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Why looking up matters
A positive attitude is important, but until now we didn’t know how important. In Up, a practicing physician and NIH-funded researcher draws on her research and experience to show that our outlook on life— our unique patterns of thinking and feeling about ourselves, others, and the world—may be the key to how well and how fast we age.
From wrinkles to cognitive decline, our outlook affects our health at every level. Using ...
Why looking up matters
A positive attitude is important, but until now we didn’t know how important. In Up, a practicing physician and NIH-funded researcher draws on her research and experience to show that our outlook on life— our unique patterns of thinking and feeling about ourselves, others, and the world—may be the key to how well and how fast we age.
From wrinkles to cognitive decline, our outlook affects our health at every level. Using the framework of outlook GPS, Up illustrates how we can gauge our current attitude latitude and move to healthier ground. Tindle brings a fresh eye to attitudinal traits such as optimism, noting that it has many faces, including the face of her own struggling optimism. Using the 7 Steps of Attitudinal Change that she applies to her own patients, Tindle offers us a path toward healthy aging.
Prescriptive and accessible, Up puts forward a paradigm shift in how we age and treat disease, giving even the most struggling optimists a chance for hope. It will appeal to readers of The Longevity Project by Howard S. Friedman and Leslie R. Martin as well as The Blue Zones by Dan Buettner.
How Our Outlook Drives Our Health and Aging
“I wonder how many times you almost died?” my father asked me while we waited for our food at the Greek diner Salonica on Fifty-seventh Street, at the edge of the University of Chicago campus. In my third year of college, a previously undiagnosed congenital heart condition came crashing into my life and set me on a path to explore the attitudes that I now view as some of the most basic building blocks of health and disease. The gravity of my condition crystallized during the first week after successful cardiac surgery, and my father finally felt safe enough to pose this obvious question. There had been several times during my childhood when I had come close to collapsing, but every one of these mishaps had followed episodes of intense exertion, like running a three-hundred yard dash in grade school or climbing out of the Grand Canyon as a high school student. Consequently, I had always passed them off as “overdoing it,” and sometimes didn’t even mention them to anyone. My dad and I reflected on the events of the past few months: The previous summer, my energy level had inexplicably taken a dive. One Sunday morning while having dim sum with friends in Chinatown, I had dropped a full glass of water—completely forgetting that my hand was supposed to be holding it—sending it clanking over the porcelain dishes and dumplings and shattering on the floor. I had even fallen asleep during my medical school entrance exams, waking up drooling over the biology section.
Having scarcely completed adolescence, it did not even occur to me that there could be something really wrong. But after several weeks involving similar incidents, I thought I may have mononucleosis and finally made an appointment at the student health center. After hearing my story, the internist detected a loud heart murmur and immediately shipped me off to get a cardiac ultrasound. In the dark, quiet viewing rooms of the echocardiography suite, there were raised eyebrows as successively senior cardiologists were called in to help interpret the results. I looked at the shadowy pictures of my beating chambers with suspense and intrigue, as if they were part of an exciting movie. Not until years later would I realize that my state of general wonder throughout this process—peppered though it was with fear and doubt—would help preserve my sanity through the events that followed. I did not yet know how to read an echocardiogram, and could not discern the mass of tissue in the middle of the heart chamber called the left ventricle. The mass was partially attached to the mitral valve—the valve bisecting the left atrium (top chamber) and the left ventricle (bottom chamber). The walls of the left ventricle had become hypertrophied, or thickened, because of the very high pressure required to pump blood through the mass and out to the rest of my body. My heart had reached a point where it was simply no longer able to perform. I needed major surgery as soon as possible.
After the initial shock and uncertainty, I became “the little patient that could.” I put the surgery date on my calendar and told my relatives, friends, professors, and classmates. I met with my cardiac surgeon, the late Dr. Robert Karp, and asked him a list of twenty-two questions I had typed out on my PC, everything from how long the surgery would take (two to three hours) to the likelihood of dying on the table (5 percent or less). My final question—“Is there anything that I can do as a patient to make your job as a doctor easier?”—produced the first grin I’d seen on him yet. “You already have,” he told me. I didn’t catch his meaning then, but now as a practicing physician I know what it’s like to work with a genuinely motivated patient, and I understand why he smiled at me. My upbeat attitude made me an easier patient to treat, someone willing to adhere to his medical advice and to do my part to attain the best possible outcome. That didn’t mean I wasn’t afraid. In fact, my concern about dying on the table prompted a couple of urgent visits to student mental health services: I didn’t want to go to my grave with too much unfinished business. Within a couple of weeks I was on the operating table while Dr. Karp cut open my left atrium, reached across my mitral valve, and sliced away the offending blob.
After a brief ICU stay and four more days on the cardiac floor, I walked out of the hospital into a sharp Chicago December wind, leaning half of my body weight on each of my parents. Now on the mend, with a fresh scar traversing my chest, I basked in the warmth of my circumstances—hot Greek food, the love of my mom and dad, support of friends and professors, and the impeccable skill of my surgeon and his team, all culminating in the miracle of my being able to sit up without assistance. I had been given a second chance, and I was ecstatic to be alive.
The very experience of having felt so weak after surgery, in which it took real effort on some mornings to even hold my head up, allowed me a glimpse of frailty that most twenty-year-olds never get. Ironically, feeling close to my own mortality provided a rare and valuable reference point that only bolstered my hopefulness. During open heart surgery, my heart stopped beating for two hours on bypass, but I woke up—knowing that every day is a gift and that it is possible to overcome the most dire of situations. Looking back twenty years later from the vantage point of an NIH-funded academic physician, wife, and mother, I realize now it was the first time a serious situation had forced my “outlook” hand, and, instinctively, I played the hope card. This somewhat unconscious act, as well as the positive outcome itself—a 360-degree spin from healthy young woman to invalid and back again—began the evolution of the can-do attitude that often becomes my default. This outlook kicks in at two a.m., overriding all circadian rhythms, when I’m on call and paged to the bedside of a patient who has just gone into cardiac arrest. It helps me visualize an ill person becoming well again, even before he heals, because having witnessed the “other side,” I know what proper care and tending can do for the human body. Above all, it fans the voice inside my head that declares things will eventually change, often for the better, even when the specifics remain uncertain.
Our outlook—a term I have chosen to describe our unique patterns of thinking, feeling, and interacting with ourselves and with the world—fundamentally impacts our health and aging. Outlook encompasses our personality, character traits, general disposition, and attitudes, all of which are words used by researchers and clinicians to describe our psychological makeup. While I use many of these terms interchangeably, I decided on the umbrella term outlook for several reasons. First, we can relate to it on a gut level: Our outlook is the lens through which we view the world. Unlike other terms, which carry connotations of permanence, outlook allows for the possibility of something new—as in “gain a new outlook on life.” This is key, because Up is not an academic discussion of the psychological underpinnings of aging, although I do include as much of the research as I can fit in. Up invites you to take a personal inventory—and, if necessary, to make changes geared toward maximizing your health at any age.
When we deconstruct our outlook into its nuts and bolts—the unique patterns of thinking and feeling that drive so much of our lives—we begin to see it from a different perspective. We begin to see not only why our outlook may lead us to decisions and behaviors but also where we may want to tweak it in the service of our own healthy aging, and how to undertake this change. Our outlook, research shows, has the potential to influence every facet of our health, from how quickly we recover from an illness or surgery to whether we become depressed, develop cardiovascular risk factors, or suffer a heart attack, stroke, or cancer, and even how well we care for ourselves when our health begins to break down.
Aspects of outlook—such as the character trait of optimism, defined by research psychologists as the general expectation of good things to come—have also been linked to longevity. Results from a study my colleagues and I published in the journal Circulation (August 2009) on almost one hundred thousand American women showed that middle-aged and older female optimists, compared with pessimists (people who have a generally negative expectation of the future), were less likely to smoke or have diabetes, high cholesterol, high blood pressure, symptoms of depression, and obesity; they were also more physically active. Optimists lived healthier and longer lives than pessimists, exhibiting a 16 percent lower risk of a first heart attack and a 30 percent lower risk of death from heart disease by the end of the study. In these same women we studied another character trait, called cynical hostility, which is a type of anger involving a deep mistrust of other people. This mistrust stems from the belief that most people are selfish, dishonest, and unworthy. Women who had the highest levels of cynical hostility, compared with those with the lowest levels, were 16 percent more likely to die over eight years of study follow-up.
My research joins the growing ranks of findings from around the world that point in the same direction: A positive outlook is good medicine. Two decades of clinical practice as an internist have brought me to the same conclusion, demonstrating repeatedly how outlook provides some people with the gumption to seize opportunities, and in other cases seems to sabotage any hope of healing. In fact, very soon after I began my formal research training, I realized that the body of evidence was pointing to something bigger than any one disease or any one subgroup of patients. Everyone owns an outlook. And the truth is, we may have more control over our outlook than anything else. My clinical practice and early research
spurred me to ask some pivotal questions that hold the promise of an exciting new reason to look up: If our outlook is associated with a higher risk of aging-related diseases such as heart attack, stroke, cancer, and death itself, is it associated with aging, period? Does an unhealthy outlook make us older faster? And does a healthy outlook actually keep us physiologically younger?
The Science of Outlook and Aging
Aging has become a loaded term these days—walk into any mall or search the Internet and you’ll be greeted with a dizzying array of antiaging products purporting to turn back the clock and make you look and feel younger. But in strictly medical terms, healthy aging is defined as growing older while steering clear of mental and physical disability, and the field has become a major medical frontier. In fact, aging experts now have a term for living healthily to a ripe old age: compression of morbidity. What it means is that, ideally, we “compress” as much of our disease and disability as possible into the very last little bit of our life, so that we remain lucid and able-bodied enough to enjoy as much time as we can prior to our demise. Or as my colleagues who are aging experts say, “Live a long and healthy life—then fall off the cliff.” Following this advice means paying as much attention, if not more, to our health span as to our life span.
So aging is much broader than the white-haired, wrinkled, cane-toting physical and mental debility most people associate with “getting old.” The process actually takes place on multiple levels, every second of every day. For simplicity’s sake, we can divide aging into three main categories: visible outward changes such as wrinkles and stooped posture; telltale variations in our organs such as atrophy of the brain, meaning loss of neurons; and microscopic changes within the cells that comprise each of our organs. Keep in mind that the full scope of aging is a more complex process that scientists still don’t fully understand, although breakthroughs are happening every day. These levels are all related: Our cellular age influences the age of our organs, which in turn influences our overall biological age. And here’s the rub: Research links our outlook to all levels of aging—from cells to organs to the whole person. What’s more, we see these connections across all age groups, from children to older adults.
In addition to my own work showing that optimists have fewer heart attacks and live longer—and that cynical women die sooner— other researchers have found that a high degree of anger also predicts early heart disease. Many of these studies, including mine, have been able to observe people for five to ten or more years, while others, such as The Longevity Project: Surprising Discoveries for Health and Long Life from the Landmark Eight-Decade Study, coauthored by Drs. Howard Friedman and Leslie Martin, followed people from early childhood over their lifetime. The most exciting finding of that study was that conscientious kids, defined as those who are dependable and goal oriented, live longer than kids who are less conscientious, corroborating similar results from other populations.
Outlook is even associated with preclinical changes in our cardiovascular system, meaning changes that are evident on testing even before we have symptoms or a major clinical event, such as a heart attack. One of my colleagues and mentors, Dr. Karen Matthews, Distinguished Professor of Psychiatry at the University of Pittsburgh, has helped shape our current understanding of how aspects of outlook, including cynical hostility, influence our risk of cardiovascular disease in adulthood, even while we are still relatively young adults. For example, in one large study of healthy men and women who were between eighteen and thirty years old when they joined, Dr. Matthews and other researchers found that people with a high degree of cynical hostility had greater coronary artery calcification, a sign of atherosclerosis—pathological narrowing of blood vessels—and a harbinger of risk for future heart attack. In a related study, young adults with a higher degree of cynical hostility were more likely than less hostile people to develop high blood pressure in the first place, indicating that unwanted cardiovascular changes were happening earlier in their bodies.
Facets of outlook also predict the development of other major physical and mental health conditions, including dementia. I worked with Dr. Ben Chapman, Dr. Paul Duberstein, and colleagues to show that older adults who are highly conscientious are less likely to develop memory problems and dementia as they age, while neurotic individuals—those who have high levels of emotional distress—are more likely than their less neurotic counterparts to suffer dementia. To look more closely at outlook and brain health, I am currently leading a study (forthcoming this year) analyzing the brains of more than fourteen hundred postmenopausal women who have undergone structural magnetic resonance imaging (MRI). Because optimists tend to have healthier physical and mental health profiles, we expect to find that they will have larger frontal gray matter than the pessimists. Generally speaking, greater brain volume in this region means more neurons and better connections between them, all supporting higher capacity to think and make decisions of all sorts, termed executive function. We expect similar findings among women with lower cynical hostility (i.e., less anger and mistrust), as compared to those with higher cynical hostility. This research begs the question: Can you think and feel yourself younger? Obviously it’s not that clear-cut, but perhaps the real fountain of youth emanates not from a cosmetic counter but from what’s between your ears. The name of the game in aging is to retain as much executive function as possible for as long as possible, so that we can more fully enjoy the things that we love to do, which will keep us happier and healthier.
Evidence also links outlook with other conditions associated with aging, including stroke and cancer. Independent groups of researchers have found that optimistic older individuals are less likely than pessimists to suffer a stroke. And when it comes to cancer, evidence shows that people with distress-prone personalities may not only have a higher risk of developing cancer in the first place, but once they get it, the cancer may be more likely to recur and cause death. I should underscore that the term cancer actually refers to a number of distinct diseases, each with its own unique behavior. In other words, breast cancer, colon cancer, and lung cancer differ by a lot more than their location in the body, and future research needs to parse out how outlook affects different types of cancer.
In addition to these major physical illnesses, our outlook tends to steer us toward—or away from—mental health problems, even in childhood. People who score as more optimistic are less likely than pessimists to become depressed, and this holds true for highschoolers and senior citizens alike, even when slightly different variations of optimism are assessed.
Teenagers with an optimistic explanatory style—which is related to the definition of optimism I introduced previously—are less likely than pessimistic kids to smoke cigarettes and marijuana, and less likely to exhibit antisocial behavior, such as getting into physical fights, running away from home, or being suspended from school. Grade-school-age kids who tend toward high degrees of hostility are more likely to start smoking in middle school. Even more intriguing, our outlook influences our long-term health trajectory. Personality psychologist Dr. Sarah Hampson and colleagues studied more than a thousand men and women in the Hawaii Personality and Health cohort and discovered that those who had been recognized by their preschool teachers as being conscientious, agreeable, or intellectually curious (terms that I’ll define in greater detail below) grew up to be healthier forty-and fifty-year-olds, and this better health was in part due to lower rates of smoking, better eating habits, and higher educational attainment.
And what about the third level of aging, the changes that take place in our cells as they grow older? Increasingly, research is also linking our outlook to these changes of cellular aging, called “cellular senescence.” Take telomeres, the specialized ends on our chromosomes (DNA)—sort of like the protective plastic on the end of shoelaces—that are vital to DNA replication. In humans, telomeres shorten with aging. Each time our cells divide and our DNA replicates, our telomeres shorten. Enzymes in the nucleus of the cell, called telomerases, rebuild the telomeres after each shortening, but they do so incompletely. Once a cell’s telomeres become too short, the DNA is highly unstable, which can result in cancerous transformation. In fact, risk of a first cancer and cancer-related death are highest among people who have the shortest telomeres. In this stage, with short telomeres, the cell can no longer replicate, and often becomes senescent, or old. And our outlook plays a role in all of this: Research has shown that pessimistic people have shorter telomeres. I am currently leading one of the largest studies to date on pessimism, cynicism, and telomere length in postmenopausal women in order to confirm and extend these results, which are expected within the next year.
Telomeres are not the only structures that change as cells age. Senescent cells also produce proteins called inflammatory markers, which are sort of like signal flares that cells fire off to each other during a general state of red alert. Short periods of red alert can help the body mobilize the immune system to combat a brief problem, such as an infection or wound, but when chronically activated, this inflammation wreaks havoc in the body. Inflammatory molecules such as C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-a), and intercellular adhesion molecule1 (ICAM-1), among others, are now understood to be part of a biological pathway common to many chronic diseases including heart disease, diabetes, and cancer. There is now even a word for the link between inflammation and aging: inflammaging. (Incidentally, smoking markedly increases your inflammatory markers, a process that is thought to explain in part why smokers die an average of thirteen years earlier than nonsmokers. Yet another reason to put out that cigarette!) So what does inflammation have to do with outlook? Similar to the case with shorter telomeres, research shows that pessimism is associated with greater inflammation.
Shortened telomeres and increased inflammation are hallmarks of cellular aging, a.k.a. senescence, not only in white blood cells but also in other cells all over the body, including those that make up your muscles, adipose (fat) tissue, brain, kidneys, liver—you name it. Most people have never even heard of senescent cells, let alone thought about how they may be relevant to aging. It is only in the past couple of years that scientists have come to understand that senescent cells are at the root of aging, and that removing those cells literally stops the clock—at least if you are a mouse. In a 2011 landmark Nature article, Mayo Clinic scientist Dr. Darren Baker and colleagues chemically removed the senescent cells from the bodies of adult mice, who remained visibly younger during the study than the group of control mice, who carried on with all of their senescent cells and became stooped, slow, and weak. So much for growing old gracefully.
What’s more, aging-associated changes in the control mice were more than skin deep: The muscle, fat, kidney, and brain tissue of the control mice showed telltale signs of aging, such as atrophy from withering and death of cells. In contrast, the cells of the experimental mice retained their youthful architecture. Furthermore, in older mice who had already started to show signs of aging, the experiment actually reversed some of these age-related changes, although more research is needed to understand just how much is reversible.
Before you race out to the nearest hospital or clinic to get the senescent cells sucked out of your body (I suspect you’re thinking this, because for an instant I was, too), I should point out that this technology is not yet ready for humans, and that it will likely be years before it is. Until then, what can we do to manage the ever-gushing river of time? The good news is . . . lots of things! It is critical that we harness our outlook—this invaluable tool we were all born with, which continues to grow with us, and which is central to our health and aging—and make it work to our advantage.
Outlook May Be the Earliest and Most Overlooked “Risk Factor” for Aging
We—meaning people in general, but also the larger medical and scientific community—may understand that there is some relationship between outlook and physical health. What we may not fully realize, however, is just how intimately tied our outlook is to our own health and aging over the course of our lives, from our humblest beginnings as babies to the adults we are today, to the older people we’ll become tomorrow. Our individualized patterns of thinking and feeling, some of which can be recognized as early as preschool, both precede and predict our risk of heart attack, stroke, and cancer: the number one, two, and four causes of death among
U.S. adults according to the latest CDC report. What’s more, attitudinal traits predict the very risk factors that are known to cause these major illnesses of aging—risk factors such as smoking, obesity, high blood pressure and cholesterol, and diabetes. Considered in this light, our outlook may be our earliest “risk factor” for accelerated aging—before all the other traditional risk factors such as smoking and cholesterol levels that we’ve come to know and fear.
Each one of these traditional risk factors has the potential to rob us of a little—or a lot—of our youth. Having more than one, especially if they remain untreated, can significantly interfere with our enjoyment of adulthood and even shorten our lives. Couple that with an unhealthy outlook and we may be facing a mountain of risk. But there is an upside here: A great deal of aging is actually modifiable, meaning that we as individuals can do something about it. We are not entirely pawns of fate. We do have at least some say in the rate at which our body ages.
How Our Outlook Gets Under Our Skin
So how is it that our outlook can prevent and delay deeper frown lines, depression, diabetes, heart disease, and other illness? Our outlook affects our physiology in a number of ways.
We Metabolize the World One Situation at a Time
Our outlook, which colors our reaction to everything, can set in motion a physiologic chain reaction that we may not even be aware of, a process that ebbs and flows constantly. In medical terminology, this process is called the “neuroendocrine response to stress,” where stress is essentially any stimulus that engages us. Our reaction to any given event, such as the intoxicating excitement of love at first sight or the wave of discomfort that wells up during a tough meeting with the boss, is reflected in our physiology. Famed scientists including Dr. Candace Pert, author of Molecules of Emotion: Why You Feel the Way You Feel, and Dr. Bruce McEwen, coauthor of The End of Stress as We Know It and The Hostage Brain, have brought this message straight out of the lab and described to us in everyday terms how our thoughts and feelings affect our bodies. Our pulse quickens. Our adrenaline surges. Hormones such as cortisol and oxytocin may be released. In the case of the dreaded meeting with the boss, our body may be responding as if it is under threat. Those “threat response” systems are absolutely critical for some situations, and when activated sparingly, they can promote survival by readying us for action. In the next chapter I’ll tell you about my own brush with a pride of lionesses—on foot—during which that system kicked in in a major way.
But chronic activation, like an iPod stuck on repeat, is unhealthy. The unrelenting experience of threat, whether actual or perceived, literally translates into wear and tear on body tissues, from our endothelium (the lining of our heart and blood vessels) to the neurons in our brains, to our DNA. In turn, our physiology may influence our thoughts and feelings, like traffic on a two-way street. For example, extreme fatigue, intense pain, hunger, or too-low blood pressure can make you feel tired and, understandably, downtrodden, so your thoughts in these physiologic states may tend toward the negative. Gaining more control over this traffic by flashing a mental stop sign when you start to feel anxious or giving the green light to relaxation is one key step toward living healthier, and perhaps, when practiced over time, even slowing down the aging process.
To round out this discussion, it bears mentioning that our acute responses to stress do not always promote survival. This is important, because we tend to think of acute stress responses as good and chronic, repetitive stress responses as bad. Medically, we see three distinct conditions in which the heart bears the brunt of the mind’s ire during fight-or-flight arousal. The first, mental stress-induced myocardial ischemia, is a phenomenon in which anger, fear, and other strong (typically negative) emotions cause low blood flow to the heart muscle. The second, takotsubo cardiomyopathy, is also called stress cardiomyopathy or “broken-heart syndrome.” In takotsubo cardiomyopathy, the heart muscle is stunned. This condition occurs following intense emotional experiences during which the apex of the heart is temporarily paralyzed by stress hormones including adrenaline and noradrenaline and unable to pump normally, causing it to resemble a takotsubo, or Japanese octopus trap. (Interestingly, myocardial stunning can also be caused by intense positive emotional experience, although this is rare.) Finally, strong emotions can also cause abnormalities in the heart’s electrical system and precipitate arrhythmias, or abnormal heartbeats. The heart is not the only organ that can be damaged during acute stress, but it is the most noticeably affected. How we manage our responses to the world influences our health, both in the short and long term.
Our Outlook Drives Our Behaviors
The most obvious way in which outlook has an effect on our health and aging is that our attitudes are in the driver’s seat when it comes to our behavior—and I’m clearly not talking about sitting quietly in the classroom with your hands folded in your lap like a good little girl or boy. Behavior encompasses almost anything you do or don’t do, and is a huge player when it comes to healthy aging. If you’re pessimistic about your own ability to overcome a challenge, for example, like starting an exercise program or losing weight, then you may be less likely to come up with a plan of attack, stick to that plan, and seek out medical and moral support. As I noted earlier, kids with an optimistic thinking style (which, like optimistic explanatory style, is similar to dispositional optimism) tend to steer clear of smoking and other substance use and integrate better socially, while pessimistic kids, and those with a high degree of anger, tend to have the opposite profiles. As kids grow up, their early experiences— colored by attitudes, which in turn drive behaviors—tend to snowball, such that they are able to build on prior successes, or not. Hindered by varying degrees of hopelessness or helplessness, many are not able to reach their full potential as adults. Henry Ford summed it up best when he said, “Whether you think you can or you can’t, you’re right.”
Outlook and Compliance with “Doctor’s Orders”
Following the proverbial doctor’s orders, termed adherence or compliance in medical lingo, is one of the most important things you can do for yourself as you age, and people with certain attitudes tend to do it best. Adherence is a little different from what I discussed above for health behaviors, although they are closely related. For example, people who start smoking as kids or young adults will be more likely to quit smoking later in life if they adopt a plan of attack—such as setting a quit date, joining a formal smoking cessation class, and using a nicotine patch or other proven medication— and adhere to it. So adherence involves formulating and recognizing a plan of action and sticking to it, regardless of whether we are talking about quitting smoking, continuing an exercise program, or taking medication for blood pressure, blood sugar, or blood cholesterol. The point is that even if you’ve stumbled into some pitfalls in the past, hewing to a sound plan right now can make a huge difference for your health and aging in the present and in the future. In one study, older female optimists were more likely to stick to the dietary plan that had been recommended for them.
Cardiovascular Disease Risk: The 99% and the 1%
Chances are you are in the camp of the 99 percent when it comes to risk of heart disease, meaning you have at least one risk factor. To understand this situation better, and to see how outlook plays a major role in why you’re in the 99 percent, let’s take a look at some real data on coronary heart disease (CHD), the number one killer of American men and women and a major cause of adult death around the world. While CHD typically affects us after fifty (the age at which heart attack risk rises precipitously), the biological processes that result in heart attacks actually begin in childhood or even earlier. Autopsy studies, one of which I worked on at the Cook County morgue as an undergraduate student, show that unfortunate teens who died from accidents, suicide, or homicide already had fatty streaks and other early signs of atherosclerosis in their major arteries. As a disease, CHD is intriguing for another reason: It is almost entirely preventable through lifestyle and simple medications.
In 2010 the American Heart Association (AHA) introduced the concept of “ideal cardiac health” to guide people to live healthier and avoid cardiovascular disease (CVD, encompassing CHD, stroke, and peripheral vascular disease, or blockages in the blood vessels of the body that occur somewhere besides the heart and brain). To achieve ideal cardiac health, a person needs to avoid most of seven major risk factors known to cause and/or accelerate CVD: smoking, impaired fasting glucose (a.k.a. diabetes), high cholesterol, high blood pressure, being sedentary, eating an unhealthy diet, and being obese (with a body mass index of 30 or higher). The AHA refers to these as the “Simple 7.” As you can see, all of these metrics are modifiable, meaning that you can do something about them. Furthermore, they do not require you to understand rocket science (homage to Ed Yong, science writer extraordinaire and creator of the Not Exactly Rocket Science blog at Discover magazine), spend loads of money, or adopt a complicated lifestyle. The instructions are: Don’t start smoking, and if you do, quit. Control your blood sugar, your blood cholesterol, and your blood pressure. Exercise on most days of the week. Eat reasonable portions of healthy foods, cut back on unhealthy ones, and maintain a weight that is healthy for your height. An important aspect of ideal cardiac health is that it not only necessitates that we avoid risky behaviors (e.g., smoking), but also that we embrace positive behaviors (physical activity, healthy diet, taking steps to control blood pressure, etc). Back in the 1990s, two decades before the AHA coined the term ideal cardiac health, my medicine professors referred to it as “bread and butter” primary care, recognizing even then that it was a road map to preventing disease.
For people with ideal cardiac health, their youthfulness at any age is marked by the distinct absence of CVD. To put a number on it, almost no one with ideal cardiac health has a heart attack or stroke during his or her life span. Conversely, those who rack up even four of the seven risk factors (the obese smoker with uncontrolled high blood pressure and cholesterol) face a nearly 50 percent chance of having a heart attack or stroke. Now here is the kicker: Looking across the nation, how many people do you think meet the standards for ideal cardiac health? Shockingly, less than 1 percent of American adults.,So what gives? Why is something that seems so simple and is almost a guaranteed get-out-of-jail-free card for CVD so difficult to attain, and rejected by up to 99 percent of our population?
It’s a question I asked myself for years as a practicing physician, and in 1999, I had a lightbulb moment. During my first year in full-time primary care practice, I began to see firsthand in my patients the living, breathing “face” of these distressing numbers. After residency training in Chicago my husband and I took our first professional positions in a large, well-established HMO practice in southern Washington state, where patients had been coming with their families since the time of the WWII shipyards. In this semirural area, many of my patients smoked, were obese, drank alcohol to excess or were addicted to painkillers, and had symptoms of depression and anxiety. Although I had taken care of my own clinic patients during residency training, the focus had been on extremely ill, hospitalized patients, many of whom were comatose and on ventilators (respirators), or otherwise too sick to have extended conversations. So it was not until I had the benefit of seeing large numbers of the same people month after month that I began to see their common need for behavior change, as well as the widespread inertia that I learned to recognize as an immense barrier to healthy aging. One night I came home, plopped myself and my briefcase down at the dining room table, and uttered two words to my husband: “Behavior change.”
“What?” he asked, opening a beer.
“Behavior change,” I said, exhausted. “Almost every one of these people needs to make some major change in their behavior to get healthy.”
He knew exactly what I was talking about, because his clinic, only three miles down the road, told the same story, as did every other physician’s clinic in our large community practice. Roughly a third of my patients needed to quit smoking. Another third needed to lose twenty-five or more pounds. Yet another third had under-treated depression or anxiety. Many described toxic social and family relationships, loneliness, and outright isolation. At that time, I could think of only one person in my clinic whose fate had been sealed by genetics. She had Huntington’s disease, an inherited condition involving the progressive loss of motor control and early death. Ironically, she was one of the few people who proactively sought my help to quit smoking, and she was successful. It was clear to me that for most people, their behavior, rather than genetic conditions or accidental injuries, was at the root of the medical problems responsible for their premature disability and disease.
But there was something else that I noticed as I continued to practice. Most people seemed surprisingly inert when it came to taking charge of their own health, even as they started to experience some of the harsh consequences of what they all-too-casually passed off as “normal aging.” In many cases these consequences— high blood pressure, high blood sugar, feeling tired all the time— were not solely a consequence of becoming chronologically older. And yet there were a few people who took what has now become the AHA blueprint for healthy cardiovascular aging and followed the instructions as if they were commandments. What was it, I wondered, that incited those few people to adopt and maintain healthy behaviors, while the vast majority resisted, even in the face of imminent suffering and early death? Where did their volition come from?
I was so fueled by this question that I left my primary care practice and moved with my husband, baby daughter, and adopted Rottweiler three thousand miles across the country to join a three-year fellowship training program at Harvard Medical School, where I learned to design clinical trials and other types of studies in hopes of generating some answers. A decade and a half later, my career continues to organize itself around my fascination with volition, behavior, and behavior change. The surface answer, and one I’ve heard tossed around in medical faculty rooms for years, is that it’s a simple equation of incentives—pizza tastes good now, cigarettes make you feel good now, and you can’t taste, smell, or feel the benefit of a healthy heart at some distant point in the future.
Given that humans are hardwired to overvalue rewards now and undervalue rewards later, this answer seems understandable and satisfying, until one thinks about that elusive 1 percent of people—those who achieve ideal cardiac health, or even the 19 percent who get a little more than halfway there, with predictably fantastic health results. How do they do it? What motivates them? Are they pushing themselves forward toward a specific goal (looking and feeling great), pushing themselves away from an undesirable result (becoming a cardiac cripple), or both? What is the script going on inside their heads, if there is one? Are they able to defy the typical human tendency to overvalue the now (the brownie) and somehow turn their full attention to a future that offers favorable odds of healthy aging because they engage that future as strongly as if they could experience it now, almost as if they could increase the immediacy of the reward? Many of these questions go beyond what the existing research has answered, but I’ll consider them further from my own perspective as a doctor and as a patient.
I believe that a big part of the mystery of the 1 percent is in our outlook—whether we can envision a positive outcome and muster the confidence and drive to work toward it, taking stock in our own abilities, our friends, and family to help us through. Earlier, I told you about the large study I led that found that optimists had more favorable cardiovascular risk profiles than pessimists. In that study, my colleagues and I looked at five of the “Simple 7,” and we found that across the board, optimists had better cardiovascular risk profiles than pessimists. Now, Dr. Randi Foraker and I are leading a study to examine how optimists and pessimists measure up for all seven components of ideal cardiac health.
I am also working with Ana Progovac, a graduate student, to study something else of great interest: whether optimists and pessimists diverge on health behaviors over time. We have already found that optimists were less likely than pessimists to be smoking at the beginning of the study. The next step is to determine whether the optimistic smokers are more likely to quit smoking over time. We will further be able to see how cynical hostility—that deep mistrust of others—influences a person’s likelihood of quitting smoking. This research will join the body of literature demonstrating that facets of our outlook do influence our ability to change behavior. For example, in the Whitehall II study of British civil servants, people with high trait anger not only started out heavier than less angry people, but over about twenty years, they also tended to gain more weight as time went by. Many more studies show that aspects of our outlook influence our behaviors over time. The implications? A healthier outlook may be like the wind in your sails when it comes to caring for your body—speeding you along on a healthier course.
Thus, our outlook affects our health and aging both directly and indirectly in myriad ways. That said, it’s critical to understand that many factors—some within our control, others not—play into how quickly we become ill or age. Based on current research, we can’t congratulate the optimist for steering clear of a heart attack any more than we can blame the pessimist for having one. The main point is to recognize that our outlook can be one of our strongest allies in the aging process.