Mindful Eco-Wellness: Steps Toward Personal and Planetary Health

Abstract

Rising greenhouse gas levels heat the earth’s surface and alter climate patterns, posing unprecedented threats to planetary ecology and human health. At the same time, obesity, diabetes, and cardiovascular disease have reached epidemic proportions across the globe, caused in part by decreases in physical activity and by over-consumption of carbon-intensive foods. Thus, interventions that support active transportation (walking or cycling rather than driving) and healthier food choices (eating plant-based rather than meat-based diets) would yield health and sustainability “co-benefits.” Emerging research suggests that mindfulness-based practices might be effective means toward these ends. At the University of Wisconsin-Madison, we have developed a mindfulness-based group program, Mindful Eco-Wellness: Steps Toward Healthier Living. Loosely based on the Mindfulness-Based Stress Reduction course, our curriculum teaches mindfulness practices in tandem with sustainability principles, following weekly themes of Air, Water, Food, Energy, Transportation, Consumption, Nature Experience, and Ethics. For example, the “Air” class offers participants practice in guided breath meditations while they learn about the benefits of clean air. The theme of “Food” is presented through mindful eating, accompanied by educational videos highlighting the consequences of food production and consumption. “Transportation” includes walking/movement meditations and highlights the health benefits of physical activity and detriments of fossil-fueled transportation. Pedagogical lessons on energy, ecological sustainability, and the ethics of planetary health are intertwined with mindful nature experience and metta (loving-kindness) meditation. Curricular materials, including teaching videos, are freely available online. Pilot testing in community settings (n = 30) and in group medical visits (n = 34) has demonstrated feasibility; pilot data suggests potential effectiveness. Rigorous evaluation and testing are needed.

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Feature Article
Global Advances in Integrative Medicine and Health
Volume 13: 1–13
© The Author(s) 2024
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/27536130241235922
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Mindful Eco-Wellness: Steps Toward
Personal and Planetary Health
Bruce Barrett, MD, PhD
1
, Sarah Walters, BS
1
,
Mary M. Checovich, MS
1
, Maggie L. Grabow, PhD, MPH
1
,
Cathy Middlecamp, PhD
2
, Beth Wortzel, MA, LSCW
3
,
Kaitlin Tetrault, MB
4
, Kevin M. Riordan, BA
5,6
, and
Simon Goldberg, PhD
5,6
Abstract
Rising greenhouse gas levels heat the earth’s surface and alter climate patterns, posing unprecedented threats to planetary ecology and
human health. At the same time, obesity, diabetes, and cardiovascular disease have reached epidemic proportions across the globe,
caused in part by decreases in physical activity and by over-consumption of carbon-intensive foods. Thus, interventions that support
active transportation (walking or cycling rather than driving) and healthier food choices (eating plant-based rather than meat-based
diets) would yield health and sustainability “co-benefits.”Emerging research suggests that mindfulness-based practices might be
effective means toward these ends. At the University of Wisconsin-Madison, we have developed a mindfulness-based group program,
Mindful Eco-Wellness: Steps Toward Healthier Living. Loosely based on the Mindfulness-Based Stress Reduction course, our curriculum
teaches mindfulness practices in tandem with sustainability principles, following weekly themes of Air, Water, Food, Energy,
Transportation, Consumption, Nature Experience, and Ethics. For example, the “Air”class offers participants practice in guided
breath meditations while they learn about the benefits of clean air. The theme of “Food”is presented through mindful eating,
accompanied by educational videos highlighting the consequences of food production and consumption. “Transportation”includes
walking/movement meditations and highlights the health benefits of physical activity and detriments of fossil-fueled transportation.
Pedagogical lessons on energy, ecological sustainability, and the ethics of planetary health are intertwined with mindful nature
experience and metta (loving-kindness) meditation. Curricular materials, including teaching videos, are freely available online. Pilot
testing in community settings (n = 30) and in group medical visits (n = 34) has demonstrated feasibility; pilot data suggests potential
effectiveness. Rigorous evaluation and testing are needed.
Keywords
carbon footprint, co-benefits, health behavior, meditation, mind body therapies, planetary health, sustainability, wellness
program
Received October 13, 2023; Revised January 31, 2024. Accepted for publication February 9, 2024
1
Department of Family Medicine and Community Health, University of Wisconsin - Madison, Madison, WI, USA
2
Nelson Institute for Environmental Studies, University of Wisconsin - Madison, Madison, WI, USA
3
Harmonia Center for Psychotherapy, Madison, WI, USA
4
Department of Biostatistics, University of Wisconsin - Madison, Madison, WI, USA
5
Department of Counseling Psychology, University of Wisconsin - Madison, Madison, WI, USA
6
Center for Healthy Minds, University of Wisconsin - Madison, Madison, WI, USA
Corresponding Author:
Bruce Barrett, MD, PhD, Department of Family Medicine and Community Health, University of Wisconsin-Madison, 610 N. Whitney Way, Madison, WI
53705, USA.
Email: bruce.barrett@fammed.wisc.edu
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use,
reproduction and distribution of the work without further permission provided the originalwork is attributed as specified on the SAGE and
Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

Background
Climate change results from the increasing concentrations
of atmospheric greenhouse gases (GHGs) that trap solar
heat and drive changes in weather patterns, posing in-
creasing threats to human health.
1-3
Over 60% of global
GHG emissions result from individual, household, and
societal behavioral patterns.
4
In general, socioeconomi-
cally advantaged individuals, communities, and nations are
disproportionately responsible for these GHG emissions
and have the greatest capacity for reducing their carbon
footprints.
5-7
Many of the changes needed to mitigate
climate change and reduce carbon footprints will also yield
health “co-benefits.”At the population level, for example,
using solar and wind rather than fossil fuels to produce
electricity will reduce air pollution and also ameliorate a
host of pulmonary and cardiovascular maladies.
8
At the
individual level, walking or bicycling instead of driving,
using stairs rather than elevators, and transitioning towards
plant-based diets will help reduce carbon emissions while
promoting healthy physical activity and nutrition.
9-11
According to Project Drawdown, the world’s leading or-
ganization for ranking climate solutions, reducing food
waste and adopting plant-rich diets are the top two strat-
egies for significantly reducing carbon emissions world-
wide, with focusing on transportation solutions following
close behind (e.g., public transit, walkable cities, bicycle
infrastructure).
12
Supporting mental health is another important pillar in
this effort because, as the World Health Organization
(WHO) acknowledges, “there can be no health or sustain-
able development without mental health.”
13
Additionally,
engagement in activities aimed at supporting both personal
health and environmental sustainability could help to
ameliorate eco-anxiety (distress or worry about ecological
collapse from climate change) while fostering well-being
through stress reduction and an increased sense of pur-
pose.
14-16
Despite obvious potential advantages, to our knowledge,
there are no well-developed and validated behavioral change
programs aimed directly at health and sustainability co-
benefits. Existing health behavior programs tend to be
disease-specific rather than preventive, usually do not con-
sider whole-person biopsychosocial health, and rarely in-
clude environmental sustainability as a major goal.
Conversely, programs targeting pro-environmental behaviors
tend to ignore health and usually focus on single domains
such as household energy, personal transportation, pur-
chasing, or recycling. There is both need and opportunity to
develop programs aimed at helping people to improve per-
sonal health while also contributing to environmental sus-
tainability. The purpose of this paper is to review relevant
literature, contribute to the broader theoretical discussion in
this area, and report on initial findings of a mindfulness-based
eco-wellness intervention that we developed.
Mindfulness
According to a widely cited definition,
17
mindfulness refers to
nonjudgmental awareness of bodily sensations, thoughts, and
emotions as they occur in the present moment. At least
336 randomized controlled trials (RCTs) (N = 30,483) have
assessed the effects of mindfulness training programs on
various health domains.
18
Dozens of meta-analyses report
that mindfulness-induced reductions in perceived stress,
anxiety, depression, and pain are both statistically and clin-
ically significant, with effect sizes as large or larger than those
from conventional treatments, such as antidepressants or
cognitive behavioral therapy.
18
Potential mechanisms by
which mindfulness might improve health outcomes include
strengthening attentional awareness, improved emotional
regulation, and conscious alignment of choices and behaviors
with personal values.
19-21
One of the most widely studied
programs, Mindfulness-Based Stress Reduction (MBSR),
includes 8 weekly group visits and teaches mindfulness
meditation practices.
22
Mindfulness and
Pro-Environmental Behavior
Over the past two decades, scholars have discussed the
possibility that mindfulness practices might enhance pro-
environmental behaviors (PEBs): human behaviors that
benefit the environment, often assessed as carbon footprint
reduction.
23-26
While various potential mechanisms linking
mindfulness and PEBs have been considered, empirical ev-
idence is primarily observational (i.e., non-experimental).
27
In 2005, Brown and Kasser (N = 206; N = 220) reported that
dispositional mindfulness was positively associated with self-
reported PEBs (β= .44; P< .001).
28
In 2009, Amel et al
reported a survey of 100 adults using Baer’s Five Facet
Mindfulness Questionnaire (FFMQ)
29
that found that the
acting-with-awareness facet was positively associated with
PEBs (β= .37; P< .001).
24
Two studies by Hunecke and
Richter using the FFMQ (N = 310; N = 560) reported that
mindfulness and acting-with-awareness predicted sustainable
food consumption (β=.11,P= .04), and that both personal
and social norms were involved with setting intentions and
then achieving sustainable diets.
30,31
Barbaro and Pickett
conducted two studies (N = 360; N = 296) that found positive
associations between self-reported PEB and mindfulness (β=
.19; P< .01; β= .30, P< .01), with analyses suggesting that
connectedness to nature might mediate these relationships.
23
A survey conducted by Jacob et al (N = 829) reported positive
associations between mindfulness meditation, subjective
well-being, and PEBs including recycling, household pur-
chasing, and sustainable eating practices (r’sranging from
.15 to .37; P< .01).
32
In a study among 300 participants with
varying levels of mindfulness practice, Thiermann et al.
found a dose-dependent relationship between mindfulness
practice and pro-environmental attitudes and practices,
2Global Advances in Integrative Medicine and Health

including concern for the environment, connectedness with
nature, and especially with reduced animal protein con-
sumption.
33
As a final example, in surveys in 3 countries (N =
703, N = 414, N = 336), Kaur and Luchs found that
mindfulness practice predicted both socially conscious and
frugal consumption (βs = .43, .44; P< .001), and that al-
truistic and environmental values mediated those relation-
ships.
34
[Table 1].
Despite promising correlational evidence, experimental
(i.e., interventional) studies assessing the effects of
mindfulness training on PEBs are limited. Geiger et al.
reported two small RCTs (N = 60, N = 71) in which
participants were randomized to either an 8-week program
based on MBSR or waitlist control.
36
Outcome data
“suggested a decline of materialistic value orientations in
both samples”butfailedtodemonstratesignificant
changes in PEBs.
36
Ray et al. reported a small RCT (N =
97) testing a 4-week online meditation program among
studentswhowererandomizedtoeitherhearingnature
sounds or musical sounds during meditation; while both
groups displayed increases in mindfulness, connectedness
to nature, and self-reported PEB, the group hearing nature
sounds showed significantly higher levels of nature con-
nectedness after the intervention.
43
In a 125-person RCT
designed to test the effects of mindfulness training on
general well-being, Riordan et al. reported that randomi-
zation to either MBSR or a structurally matched “health
enhancement program”active control led to substantive
increases in self-reported PEB and sustainable well-being
relative to waitlist, but with no differences between the
active intervention groups.
44
Mindfulness for Physical Activity
Evidence exists that mindfulness training can positively in-
fluence physical activity, which could include less carbon-
dependent modes of transportation such as walking and
cycling. A 2018 systematic review by Schneider et al. found
20 observational studies that together identified a consistent
positive relationship between dispositional mindfulness and
regular physical activity.
47
The largest mindfulness-based
RCT on this topic (N = 324) found small improvements in
exercise capacity (d= .22 [95% CI .05 to .39]), systolic blood
pressure (d= .19 [.03 to .36]), mental functioning (d=
.22 [.05 to .38]), and depressive symptoms (d= .18 [.02 to
.35]).
37
The second largest RCT randomized 168 patients
with fibromyalgia to MBSR or active control, and found no
difference in accelerometer-assessed physical activity.
38
Most
of the other 12 RCTs reported positive results, but all
had <100 participants and were otherwise limited in meth-
odological quality. Schneider et al. concluded that programs
targeting psychological factors related to physical activity
were most likely to be effective.
47
However, none of these
trials looked at movement in terms of active transportation or
sustainability.
Mindfulness for Healthy Eating
Transitioning towards a plant-based diet could improve
population health while also substantively reducing carbon
footprint.
10,48
For instance, 1 kg of nuts has an estimated
carbon footprint of about 0.3 kg of carbon dioxide equivalent,
whereas a kilo of beef can have a carbon footprint of >50 kg
of CO
2
equivalent.
49
Evidence suggests mindfulness may
support positive dietary change. For example, in 2019,
Fuentes et al conducted meta-analysis of 10 RCTs mostly
low-to-moderate quality, reporting modest weight loss effects
of mindfulness-based eating strategies compared to nonin-
tervention controls (.348 kg [.591 to .105]).
35
A
2021 meta-analysis by Mercado et al 4
42
(k= 12, N = 632)
reported that mindfulness-based dietary interventions in-
crease mindful eating and decrease binge-eating, but their
analyses did not confirm effects on body weight. The SHINE
trial, perhaps the most rigorous mindfulness-for-dietary in-
take RCT, randomized 194 adults with obesity (BMI 30-45)
to a 5.5-month diet and exercise program, with or without
additional mindfulness training. Reporting their data in two
publications, Mason et al 4
40,41
found increased mindful
eating, decreased consumption of sweets, and improved
fasting glucose in the mindfulness group, factors which
predicted weight loss at 12 months.
40
The two-site MB-EAT
trial reported by Kristeller et al. randomized 150 overweight
or obese adults to three groups: mindfulness training, cog-
nitive behavioral therapy, or wait-list control.
39
Both active
interventions showed benefits relative to control, with trends
favoring mindfulness. The authors reported that mindfulness
practice uptake predicted improvements on several variables,
including weight loss (r=.38, P< .05).
39
Mindfulness for Both Diet and Exercise
A 2019 meta-analysis of 125 observational studies (N =
31,697) by Sala et al found positive associations between
mindfulness and physical activity (r= .09 [.06 to .12]) and
healthy eating (r= .14 [.08 to .19]), as well as sleep and
alcohol and drug use.
46
Additionally, a 2017 meta-analysis of
12 mindfulness RCTs by Ruffault et al (N = 626) found
reductions in both impulsive eating as well as positive effects
on physical activity (d= .42 [.15 to .69]). They also reported
that longer follow-up periods were associated with greater
weight loss,
45
unlike most interventions where effects tend to
dissipate over time.
Connectedness with Nature as Catalyst Towards
Behavior Change
Observational evidence suggests that mindful experience and
appreciation of nature and natural environments is associated
with psychological and physical health.
50-52
Several small
RCTs suggest that nature immersion may positively influence
both personal health and PEBs.
53-56
A 2019 systematic
Barrett et al. 3

Table 1. Empiric Studies of Mindfulness for Improving Eco-wellness Behaviors.
Author &
Year Study Design Sample
Intervention/
Predictor Mediator(s) Outcome Coefficient/Effect Size
Amel et al
2009
24
Survey n = 100 Mindful
attentiveness
PEB β= .37; P< .001
Barbaro
et al
2016
23
Surveys Mindfulness PEB Study 1: mindfulness and PEB: β= .19,
t(309) = 3.45, P< .01; mindfulness and
connectedness to nature (β= .28,
t(332) = 5.21, P< .01; controlling for
mindfulness, connectedness to nature
and PEB (β= .29, t(308) = 5.11, P<
.01).
Study 1: n = 360; Nature
Connectedness
Study 2: mindfulness and PEB (β= .30,
t(296) = 5.43, P< .01), mindfulness and
connectedness to nature (β= .42,
t(296) = 8.01, P< .01; controlling for
mindfulness, connectedness to nature
and PEB (β= .51, t(296) = 9.59, P<
.01)
Study 2: n = 296
Brown &
Kasser
2005
28
Two surveys Mindfulness Subjective Well-
Being
In both studies, subjective well-being was
associated with self-reported
ecological responsible behaviors.
Structural equation models found that
mindfulness helped to explain that
relationship.
n = 206 students aged
10-18.
PEB “Ecological
Responsible
Behavior”
β= .44, t = 4.01, P< .001
n = 200 adults
Fischer et al
2017
25
Systematic review
7 studies
Mindfulness Sustainable
consumption
Inconclusive findings
Fuentes et al
2019
35
Meta-analysis Mindful/intuitive
eating
strategies
Weight loss .348 kg [95% CI: .591 to .105] P=
.005
10 RCTs Body mass index .137 kg/m
2
[.365 to .091] P= .240
N = 716 Waist
circumference
.358 cm [.916 to .200] P= .209
Geiger et al
2019
36
Two surveys n = 60,
n=71
Mindfulness-
based stress
reduction
PEB r = .30, P= .001
Sustainable
nutrition
behavior
r = .31, P< .001
Sustainable clothing
consumption
positively
Gotink et al
2017
37
RCT n = 324 Mindfulness Exercise capacity d = .22 [95% CI: .05 to .39])
Systolic blood
pressure
d = .19 [ 95% CI: .03 to .36])
Mental functioning d = .22 [.05 to .38])
Depressive
symptoms
d = .18 [95% CI:0.02 to .35]
Grossman
et al
2017
38
RCT n = 168 women
with fibromyalgia
MBSR Objective measures
of cardiovascular
and respiratory
functioning
NS
Hunecke &
Richter
2019
30
Survey n = 310 Mindfulness and
acting-with-
awareness
Personal and social
norms
Sustainable food
consumption
β= .11, P< .05
Jacob et al
2009
32
Survey n = 829 Mindfulness Subjective well-
being and PEB
r’s ranging from .15 to .37; P< .01
(continued)
4Global Advances in Integrative Medicine and Health

Table 1. (continued)
Author &
Year Study Design Sample
Intervention/
Predictor Mediator(s) Outcome Coefficient/Effect Size
Kaur &
Luchs
2022
34
Three surveys n =
703, n = 414, n =
336
Mindfulness Altruistic and
environmental
values
Socially conscious
and frugal
consumption
βs = .43, .44; P< .001
Kristeller
2014
39
RCT n = 150 Mindfulness-
based eating
awareness
training
Weight loss r = .38; P< .05
RCT Binge-eating
disorder
Significant reduction in those meeting
binge-eating disorder criteria 4-
months post-intervention in those
receiving mindfulness training
compared to those in cognitive
behavioral therapy or wait-list control
groups (P< .05)
Mason et al
2016
40
RCT n = 194 Mindfulness
training
Reward-driven
eating
Weight loss Mindfulness (relative to control)
participants had significant reductions
in reward-driven eating at 6 months
(post-intervention), which, in turn,
predicted weight loss at 12 months.
Post-intervention reward-driven
eating mediated 47.1% of the total
intervention arm effect on weight loss
at 12 months [β=.06, SE(β) = .03,
P= .030, 95% CI (.12, .01)
Mason et al
2016
41
RCT n = 194 Mindfulness
training
Mindful eating and
maintenance of
fasting glucose
Mindfulness intervention participants
showed greater increases in mindful
eating from baseline to 12 months, P=
.036, diff = .11, 95 % CI (.22, .01)
Mercado
et al
2021
42
Meta-analysis Mindfulness Body mass NS
12 studies n = 632 Binge eating SMD = 6.49 [10.80 to 2.185]
Ray et al
2021
43
RCT n = 97 Meditation with
or without
nature sounds
Connectedness to
nature
PEBs “Mindfulness had a direct relationship
with the change in PEBs (c’= .21, t =
2.68, P< .01)…Change in mindfulness
predicted change in connectedness to
nature (a1i = .38, t = 2.66, P< .01), and
change in connectedness to nature
predicted change in pro-
environmental behavior (bi = .17,t =
3.00, P< .01).”
Mindfulness
Richter &
Hunecke
2020
31
Survey n = 560 Mindfulness and
acting-with-
awareness
Personal and social
norms
Sustainable food
consumption
β= .157, P= .046
Riordan et al
2022
44
RCT n = 156 MBSR Long-term
meditation
training
PEB; environmental
attitudes;
sustainable well-
being
Cohen’s d ranged from .63 (P< .01)
to .14
Ruffault
2017
45
Meta-analysis
12 studies n = 626
Mindfulness Weight loss and
related health
behaviors
Physical activity d = 1.13 [1.93 to .33])
Binge eating d = .90 [1.52 to .28])
Sala 2020
46
Meta-analysis Mindfulness Physical activity r = .09 [.06 to .12]
125 samples n =
31,697
Healthy eating r = .14 [.08 to .19]
(continued)
Barrett et al. 5

review and meta-analysis of 75 correlational studies and
17 experimental research projects reported “a strong and
robust association”between nature experience and PEB (r=
.37 [.34 to .40]), with the RCT evidence suggesting a causal
connection (d= .21 [.07, .35]).
57
A separate 2022 meta-
analysis of six RCTs (n = 332) testing forest-based therapies
against control conditions reported that overall effect size
(Hedges g) was 1.25 [.93 to 1.57].
58
A cross-sectional study
(N = 300) by Thiermann et al reported that the potentially
causal relationship of “mindful compassion practice on
greenhouse gas emissions from animal-protein consumption
is partially mediated by [connectedness with nature].”
33
It
should be noted that most studies are limited by design,
outcomes measured, sample size, and other factors; much
more work will need to be done before findings can be
considered robust.
27
From the eco-wellness perspective,
experiencing and appreciating natural environments is likely
both a cause and consequence of good health (and a reflection
of privilege) and is deeply tied to the motivations and fa-
cilitators surrounding PEBs.
Mindful Eco-Wellness: Steps Towards
Healthier Living
Mindful Eco-Wellness was first conceived in 2014 and de-
scribed in our first publication in 2016, initially called
Mindful Climate Action (MCA).
59
Loosely based on MBSR,
this mindfulness-based eco-wellness training occurs in a
group format and includes weekly 2-h classes and suggested
home practices. The curriculum, teaching videos, and asso-
ciated materials are freely available to the public (https://
www.fammed.wisc.edu/mca/). From the beginning, this
mindfulness-based eco-wellness program was aimed at
deepening awareness and insight, which are hypothesized to
support more thoughtful choices and behaviors regarding
both health and sustainability.
27,59
The first pilot study (2016;
N = 16) demonstrated the feasibility of interweaving mind-
fulness training with sustainability education [Table 2].
60
While participant attendance and enthusiasm were high, it
proved challenging to coordinate the timing of mini-lectures
by University of Wisconsin-Madison environmental scien-
tists. This led to the development of short videos narrated by
the scientists and focused on the weekly ecological themes of
Air, Water, Food, Energy, Transportation, Consumption and
Ethics. These videos were then used by mindfulness in-
structors in a second pilot trial (2019; N = 15).
61
In both
community-based pilots, we assessed the feasibility of col-
lecting data on active transport, automobile use, dietary intake
and general health. Automobile transport, dietary intake, and
household energy use (utility records) were used to calculate
carbon footprint [Table 3]. Both pilots were aimed at qual-
itatively assessing and refining the program’s curriculum and
delivery rather than efficacy-testing.
Following pandemic-associated interruptions, four more
small pilots were conducted as group medical visits (GMVs),
Table 1. (continued)
Author &
Year Study Design Sample
Intervention/
Predictor Mediator(s) Outcome Coefficient/Effect Size
Schneider
et al
2018
47
Systematic review Dispositional
mindfulness
Stress, psychologic
flexibility,
negative affect,
shame,
satisfaction, state
mindfulness
Physical activity Quantitative findings not described well
40 studies (20 cross-
sectional,
20 interventional)
“Mindfulness-based interventions were
more likely to be successful if they
were physical activity-specific and
targeted psychological factors related
to physical activity.”
Thiermann
et al
2020
33
Cross-sectional study
n = 300
Mindfulness and
acting-with-
awareness
Connectedness to
nature
Pro-environmental
attitudes &
practices;
personal health;
greenhouse gas
emissions, land
occupation, and
water use
Diet-related environmental impacts
were lower for meditators compared
to non-meditators F(8, 358) = 2.65,
P= .008, ƞp2 = .056; small statistically
significant differences between
meditation groups on GHG emissions,
F(2, 290) = 4.051, P= .018; ƞp2 = .027;
small significant main effect of practice
level on land use impacts F(2, 290) =
3.860, P= .022; ƞp2 = .026; groups
showed a small significant difference in
water use, F(2, 290) = 4.032, P= .019;
ƞp2 = .027
MBSR = Mindfulness-Based Stress Reduction.
NS = Non-Significant.
PEB = Pro-Environmental Behavior(s).
RCT = Randomized controlled trial.
SMD = Standardized Mean Difference.
6Global Advances in Integrative Medicine and Health

led by Dr. Barrett and a mindfulness instructor (psycho-
therapist Beth Wortzel for three of these). We changed the
name of the course from Mindful Climate Action to Mindful
Eco-Wellness: Steps towards Healthier Living because the
phrase “climate action”was considered by some to be
politically charged or off-putting. For these group visits,
patients in the UW Health system with at least one mental
health condition (anxiety, depression, stress, insomnia) or
cardiovascular risk factor (elevated glucose, cholesterol,
blood pressure, body weight) attended Mindful Eco-
Welln e s s sessions for either 6 or 7 weeks. The length was
reduced from 8 to either 6 or 7 weeks to reduce burden on
patients and their health insurance; exit interviews found
that the longer 7-week format was preferred. Following
feedback from participants in the two community-
based pilots and first GMV, we replaced the earlier
Consumption theme with Nature Connectedness, accom-
panied by mindfulness-in-nature practices. Each patient
chose their own health goals, typically to eat better and
exercise more. Reducing stress and supporting interpersonal
relationships also were named by participants as reasons for
attending the course. These sessions were considered
healthcare rather than research, with clinical notes in the
electronic health record and billing to insurance where
appropriate. Attendance was high with 7 to 9 patients at-
tending the firstclassand5to7completingtheGMVseries.
Pre-to-post trends in self-reported health and pro-
environmental behaviors were positive [Tab le 4]. While
statistical testing comparing pre- (initial) and post- (follow-
up) PROMIS-29 scores did find statistically significant
improvements in four domains (anxiety, depression, phys-
ical health, fatigue), issues including multiple comparison,
Table 3. Sustainability-Related Findings from Two Pilot Studies.
Mean S.D. Range Range of Underlying Data
a
Dietary [CF kg CO
2
e] 1.6 .87 .9 to 3.0 89 to 230 food items logged
b
Walk [mi/wk] 1.55 .86 .48 to 2.42 .61 to 2.87 hr/wk
b
Bicycle [mi/wk] 1.28 1.45 .01 to 2.82 .00 to 1.09 hr/wk
b
Motor vehicle [mi/wk] 94.0 62.7 34.7 to 185.2 2.85 to 11.5 hr/wk
c
Motor vehicle [kgCO
2
e] 1.6 1.0 .25 to 3.34
d
Electricity [12 mo] 331 87 (equivalent to 3.0 metric tons CO
2
e per year)
e
Gas [12 mo] 50 25 (equivalent to 3.5 metric tons CO
2
e per year)
a
CF = carbon footprint shown in estimated kg CO
2
. Range also shown in number of food items logged on ASA24 dietary assessment tool.
b
Personal transport data in miles/week, from smart phone GPS (Moves app). Range also shown in hours/week.
c
Motor vehicle CF calculated using vehicle make-year-model and miles driven at: https://www.fueleconomy.gov.
d
Household electricity in kilowatt hours per month.
e
Household gas in therms/month over a year of utility records. Data previously reported in: Grabow M, Bryan T, Checovich M, et al. “Mindfulness and climate
change action: A feasibility study”Sustainability. 2018;10(5).
60
Table 2. Community-Based Pilot Studies and Group Medical Visits to Date.
Pilot 1 (2017) Pilot 2 (2019) GMV 1 (2022) GMV 2 (2023) GMV 3 (2023) GMV 4 (2023)
Group size,
Gender
n = 16, (9 F, 7 M) n = 14, (14 F, 0 M) n = 8 (5 F, 3 M) n = 8 (5 F, 3 M) n = 9 (5 F, 4 M) n = 9 (5 F, 3 M)
Age Range 30-63 30-68 50-76 53-81 48-83 25-72
Dietary Intake ASA24 ASA24 None None None None
Movement Moves app; Moves app; None None None None
Odometer
readings
Odometer
readings
Sustainability Carbon Footprint
from Auto
travel, Diet, Gas
& electric
Carbon Footprint
from Auto
travel, Diet, Gas
& electric
Pro-envrionmental
behavior
checklist
Pro-envrionmental
behavior
checklist
Pro-envrionmental
behavior
checklist
Pro-envrionmental
behavior
checklist
Self-report CES-D, SPS-6, PSS-
10, SF-36
SF-36 Feeling Loved Feeling Loved Feeling Loved Feeling Loved
Health
Questionnaires PROMIS-29 PROMIS-29 PROMIS-29 PROMIS-29
ASA-24 = Automated Self-Administered dietary assessment tool; CES-D = Center for Epidemiologic Studies depression scale; PROMIS-29 = Patients Reported
Outcomes general health; PSS-10 = Perceived Stress Scale; SF-36 = Medical Outcomes Study Short Form general health; SPS-6 = Stanford Presenteeism Scale;
Feeling Loved was developed and validated by Barrett et al (2018).
Barrett et al. 7

Table 4. Initial (pre) and Follow-Up (post) Scores for PROMIS-29, Feeling Loved, and Pro-environmental Behavior Checklist.
Instrument Measure
Initial Mean
(SD)
Follow-up Mean
(SD)
↑= improve
↓= worsen
Score
Range P-value
PROMIS-29
a,62
Physical Function 16.85 (4.64) 17.38 (4.57) ↑(4, 20) .02 *
Anxiety 6.52 (2.62) 5.64 (1.93) ↑(4, 20) .02 *
Depression 6.54 (3.6) 5.31 (2.15) ↑(4, 20) .003 **
Fatigue 9.65 (3.85) 8.73 (4.1) ↑(4, 20) .049 *
Sleep Disturbance 7.91 (2.94) 8.09 (2.97) ↓(4, 20) 0.7
Social Roles 14.92 (3.97) 16 (4.2) ↑(4, 20) .13
Pain 7.85 (4.18) 7.12 (4.11) ↑(4, 20) .12
Global Pain 2.46 (1.98) 2.15 (1.99) ↑(0, 10) .32
Physical Health Summary (T)
b,c
47.14 (9.99) 50.47 (9.94) ↑(20, 80)
Mental Health Summary (T)
b,c
50.29 (7.71) 53.64 (6.76) ↑(20, 80)
Feeling Loved
63
How loved do you feel? 86.54 (20.68) 86.85 (16.65) ↑(0, 100) .87
How much do you love yourself? 77.84 (20.28) 81.48 (17.73) ↑(0, 100) .23
Global Score 352.04
(76.62)
359.8 (64.45) ↑(0, 400) .23
Pro-Environmental Behaviors
d,e,64
Minimize air conditioning in summer 3.22 (.94) 3.5 (.99) ↑(1, 5)
e
.14
Set thermostat lower in winter 4.33 (.69) 4.39 (.7) ↑(1, 5) .72
Use high-efficiency light bulbs (LED) 4.37 (.6) 4.53 (.7) ↑(1, 5) .38
Turn off electronics when not in use 4.21 (.79) 4.21 (.71) (1, 5) 1
Air dry laundry instead of dryer 2.79 (1.08) 2.74 (1.33) ↓(1, 5) .67
Use automobile only when needed 3.58 (1.02) 3.84 (1.12) ↑(1, 5) 0.2
Replace driving with biking, walking, bus,
carpool
2.06 (.87) 2.28 (.89) ↑(1, 5) .22
Reduce highway speed 3.22 (.94) 3.28 (.96) ↑(1, 5) .79
Reduce air travel 3.53 (1.28) 3.76 (1.03) ↑(1, 5) .16
Reduce meat consumption 3 (1.03) 3.06 (.94) ↑(1, 5) .77
Reduce dairy consumption 2.95 (.85) 3.11 (1.1) ↑(1, 5) .42
Eat organic food 3 (.88) 3 (.82) (1, 5) 1
Eat local food 3.22 (.55) 3.39 (.7) ↑(1, 5) .33
Eat food from a home garden 2.83 (1.1) 2.78 (1.06) ↓(1, 5) .58
Reduce food waste 3.89 (.99) 4 (1) ↑(1, 5) .69
Compost food scraps 2.79 (1.65) 2.95 (1.72) ↑(1, 5) .08
Check for leaky faucets and fix/replace 4.26 (1.15) 4.32 (.82) ↑(1, 5) .75
Install high-efficiency/low-flow shower
heads
4.03 (1.23) 4 (1.06) ↓(1, 5) .86
Water your lawn and plants less 3.56 (.92) 3.67 (1.28) ↑(1, 5) .71
Reduce water waste 3.97 (.95) 4.17 (.92) ↑(1, 5) .09
Reduce purchasing 3.5 (.52) 3.81 (.54) ↑(1, 5) .06
Repair and reuse rather than replace 3.79 (.85) 3.89 (.88) ↑(1, 5) .49
Buy clothes second-hand/used/vintage 3.06 (1.3) 3.28 (1.41) ↑(1, 5) .16
Use reusable bags when shopping 3.63 (.96) 4 (.88) ↑(1, 5) .07
Use reusable bottles and cups for water,
coffee, tea, etc.
4.11 (.68) 4.11 (1.02) (1, 5) 1
Avoid single use plastic 3.78 (.65) 3.78 (.81) (1, 5) 1
Reduce/avoid aerosol use 3.84 (.83) 3.84 (.76) (1, 5) 1
Educate oneself about the environment 4.05 (.85) 4.11 (.81) ↑(1, 5) .77
Discuss environmental topics 3.95 (1.03) 3.89 (.99) ↓(1, 5) .67
(continued)
8Global Advances in Integrative Medicine and Health

lack of control condition, and potential social desirability
bias all limit interpretation. Nevertheless, we are encour-
aged by the finding that nearly all trends were in positive
directions. In summary, while the small sample size and
uncontrolled design of these six pilots made it impossible
to assess efficacy, we were able to demonstrate accept-
ability of Mindful Eco-Wellness delivered in these settings,
as well as feasibility of recruiting participants, intervention
delivering, and obtaining relevant outcome data. We also
used participant feedback to refine the course’s curriculum,
whichcanbedeliveredin6-,7-,or8-weekformat.
Conceptual Framework
The behavior change conceptual framework most relevant to
this research is the transtheoretical (stages of change) model
developed by Prochaska and Diclemente, which proposes
that intentional behavior change occurs by using cognitive
Table 4. (continued)
Instrument Measure
Initial Mean
(SD)
Follow-up Mean
(SD)
↑= improve
↓= worsen
Score
Range P-value
Vote and engage with political
representatives
4.17 (1.04) 4.06 (1) ↓(1, 5) .71
Engage in environmental activism 2.79 (.98) 2.95 (.78) ↑(1, 5) .42
Pro-Environmental
Behaviors
d
% (n) % (n)
Do a home-energy audit and insulate
where needed
75% (28) 83.33% (18) ↑(Yes, No) .76
Install solar or geothermal 3.7% (27) 11.76% (17) ↑(Yes, No) .68
Purchase a hybrid or electric vehicle 29.63% (27) 26.32% (19) ↓(Yes, No) 1
Make your current vehicle last as long as it
can
96.3% (27) 100% (18) ↑(Yes, No) 1
a
N ranges from 23 to 26 due to individual scores missing.
b
PROMIS-29 Physical Health Summary (T) and Mental Health Summary (T) were calculated following Spritzer and Hays.
c
Summary (T) includes the following domains: Physical Function, Fatigue, Sleep Distribution, Pain composite (Pain + Global Pain), and Emotional composite
(Anxiety + Depression); calculated with different coefficients for each respective Summary (T).
d
N ranges from 16-19 and only includes cohorts 2-4; cohort 1 used different version of PEB and data could not be included.
e
Pro-Environmental Behavior (PEB) questionnaire adapted from Recurring Pro-Environmental Behavior Scale
64
; Response range: 1 = Never, 2 = Rarely, 3 =
Sometimes, 4 = Usually, 5 = Always.
Statistical Methods: Student T-tests were used to assess differences in initial and follow-up PROMIS-29, Feeling Loved, and PEB for continuous measures and a
test of proportions were used to assess differences in binary measures in the PEB survey. Following Hays and Spritzer,
62
a composite score was created for
PROMIS-29 Physical Health and Mental Health. All analyses were done in R (v. 4.1.1; R Core Team 2021). A P-value of < .05 was considered statistically
significant.
Figure 1. Stages of change for climate-related pro environmental behaviors.
Barrett et al. 9

and behavioral processes to transition through stages until
the desired behavior is achieved and maintained.
65-67
For
eco-wellness, the behavioral change model is conceptual-
ized as bi-axial, with desired changes conceptualized on
both personal health and pro-environmental axes. For ex-
ample, a person could be in pre-contemplation or con-
templation stages regarding health behaviors (e.g., eating
too many sweets or processed foods, and not exercising), but
already in action or maintenance stage of PEB change (e.g.,
recycling regularly and reducing driving). In general, most
participants who take part in this research will likely be in
contemplation or preparation stages on both axes when they
enroll. If the Mindful Eco-Wellness class is successful,
participants will transition into action or even maintenance
stages on both health and PEB axes. While we have not
rigorously assessed stage of change in our work so far, this
could be done, perhaps with interviews, focus groups, and
statistical models based on data from validated self-report
instruments.
68
[Figure 1] Reproduced from Barrett et al 2016
59
Mindful Eco-Wellness is a multi-component intervention
that could influence several health and sustainability out-
comes through several different mechanisms. To reduce this
multiplicity, we are currently focusing on two health be-
haviors (dietary intake and physical activity) and two po-
tential pathways (stress reduction and mindful awareness).
Dietary intake and bodily movement are central to this
model because of the strong impact these behaviors have on
both health and sustainability. Stress reduction and
awareness enhancement are included because of the many
studies implicating these factors as pathways through which
people positively change their behaviors. Our conceptual
model also considers three potential moderating factors
which might predispose people towards mindfulness uptake
and behavioral change: (i) health-enhancement motivation,
(ii) pro-environmental motivation, and (iii) connectedness
with nature. Figure 2 shows this conceptual framework.
Conclusions, Discussion, Next Steps
In the face of rising chronic illness and the unfolding climate
crisis,
1-3
we urgently need effective interventions to help
people improve choices and behaviors that benefit both in-
dividual and planetary health. Ecological and individual
wellness are inseparably intertwined and should be jointly
targeted. Yet to our knowledge, despite many examples of
behaviors supporting both individual wellness and planetary
health, no such interventions have been rigorously developed
and tested. The Mindful Eco-Wellness program is one such
effort that has shown encouraging potential across several
pilot studies and is now ready for rigorous experimental
testing.
Nevertheless, we must be careful not to overgeneralize
intervention design strategies, targeted outcomes, or con-
ceptual models across populations. In its present form, the
Mindful Eco-Wellness program was piloted among individ-
uals from majority white cultures whose environmental
impacts are, on average, more substantial than those of mi-
noritized or low income populations.
4-7
Those with higher
socioeconomic status have greater capacity to make the
behavioral and lifestyle modifications necessary to reduce
their carbon footprints. Thus, although targeting these pop-
ulations first may enhance environmental and public health
benefits, the results may not generalize to less advantaged
groups who are at higher risk from climate change, and who
would benefit most from health-enhancement activities.
69-72
If the Mindful Eco-Wellness program is to be effective
across diverse populations, it will likely need substantive
adaptation. Nondominant groups will benefit from tailored
interventions that account for broader systemic forces such as
Figure 2. Conceptual framework.
10 Global Advances in Integrative Medicine and Health

public policy, macroeconomics, and systemic racism and
classism, all of which can heavily constrain individual be-
haviors and choices. For example, access to healthy foods and
active transportation options is limited for low income and
minoritized groups.
In addition, people who identify as Black, Indigenous, or
People of Color (BIPOC) may hold cultural-ecological
worldviews different from the dominant white culture. Ac-
counting for such differences will be critical for the success of
Mindful Eco-Wellness or similar programs. For example,
some BIPOC individuals may question the program’s em-
phasis on personal behaviors, considering that low income
and minoritized communities are neither equally responsible
for nor equally empowered to influence the societal level
changes needed. Other BIPOC individuals may be motivated
to participate based on more pragmatic factors (e.g., to reduce
chronic disease or food insecurity, lower healthcare costs,
benefitone’s community, restore ancestral lands), whereas
individuals from the dominant majority may be motivated by
more abstract motivations such as mitigating climate change,
feeling healthier, or experiencing less eco-anxiety.
Future research projects will need to examine such issues
using a variety of study designs, including observational and
experimental approaches that use quantitative, qualitative, or
mixed methods. Also worth investigating is whether an
emphasis on interpersonal ethics and prosociality
73
might
increase adherence or effectiveness of the intervention, given
that pro-environmental behavior has the potential to reduce
the suffering of others.
At this stage, we aim to test the current format of the
intervention in a population-based sample using randomized
experimental design and a combination of self-report and
objective behavioral measures (e.g., wearable fitness trackers,
vehicle odometer readings, mobile phone location data
mapped to roads, walkways, and biking paths). Computer-
assisted analysis of meal photographs could support dietary
intake assessment and reduce participant burden.
74
Biomet-
rics such as body weight, cholesterol, blood sugar, and blood
pressure also could be employed.
In summary, while the importance of developing a science
of behavioral eco-wellness - defined as the study of how
individual choices, behaviors, and habits impact both per-
sonal health and environmental sustainability
10
- is unde-
niable, efforts in this direction have only just begun.
Acknowledgments
Mindful Eco-Wellness, formerly known as Mindful Climate Action,
has been supported with institutional funding within the University
of Wisconsin - Madison, and has been housed by the Department of
Family Medicine and Community Health (see https://www.fammed.
wisc.edu/mca/). The authors would like to acknowledge the con-
tributions of all the patients and community members who have
participated in group sessions and provided feedback, and the many
colleagues from across the globe who have conducted their own
relevant research, and those who have made suggestions or provided
critical feedback regarding the Mindful Eco-Wellness project.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This work
has been supported by the University of Wisconsin - Madison and
the Department of Family Medicine and Community Health, but no
outside agencies and Simon B. Goldberg was partially supported by
the National Center for Complementary and Integrative Health while
this paper was being written (K23AT010879).
ORCID iD
Bruce Barrett https://orcid.org/0000-0002-3953-4718
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