How Joy is Linked to Gratitude and Well-being

By Donovan Giang

With the holiday season upon us, the spirit of joy is in the air. From magazine advertisements of happy families having a delicious meal to hearing Christmas carols in department stores, we are constantly being fed the message that we should be joyful at this time of year. However, if we are not feeling joy, these messages can be a continual reminder of what we are missing, often making us feel worse.

Luckily, researchers such as Akivah Northern, DSci (c), MDiv member of the Stanford Lifestyle Medicine Gratitude and Reflection pillar, explore different ways to experience and cultivate joy in our lives. Northern is a chaplain, doctoral candidate at Loma Linda University and she received her Masters of Divinity from Yale University. Her dissertation research is a Stanford IRB approved study, exploring medical students’ joys and challenges as they were expressed during Reflection Rounds, a required course for medical students taking their core clinical clerkships at Stanford School of Medicine. Northern co-facilities Reflection Rounds with Bruce Feldstein, MD, BBC who brought Reflection Rounds to Stanford seven years ago.

“We know that medical students are challenged, however less is spoken about their joys, which are equally as important,” says Northern. “Joy in medicine is an ancient aspiration that dates back to the fourth-century Hippocratic Oath, which is still taken by physicians today. Experiencing joy as a physician is part of the very foundation of medicine, so it is essential to cultivate it as medical students begin working with patients.”

So, how does one define joy? In Hebrew and Greek, joy has many meanings, such as delight, exaltation, rejoice, gladness, cheer, exuberance, and triumph. Northern shares that during challenging times, feelings of sorrow and grief are valid and a natural part of the human experience.

“There are times when life brings us situations when we have to lament, but we don’t have to stay there ,” she says. “There are so many different types of joy, such as received joy, divine joy, announcing joy, profit joy, fruit of the spirit joy, and jumping for joy, joy! So, even during hard times, we can choose to savor the myriad of joys and intentionally create reasons for joy.”

 Joy Linked to Gratitude

In exploring joy, researchers examined the relationship between joy and gratitude. This study consisted of self-report measures from university students. To measure joy, the researchers used scales developed within the study, such as the State Joy Scale and the Dispositional Joy Scale. To quantify gratitude, the researchers used scales of Dispositional Gratitude, a Gratitude Questionnaire, and a Gratitude, Resentment, and Appreciation Test. These self-report measures found that joy can increase gratitude and gratitude can increase joy, suggesting an “intriguing upward spiral” between the two.

“Research linking positive emotions like joy and gratitude to well-being is vital for patients as well as for  healthcare providers,” says Northern. “For example, preliminary results from my research showed that medical students’ expressed joy when they were grateful for teachers, peers, and for the profession of medicine, but especially for their patients”

Looking at her data, Northern found that in 30 expressions of joy by medical students, 17 were associated with gratitude. For example, one medical student expressed joy as gratitude for being “deeply honored” to have met and had “easy, comfortable conversations” with a patient, his spouse and family. Another student expressed joy as appreciation for the way his physician mentor engaged with a patient, describing the interaction as “beautiful and wonderful.” The student appreciated seeing the physician be present with the patient, admiring the quality of the physician’s presence and the “commonality” the physician and patient shared. A third medical student expressed that although she could not deliver medical care to a distraught patient with overwhelming life stressors, she still felt joy because “ultimately, just being a listening human was the number one therapy delivered that day.”  

“A surprising finding from the research was when medical students’ expressed joys and challenges simultaneously, they often had a breakthrough to a discovery or new joys and insights,” says Northern. “When we allow joys and challenges together, we become more resilient and emotionally buoyant, and often something new emerges from the experience.”  

Joy Linked to Well-being

In recent years, joy has become an object of study in the humanities and medicine. Joy, as a positive emotion, has consistently been suggested to be a key aspect of well-being in the field of positive psychology. Martin Seligman, the founder of this field, developed the PERMA+ Model. The “P” in PERMA+ stands for positive emotion (joy, gratitude, and optimism), the “E” for engagement, the “R” for relationships, the “M” for meaning, the “A” for accomplishments, and the “+” for other elements beyond these. 

In further research on joy as a positive emotion, researchers conducted a study to examine the pre-existing strategies individuals use to maintain high levels of positive emotion. To measure the strategies the participants (university students) used, the researchers applied an Emotion Regulation Profile to categorize participant reactions to hypothetical situations. One result from this study found that mindfulness (being present in the moment) was positively correlated with positive affect.

Another way positive emotions (including joy) increase well-being at the physiological level is by increasing one’s resilience. In this study, university students prepared a short speech, which served the purpose of stimulating a stress response. Using cardiovascular measures (to gauge the stress response), ambient mood and emotion measures, and psychological resilience measures, the researchers found that positive emotions hastened cardiovascular recovery (a lower amount of time needed to return to baseline cardiovascular measures, including heart rate and finger pulse data) after the experimental stressor. 

Another study examining the influence of positive emotions on physiological stress processes was the first to demonstrate that gratitude and thankfulness can buffer against the negative effects of acute stress on cardiovascular responses.

“Even in stressful times, joy can be a choice,” says Northern. “Even in a hard situation, we can look for joy. Even if we can’t see the joy currently, we can anticipate the joy that may come in the future from accepting the challenge, resolving it or reframing our understanding.. When we choose to approach challenges in the company of  joy and hope,  we are investing in our own well-being and our future.”


Optimism as a Means to a Longer Life

By Jonanne Talebloo

We have all heard the saying “mind over matter” when it comes to athletics and physical challenges. But can this saying be applied to health, healing, aging, and longevity? Studies suggest that optimism may play a leading role in improving not only one’s emotional well-being but also physical health and increasing lifespan.

Optimism, defined as the tendency to be hopeful and expect positive outcomes, has been linked to improved mental health and well-being in that it uplifts one’s mood and outlook on life. Optimism alone may not be the silver bullet for health and happiness, but studies show that it is one of many factors that can positively influence health, longevity, and lifespan.

For example, research shows that optimism helps diminish stress and anxiety, which lowers the stress hormone cortisol. Elevated levels of cortisol and blood pressure have been linked to an increased risk of stroke, hypertension and heart attack. Chronic stress can have negative effects on almost all of our bodily systems, including the endocrine system, where stress can impair communication between the immune system and the hypothalamic-pituitary-adrenal (HPA) axis, and potentially lead to immune disorders.

Optimism also assists with healing. Akivah Northern is part of the Stanford Lifestyle Medicine Gratitude and Reflection Pillar and earning her doctoral degree in Religion and Health at Loma Linda University. She is a chaplain, which are professionals who listen and accompany patients and their families in life-threatening, physical, existential, moral, or spiritual distress. Northern is the founder of a soon-to-open healthcare center that incorporates lifestyle medicine, chaplaincy intervention, and the arts.

“Optimism is not just helpful, it is vital for those who are suffering,” says Northern. “As a chaplain, I engaged patients in optimism and hope, instilled a sense of the sacred, and offered explorations regarding ultimate meanings. These conversations served as calming, hope-filled, and relieving medicine for patients.”

Optimism and Longevity

Recent studies have explored the connection between optimism and longevity and how a person with a positive outlook has the potential to live a longer, healthier life. A recent study revealed that optimism (defined as “the global expectation that things will turn out well in the future” and measured by cortisol stress reactivity and questionnaires) was linked to decreased cortisol levels, which is an important factor regarding increased longevity. Another study found that higher levels of optimism (assessed using the Revised Optimism-Pessimism Scale) were linked to increasing lifespan by as much as 15 percent.

In a review article examining a variety of health and longevity benefits associated with optimism, researchers found a whole host of benefits. Highlights from the review were that greater optimism predicted greater career success, better social relations, and better health. The article also concluded that the positive effects of optimism appeared to reflect individuals with a greater engagement in pursuit of desired goals. Another large-scale study showed that the link between optimism and increased longevity was independent of ethnic origin and applied across many racial and ethnic groups.

In order to understand how optimism can make such dramatic impacts on our health and longevity, the neural underpinnings of optimism have also been studied. Research suggests optimism activates areas of the brain involved in mood regulation, attention allocation, emotional expression, language processing, and perception of oneself. Modulating these areas with our thoughts may improve psychological well-being by improving one’s perception of the world, themselves, and self-expression.  

“Optimism is the opposite of stress, worry and anxiety, which can increase inflammation and chronic illness in the body,” says Northern. “By leaning toward a calming and optimistic way of being, we are increasing not only our mental, emotional, and spiritual well-being, but also our physical health and longevity.”

Optimism can be Cultivated

Although optimism is defined as a trait ingrained in individuals, people can learn to develop optimism over time. Learned optimism can be cultivated through music, gatherings, and culture in community. This sense of community strengthened by optimism can promote individual well-being, contribute to advancements in public health, and even inspire social change on a global scale.

An example of cultivated optimism through culture and community is the fact that millions of Iranian women worldwide have learned to adopt an optimistic attitude in their fight for freedom and equality. Research also shows that optimism improves resilience, another essential characteristic for Iranian women. Optimism and resilience among the Iranian diaspora have been the foundation of a global community that continues to inspire change regarding women’s rights. 

Optimism can also be developed at the individual level by working with internal thoughts, such as breaking pessimistic thought patterns or cultivating the experience of gratitude by keeping a gratitude journal. Another way to work towards adopting an optimistic mindset is by challenging and re-writing negative self-talk. For example, this can mean changing phrases such as “I will never be able to do this.” to “This is a challenge I look forward to working towards overcoming.” Furthermore, one study notably found that optimism can be increased through a very simple intervention in which individuals imagined their best possible self for five minutes each day.

“Our internal dialogue is everything. What we tell ourselves, the language we use on the inside will come out on the outside,” says Northern. “So, we need to be intentional about being optimistic, generous, and forgiving—this will make such a difference not only for those around us, but for our own health and healing.”


The Unexpected Health Benefits of Forest Bathing

By Vedika Patani and Carly Smith, BS, MPH(c)

This blog is part of the Stress Management newsletter. If you like this content, sign up here to receive our monthly newsletter!

Many people know that hiking in nature can help reduce stress and anxiety. But not everyone knows that forest bathing is a way to take the therapeutic effects of a scenic walk to the next level. While hiking is a great way to get outdoors and exercise, forest bathing is a practice of being calm and quiet among trees and being present with our natural surroundings.

“Both hiking and forest bathing harness the power of nature to offer a wide range of benefits for our physical and mental wellbeing,” says Rusly Harsono, MD, head of Stanford Lifestyle Medicine Social Engagement and Clinical Assistant Professor at the Stanford School of Medicine. “Hiking provides an outdoor activity that activates our nervous system for greater physical health, whereas forest bathing calms our nervous system and improves our emotional wellbeing, which is equally important to physical health.”


What is Forest Bathing?

Forest bathing, or Shinrin Yoku, originated in Japan in the 1980s and involves taking deep breaths and experiencing the forest with full presence. Contrary to hiking, where the mind can still ruminate about work or challenging relationships, forest bathing is a mindfulness practice in that it brings the mind into the present moment by taking in the forest with all five senses. For example, a forest bather would visually observe the colors of the leaves and stop to notice the sun’s rays through the trees. They might close their eyes and take in a deep breath through the nose to capture the scent of pine. As they take a step, they may hear the crackling of a fallen leaf from under their shoe, and then pause to notice the sensation of the wind on their cheeks.

During the pandemic, forest bathing grew in popularity in the US as people searched for ways to calm their nervous system and connect outdoors while social distancing. But forest bathing is proving to be more than a lifestyle trend. Research is attributing this practice to numerous health benefits. 

Forest Bathing and Mental Health

While hiking focuses on the improvement of physical fitness, forest bathing fosters improved mental and emotional health. Some people who experience anxiety find that forest bathing calms their nervous system because their attention shifts from their worries to noticing the natural elements all around them—and these results are scientifically measurable.

Studies show that forest bathing can decrease the stress hormone cortisol. In one meta-analysis, researchers reviewed 971 articles and found that forest bathing effectively reduced serum and salivary cortisol levels, indicating its potential to reduce stress. 

Another meta-analysis reviewed studies where forest bathing was introduced to people living in urban environments, who generally have a higher risk of hypertension and psychological stress. Not only did the practice reduce their stress, but it also significantly lowered their blood pressure. 

“Forest bathing can be beneficial for everyone, but it is particularly advantageous for individuals living in urban environments,” says Dr. Harsono. “Urban dwellers typically experience higher stress levels, noise pollution, and reduced access to natural settings. Forest bathing provides them a valuable opportunity to escape these stressors and experience improved wellbeing through connection with nature.”

A Natural Immune Supporter

Forest bathing is not just important for improving wellbeing, but it may also improve one’s physical health. Studies have found that forest bathing could increase immune cell activity and aid in the expression of anti-cancer proteins. In one study, a group of 12 men aged 37-55 spent three days practicing forest bathing in three different forests. Afterward, the men showed a 50 percent increase in natural killer cells (which can kill tumor cells) and an increase in the anti-cancer proteins perforin, granzymes, and granulysin. 

Another research study showed that forest bathing improved immune function. When we inhale the oils released from trees (phytoncides), our cortisol levels decrease, and natural killer cell activity increases. These findings suggest forest bathing may have a preventive effect on cancer due to its ability to stimulate immune responses; however, more research needs to be conducted to better understand this phenomenon.

Forest Bathing Everywhere

One would think that forest bathing is only possible if you live in the country, however, this study showed that urban forest bathing (i.e. being mindful at a nearby park) still brought feelings of peacefulness to adolescents that live in metropolitan areas. This study observed the changes in the mental wellbeing of 44 adolescents before and after urban forest bathing. The results reported reduced anxiety, rumination, and skepticism, as well as increased feelings of social connectedness.

Lastly, landscape designers have taken note of the research supporting the healing effects of nature. At Stanford’s Lucile Packard Children’s Hospital in the heart of the San Francisco Bay Area, patients and their families have access to gardens and outdoor spaces to stroll and mindfully take in the natural beauty.

“Lucile Salter Packard’s vision for the hospital was to nurture the body and soul of every child by creating a restorative environment by integrating nature and art,” says Dr. Harsono, Pediatrician at Stanford Medicine Children’s Health. “We frequently bring children to the hospital garden during their recovery to help them manage their treatment and discomfort. Research supports this idea of incorporating forest bathing experiences into the care of sick children to improve their health outcomes and overall quality of life.”


Aerobic & Resistance

Aerobic & Resistance Exercise Improves Sleep

Sleep, a fundamental element of human biology, plays a crucial role in various physiological processes. A good night’s sleep is essential for immune function, cognitive performance, emotional well-being, and overall physical health. Exercise is another critical lifestyle factor with tremendous potential to improve your health. Regular physical activity has numerous benefits, from reducing the risk of chronic diseases to improving mental health. However, could exercise improve your sleep?

Impact of Resistance Exercise on Sleep

A 2017 review found that “chronic resistance exercise improves all aspects of sleep, with the greatest benefit for sleep quality” in individuals with sleep problems. In this study, Kovacevic et al. employed a systematic review methodology by conducting an electronic database search of randomized controlled trials. Many studies fit the criteria, but three acute resistance exercise studies, seven chronic resistance exercise studies, and three combined aerobic and resistance exercise studies met the researcher’s inclusion criteria and were analyzed for sleep outcomes. The primary finding from this review was improvements in sleep from chronic exercise; these improvements were “moderate-to-large, and commonly affected overall sleep quality, sleep latency, sleep efficiency, mid-sleep disturbance, and daytime dysfunction”. In comparison, the primary medications prescribed to improve sleep quality had “only small-to-moderate effects on sleep quality” and instead have “adverse effects such as rebound insomnia, depression and anxiety, cognitive impairment, and an increased risk of falls, cancer, and overall mortality” if used in the long-term. Kovacevic et al. call for further research and more data on aerobic exercise but cites an earlier paper that noted how aerobic exercise could improve sleep quality.

Furthermore, their work highlighted how “higher intensity and greater frequency of training offer greater sleep benefits”. More specifically, the chronic resistance exercises studied that had the most benefits included machine-based resistance exercise, circuit training, and resistance bands for an average duration of 14 weeks total with approximately 60 minutes per session. Studies with high exercise intensity as compared to low-to-moderate intensity, and with a frequency of 3 days/week as compared to 1-2 days/week, had a larger beneficial effect on sleep quality.

The review presented another pathway by which exercise could improve sleep; exercise improves levels of anxiety and depression, both of which deeply affect sleep — “notably, exercise has been shown to be an effective treatment for major depression and sleep disturbance is one of the core symptoms of depressive illness” and “the majority of chronic studies included in this review reported significant improvements in neuropsychological outcomes”.

Impact of Aerobic Exercise on Sleep

Additional research has also shown the further benefits of aerobic exercise for people with established sleep disorders. One study showcased how “4 months of aerobic exercise training in a sample of older adults with insomnia significantly improved sleep quality while also reducing daytime sleepiness and depressive symptoms”. Another study found that “12 weeks of moderate-intensity aerobic and resistance exercise resulted in a 25% reduction in OSA [obstructive sleep apnea] severity”. Lastly, studies have even shown that the circadian rhythms disrupted in neurodegenerative disease can be improved with exercise — “exercise has proven to be a low risk and beneficial intervention to improve overall health and sleep disorders in AD [Alzheimer’s disease] and PD [Parkinson’s Disease]”. In particular, “physical activity, even at low intensities, has been reported to improve sleep quality, reduce time to fall asleep, and increase the duration of sleep in the elderly… evidence indicates that exercise increases total sleep time and slow-wave sleep”.

We all strive for better sleep even if we do not have a known sleep disorder, and it could be within our grasp through a novel route. Exercising for an hour three times a week at high intensity with machine-based resistance exercise, circuit training, or resistance bands can improve your sleep quality and decrease issues in the day. Even once a week at a lesser intensity for 40 minutes showed beneficial effects! Sleep and exercise are significant pillars in lifestyle medicine, and it is fascinating how one affects the other. Rather than relying on medications that can have adverse effects, research suggest exercise is a natural way we can improve our sleep. While further research is needed, recognizing the interconnectedness of exercise and sleep as critical components of a healthy lifestyle is crucial.

By: Keshav Saigal, BS(c)


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