Behavioral health

Positive Health III: Well-Being, Fitness and Survival

August 11th, 2011 | 1 Comment | Source: Commentary

Martin Seligman is the originator of an increasingly mainstream theory of health and behavior known as Positive Health. His theory suggests that we should cultivate and maintain ‘positive health assets’ – things like optimism, connectedness, a stable marriage and so forth – because they contribute to a healthier, more fulfilling life and improved life expectancy as well.

In earlier posts on the matter, I reviewed 2 studies that support Seligman’s theory. In the first, Harvard scientists showed that emotional and cognitive well-being was associated with a reduced rate of coronary events.  In the second, University of Michigan scientists showed that optimism was an independent predictor of short term stroke risk.

While both studies suggest that the presence of certain positive health assets can be protective, they do not look at whether the absence of certain negative attributes can be similarly helpful.

Recently, scientists at the Karolinska Institutet undertook to study this aspect of Positive Health. Once again, the findings support Seligman’s concept.

As was the case for the first 2 studies, support for the new study was provided by the Robert Wood Johnson’s Pioneer Portfolio.

In the new study, Francisco Ortega and colleagues set-out to study the association between psychological well-being and cardiorespiratory fitness, and their combined effects on survival.

The scientists used data from the Aerobics Center Longitudinal Study (ACLS), a prospective epidemiologic investigation of more than 5,000 volunteers that began in 1988. At the time of enrollment, participants had a thorough clinical evaluation including a history, physical exam, blood chemistry tests and an exercise test. Participants ranged in age from 20-81. They were followed annually until they died or the study ended, in 2003.

In ACLS, psychological well-being was evaluated at the time of enrollment using negative and positive emotion subscales from the Center for Epidemiologic Studies depression (CES-D) test. Questions in this test asked about how frequently respondents experienced certain feelings in the preceding week. The negative emotion subscale included things like ‘my life had been a failure’, ‘not able to shake off the blues’, and ‘depressed’. The positive emotion subscale included things like ‘feeling as good as other people’, ‘happy’ and ‘hopeful’.

What Did They Find?
After adjusting for traditional cardiovascular risk factors, the scientists found that participants with low levels of negative emotion had a 34% lower risk of death than peers reporting high levels of negative emotion. The protective effect was localized to those with high levels of cardiorespiratory fitness (CRF): high levels of CRF were themselves associated with a 46% reduction in mortality risk, but in the subset of participants that had both high levels of CRF and low levels of negative emotion, there was a 63% lower mortality risk. (more…)



Positive Health II: Optimism and the Risk of Stroke

August 10th, 2011 | 1 Comment | Source: Commentary

Way back in 1946, the chartering documents of a new UN agency—the World Health Organization—defined health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”

We have made astounding progress in medicine and public health since the WHO charter was crafted, yet we have actualized only part of its comprehensive vision for health. What we call health care today is really just illness care. Even our disease prevention and health promotion programs focus on reducing risk factors for disease. It is the rare initiative indeed that encourages good health for its own sake.

New initiatives focused on the concept of Positive Health are changing that by helping us understand what it means to be healthy in a comprehensive sense, beyond the simple absence of symptoms and illnesses. The initiatives focus on health assets, which are biological, psychological, social and other characteristics that are associated with prolonged life, reduced morbidity and health care costs, and improved quality of life.

The initiatives have been triggered by the seminal contributions of Martin Seligman. Many are funded by the Robert Wood Johnson Foundation’s Pioneer Program. They have already produced provocative results, one of which I discussed last week.

In this post–the second in a continuing series–I review another initiative in the field of Positive Health. This one examines how optimism impacts the risk of stroke, the nation’s third leading cause of mortality and disability after heart disease and cancer.

The Study
The classic risk factors for cardiovascular disease (including stroke) include high blood pressure and cholesterol levels, cigarette smoking and diabetes. ‘Negative’ psychosocial factors like depression, anxiety, work stress, low socioeconomic status and poor social support also predict cardiovascular events. More recently, a few studies have filtered into the literature suggesting that health assets like life satisfaction are also predictive.

However, as the National Heart, Lung and Blood institute recently emphasized, essentially none of these factors are all that good at predicting near term (that is, 1-2 years) cardiovascular events, especially in asymptomatic adults. Furthermore, almost no studies have examined whether positive health assets can impact the risk of stroke, per se. (more…)



Positive Health and the Heart

August 9th, 2011 | 4 Comments | Source: Commentary

For centuries, health providers have focused on the prevention, diagnosis and treatment of disease. This time-honored paradigm has generated phenomenal advances in medicine, especially during the last 60 years. It has also created an image problem for providers, because the paradigm encourages consumers to perceive health care as a negative good – that is, a product or a service that we use because we must, not because we want to. Recent trends towards empowered consumers are a symptom of this problem more than a solution to it, as I described here.

Recently, the concept of Positive Health has emerged as a possible antidote for the malaise.

Pioneered by University of Pennsylvania psychologist Martin Seligman, Positive Health encourages us to identify and promote positive health assets—which Seligman describes as strengths that contribute to a healthier, more fulfilling life and yes, improved life expectancy as well. According to Seligman, “people desire well-being in its own right and they desire it above and beyond the relief of their suffering.”

Proponents of Positive Health have proposed that several social and functional factors are positive health assets. These include optimism, connectedness, a stable marriage and so forth. Scientists, often supported by the Robert Wood Johnson’s Pioneer Program, have begun studying these proposals. Their results have been compelling to say the least.

This post is the first of a series on Positive Health. In each post, I’ll review scientific studies of the matter and as the series unfolds, I’ll  discuss the relationship between this emerging paradigm and the traditional disease-oriented paradigm favored by today’s health providers.

Heart Health Linked to Satisfaction with Life
Most people know that negative psychological states like stress, anxiety and depression are linked to poor health outcomes, including a slew of adverse cardiac outcomes. Does it follow that a state of emotional and cognitive well-being can have a protective effect on cardiovascular health?

To answer this question, Harvard’s Julia Boehm and colleagues reviewed data from the Whitehall II study, which involved nearly 8,000 British civil servants. As part of that study, each participant had assessed his or her satisfaction with several dimensions of life experience including leisure activities, standard of living, job, health, family life, sex life, marital or love relationships and overall feelings about themselves as a person. Participants also provided yes/no answers regarding negative aspects of their lives including the presence of depression, anxiety and so forth. (more…)



The Age of the ePatient: Not Quite There Yet

July 25th, 2011 | 2 Comments | Source: Commentary

The Internet has transformed every aspect of health care. Online communities provide new forms of support for people with a thousand different medical conditions. Email has streamlined communication between stakeholders in the system. Electronic medical records and social networking sites hold a wealth of data that can be leveraged to study the effects of various treatments.

The most significant advance by far though, has been the ease with which people can access information about their health. As many as 74% of all people search for information about their symptoms and treatments online. Many of these information-empowered people now see physicians as guides to and interpreters of this information, a far cry from the era in which passive patients simply recounted their symptoms and relied on paternalistic physicians to act in their best interests.

There are problems with the new paradigm, just as there were with the one it replaced. In particular, online health information can be incomplete, biased, lacking for proper context or flat-out inaccurate…and not everyone can sort through these deficiencies in a way that assures they are properly informed.

A recent study by Alexander van Deursen and Jan van Dijk of the University of Twente has quantified these problems. The scientists used performance tests to assess health-related Internet search and other online skills in a representative sample of the people in the Netherlands.

Their tests focused on four types of skills:
Operational-These included basic internet skills like opening a health website, saving a PDF file and adding a website to a list of “favorites.”
Formal-These included navigating health-related menus and websites, and surfing a list of websites.
Finding Information-These included accessing specific information regarding medical conditions and answering specific questions like whether it is appropriate to begin a treatment after being infected with a particular germ.
Strategic-These included extracting information from different sources and making decisions based on the information. For example, “find out whether it is wise to give a 3-year-old boy Vitamin A and D.” (more…)


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Does Being Diagnosed with a Chronic Disease Improve Healthy Behavior?

June 16th, 2011 | 1 Comment | Source: Commentary

We have all seen people exhibit flagrantly unhealthy behavior. Some of us–though we’d never admit it–derive a certain, smug satisfaction by observing them. At least I don’t do that!

Somewhere in the course of our daily lives though, most of us do exhibit behavior that suggests at least some disregard for our health. We don’t change our diet, though we know we should. We don’t floss, take medications as prescribed, or get the screening tests we’re supposed to. 

Multiple intertwining causes underlie all unhealthy behavior, of course. I had always figured that one pervasive cause was the lack of a simple, observable connection between health-related behaviors and health outcomes. There is a long delay for example, between establishing unhealthy dietary preferences  and the sequellae of that behavior ( a heart attack, diabetes or whatever). The longer the delay between cause and effect, the more likely someone will be to exhibit unhealthy behavior.

On the other hand, if there’s a short interval between cause and effect—it only takes minutes for susceptible people to develop a severe allergic reaction after eating peanuts, for example—well, that’s where I’d expect high adherence to the required healthy behavior.

If I’m right, then we have a problem. For many chronic diseases (diabetes, heart disease, some cancers) the interval between cause and effect can be decades.

How might this reasoning apply to a person that has already been diagnosed with a chronic disease? Assuming providers have explained things to him or he has learned these things on his own, that’s a person that knows his behavior caused his predicament. And if he knows that, he should also know he has a fresh chance to rectify matters, at least to a degree. If he modifies his unhealthy behavior, then he can control the progression of, and indeed sometimes reverse the progression of his disease. (more…)



The Effectiveness of Online Health Intervention Programs

June 13th, 2011 | No Comments | Source: Commentary

In recent posts on Web-based and mobile behavioral intervention programs, we reviewed evidence suggesting that social support, in one form or another, can improve participants’ adherence and engagement with the program. That didn’t always mean however, that participants achieved better outcomes as a result. In one study for example, an online community increased engagement with and utilization of a Web-based activity program, but it did not increase participants’ actual activity levels.

Another study, slightly older than the ones reviewed above, did show that a Web-based program improved outcomes. In this case, the intervention was an online videogame known as Re-Mission. Since I haven’t touched previously on outcome studies for automated lifestyle intervention tools or videogames as an example of such programs, I’ll do that here.

Re-Mission is intended improve medication compliance in teens and young adults with a history of cancer. In the game, players control a nanobot within a 3-dimensional body of a young person that has cancer. Play involves destroying cancer cells and managing chemotherapy-related adverse effects like vomiting and bacterial infections by using antiemetics and antibiotics. The game purports to help users understand their disease and its treatment and improve their sense of self-efficacy: they can take control of their disease.

In their randomized trial of Re-Mission, Pamela Kato and colleagues chose compliance with prescribed medications as the behavioral outcome. The Stanford scientists randomized 375 teens to play either Re-Mission or Indiana Jones and the Emperor’s Tomb, an entertainment game with a structure and controller interface similar to that in Re-Mission. They asked participants in both groups to play the assigned game for 1 hour each week during the 3-month study.

Kato’s group measured pre- and post-intervention adherence to the antibiotic trimethoprim-sulfamethoxazole using an electronic pill-monitoring device. They measured adherence to 6-mercaptopurine, chemotherapy drug used to treat many childhood cancers, using serum assays. (more…)


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Online Communities & Attrition from Health Intervention Programs

June 8th, 2011 | No Comments | Source: Commentary

Provider-centric, face-to-face health intervention programs that help people quit smoking, lose weight and increase activity levels have been shown to work, but they are expensive, don’t scale, and inconvenient. By contrast, Internet-based programs with similar goals can be disseminated widely and inexpensively, and can be accessed by consumers at a convenient time and place.

Although many of the latter programs have been shown in clinical trial settings to be efficacious, attempts to commercialize them have been plagued by attrition. People stop using the programs because they lose motivation, can’t find the time, or become frustrated by clunky interfaces and data entry requirements.

In one study for example, only 26% of participants in a randomized trial of a free physical activity website dropped out of the study before it was completed, whereas 67% of registered open access users dropped out during the same course of time. The open access users also spent less time on the site.

The lower attrition rate in the trial was likely driven by the emotional, cognitive and logistic support provided by trial personnel. It follows that the commercial success of online health intervention programs hinges on their ability to support users in the same way as trained personnel do in clinical trial settings.

Online communities have been proposed for this purpose. These tools permit users to communicate via the posting and reading of messages on a group message board. Social learning theory suggests they can reduce attrition by favorably impacting motivation to change, helping users learn vicariously and gain inspiration, and providing content that encourages users to return to the site.

Recently, a study by Caroline Richardson and colleagues at the University of Michigan showed in fact that an online community associated with an Internet-mediated walking program did reduce attrition.

Richardson’s group randomized 324 sedentary adults into 2 groups. Both groups were granted access to a Web-based walking program that required them to wear pedometers for 16 weeks and upload step-count data to a server. All participants could also view graphs of their progress and receive individually-tailored motivational messages. Participants who were randomized to the “online community” group had, in addition, access to online community features embedded in their intervention webpage, enabling them to post and view messages left by other participants. Those in the “no online community” group were not granted access to these features. (more…)


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Attrition from Online Health Intervention Programs

June 2nd, 2011 | No Comments | Source: Commentary

In recent years, developers have released thousands of Web-based and mobile intervention programs that purport to help people quit smoking, improve their nutrition and activity levels, and institute other salutary changes in health-related behavior.

These programs have drawn attention because of their potential to improve health for millions, at low cost. In addition, the platforms on which some are built permit developers to add new tools like games, online communities and analytical capacity that can, many believe, enhance their impact.

Clinical trials have shown that many of these programs do work.

For example, a randomized trial by Australian scientists showed that public registrants to a cognitive behavior therapy website had reductions in symptoms of anxiety and depression. Another randomized trial by Swiss scientists revealed that an Internet-based smoking cessation program helped people quit their habit.

Nevertheless, with a few notable exceptions, venture capital firms have been reluctant to invest in startups proposing to commercialize programs like these. It’s likely they’ll stay on the sidelines until startups prove their programs attract large, active user bases and users maintain targeted health benefits outside the controlled environment of a clinical trial. It wouldn’t hurt if startups also had a plan to monetize their applications, as well.

The challenge can be boiled down to the problem of attrition. People stop accessing these programs because they lose motivation, can’t find the time, or become frustrated by clunky interfaces and data entry requirements. Sometimes, they simply move on to another application.

Recently, a study by Miriam Wanner and colleagues from the Institute of Social and Preventive Medicine validated investor concerns about the attrition problem. But to some, it offered hope that newer platform features like games and onlne communities may be able to address it satisfactorily.

The scientists set-out to understand the determinants of utilization of Active-online, a free physical activity website in Switzerland. They found that the key predictor of sustained use was the circumstance in which people began using the site in the first place. Specifically, the attrition rate was 67% among registered open access users and only 26% among those who participated in a randomized trial of the site. Similarly, open access users spent less time on tailored modules (7.5 vs. 9.2 minutes) than trial participants. (more…)


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HealthTech 2011: Conference Recap

May 15th, 2011 | No Comments | Source: Commentary

@MichaelSheeley  #ciht11 Lots of cool & innovation going on in the health & fitness world. Very exciting things are happening!

Indeed there are. The latest evidence for this could be found at Friday’s HealthTech 2011 conference in Boston. Sponsored by Careinnovators, #ciht11 drew hundreds of entrepreneurs, who used the day to share ideas, hear what investors thought about their space, and for a few of the heartiest, to nail their elevator pitch in a bar during the height of happy hour.

The Entrepreneurs
The large, engaged crowd suggests that #ciht11 touched a nerve, at least among entrepreneurs. Many of them believe we are entering a renaissance era in health and wellness, even bigger than the 1980s bubble which produced Access Health and HealthWise, among others.

The renaissance is being driven, they say, by strong tailwinds from many sources. The aging of the baby boomers creates a vast new market, including millions who want to maintain good health and even more who will inevitably develop chronic diseases. Inexpensive smartphones and monitoring devices are becoming ubiquitous, giving consumers real-time access to support networks and non-obtrusive ways to record data. Today’s Web-based platforms make it easy to develop products and store data.

Plus, it won’t be long before people who never knew life without the Internet will outnumber those who grew up before it. If these people can spend hours tending to eStrawberries on an eFarm, then surely they will use cool games that help them stay healthy.

There have been early successes in the space, as yesterday’s conference showed. Companies that track your work-out, like MapMyRun and RunKeeper have up to 5.5 million registered users and 300,000 active users, according to speakers and Twitterers at the conference. Shape Up the Nation provides health and wellness services to more than 2 million people via contracts with employers and payers.

The Venture Capitalists

@PearlF #ciht11 Bessemer’s Stephen Kraus: there will be next generation gaming plays on wellness, 4 now not investing, hard 2 separate from noise

Venture Capitalists seem to be more circumspect about the supposed renaissance, however. They have invested only sporadically in the space, although the few investments they have made—including a remarkable $2.25 million bet that Aza Raskin, the former creative lead at Firefox and Sutha Kamal can grow Massive Health from scratch—are noteworthy.

To be sure, most VCs absolutely do believe that some startups in this space will become wildly successful. It’s just they haven’t yet seen many startups that merit an investment at this point. Too many unproven business models. Too many marketing plans based on the premise—famously recounted at the conference by Excel Venture Management’s Rick Blume—that ‘if I build it, they will come.’

How will these startups overcome the troubling reality that 26% of people who download a health-related app use it just once, or that nearly a third of those who use health apps don’t use them as their developers intended? How realistic is a business plan that relies on users to fundamentally change their health-related behaviors?

@MatthewBrowning #ciht11 ROI, ROI, ROI is most important to investors



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How to Measure Happiness

April 20th, 2011 | 3 Comments | Source: Commentary

Nowadays, a lot of folks pursue happiness as if it were their primary mission in life. But what is happiness?

Philosophers tell us there are at least 2 kinds. There is so-called “hedonic well-being” which is short-term pleasure derived from things like a tasty meal, great sex or a day in the amusement park.  Then there’s “eudaimonic well-being” which comes from living with a sense of purpose, which is usually actualized by participating in meaningful activities like volunteering for a worthy cause, raising children or caring for others.

Scientists have recently joined their philosopher brethren in the analysis of happiness. Remarkably, they have produced evidence which suggests that people who are driven to achieve eudaimonic  happiness actually have better health outcomes than those motivated to achieve hedonic happiness. They are more likely to remain intact cognitively, for example. They even tend to live longer.

For example, in a cohort study of 7,000 people known as MIDUS (the Mid-Life in the US National Study of Americans), Carol Ryff and colleagues at the University of Wisconsin have tried to identify social and behavioral factors that predict one’s ability to maintain good health into old age. The team has focused on sociocultural sub-populations known to be associated with poor health outcomes…things like low education level.

Ryff’s group showed that people with low education levels and high levels of eudaimonic well-being had lower blood levels of interleukin-6, a bio-marker of inflammation that has been linked to cardiovascular disease, Alzheimer’s disease, even after accounting for hedonic well-being into account. Their write-up appears in Health Psychology.

As well, a study of 950 community-dwelling elderly folks linked eudaimonic well-being to a lower risk of developing Alzheimer’s disease. During their 7-year follow-up of this cohort, David Bennett and colleagues at Rush University Medical Center found that participants who reported having less of a sense of purpose in their lives were at least twice as likely to develop the debilitating condition as those who reported a greater sense of purpose. Their write-up appears the journal Archives of General Psychiatry. (more…)



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