Positive Health, a breakthrough concept developed by Martin Seligman, encourages us to promote positive health assets—things like optimism, connectedness, a stable marriage and so forth—because  they contribute to a healthier, more fulfilling life and yes, improved life expectancy.

In earlier posts in my series on Positive Health, I reviewed 2 studies which support Seligman’s concept. 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, their 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 and 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, depressed, sad, fearful, lonely and crying spells. The positive emotion subscale included things like feeling as good as other people, happy, hopeful, and joy.

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.

These associations were present across all age groups and both genders. They persisted after adjusting for the presence of underlying diseases and the impact of positive emotion. Interestingly, high levels of positive emotion were not associated with mortality.

What Do We Make of This?
Ortega’s study suggests that low levels of negative emotion and high levels of cardiorespiratory fitness are independent predictors of long-term survival. What is more, these two parameters exerted a strong combined effect such that participants having both low-level negative emotion and high CRF experienced a 63% lower mortality risk than those with high negative emotion and low CRF.

This study should be considered in light of several limitations, as noted by the authors. For example, although they controlled for many risk factors for premature mortality, it may be that uncontrolled factors like dietary habits could also have played a role. These data were not available to Ortega’s group.

In addition, nearly 98% of the ACLS participants were well-educated, white, and in middle or high socioeconomic strata. It remains to be determined whether these findings will hold up in populations with more varied ethnicity and socioeconomic status. Also, the ACLS provided only a baseline assessment of negative and positive emotion. Although the authors cite previous studies suggesting that measures of psychological well-being remain stable over time, this assertion doesn’t necessarily jive with my anecdotal experiences (!).

Finally, the beneficial effect of low-level negative emotion on survival was seen only in participants with high levels of cardiovascular fitness. It did not impact those with low or moderate CRF levels…a strange, inexplicable finding that bears further scrutiny.

These limitations mean it’s unwise to recommend at this time that health professionals should routinely assess psychological health of their patients during, say, an annual physical examination, or that providers should intervene to reduce negative emotions (if that’s possible) in addition to encouraging increased physical activity. That said, the current study suggests a lot is at stake. If the findings do hold up in follow-up investigations, we might well have another compelling way to help people maintain health.

It’s worth mentioning in closing that Ortega’s group found only a modest correlation between positive and negative emotion scores: people with high levels of positive emotion do not necessarily have low levels of negative emotion, and vice versa. The group concluded that positive and negative emotion are distinct from each other and can impact survival in their own, unique ways.

Way back in 1946, the chartering documents for a new agency of the UN—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 in large part 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.

A study by Eric Kim, of the University of Michigan, and colleagues has addressed this opportunity. They concluded that optimism was in fact an independent predictor of short term stroke risk.

To reach this conclusion, Kim’s group looked at data from 6,044 adults with no prior history of cardiovascular or cerebrovascular disease. The subjects had participated in the Health and Retirement Study, a nationally representative, prospective study of Americans who were at least 50 years old.

The scientists assessed optimism using the Life Orientation Test, in which participants respond to 3 questions using a 6-point Likert scale. Kim’s group created an ‘optimism scale’ based on participants’ responses. The scale ranged from 3 (extremely pessimistic) to 18 (extremely optimistic).

It turned out across the entire survey population, each unit increase on the scale was associated with an age-adjusted 9% decrease in stroke-risk during the 2 year follow-up.

Negative psychological factors like anxiety, depression and neuroticism were also predictive of short-term risk for stroke, but optimism offset their impact.

Of note, the association between optimism and stroke risk persisted after controlling for cardiac disease and dozens of biological, behavioral and sociodemographic factors (including race/ethnicity, marital status, educational status, cigarette smoking history, exercise, alcohol use, diabetes, body mass index, blood pressure).

What Can We Make of This?
Kim’s study is the first to suggest that optimism may protect against stroke in older adults. It is consistent with other research which has shown that positive psychological factors like optimism are associated with a range of cardiovascular benefits, including a reduced risk of rehospitalization following bypass surgery, reduced  risk of coronary heart disease and even reduced cardiovascular mortality.

One potential flaw in Kim’s study is that stroke incidence was ascertained via self-reporting from participants, based on what they understood from their doctor or by proxy reports for participants that had died (many of the covariates were also self-reported in Kim’s study). According to Kim’s team however, self-reported stroke has been shown in several other studies to provide an accurate estimate of stoke incidence.

Why might optimism reduce stroke risk? Kim’s group mentioned several studies showing that high optimism is associated with health knowledge and the pursuit of healthy behaviors. They hypothesized that optimists might be more proactive about their health in general, perhaps by adopting a healthier lifestyle that minimizes health risks and increases health and well-being.

These theories make sense but require further validation, especially before we can comfortably recommend interventions designed to promote optimism in the effort to reduce the incidence of stroke.

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 a bit of an image problem for providers. That’s because the paradigm encourages consumers to perceive health care as a negative good; an economic term describing a bundle of products and services 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.

The Whitehall II study also collected information regarding age, gender and traditional cardiovascular risk factors like cigarette smoking, diabetes and hypertension,. It assessed the incidence of coronary heart disease using three measures, presence of angina, documented heart attacks, and deaths from coronary disease during a 5-year follow-up period after the information had been collected.

Boehm’s team examined these data and found a clear, indirect relationship between satisfaction with each life domain and the risk of coronary heart disease: people reporting higher satisfaction had lower cardiac risk. Specifically, subjects in the highest tertile of satisfaction had a 26% lower risk of coronary events, and those in the middle third had a 20% reduced risk compared with those reporting the lowest levels of life satisfaction.

These trends reached statistical significance in 4 of the 7 dimensions: satisfaction with job, family life, sex life and overall feelings about themselves, and they persisted after controlling for age, gender, health behaviors, blood pressure, and metabolic functioning.

What to Make of This?
The study provides strong, though narrowly focused support for Seligman’s theories about Positive Health. Being satisfied with specific life domains—especially the 4 mentioned above—is associated with lower risk of coronary heart disease, even after accounting for traditional cardiovascular risk factors. If these findings can be validated, scientists should follow-up with studies to determine whether interventions designed to enhance life satisfaction can reduce cardiovascular risk.

Of note, the beneficial effects in this study were localized to angina, one of 3 outcome measures examined by Boehm’s group. There was no association between life satisfaction and the so-called ‘hard’ cardiovascular outcomes like heart attacks and cardiovascular deaths. Reporting bias could explain these findings: people that have favorable feelings about their lives might be more likely to report favorably about their health or have a higher tolerance for pain.

On the other hand, subjects in the Whitehall II study were relatively young (mean age = 50). In the natural history of coronary artery disease, angina frequently becomes manifest before heart attacks and death from cardiovascular causes. Participants in the study were followed for a fairly short time, only 5 years. It’s possible that longer follow-up would have revealed higher incidence of ‘hard’ cardiovascular outcomes.

It’s also possible that–since nearly all patients who sustain heart attacks have coronary artery disease, but only some with atherosclerosis sustain a heart attack—life satisfaction might be associated with increased risk of atherosclerosis but not with the specific factors that predispose to thrombotic events, plaque rupture and other antecedent events to heart attacks.

Further studies are required to sort through these alternative explanations.

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 however, 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, and 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 presented symptoms and relied on paternalistic physicians to act in their best interests.

But there are problems with the new paradigm, just as there were with the one it replaced. Online health information can be incomplete, biased, lacking for proper context or flat-out inaccurate. And not everyone, especially those without a medical background, 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.”

On average, study subjects successfully completed only 73% of the operational skill tasks and 73% of the formal skill tasks. They completed only 50% of the finding information tasks. An abysmal 35% used their findings strategically.

Only 28% of the subjects successfully completed all operational skills tasks, 39% completed all formal skills tasks, 13% successfully completed all information skills tasks, and 20% completed all the strategic skill tasks. There was substantial variation in the time required to complete any particular task successfully.

According to the scientists, age and educational level were strong predictors of success with operational and formal Internet skills. In the latter case, years of Internet experience was also somewhat predictive. When it came to information finding and strategic internet skills, educational level was the most important predictor of success.

What Should We Make of This?
The study, if it can be generalized, suggests that a surprisingly large fraction of the general population lacks basic Internet skills needed to keep pace with the explosion of online health information and services. Many more, including a surprisingly large number of younger folks, have problems finding information on the Internet and using it appropriately. In the latter group for example, subjects often failed to recognize that key information was missing, that the information they encountered was biased, and that claims made on certain sites were not based on scientific evidence. More pernicious problems included a tendency to focus on finding information quickly rather than information that answers specific questions. Frequently for example, subjects visited only the top-listed links (which are often sponsored) derived from a search.

What Should We Do?
First, we need to recognize there is a problem. I am just as bullish about the potential of the Internet as the next guy, but this potential will only be reached if we implement policies and procedures that improve Internet skills for the general population. Adult education and computer classes should be made available to teach operational and formal Internet skills, especially for older folks. Similar training in information finding and strategic Internet skills are required for people of all ages. It is dangerous and often flat-out wrong to assume that, just because the Internet has become ubiquitous, people know how to use it properly.

As for the age of the empowered e-patient, this study suggests that millions of people, perhaps tens or hundreds of millions, aren’t quite there yet. Even today, medical professionals must act as curators of credible information. They shouldn’t assume their patients can identify and use evidence-based information from the Internet. Minimally, their job is to steer patients away from the sponsored sites and ones touting miracle cures, and towards the ones which are reliable and free from bias.

African-American Men More Likely to Stay Alive In Prison than Out. A study of North Carolina inmates found that African-American males are half as likely to die in prison as out of prison. The study, in the Annals of Epidemiology, found that African-American inmates were protected against drug and alcohol-related deaths, fatal accidents and some chronic diseases.

Injuries of Veterans, Football Players Linked to Dementia Later in Life. Two studies provide new evidence that head injuries such as concussions are linked to dementia later in life and may make the brain more vulnerable to the development of symptoms characteristic of Alzheimer’s disease.

A Wife May Shorten Time to MI Care. Married men arrive at a hospital quicker than age-matched single men after developing chest pains suggestive of a heart attack, researchers found.

FDA Issues Draft Document on Mobile App Regulations. The 30-page draft provides guidance outlining how mobile medical apps should be regulated as medical devices, targeting an issue that has long plagued physicians looking to adopt apps and vendors wondering how far they can go without incurring the regulations.

Reddit Cofounder Charged With Hacking MIT Computer. Federal prosecutors have accused Aaron Swartz of stealing 4 million documents over a 3-month period in 2010. He faces charges of wire fraud, computer fraud, unlawfully acquiring information and recklessly damaging a protected computer. If found guilty, Swartz could spend 35 years in jail and be fined $1 million.

Budget Impasse Unlikely To Affect EHR Incentive Payouts. Despite the ongoing stalemate in federal budget negotiations, it is unlikely that Congress will eliminate future funding for incentive payments for the meaningful use of electronic health records, according to David Roberts, VP government relations at HIMSS.

Greenway Medical Files to Go Public. The vendor of integrated physician practice management/electronic health records software has filed for a $100 million initial public offering of stock.

Tobacco Use in Movies Continues Dramatic Drop. The number of onscreen tobacco incidents in youth-rated (G, PG, or PG-13) movies continued a downward trend, decreasing 71.6% from 2,093 incidents in 2005 to 595 in 2010, the CDC reported. The rate of decline varied substantially by motion picture company.

Kids Safer With Granny Behind the Wheel. Grandma may be better behind the wheel than mom when it comes to injuries from car crashes involving children, an insurance database showed.

Supply of Essential Medicines Falls Short in US Hospitals. Shortages of common medicines have reached a record high and are a nearly universal problem for community hospitals in the US, where the problem is leading to rationing and higher costs for care.

Gain Fitness Launches iPhone App. Gain Fitness, a startup that creates personalized workouts based on certified trainers’ expertise, has launched an iPhone app that allows fitness enthusiasts to access to personal trainer quality exercise without having to research workouts or book expensive trainers.

Web Changing How People Recall Facts. Access to a wealth of information on the Internet is altering what people remember, prompting us to retain fewer facts but more information about how to find those facts, say scientists at Harvard and Columbia.

Second-Hand Smoke Tied to ADHD. Researchers found that of more than 55,000 US children younger than age 12, 6% lived with a smoker. Those kids were more likely to have attention-deficit hyperactivity disorder (ADHD) than children living in smoke-free homes.

Florida Pain Doctor Suspended; 34 Patients Dead. Dr. Joseph Hernandez was suspended earlier this month by the Florida Department of Health for overprescribing opiate painkillers. Of the 761 patients Hernandez saw between January and April 2011, 34 have died.

When Medicaid Paid Better, Kids Had More Dental Visits. When dentists were reimbursed more for preventive visits, kids on Medicaid ended up in their chairs more often, probably because the increased compensation made them more willing to accept those patients, a government researcher said.

Industries Lobby Against Nutrition Guidelines. The food and advertising industries have launched a multi-pronged campaign against government efforts to create voluntary nutritional guidelines for foods marketed to children.

Electronic Glasses Can Read Emotions. The ‘emo-specs’ use a camera to record facial motions and facial expression software that interprets the wearer’s emotions based on a database of previously-collected facial expressions. The emotion is then displayed visually within the glasses.

Unlocking Dyslexia in Japanese. Scientists have shown that some dyslexics have an easier time with a character-based language like Japanese, than a language based on phonemes, like English. The observations could help improve teaching techniques for affected individuals.

Colorectal Cancer Screenings Make a Difference. Increased screening during the last decade for colorectal cancer, the nation’s second-leading cause of cancer deaths, has put a dent in the prevalence of the disease and in the number of deaths resulting from it, the CDC said.

CMS Pilot Programs to Analyze Quality Data Collection via EHRs. CMS rules proposed last week provide new details of pilot programs aimed at testing online reporting of clinical quality data from electronic health records.

ONC Agrees to Delay Stage 2 Meaningful Use. The national coordinator for health information technology announced that he’s supporting a delay in Stage 2 of electronic health records meaningful use by one year to 2014 for providers who attest to Stage 1 in 2011.

Celebrex Might Prevent Lung Cancer in Former Smokers. Early studies suggest the Cox-2 inhibitor, which is normally used to treat arthritis and other inflammatory diseases, prevents a proliferation of cells that is linked to lung cancer.

Review Raises Doubt about Cutting Salt Intake. Researchers have found no evidence that moderate cuts to salt intake reduce the risk of developing heart disease or dying prematurely, though it does lead to slight reductions in blood pressure.

Medical Tourism Market Slow to Grow. Traveling abroad for medical procedures was touted as a trend and it even has its own trade group, the Medical Tourism Association. However, some question whether it’s as big a growth market as once thought.

Late-Talking Toddlers Grow Out of Behavioral Problems. Kids who aren’t uttering words by age 2 have no increased risk of behavioral or emotional problems when they reach elementary school, and usually outgrow the language delay on their own, a study shows.

Social Media Shows Promise for Clinical Trials. Social media can be used to increase enrollment and reduce clinical trial delays, according to a new survey by Blue Chip Patient Recruitment.

ACSM Releases New Exercise Guidelines. The new guidelines by the American College of Sports Medicine aren’t all that different from their old ones, except they emphasize that sitting for long periods is a health risk that can’t be negated simply by exercising regularly.

Spine Journal Takes Aim at Infuse Research. The Spine Journal is devoting an entire issue to critical reviews of published studies of Medtronic’s bone morphogenetic protein-2 product known as Infuse (see Pizaazz coverage of the matter here).

Google+ Begins Limited Field Testing. The company’s top secret social layer supposedly turns the search engine into a giant social network. It’s the culmination of a year-long project, and amounts to Google’s answer to Facebook.

Social Media Being Used as a Platform to Disclose Illness. The Internet has not only transformed how consumers gain access to health information, it is also significantly changing how they seek comfort during a health crisis, according to new research from Russell Herder.