Prevalence of traditional Chinese medicine body constitutions in a large community-based study in Hangzhou, China

Background: Traditional Chinese medicine (TCM) views body constitution as a foundational determinant of health and disease risk. Understanding the distribution of body constitutions across the population can help in developing personalized strategies to prevent disease, but few studies have examined composite constitutions or unbalanced tendencies.
Methods: This cross-sectional study assessed the prevalence of singular and composite (multiple) TCM body constitutions and tendencies in a sample of adult residents of Hangzhou, China. We used the 2016 version of the Constitution in Chinese Medicine Questionnaire (CCMQ, 54 items) to classify participants into nine body constitutions and tendencies toward those body constitutions and examined variations in those distributions by demographics and selected lifestyle factors.
Results: Among 8,665 participants aged 18-80 years, 74.2% had one or more body constitutions, and 25.8% had unbalanced tendencies only. The Balanced constitution was the most common (22.3%). Of the eight unbalanced constitutions, Qi Deficiency (16.4%), Phlegm Dampness (11.0%), and Yang Deficiency (9.4%) were most prevalent. Over half of the individuals with an unbalanced constitution also had other constitutions (composite). The most frequent composite combinations included Qi Stagnation with Qi Deficiency, Blood Stasis and Qi Deficiency, and Damp Heat with Phlegm Dampness. Body constitution distribution varied significantly by age, sex, and body mass index (BMI). Younger adults (18-39 years) were less likely to have the Balanced constitution (13.1%) and more likely to have composite unbalanced constitutions. Men were more likely to have Phlegm Dampness or Damp Heat, while women were more likely to have Yang Deficiency or Yin Deficiency. After adjusting for age and sex, individuals with obesity had a higher prevalence of Phlegm Dampness and a lower prevalence of the Balanced, Yang Deficiency, or Yin Deficiency constitutions.
Conclusions: Our results provide a comprehensive profile of the patterns and distribution of TCM body constitutions across demographic and lifestyle subgroups. This more complete understanding of TCM body constitutions can inform personalized medicine, support individual risk assessment, and help improve health outcomes.

Wu YH, Wang J, Bai MH, Wang Q, Myers A, Gao P, Delzell E, Huang D, Yang F, He W, Zhu S, Hsing AW. Prevalence of traditional Chinese medicine body constitutions in a large community-based study in Hangzhou, China. Chin Med. 2025 Nov 28;20(1):206. doi: 10.1186/s13020-025-01268-x

Traditional Chinese medicine body constitution and sleep quality 

Study objectives: To investigate the relationships between Traditional Chinese Medicine (TCM) body constitution and sleep quality in a large population-based cohort.
Methods: This cross-sectional study included 8517 participants from the WELL China cohort. We used the Wang Qi Nine Body Constitution Questionnaire (WQ-9BC) to assess TCM body constitution and the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality. We used multivariable logistic regression analyses to estimate odds ratios (ORs) for the association between body constitution and poor sleep quality (PSQI score > 5), adjusting for demographics, lifestyle factors, and comorbidities.
Results: Compared with a balanced body constitution (1898; 22%), individuals with an unbalanced constitution had a 2.6-fold risk (95% CI = 2.3% to 3.0%), and those with an unbalanced tendency had a 1.5-fold risk of poor sleep quality (95% CI = 1.3% to 1.8%). All eight unbalanced constitutions were associated with a higher risk of poor sleep quality, with Qi stagnation (OR 4.0 [95% CI = 3.0% to 5.5%]) and blood stasis (OR 3.8 [95% CI = 2.3% to 6.2%]) having the highest ORs. About 52% of participants had multiple unbalanced constitutions and/or tendencies. The OR for poor sleep quality increased with the composite number of Yang deficiency, Yin deficiency, Qi deficiency, heat dampness, blood stasis, and Qi stagnation constitutions and/or tendencies.
Conclusions: All eight unbalanced constitutions are associated with poor sleep quality in a dose-dependent manner, with Qi stagnation and blood stasis displaying the strongest associations. Multiple unbalanced constitutions and/or tendencies are cumulatively associated with poor sleep quality. Identifying TCM body constitution could help in detecting high-risk groups and designing targeted interventions.

Gao P, Wang J, Wu YH, Bai M, Myers A, Wang Q, Delzell E, Kushida CA, Huang D, Yang F, He W, Lu Y, Zhu S, Hsing AW. Traditional Chinese medicine body constitution and sleep quality. Sleep Adv. 2025 Oct 14;6(4):zpaf069. doi: 10.1093/sleepadvances/zpaf069

Fried food consumption-related gut microbiota is associated with obesity, fat distribution, and cardiometabolic diseases: results from 2 large longitudinal cohorts with sibling comparison analyses

Background: In prospective cohort studies, the relationship between fried food consumption, gut microbiota, obesity, and cardiometabolic diseases remains unknown.
Objectives: We aimed to explore associations of fried food consumption with gut microbiota and associations of fried food consumption-related microbiota with obesity and related disorders.
Methods: We analyzed 6637 individuals from the Wellness Living Laboratory China cohort (baseline 2016-2019) and 3466 from the Lanxi cohort (baseline 2017-2019), with follow-up until 24 June, 2024. Face-to-face interviews provided data on fried food consumption and other covariates. Analysis of 16S ribosomal ribonucleic acid data from fecal samples collected at baseline identified microbial genera. Body composition was evaluated using dual-energy x-ray absorptiometry. The microbiome multivariable associations with linear models helped identify genera associated with the frequency of fried food consumption in the cross-sectional analysis. Cox regression models examined the relationship of fried food consumption-related microbiota with cardiometabolic diseases during follow-up. Sibling comparison analyses were used to control for unmeasured familial confounders using the between-within model.
Results: Twenty-five microbial genera were significantly associated with fried food consumption frequency. Using these genera, we constructed a fried food consumption-related microbiota index. Meta-analysis of both cohorts found a positive relationship of this index with overall adiposity measures [body mass index (kg/m2)] [β coefficient: 0.26; 95% confidence interval (CI): 0.19, 0.32] and central fat distribution parameters [including android-gynoid fat ratio (β: 1.48; 95% CI: 1.14, 1.82)]. Longitudinal analyses indicated that a higher fried food consumption-related microbiota index was linked to a higher risk of developing cardiometabolic diseases, with adjusted hazard ratios (95% CI) of 1.16 (1.07, 1.27) for diabetes and 1.16 (1.06, 1.26) for major adverse cardiovascular events. Sibling comparison analyses yielded similar results.
Conclusions: Fried food consumption-related microbiome is associated with a higher risk of obesity, central fat distribution, and cardiometabolic diseases, emphasizing the importance of dietary choices in the management and prevention of chronic diseases.

Duan Y, Li Y, Xu C, Wang W, Wang X, Zheng W, Hsing JC, Wu J, Myers A, Hsing AW, He W, Zhu S. Fried food consumption-related gut microbiota is associated with obesity, fat distribution, and cardiometabolic diseases: results from 2 large longitudinal cohorts with sibling comparison analyses. Am J Clin Nutr. 2025 Sep;122(3):733-743. doi: 10.1016/j.ajcnut.2025.06.025

Smoking-related gut microbiota alteration is associated with obesity and obesity-related diseases: results from two cohorts with sibling comparison analyses

Background: Individuals who smoke tend to have a lower body mass index (BMI) but face an increased risk of obesity-related diseases. This study investigates this paradox from the perspective of gut microbiota.
Methods: We conducted microbiome analyses to identify smoking-related microbial genera and created a smoking-related microbiota index (SMI) using 16S rRNA sequencing data from 4000 male participants in WELL-China cohort and Lanxi cohort. We employed logistic regression to explore the association between SMI and obesity indices derived from dual-energy X-ray absorptiometry. Cox regression analyses were conducted to explore the association of SMI with incident of obesity-related diseases. To further control for unmeasured familial confounders, sibling comparison analyses were conducted using between-within (BW) model.
Results: The smoking-related microbiota index (SMI) showed a positive association with BMI and other obesity indices. Further analyses revealed that SMI is linked to obesity-related diseases, with hazard ratios (95% confidence intervals) of 1.97 (1.41–2.75) for incident diabetes, 1.31 (1.01–1.71) for major adverse cardiovascular events, and 1.70 (1.05–2.75) for obesity-related cancers. Results from sibling comparison analyses reinforced these findings.
Conclusions: While smoking may reduce weight through various mechanisms, alterations in gut microbiota related to smoking are associated with weight gain. Further research is required to determine if changes in the smoking-related microbiome contribute to weight gain following smoking cessation.

Duan Y, Xu C, Wang W, Wang X, Xu N, Zhong J, Gong W, Zheng W, Wu YH, Myers A, Chu L, Lu Y, Delzell E, Hsing AW, Yu M, He W, Zhu S. Smoking-related gut microbiota alteration is associated with obesity and obesity-related diseases: results from two cohorts with sibling comparison analyses. BMC Med. 2025 Mar 10;23(1):146. doi: 10.1186/s12916-025-03969-4

Distinct Gut Microbiota Profiles in Normal Weight Obesity and Their Association With Cardiometabolic Diseases: Results From Two Independent Cohort Studies

Background: Normal weight obesity (NWO) is characterized by excess body fat in individuals with normal body mass index (BMI). This study aimed to investigate gut microbiota alterations in NWO and their potential associations with cardiometabolic diseases (CMD) risk in two independent cohorts.
Methods: Our NWO-CMD mortality analysis included 168 099 adults with normal BMI from two large open-access databases, while our NWO-gut microbiota study involved 5467 adults with normal BMI from two independent cohorts: the WELL-China cohort and the Lanxi cohort. NWO was defined as having a normal BMI (18.5-23.9 kg/m2) but an excess per cent body fat (PBF, ≥ 25% in men and ≥ 35% in women). Normal weight lean was defined as having a normal BMI and normal PBF. The 16S rRNA gene sequencing method was used to analyse gut microbiota data.
Results: The study comprised 3620 (64.0% female, median age 58 years) and 1847 (64.3% female, median age 56 years) participants from the WELL-China and Lanxi cohorts. In our meta-analysis, NWO is associated with 26% (95% CI: 1.07-1.41) higher risk of CMD mortality. Gut microbial analyses indicated that the NWO group exhibited reduced levels of observed species (p = 0.009 and p = 0.013) and Chao 1 index (p = 0.002 and p = 0.002) and altered gut microbial compositions (p = 0.009 and p < 0.001) compared with the NWL group. Seven genera were consistently observed to be associated with NWO in both two cohorts (all Q < 0.25). Among them, five (Fusobacterium, Ruminococcus gnavus group, Ruminococcus torques group, Coprococcus and Christensenellaceae_R7_group) have been previously linked to obesity, while the other two (Phascolarctobacterium and Clostridia_UCG-014) were minimally reported. We also found statistically significant differences in the microbial composition between the NWO group and the obesity group (p = 0.001 and p = 0.001). Furthermore, the NWO-related gut microbiome was associated with an elevated risk of hypertension, dyslipidaemia and metabolic syndrome, the corresponding HR (95% CIs) were 1.11 (1.01-1.22), 1.19 (1.10-1.29) and 1.17 (1.05-1.30) in the WELL-China cohort and 1.14 (1.02-1.27), 1.15 (1.02-1.29) and 1.16 (1.02-1.32) in the Lanxi cohort.
Conclusions: These two large cohorts provided reliable evidence that gut microbiota alterations in NWO resemble those found in obesity, yet also display unique aspects. This distinct microbiota profile may contribute to heightened cardiometabolic risks in adults with normal BMI.

Wang W, Wang F, Li Y, Shi Y, Wang X, Chen X, Zheng W, Hsing JC, Lu Y, Wu YS, Hsing AW, Kan J, He W, Zhu S. Distinct Gut Microbiota Profiles in Normal Weight Obesity and Their Association With Cardiometabolic Diseases: Results From Two Independent Cohort Studies. J Cachexia Sarcopenia Muscle. 2025 Feb;16(1):e13644. doi: 10.1002/jcsm.13644

Nonalcoholic fatty liver disease (NAFLD) detection and deep learning in a Chinese community-based population

Objectives: We aimed to develop and validate a deep learning system (DLS) by using an auxiliary section that extracts and outputs specific ultrasound diagnostic features to improve the explainable, clinical relevant utility of using DLS for detecting NAFLD.
Methods: In a community-based study of 4144 participants with abdominal ultrasound scan in Hangzhou, China, we sampled 928 (617 [66.5%] females, mean age: 56 years ± 13 [standard deviation]) participants (2 images per participant) to develop and validate DLS, a two-section neural network (2S-NNet). Radiologists' consensus diagnosis classified hepatic steatosis as none steatosis, mild, moderate, and severe. We also explored the NAFLD detection performance of six one-section neural network models and five fatty liver indices on our data set. We further evaluated the influence of participants' characteristics on the correctness of 2S-NNet by logistic regression.
Results: Area under the curve (AUROC) of 2S-NNet for hepatic steatosis was 0.90 for ≥ mild, 0.85 for ≥ moderate, and 0.93 for severe steatosis, and was 0.90 for NAFLD presence, 0.84 for moderate to severe NAFLD, and 0.93 for severe NAFLD. The AUROC of NAFLD severity was 0.88 for 2S-NNet, and 0.79-0.86 for one-section models. The AUROC of NAFLD presence was 0.90 for 2S-NNet, and 0.54-0.82 for fatty liver indices. Age, sex, body mass index, diabetes, fibrosis-4 index, android fat ratio, and skeletal muscle via dual-energy X-ray absorptiometry had no significant impact on the correctness of 2S-NNet (p > 0.05).
Conclusions: By using two-section design, 2S-NNet had improved the performance for detecting NAFLD with more explainable, clinical relevant utility than using one-section design.
Key points: Based on the consensus review derived from radiologists, our DLS (2S-NNet) had an AUROC of 0.88 by using two-section design and yielded better performance for detecting NAFLD than using one-section design with more explainable, clinical relevant utility. The 2S-NNet outperformed five fatty liver indices with the highest AUROCs (0.84-0.93 vs. 0.54-0.82) for different NAFLD severity screening, indicating screening utility of deep learning-based radiology may perform better than blood biomarker panels in epidemiology. The correctness of 2S-NNet was not significantly influenced by individual's characteristics, including age, sex, body mass index, diabetes, fibrosis-4 index, android fat ratio, and skeletal muscle via dual-energy X-ray absorptiometry.

Changes in lifestyles and depressive symptom among patients with chronic diseases during COVID-19 lockdown

Well-being in Thailand: A Culturally Driven Grounded Inquiry Exploration of a Complex Construct.

Methods: A purposeful sample of 50 Thai adults living in Bangkok shared their personal stories of times when they experienced high and low levels of well-being. Data were inductively coded and analysed to identify key domains of participants’ well-being and their inter-connections.
Results: The results reflect three layers of well-being. Social relationships (i.e., family, friends and acquaintances, and relationships at work or education) are at the center of well-being in Thailand, connecting and supporting a second layer of eight constituent domains of well-being (experience of emotions, sense of self, finances, self-care, demands and responsibilities, thoughts and feelings about the future, personal health, spirituality). The third layer is composed of the societal and physical contexts that are formative for well-being.
Conclusions: Our findings suggest both universal and culturally unique components of well-being among Thai adults. Implications for the promotion of well-being in Thailand are discussed.

Suavansri, Panita & Pichayayothin, Nipat & Rodriguez Espinosa, Patricia & Areekit, Poonsub & Nilchantuk, Chureerat & Jones, Torin & French, Joanna & Mam, Emily & Moore, Jessie & Heaney, Catherine. (2022). Applied Research in Quality of Life. https://doi.org/10.1007/s11482-022-10067-7

Found in Translation: Reflections and Lessons for Qualitative Research Collaborations Across Language and Culture

Qualitative scholars are increasingly engaged in global research where members of the research team are from different countries and cultures and have different primary languages. However, in-depth descriptions of how to work as a transnational team successfully and rigorously are scarce. Using a collaboration between Stanford University in the US and Chulalongkorn University in Thailand as a case example, we present the nuances and challenges experienced in this research collaboration, as well as the strategies employed to optimize the validity and reliability of the study findings. While we started our data analysis following a more typical qualitative analysis path, shortcomings of this approach brought us to explore an alternative, involving data review and coding by transnational coding sub-teams. This approach was better able to illuminate cultural nuances, address coding discrepancies, and bring forward discussions to enhance interpretation and validity of findings. We describe our collaborative and iterative approach, and highlight methodological implications around team composition, language nuances and translation challenges, our coding process involving transnational coding sub-teams, and important considerations for managing team dynamics (e.g., power and hierarchy) and the partnership process and engagement over time. Moreover, we highlight the benefits of integrating insiders and outsiders throughout the research process, from data collection to coding and interpretation. Our process can serve as a model for similar transnational teams seeking ways to fully benefit from cross-cultural research collaborations.

Rodriguez Espinosa, P., Pichayayothin, N. B., Suavansri, P., French, J. J., Areekit, P., Nilchantuk, C., Jones, T. S., Mam, E., Moore, J. B., & Heaney, C. A. (2022). SAGE Journals. https://doi.org/10.25384/SAGE.19808722.v1.

Metabolomic Profiles of Plasma Retinol-Associated Dyslipidemia in Men and Women

Background and Aims: Studies of both animals and humans show that a high intake of vitamin A is associated with a lower risk of dyslipidemia. However, an association of plasma retinol levels with dyslipidemia is unclear. Therefore, the aim of this study is to investigate an association between plasma retinol and dyslipidemia and to identify related metabolites and pathways in the general population.
Methods: We included 250 participants aged 20-80 years from the Wellness Living Laboratory (WELL) China cohort. Associations between plasma retinol levels and dyslipidemia were analyzed using adjusted logistic models. Related metabolites were identified using ANCOVA, adjusted for the false discovery rate (FDR) and used for pathway analyses. Because there are sex differences in plasma retinol levels, all analyses were conducted separately by sex. Results: Plasma retinol was significantly higher in men than in women. A positive association between plasma retinol and dyslipidemia was found in both sexes. In men, the 2nd and 3rd tertiles showed significantly higher proportions of dyslipidemia than the 1st tertile (1st tertile vs. 2nd tertile: p = 0.026; 1st tertile vs. 3rd tertile: p = 0.003). In women, the 3rd tertile showed a significantly higher proportion of dyslipidemia than the 1st and 2nd tertile (3rd tertile vs. 1st tertile: p = 0.002, 3rd tertile vs. 2nd tertile: p = 0.002). Overall, 75 and 30 metabolites were significantly associated with retinol levels in men and women, respectively. According to these metabolites, lipid metabolic pathways, including glycerophospholipid, arachidonic acid, linoleic acid, alpha-linolenic acid, and glycosylphosphatidylinositol (GPI), as well as steroid hormone biosynthesis pathways were found to overlap across the sexes. These pathways showed that elevated retinol levels might be associated with hormone metabolism and inflammation status.
Conclusions: We found a positive association between plasma retinol levels and dyslipidemia. Related metabolomic profiles and interrupted pathways showed that such an increase might be associated with steroid hormone synthesis and inflammation. In addition, large, population-based longitudinal studies and intervention studies are needed to confirm the role of retinol in lipid metabolism and the prevention of cardiovascular disease (CVD).

Wang N, Ru Y, Yang Z, Sun C, Li S, Min Y, Zhao X, Lu Y, Hsing AW, Zhu S. Metabolomic Profiles of Plasma Retinol-Associated Dyslipidemia in Men and Women. Front Nutr. 2021 Nov 17;8:740435. doi: 10.3389/fnut.2021.740435. PMID: 34869520; PMCID: PMC8635783.

Daytime napping is associated with retinal microcirculation: a large population-based study in China

Study objectives: To investigate the association between daytime napping and retinal microcirculation.
Methods This is a cross-sectional study from a prospective population-based cohort. 2,662 participants were recruited after quota sampling. Information on napping was collected through face-to-face interviews. Retinal vascular calibers (RVCs), including central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE), and arterio-to-venous ratio (AVR), were obtained from fundus photography. Multivariate regression and restricted cubic spline curve were performed to determine the association between RVCs and daytime napping duration.
Results: 56.4% participants reported daytime napping regularly. Compared to no nap, daytime nap was related to higher CRAE, with nap duration of 0.5-1 h showing the most significant association. 0.5-1 h daytime nappers displayed an average of 4.18 µm (95% confidence interval [CI] 2.45-5.91, p < 0.001) wider CRAE than non-nappers after adjustment. No significant association was found between CRVE and daytime napping. Moreover, individuals with 0.5-1 h daytime napping had a lower risk for AVR reduction (odds ratio [OR] 0.70, 95% confidence interval [CI] 0.56-0.86, p = 0.001) than non-nappers. Similar association persisted in non-hypertensive population. Restricted cubic spline indicated a J-shaped relationship between AVR reduction and nap duration.
Conclusion: Retinal microcirculation was positively associated with self-reported 0.5-1 h daytime napping. Better indicators of retinal microcirculation were probably related to nap duration in a J-shaped manner. Also, the possibly beneficial role of 0.5-1 h daytime napping on retinal microcirculation might be independent of clinically diagnosed vascular diseases.

Liu X, Wang G, Wang X, Wang Y, Min Y, Zhang J, Chang RT, Zhao X, He W, Moshfeghi DM, Lu Y, Hsing AW, Yao K, Zhu S. Daytime napping is associated with retinal microcirculation: a large population-based study in China. Sleep. 2021 Nov 20:zsab277. doi: 10.1093/sleep/zsab277. Epub ahead of print. PMID: 34875091.

Cohort Profile: WELL Living Laboratory in China (WELL-China)

Key Features of the WELL China Cohort

WELL-China is a prospective longitudinal study for the investigation of well-being. The cohort aims to assess multidimensional well-being in a large sample and provides a platform for future intervention studies to help promote well-being at individual and community levels.

A total of 10 268 participants aged between 18 and 80 years were recruited from the City of Hangzhou, China between 2016 and 2019; 40% of the cohort are men.

Follow-up will take place between 2020 and 2021, and will reoccur every 2 years; the nested-omics sub-cohort will be followed every 6 months.

WELL-China has collected in-person survey data, physical and clinical examinations, laboratory tests and biospecimens. The survey included >1000 questions and includes the Stanford WELL for Life Scale, lifestyle behaviours, eye disease and traditional Chinese medicine body constitutions. In-person examinations included anthropometrics, functionalities, vitals, eye exams, traditional Chinese medicine diagnosis and abdominal ultrasound. Laboratory tests included complete blood count, liver and renal panel, lipid panel, etc. Biospecimens included blood, stool, hair and toenails, which were collected at baseline. Specimens have been processed and aliquoted for storage at –80C in a freezer. Currently, WELL-China has >200 000 aliquots of biospecimens in the WELL-China biobank. A subset of 250 participants also currently have microbiome and metabolomic information.

WELL-China data contain several unique features. The novel Stanford WELL for Life Scale quantifies one’s overall well-being and domain-specific well-being. Dual-energy X-ray absorptiometry (DXA) scans provide detailed information on body composition and bone mineral density. Thorough eye examinations and ophthalmology surveys are unique compared with other China-based cohorts. Abdominal ultrasound provides important information to identify fatty liver diseases, including non-alcoholic fatty liver disease. The cohort setup also permits the rapid implementation of intervention testing.

WELL-China welcomes collaborations globally. Applicants must submit an ancillary study application package including a research proposal, requested variables and biospecimens. For more information, please contact annhsing@stanford.edu (the USA-based PI) or zsk@zju.edu.cn (the China-based PI).

Yan Min, Xueyin Zhao, Randall S Stafford, Xiaoguang Ma, Shih-Hua Chen, Da Gan, Chen Wei, Chao Huang, Lijin Chen, Peng Gao, Fei Yang, Sandra J Winter, Yi-Hsuan Wu, Catherine A Heaney, Mike Baiocchi, John P A Ioannidis, Ann W Hsing, Shankuan Zhu, Cohort Profile: WELL Living Laboratory in China (WELL-China), International Journal of Epidemiology, 2021;, dyaa283,

Associations of park access, park use and physical activity in parks with wellbeing in an Asian urban environment: a cross-sectional study

Relationships between park access, park use, and wellbeing remain poorly understood. The objectives of this study were to investigate: (1) perceived and objective park access in relation to park use and physical activity in parks; and; (2) perceived and objective park access, park use and physical activity in parks and their associations with wellbeing. An interviewer-assisted survey collected data on perceived time to walk to parks, park use time, park physical activity time and wellbeing (using a scale containing nine domains) amongst adult participants of the Singapore Multi-Ethnic Cohort. Geospatial maps of parks and the “walkable” street networks were created for the city-state of Singapore to objectively determine distances to accessible points on park boundaries. Multiple linear regression models estimated the importance of park access to park use and associations of park access and park use with wellbeing, adjusting for potential confounders. Participants’ (n = 3435) average age was 48.8 years (SD, 12.8), 44.8% were male and 72.6% were of Chinese ethnicity. Better perceived but not true park access was significantly associated with greater park use. Park access (perceived or true) was not associated with physical activity time in parks. Greater participant park time and physical activity time in parks were associated with higher wellbeing scores (p < 0.001). The differences in wellbeing scores between the reference groups, who spent negligible time in parks, and the highest quartiles of time in parks (10.8 h/month) and physical activity in parks (8.3 h/month) were 3.2 (95% CI 2.1–4.4) and 4.2 (95% CI 4.1–6.3) points out of 100 respectively. These associations were similar for most domains of wellbeing, with clear dose-response relationships. While perceived park access was strongly associated with park use and well-being, true park access was not, and neither park access measure was associated with park physical activity. Future studies could investigate the influence of park attributes on park use, physical activity in parks and wellbeing. The consistent associations of park use and particularly physical activity in parks with wellbeing suggest that promoting park use, and especially physical activity in parks, is a promising strategy for improving wellbeing in urban settings.

Petrunoff, N. A., Yi, N. X., Dickens, B., Sia, A., Koo, J., Cook, A. R., Lin, W. H., Ying, L., Hsing, A. W., van Dam, R. M., & Müller-Riemenschneider, F. (2021). Associations of park access, park use and physical activity in parks with wellbeing in an Asian urban environment: A cross-sectional study. International Journal of Behavioral Nutrition and Physical Activity, 18(1), 87. https://doi.org/10.1186/s12966-021-01147-2

Coping with the COVID-19 pandemic: Contemplative practice behaviors are associated with better mental health outcomes and compliance with shelter-in-place orders in a prospective cohort study

Psychosocial health can influence the development and experience of several chronic diseases, and has been negatively affected for many individuals amid the COVID-19 global pandemic. To understand the impact of contemplative practices on emotional and mental health during COVID-19, the Stanford WELL for Life Study (US component), incorporated a series of additional surveys into its ongoing study. A total of 1,097 participants residing in California who responded to at least one of three COVID-19 surveys were included in this analysis. Linear and generalized mixed-effects regression models were used to investigate relationships between individual contemplative practice behaviors (CPB) (embodied observing meditation, non-reactive mindfulness meditation, self-compassion cultivation, cultivation of compassion for others) and four psychosocial outcomes measured in the original WELL questionnaire (resilience, dealing with stress, positive emotions, and negative emotions). In addition, the associations between CPB and depression, distress, and compliance with local Shelter-In-Place orders were also investigated. Participants who engaged in any contemplative practice reported significantly more resilience and positive emotions, dealing better with stress, lower distress, and were less likely to report an experience with depression in the last week. Similar findings held when CPB was modeled as a continuous variable. Significant interactions between the duration of the SIP and CPB were also observed for resilience and SIP compliance outcomes, indicating that steeper declines were observed among participants with little or no CPB across the study period. Further investigation into the potential protective benefits of CPB during times of major disruption and uncertainty is warranted.

Chrisinger, B. W., Rich, T., Lounsbury, D., Peng, K., Zhang, J., Heaney, C. A., Lu, Y., & Hsing, A. W. (2021). Coping with the COVID-19 pandemic: Contemplative practice behaviors are associated with better mental health outcomes and compliance with shelter-in-place orders in a prospective cohort study. Preventive Medicine Reports, 23, 101451. https://doi.org/10.1016/j.pmedr.2021.101451

Association between contact with a general practitioner and depressive symptoms during the COVID-19 pandemic and lockdown: a large community-based study in Hangzhou, China

 In April 2020, a follow-up survey was conducted on the basis of a baseline survey conducted between October 2018 and May 2019. The survey was embedded in the Stanford Wellness Living Laboratory-China (WELL China) study, an ongoing prospective community-based cohort study during 2018-2019. The survey was conducted by telephone interview among 4144 adult urban residents participating in the WELL China study at baseline. We collected information on sociodemographic characteristics, depressive symptoms and GP contact during the lockdown period (February to March 2020). Depressive symptoms were measured using the WHO-Five Well-being Index, comprising five questionnaire items that briefly indicate psychological well-being. Logistic regression models were applied to assess the association between GP contact and depressive symptoms. In total, 3356 participants responded to the survey; 203 were excluded owing to missing data on depressive symptoms, leaving 3153 participants in the present study. During lockdown, 449 participants had GP contact. GP contact was significantly negatively associated with prevalent depressive symptoms (OR, 0.67; 95% CI 0.51 to 0.89; p<0.01) and incident depressive symptoms (OR 0.68; 95% CI 0.51 to 0.93; p<0.05). Stratified analysis showed a significant negative association between depressive symptoms and GP contact in individuals who were 45-64 years old (p<0.01), had a middle or high education (p<0.01) and had self-reported non-communicable diseases (p<0.05). Contact with GPs during the COVID-19 pandemic and lockdowns may have a negative association with depressive symptoms in community-dwelling populations. Given the possibility of further surges in COVID-19 infections, GPs' contact in the community should be enhanced.

Yang F, Lin W, Frost E, Min Y, Xu X, Wang X, Li W, Leng Y, Zhao X, He W, Hsing AW, Zhu S. Association between contact with a general practitioner and depressive symptoms during the COVID-19 pandemic and lockdown: a large community-based study in Hangzhou, China. BMJ Open. 2021 Aug 13;11(8):e052383. doi: 10.1136/bmjopen-2021-052383. PMID: 34389582; PMCID: PMC8366284.

Changes in cannabis use, exposure, and health perceptions following legalization of adult recreational cannabis use in California: a prospective observational study

Most U.S. states have legalized cannabis for medical and/or recreational use. In a 6-month prospective observational study, we examined changes in adult cannabis use patterns and health perceptions following broadened legalization of cannabis use from medical to recreational purposes in California. Respondents were part of Stanford University's WELL for Life registry, an online adult cohort concentrated in Northern California. Surveys were administered online in the 10 days prior to state legalization of recreational use (1/1/18) and 1-month (2/1/18-2/15/18) and 6-months (7/1/2018-7/15/18) following the change in state policy. Online surveys assessed self-reported past 30-day cannabis use, exposure to others' cannabis use, and health perceptions of cannabis use. Logistic regression models and generalized estimating equations (GEE) examined associations between participant characteristics and cannabis use pre- to 1-month and 6-months post-legalization. The sample (N = 429, 51% female, 55% non-Hispanic White, age mean = 56 ± 14.6) voted 58% in favor of state legalization of recreational cannabis use, with 26% opposed, and 16% abstained. Cannabis use in the past 30-days significantly increased from pre-legalization (17%) to 1-month post-legalization (21%; odds ratio (OR) = 1.28, p-value (p) = .01) and stayed elevated over pre-legalization levels at 6-months post-legalization (20%; OR = 1.28, p = .01). Exposure to others' cannabis use in the past 30 days did not change significantly over time: 41% pre-legalization, 44% 1-month post-legalization (OR = 1.18, p = .11), and 42% 6-months post-legalization (OR = 1.08, p = .61). Perceptions of health benefits of cannabis use increased from pre-legalization to 6-months post-legalization (OR = 1.19, p = .02). Younger adults, those with fewer years of education, and those reporting histories of depression were more likely to report recent cannabis use pre- and post-legalization. Other mental illness was associated with cannabis use at post-legalization only. In a multivariate GEE adjusted for sociodemographic characteristics and diagnoses, favoring legalization and the interaction of time and positive health perceptions were associated with a greater likelihood of using cannabis. Legalized recreational cannabis use was associated with greater self-reported past 30-day use post-legalization, and with more-positive health perceptions of cannabis use. Future research is needed to examine longer-term perceptions and behavioral patterns following legalization of recreational cannabis use, especially among those with mental illness.

Gali K, Winter SJ, Ahuja NJ, Frank E, Prochaska JJ. Changes in cannabis use, exposure, and health perceptions following legalization of adult recreational cannabis use in California: a prospective observational study. Subst Abuse Treat Prev Policy. 2021 Feb 12;16(1):16. doi: 10.1186/s13011-021-00352-3. PMID: 33579324; PMCID: PMC7881543.

An in-depth comparison of well-being among Latinx and non-Latinx White adults: A cautionary tale

Understanding how to optimize the health and well-being of Latinxs is crucial and will aid in informing actions to address inequities. Latinxs' unique cultural backgrounds and lived experiences could have implications for their well-being, which may differ from other racial/ethnic groups. We compared overall and domain-specific well-being and their socio-demographic correlates among two samples of Latinxs and a sample of non-Latinx Whites. Cross-sectional samples were independently drawn from the Stanford WELL Initiative (n = 217 Latinxs, n = 943 non-Latinx Whites) and the On the Move Trial (n = 238 Latinxs), both recruiting in Northern California. Well-being was assessed using the Stanford WELL scale, a novel multifaceted measure. Propensity score matching and mixed effect regressions were employed to compare well-being between samples. Overall well-being levels did not differ between groups. However, when examining constituent domains of well-being, several differences were found. Both Latinx samples reported experiencing more stress, having worse physical health, and being more religious than did the matched non-Latinx White sample. However, on four other well-being domains, only one of the Latinx samples differed from the non-Latinx White sample. Moreover, the two Latinx samples differed from each other in four out of nine domains examined. When evaluating well-being across racial/ethnic groups, we recommend employing multidimensional measures and multiple samples to promote greater confidence in the conclusions. This approach can better inform future research and the tailoring of public health efforts by furthering our understanding of the nature of group well-being differences. Our methods offer a blueprint for similar studies examining well-being in multi-ethnic groups.

Rodriguez Espinosa P, Patel ML, King AC, Campero I, Freeman M 2nd, Garcia DM, Winter SJ, Heaney CA. An in-depth comparison of well-being among Latinx and non-Latinx White adults: A cautionary tale. Prev Med Rep. 2021 Aug 3;24:101513. doi: 10.1016/j.pmedr.2021.101513. PMID: 34401222; PMCID: PMC8358695.

Physical activity and stress management during COVID-19: a longitudinal survey study

Physical activity (PA) during COVID-19 shelter-in-place (SIP) may offset stress. This study examined associations between PA, stress and stress management strategies during SIP. Participants (N = 990) from a cohort of Northern California adults completed surveys during early SIP (3/23/20-4/2/20) and mid-SIP (4/24/20-5/8/20). Participants self-reported past-month PA (meeting vs. not meeting guidelines), changes in stress (decreased/unchanged vs. increased) and use (yes/no) of 10 stress management strategies. We tested differences in mid-SIP stress and stress management strategies by PA, and differences in mid-SIP stress by stress management strategies. Compared to participants inactive at mid-SIP, active participants reported less stress (AOR = 0.60 [0.45, 0.81]). Active participants were more likely to manage stress using outdoor PA, indoor PA, yoga/meditation/prayer, gardening, and reading (AORs > 1.42), and less likely to sleep (AOR = 0.65 [0.48, 0.89]) or eat ([AOR = 0.48 [0.35, 0.66]) more. Managing stress using outdoor PA, indoor PA or reading was associated with lower stress; managing stress using TV/movies, sleeping or eating was associated with increased stress (ps < 0.05). Meeting PA guidelines during SIP was associated with less stress. Inactive participants reported greater sleeping and eating to cope; active participants used active stress management strategies. Engagement in physically active stress management was associated with lower stress.

Vogel EA, Zhang JS, Peng K, Heaney CA, Lu Y, Lounsbury D, Hsing AW, Prochaska JJ. Physical activity and stress management during COVID-19: a longitudinal survey study. Psychol Health. 2021 Jan 6:1-11. doi: 10.1080/08870446.2020.1869740. Epub ahead of print. PMID: 33405969.

Exploring health and well-being in Taiwan: what we can learn from individuals' narratives

Little is known about how individuals achieve health and well-being, and their roles in the pursuit of a good life. We hoped to identify important components of these concepts that may provide new targets and messages to strengthen existing public health programs. An improved understanding of health and well-being - or what it means to be well - can guide interventions that help people lead healthier, more fulfilling lives. Eight constituent domains emerged regarding well-being and health. While the same domains were found for both constructs, important frequency differences were found when participants discussed health versus well-being. Physical health and lifestyle behaviors emerged as key domains for health. Disease-related comments were the most frequently mentioned sub-category within the physical health domain, along with health care use and aging-related changes. For well-being, family and finances emerged as key domains. Family appears to be a cornerstone element of well-being in this sample, with participants often describing their personal well-being as closely tied to - and often indistinguishable from - their family. Other domains included work-life, sense of self, resilience, and religion/spirituality. 

Rodriguez Espinosa, P., Chen, Y., Sun, C. et al. Exploring health and well-being in Taiwan: what we can learn from individuals’ narratives. BMC Public Health 20, 159 (2020). https://doi.org/10.1186/s12889-020-8201-3 PMID: 32013898 PMCID: PMC6998329 

The WELL Diet Score Correlates with the Alternative Healthy Eating Index-2010

The quality of one's overall diet has proven to be of great importance to health and well‐being. Unfortunately, diet quality is time‐consuming to assess. The Stanford Wellness Living Laboratory (WELL) administered an online survey that included the WELL Diet Score (a novel diet quality assessment calculated from 12 diet‐related items). Subsequently, WELL participants were asked to complete the 127‐item Block Food Frequency Questionnaire (FFQ) online. The present study's primary objective was to compare the WELL Diet Score with the established FFQ‐based Alternative Healthy Eating Index‐2010 (AHEI‐2010), in a subset of WELL participants (n = 248) who completed both dietary measures through WELL’s online platform. The two scores were significantly correlated (r = .69; p < .0001). Regression analyses demonstrated that the WELL Diet Score was positively significantly associated with sociodemographic determinants of diet quality and protective health factors, including older age, higher education, lower BMI, and higher physical activity. In summary, the WELL Diet Score, derived from 12 small diet‐related items that can be completed in 5 min, was significantly positively correlated with the AHEI‐2010 derived from the lengthy 127‐item FFQ, suggesting the potential utility of the WELL Diet Score in future large‐scale studies, including future WELL studies.

Springfield, S, Cunanan, K, Heaney, C, Peng, K, Gardner, C. The WELL diet score correlates with the alternative healthy eating index‐2010. Food Sci Nutr. 2020; 00: 1– 9. https://doi.org/10.1002/fsn3.1558

Well-Being without a Roof: Examining Well-Being among Unhoused Individuals Using Mixed Methods and Propensity Score Matching

The morbidity and mortality experiences of people who are unhoused have been well-described, but much less is known about the overall well-being of these individuals. In this mixed methods study, housed and unhoused participants completed a multi-faceted 10 domain measure of well-being (the Stanford WELL Survey), and a subset of unhoused participants shared their experiences during qualitative interviews. Using propensity score matching, unhoused participants (n = 51) were matched at a ratio of 1:5 with housed participants (n = 255). The mean overall well-being score of the unhoused participants was significantly lower than that of the matched housed participants (B = -5.022, p = 0.013). Additionally, the two groups differed on some of the constituent domains of well-being, with unhoused participants reporting statistically significantly lower mean scores on social connectedness (B = -1.086, p = 0.000), lifestyle and daily practices (B = -1.219, p = 0.000), stress and resilience (B = -0.493, p = 0.023), experience of emotions (B = -0.632, p = 0.009), physical health (B = -0.944, p = 0.0001), and finances (B = -3.099, p = 0.000). The unhoused participants had a statistically significantly higher mean score for spirituality and religiosity (B = 2.401, p = 0.000) than their matched housed counterparts. The qualitative interviews further highlighted spirituality and religion as a coping mechanism for the unhoused. The results of this study highlight both unexpected strengths exhibited by the unhoused individuals and areas of challenge.

Ahuja, N.J.; Nguyen, A.; Winter, S.J.; Freeman, M.; Shi, R.; Rodriguez Espinosa, P.; Heaney, C.A. Well-Being without a Roof: Examining Well-Being among Unhoused Individuals Using Mixed Methods and Propensity Score Matching. Int. J. Environ. Res. Public Health 2020, 17, 7228.

Characterization of dietary patterns and assessment of their relationships with metabolomic profiles: A community-based study

Determining dietary patterns in China is challenging due to lack of external validation and objective measurements. We aimed to characterize dietary patterns in a community-based population and to validate these patterns using external validation cohort and metabolomic profiles. We studied 5145 participants, aged 18-80 years, from two districts of Hangzhou, China. We used one district as the discovery cohort (N = 2521) and the other as the external validation cohort (N = 2624). We identified dietary patterns using a k-means clustering. Associations between dietary patterns and metabolic conditions were analyzed using adjusted logistic models. We assessed relationships between metabolomic profile and dietary patterns in 214 participants with metabolomics data. We identified three dietary patterns: the traditional (rice-based), the mixed (rich in dairy products, eggs, nuts, etc.), and the high-alcohol diets. Relative to the traditional diet, the mixed (ORadj = 1.7, CI 1.3-2.4) and the high-alcohol diets (ORadj = 1.9, CI 1.3-2.7) were associated with type 2 diabetes and hypertension, respectively. Similar results were confirmed in the external validation cohort. In addition, we also identified 18 and 22 metabolites that could distinguish the mixed (error rate = 12%; AUC = 96%) and traditional diets (error rate = 19%; AUC = 88%) from the high-alcohol diet. Despite the complexity of Chinese diet, identifying dietary patterns helps distinguish groups of individuals with high risk of metabolic diseases, which can also be validated by external population and metabolomic profiles

Ru, Y.; Wang, N.; Min, Y.; Wang, X.; McGurie, V.; Duan, M.; Xu, X.; Zhao, X.; Wu, Y.; Lu, Y.; Lu, Y.; Hsing, A.W.; Zhu, S. Characterization of dietary patterns and assessment of their relationships with metabolomic profile: A community-based study. Clinical Nutrition 2020, 17, 7228.

Associations Between Body Fat, Muscle Mass, and Nonalcoholic Fatty Liver Disease: A Population-Based Study

Nonalcoholic fatty liver disease (NAFLD) is one of the most common forms of liver disease worldwide and has emerged as a significant public health concern in China. A better understanding of the etiology of NAFLD can inform effective management strategies for this disease. We examined factors associated with NAFLD in two districts of Hangzhou, China, focusing on the relationship of regional body fat distribution, muscle mass, and NAFLD. Multivariate logistic regressions were performed to assess independent associations between NAFLD and metabolic risk factors and dual x-ray absorptiometry (DX A)-derived measures (e.g., android fat ratio [AFR] and skeletal muscle index [SMI]). According to our analysis, android fat ration (AFR), insulin resistance, high alanine aminotransferase levels, smoking, and male sex were positively associated with NAFLD risk, while skeletal muscle index (SMI) was inversely associated with NAFLD risk.

Julianna C. Hsing, M. Nguyen, B. Yang, Y. Min, S. Han, E. Pung, S. J. Winter, X. Zhao, D. Gan, A. W. Hsing, S. Zhu. C. J. Wang. “Associations Between Body Fat, Muscle Mass, and Nonalcoholic Fatty Liver Disease: A Population-Based Study,” Hepatology Communications 0, no. 0, accessed July 12, 2019, https://doi.org/10.1002/hep4.1392.

Dry eye and sleep quality: a large community-based study in Hangzhou

Dry eye and sleep dysfunction draw global  public health concerns with their high prevalence and extensive adverse effects. Our study discovered a strong association between these two conditions. This is the firstpopulation-based study to evaluate the association of dry eye and sleep quality using previously validated tools, the Ocular Surface Disease Index (OSDI) and the Chinese version of the Pittsburg Sleep Quality index (CPS!I), respectively. Results indicated a strong positive association between poor sleep quality and higher severity for dry eye. It is plausible to suggest that improvement of sleep quality would alleviate the syndromes of dry eye, and vice versa. Our large comunity-based study showed a strong association between poor sleep quality and an increased severity of dry eye, suggesting that preventing either one of the discomforts might alleviate the other. 

Zhu S, Yao K. Dry eye and sleep quality: a large community-based study in Hangzhou. Sleep. 2019 Jul 15. pii: zsz160. doi: 10.1093/sleep/zsz160. [Epub ahead of pring] PubMed PMID: 31310315.

Sex-specific Association Between Gut Microbiome and Fat Distribution

The gut microbiome has been linked to host obesity; however, sex-specific associations between microbiome and fat distribution are not well understood. Here we show sex-specific microbiome signatures contributing to obesity despite both sexes having similar gut micro-biome characteristics, including overall abundance and diversity. Our comparisons of the taxa associated with the android fat ratio in men and women found that there is no widespread species-level overlap. We did observe overlap between the sexes at the genus and family levels in the gut microbiome, such as Holdemanella and Gemmiger; however, they had opposite correlations with fat distribution in men and women. Our findings support a role for fat distribution in sex-specific relationships with the composition of the microbiome. Our results suggest that studies of the gut microbiome and abdominal obesity-related disease outcomes should account for sex-specific differences.

Min, Yan, Xiaoguang Ma, Kris Sankaran, Yuan Ru, Lijin Chen, Mike Baiocchi, and Shankuan Zhu. "Sex-specific Association between Gut Microbiome and Fat Distribution." Nature Communications10, no. 1 (June 03, 2019). doi:10.1038/s41467-019-10440-5.

Understanding Where We Are Well: Neighborhood-Level Social and Environmental Correlates of Well-Being in the Stanford Well for Life Study

Individual well-being is a complex concept that varies among and between individuals and is impacted by individual, interpersonal, community, organizational, policy and environmental factors. This research explored associations between select environmental characteristics measured at the ZIPcode level and individual well-being. Twelve identical or analogous neighborhood (ZIP-code level) indicators were selected to test against the SWLS measure and data were collected from secondary sources to describe socio-economic, demographic, and physical environment, and healthcare. Linear mixed models were fit to assess relationships between each neighborhood measure and each of the ten domains of well-being, as well as the overall SWLS well-being measure, and were adjusted for spatial autocorrelation and individual-level covariates. Our observational insights suggest that neighborhood factors are associated with individuals’ overall self-rated well-being, though variation exists among its constituent domains.

Chrisinger BW, Gustafson JA, King AC, Winter SJ. Understanding Where We Are Well: Neighborhood-Level Social and Environmental Correlates of Well-Being in the Stanford Well for life Study. Int J Environ Res Public Health. 2019 May 20;16(10).pii: E1786. doi: 10.3390/ijerph16101786. PubMed PMID: 31137589; PubMed Central PMCID: PMC6571676

Stanford WELL For Life: Learning What it Means to Be Well

Stanford WELL For Life researchers were invited to share how they approached the development of a new well-being index by first asking individuals what the conecept of well-being meant to them. Read on to discover what their top driver of well-being was, which represents an often overlooked area of measurement in workplace wellness.

Heaney, C.A.; Avery, E.C.; Rich, T.; Ahuja, N.J.; Winter, S.J.; Stanford WELL for Life Measures Work Group. Stanford WELL for Life: Learning What It Means to Be Well. American Journal of Health Promotion 2017, Vol 31(5) 444-456