASH diet has been found to improve risk factors for cardiovascular disease including LDL cholesterol and total cholesterol levels, as well as excess weight and insulin sensitivity.1 It also resulted in a significant decrease in adverse outcomes including cardiovascular disease, coronary heart disease, stroke, heart failure, metabolic syndrome, and diabetes.1
The MedDiet and DASH diet are not the only healthy dietary patterns to choose from when looking for a healthy dietary pattern. The MIND (Mediterranean-Dash Intervention for Neurodegenerative Delay) diet combines components of both the Mediterranean and DASH diets with a focus on preserving cognitive health in aging by including brain-healthy foods such as green leafy vegetables while reducing foods considered unhealthy for the brain such as sweets and fried foods.1 The Nordic diet and traditional Korean diet are also dietary patterns that have been shown to have beneficial outcomes on health and reduce the risk of certain diseases.1
Nutrients, Phytonutrients, and the Whole Food Advantage
The Color of Food series is designed to improve understanding of the significance of phytonutrient and nutrient gaps, the GAE connection, and the whole food advantage to provide the tools needed to make conscious decisions about our health and the health of the people around us.Download: View PDF
Both the American Heart Association and CDC recommend that adults perform 150 minutes of moderate-intensity physical activity per week with two days of resistance training, or muscle strengthening activity. Moderate intensity would include any activity that raises the heart rate but still allows participants to be able to talk. Including more time or increasing the intensity of physical activity provides additional benefits. Physical activity can also be broken up throughout the week, and any physical activity is better than none. Physical activity regimens should include exercises that increases aerobic capacity and muscle strength but also flexibility. In a busy world with limited time for exercise, stretching is usually the first component to be skipped but focusing on flexibility will help increase gains in both cardiorespiratory fitness and resistance training and protect muscles and joints over time.
Physical activity provides many benefits to the body, affecting every organ and system. The benefits of exercise were recognized as far back as the fifth century B.C., and the current lack of exercise in the general population has been classified as an official cause of chronic diseases and death.7 Specifically, lack of exercise can lead to worsening of function in the brain, heart, skeletal muscle, pancreas, bone, and liver. It can also worsen conditions including aging, cognitive dysfunction, constipation, anxiety and depression, metabolic syndrome, and polycystic ovarian syndrome.7
The benefits of exercise are so extensive that no pill has been able to replicate them. At the cellar-, tissue-, and system-level, exercise provides benefits as soon as one session. Benefits of regular physical activity include:7
- Improved cardiorespiratory fitness
- Improved mental health including cognition, depression, anxiety, neurodegenerative diseases, and addiction
- Improved insulin resistance and lower risk of developing type 2 diabetes
- Increased production of myokines which travel to and positively benefit the bone, pancreas, gut, liver, white adipose tissue, brown adipose tissue, and brain
Any increase in physical activity should be approved by a healthcare practitioner and should begin gradually to avoid injuries. Incorporating all three areas of fitness can help increase health, reduce fat mass while increasing lean mass, and improve health outcomes in the future.
The third pillar of physical health is getting adequate sleep. For adults, the recommended amount of sleep per night is at least seven hours; however, over half of Americans report sleeping for less than seven hours per night.8 Both quantity and quality of sleep are important to survival as sleep affects every tissue in the body. Sleep provides an opportunity for the body to reset at the end of each day, including in the brain where cells flush and clear out toxic metabolites during sleep.
Obtaining adequate sleep is also important for metabolic health. Epidemiological studies first found an association between workers with altered work schedules (night shift) and risk of certain diseases such as obesity and type 2 diabetes.8 Studies have shown that there is a U-shaped relationship between sleep duration and BMI, such that both too little and too much sleep may contribute to weight gain.8 For example, sleep restriction to four hours per night increases blood pressure, cortisol, and insulin levels, promotes increased appetite, and leads to increased pro-inflammatory cytokines.9 Getting adequate sleep is important for regulation of satiety hormones, circadian rhythm, lipid metabolism, glucose metabolism, and energy expenditure.8 Maintaining a healthy sleep schedule contributes to the management of a proper circadian rhythm, metabolic health, improved athletic performance, and healthier eating habits.
The fourth pillar of physical health is stress management. At the most basic level, the body responds to stress by releasing chemicals that mediate the response and help the body cope with the stressor. When these mediators are chronically elevated, either due to chronic stress or lack of healthy resolution, they can damage systems and lead to conditions such as heart attack or stroke.9 Several of the stress response molecules are also involved in metabolism and the function of the immune system, central nervous system, and cardiovascular system, partially explaining why stress can have such a significant impact on the body.9 Finding a way to manage stress is essential to brain health as well as whole-body health. Maintaining a positive outlook and good self-esteem have long-lasting effects on health as does having good social support.9 Improving sleep quality, maintaining a healthy diet, not smoking, and regular physical activity can also help with stress management.9
Other Areas of Health
Whereas physical health is easier to quantify and evaluate via laboratory or anthropometric measures, the other areas of health including spiritual, emotional, and mental health are much more challenging to precisely define and measure. However, it is important to nurture these areas as well because they have direct impacts on physical health as well as on each other and leading a healthy life involves more than optimizing physical health.
Spiritual health and spirituality can be studied from various angles, but they center on a connection with self, others, nature, and a higher power.10 The basic characteristics of spiritual health are living a proper lifestyle, connection with others, considering the meaning and purpose of life, and transcendence.10 Engaging in practices that cultivate spiritual health can be accessible to everyone and regularly practicing offers health benefits in other areas. Spiritual health can lead to improved mental health and is positively related to some aspects of physical health.10
Mental health, like spiritual health, can also be difficult to precisely define. The World Health Organization defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”11 However, others propose a different definition where mental health is “a dynamic state of internal equilibrium which enables individuals to use their abilities in harmony with the universal values of society.”11 Part of this definition includes components of emotional intelligence: the ability to recognize, express and modulate one’s own emotions and express empathy to others.
An effective strategy for improving mental health is meditation or practicing mindfulness. This practice encourages awareness of the senses and feelings in the moment, without interpretation or judgement. Mindfulness is significantly different than mind-fullness, which runs rampant in modern society where everyone can be digitally connected to anyone else in the world. In fact, disconnecting requires more intention and work than staying connected and is typically hard to achieve for long periods of time. Focusing on being mindful instead of living with a mind full of meetings, commitments, responsibilities, obligations, and invites can provide many benefits, both mental and physical.
Finally, financial health contributes to overall health and well-being. Financial health is unique to each person, but it typically centers on four elements: spend, save, borrow, and plan. Financial safety has been found to be positively associated with self-reported measures of physical and mental health and associated with a reduced risk of depression and anxiety.12 Stressors, including financial stress, can trigger physiological responses including increasing cortisol levels which can affect physical health.12 Creating a financial cushion, gaining financial literacy, and other financial health maneuvers can help minimize financial distress and may positively affect physical and mental health.
Setting and achieving goals
The first step in deciding on personal health goals is to identify underlying motivations followed by setting goals that are SMART: specific, measurable, achievable, relevant, and time bound. Focusing on SMART goals can help create more well-defined routes to achieve those goals. Examples of SMART goals include:
- Walk for 30 minutes after dinner at least three nights each week
- Increase vegetable intake by one serving per day for the next four weeks by including a salad or vegetable dish with lunch
- Put phone down 30 minutes before bed at least four days a week
- Meditate for at least five minutes on each weekend morning
Supplements for health
Even after pouring money, time, and effort into grocery shopping and meal preparation, it is possible that dietary intake could still fall short of nutritional recommendations. It can be very difficult to achieve the recommended intake for every nutrient day after day, despite best efforts. Because of the difficulty in consuming nutrients at the recommended levels, dietary supplements can be an effective way of filling in the gaps. From a health perspective, the role of supplements should be to fill in gaps as a supplement to the diet, not as an attempt to make-up for a poor diet.
Alternative strategies for health
Other strategies to increase health and wellness in life include practices found in types of alternative medicines. Acupuncture has been found to help with a variety of ailments and pain including tension headaches, blood pressure, and peripheral neuropathy.13-15 Massage therapy can also promote relaxation, increase circulation, ease muscle tension and is a safe and effective strategy for painful conditions, including osteoarthritis.16 Additionally, chiropractic therapy including spinal manipulative therapy may provide short-term pain relief and improved function for conditions including migraine headaches and neck pain.17 In addition to adding beneficial components that support health, it is also good to minimize elements that negatively affect health including tobacco use, excessive alcohol consumption, and excessive screen time.1
Living a healthy life should include promoting positive habits in the areas of physical, spiritual, mental, and financial health. Within physical health, food, physical activity, sleep, and stress management should be targeted in order to increase health outcomes and general well-being in both the short- and long-term. Focusing on SMART goals while avoiding stress about being healthy can help avoid a vicious cycle. Additionally, replacing unhealthy habits with healthier ones and having a plan ready for when things go off-track can help with achieving and maintaining health goals, both short- and long-term.
- Cena, H., Calder, P.C. (2020). Defining a Healthy Diet: Evidence for the Role of Contemporary Dietary Patterns in Health and Disease. Nutrients, 12(2):334-348.
- Locke, A., Schneiderhan, J., Zick, S.M. (2018). Diets for Health: Goals and Guidelines. Am Fam Physician, 97(11):721-728.
- García-Montero, C., Fraile-Martínez, O., Gómez-Lahoz, A.M., Pekarek, L., Castellanos, A.J., Noguerales-Fraguas, F., Coca, S., Guijarro, L.G., García-Honduvilla, N., Asúnsolo, A., Sanchez-Trujillo, L., Lahera, G., Bujan, J., Monserrat, J., Álvarez-Mon, M., Álvarez-Mon, M., Ortega, M.A. (2021). Nutritional Components in Western Diet Versus Mediterranean Diet at the Gut Microbiota-Immune System Interplay. Implications for Health and Disease. Nutrients, 13(2):699-747.
- Simopoulos, A.P. (2006). Evolutionary aspects of diet, the omega-6/omega-3 ratio and genetic variation: nutritional implications for chronic diseases. Biomed Pharmacother, 60(9):502-507.
- Grillo, A., Salvi, L., Coruzzi, P., Salvi, P., Parati, G. (2019). Sodium intake and hypertension. Nutrients, 11(9):1970-1985.
- Fothergill, E., Guo, J., Howard, L., Kerns, J.C., Knuth, N.D., Brychta, R., Chen, K.Y., Skarulis, M.C., Walter, M., Walter, P.J., Hall, K.D. (2016). Persistent Metabolic Adaptation 6 Years After “The Biggest Loser” Competition. Obesity, 24(8):1612-1619.
- Ruegsegger, G.N., Booth, F.W. (2018). Health Benefits of Exercise. CSH Perspect Med, 8(7):a029694
- Depner, C.M., Stothard, E.R., Wright, K.P. (2014). Metabolic consequences of sleep and circadian disorders. Curr Diab Rep, 14(7):507
- McEwen, B.S. (2006). Protective and damaging effects of stress mediators: central role of the brain. Dialogues Clin Neurosci, 8(4):367-381.
- Ghaderi, A., Tabatabaei, S.M., Nedjat, S., Javadi, M., Larijani, B. (2018). Explanatory definition of the concept of spiritual health: a qualitative study in Iran. J Med Ethics Hist Med, 11:3.
- Galderisi, S., Heinz, A., Kastrup, M., Beezhold, J., Sartorius, N. (2017). A proposed new definition of mental health. Psychiatr Pol, 51(3):407-411.
- Bialowolski, P., Weziak-Bialowoska, D., Lee, M.T., Chen, Y., VanderWeele, T.J., McNeely, E. (2021). The role of financial conditions for physical and mental health. Evidence from a longitudinal survey and insurance claims data. Soc Sci Med, 281:114041.
- Bao, T., Patil, S., Chen, C., Zhi, I.W., Li, Q.S., Piulson, L., Mao, J.J. (2020). Effect of Acupuncture vs Sham Procedure on Chemotherapy-Induced Peripheral Neuropathy Symptoms: A Randomized Clinical Trial. JAMA Netw Open, 3(3):e200681.
- Linde, K., Allais, G., Brinkhaus, B., Fei, Y., Mehring, M., Shin, B.C., Vickers, A., White, A.R. (2016). Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev, 4(4):CD007587.
- Zheng, H., Li, J., Li, Y., Zhao, L., Wu, X., Chen, J., Li, X., Haung, Y.L., Chang, X.R., Liu, M., Cui, J., Wang, R.H., Du, X., Shi, J., Guo, T.P., Liang, F.R. (2019). Acupuncture for patients with mild hypertension: A randomized controlled trial. J Clin Hypertens, 21(3):412-420.
- Perlman, A., Fogerite, S.G., Glass, O. Bechard, E., Ali, A., Njike, V.Y., Pieper, C., Dmitrieva, N.O., Luciano, A., Rosenberger, L., Keever, T., Milak, C., Finkelstein, E.A., Mahon, G., Campanile, G., Cotter, A., Katz, D.L. (2019). Efficacy and Safety of Massage for Osteoarthritis of the Knee: a Randomized Clinical Trial. J Gen Intern Med, 34(3):379-386.
- Smith, M.S., Olivas, J., Smith, K. (2019). Manipulative Therapies: What Works. Am Fam Physician, 99(4): 248-252.