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By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
SYNOPSIS: An analysis of 10-year follow-up data from the Nurses’ Health Study and 30-year follow-up data from the Veteran Affairs Normative Aging Study revealed a significant association between baseline levels of higher optimism and longevity, even when data were adjusted for health behaviors and psychosocial factors.
SOURCE: Lee LO, James P, Zevon ES, et al. Optimism is associated with exceptional longevity in 2 epidemiologic cohorts of men and women. Proc Natl Acad Sci U S A 2019;116:18357-18362.
In a landmark 1910 address to The College of Physicians and Surgeons, the reigning president, Dr. E.L. Trudeau, known for his innovative approach in treatment of tuberculosis, spoke about the importance of optimism in medicine.1 He ended his speech with a quote from one of his own patients, literary giant Robert Louis Stevenson: “To travel hopefully is a better thing than to arrive, and the true success is in the labour.”2
Dr. Trudeau, experiencing illness from the perspective of both a physician and a tuberculosis patient himself, believed that an optimistic physician conveys this stance to patients, and that this interaction enhances both healing and recovery for the patient.1,3 A review of publications since that time shows bursts of interest in this relationship, with more rigorous studies appearing in more recent years.4
Lee et al noted the current research supports an association of optimism with a reduced risk of cardiovascular disease, lung function deterioration, and premature mortality, but that there are no studies regarding optimism and life span. Specifically, Lee et al were interested in a relationship between optimism and “exceptional longevity,” which they defined as survival to 85 years of age or older. To address this knowledge gap, the team examined data from two long-term, broad-based, prospective investigations: the Nurses’ Health Study (NHS) and the Veterans Affairs Normative Aging Study (NAS). The NHS, currently in its third generation, launched in 1976 with periodic questionnaires designed to collect information about the potential for long-term side effects from the use of oral contraceptives. Quickly, the researchers expanded the scope of the project to collect information on a variety of lifestyle factors, behaviors, and psychosocial factors influencing more than 30 chronic diseases. In 2004, an optimism assessment was included in the questionnaire. For the purposes of this study, mortality information was tracked until 2014.5
The NAS dates its birth to 1963. Devised as a longitudinal study on “non-pathological” aging, about 2,000 male veterans from diverse socioeconomic backgrounds agreed to periodic outpatient assessments during their lifetime. In 1989, the assessment included an optimism scale, and mortality in these subjects has been tracked until 2016.6
The tools used to assess optimism for these two groups were different. The NHS used the Life Orientation Test-Revised (LOT-R) while the NAS employed a subsection of the Minnesota Multiphasic Personality Inventory-2. (MMPI 2). Previous research regarding these tools allowed correlation of optimism scores, with results from the NHS divided into quartiles, and results from the more broadly based NAS placed into quintiles.
The LOT-R is a self-administered questionnaire asking for relative agreement or disagreement with 12 statements regarding general expectations. For example: “In uncertain times, I usually expect the best.”7 The perhaps more widely known MMPI includes an optimism and pessimism scale. This test approaches measurement of optimism in a slightly different manner, considering responses on the broader MMPI and analyzing the style of responses as more pessimistic or optimistic in general.8
Analysis included results for three different models based on 69,744 women respondents from NHS and 1,429 men from NAS. The first model was adjusted for social demographics such as race, age, education, and marital status. The second was adjusted for demographics and health conditions such as high cholesterol, depression, cancer, and stroke at baseline. The third was adjusted for demographics, health conditions, and health behaviors such as smoking, alcohol use, physical activity, and diet.
Results for each model in each cohort showed association of higher levels of optimism with a longer life span (P trend < 0.0001 for NHS and P trend = 0.002 for NAS). In both groups, results were attenuated for the third model (adding adjustment for health behaviors). In other words, when adjusting results for health behaviors such as smoking, alcohol use, or diet in addition to demographics and health conditions, working from a baseline high level of optimism still was significant, but less of a factor toward a longer life span.
Lee et al also studied the likelihood of survival to at least 85 years of age (exceptional longevity) by shrinking the pool of respondents to only those born early enough to reach this age by the end of the follow-up period. This approach allowed analysis of results from 13,045 women in the NHS and 1,117 men from the NAS. A pattern similar to the original analysis emerged, with higher optimism associated with greater odds of reaching exceptional longevity, and attenuation of these results with adjustment for health behaviors. The P trend was < 0.01 for both cohorts before adjustment for health behaviors.
Headlines reveal that the press was interested in this study.9-11 It was clear that this research struck a chord. While longevity is of general interest to the public, the implications of achieving exceptional longevity for public health policy and population health are of particular significance to the medical world. Yet, a close look at the study reveals some strengths but also some glaring gaps, making hard and fast conclusions difficult to support.
Perhaps the greatest strength of the study resides in numbers: the exceptionally large group of respondents (1,429 in NAS and 69,744 in NHS) and the 10-30 years of follow-up. While these robust data lend credibility to the results, replication of the study faces significant hurdles. Additionally, the participants by definition are drawn from relatively homogenous pools (especially in the NHS cohort), and the overwhelming majority of the participants were women, limiting the ability to generalize the findings.
Another concerning factor is that in both the NHS and NAS cohorts, optimism was measured only once — at baseline. There is no way to know if these measures were stable over time. The results from both studies attenuated when health behaviors, such as smoking and alcohol use, were considered. This certainly may be due to a link between optimism and healthy behaviors, but clear evidence that optimism scores remained stable would be helpful to advance knowledge regarding these relationships. All patients enrolled in the NHS and NAS were adults by the time of the initial optimism assessment. Future studies are needed to understand how optimism develops over time, the relative stability of this trait, and any relationship to health benefits and longevity.
For now, we know only that a higher level of optimism during middle-age years was associated with greater longevity and greater odds of reaching exceptional longevity in two long-term, prospective studies. Notably, this study tells us nothing about whether we can affect or change optimism in adults or help develop optimism in children. Furthermore, it does not tell us if changing optimism at any stage of life is associated with health benefits.
As referenced earlier, the concept of optimism as a healing force in medicine is not new. When Dr. Trudeau spoke about optimism in medicine in the early 1900s, he was explicitly referring to the optimism of physicians. He believed an optimistic physician conveyed this attitude to patients, and thus, promoted healing.1,2 More than 100 years later, this work by Lee et al demonstrates how far we have come in our understanding of optimism in medicine and suggests a path to further our understanding.
For now, we can tell patients that attitude and a positive outlook may help with lengthening life span and achieving exceptional longevity. Working toward a more optimistic approach to life may not come easily to many of our patients and may not feel natural for a provider. In speaking with patients, listen for echoes of self-blame. For example, “I have caused my own health problems because of my pessimism.” When a provider acknowledges the difficulties inherent in such a change, it can be reassuring and affirming for patients. Remind patients that optimism occurs on a gradient, and that looking for incremental movement may be achievable and more palatable for many.
In addition, this study also may serve as a reminder of the added value of understanding and addressing psychological factors while interviewing patients, and the intrinsic value of appreciating such traits when developing comprehensive wellness and treatment plans.
Financial Disclosure: Internal Medicine Alert’s Physician Editor Stephen Brunton, MD, is a retained consultant for Abbott Diabetes, Acadia, AstraZeneca, and Boehringer Ingelheim; and he serves on the speakers bureau of AstraZeneca, Boehringer Ingelheim, Janssen, Lilly, and Novo Nordisk. Peer Reviewer Gerald Roberts, MD; Editor Jonathan Springston; Editor Jason Schneider; Editorial Group Manager Leslie Coplin; and Accreditations Manager Amy M. Johnson, MSN, RN, CPN, report no financial relationships relevant to this field of study.