Author + information
- Received May 28, 2015
- Revision received February 26, 2016
- Accepted March 25, 2016
- Published online August 23, 2016.
- Darwin R. Labarthe, MD, MPH, PhDa,∗ (, )
- Laura D. Kubzansky, PhD, MPHb,
- Julia K. Boehm, PhDc,
- Donald M. Lloyd-Jones, MD, ScMa,
- Jarett D. Berry, MD, MSd and
- Martin E.P. Seligman, PhDe
- aDepartment of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- bDepartment of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- cDepartment of Psychology, Chapman University, Orange, California
- dDepartment of Medicine, Division of Cardiology, Department of Clinical Sciences, University of Texas Southwestern, Dallas, Texas
- eDepartment of Psychology, Positive Psychology Center, University of Pennsylvania, Philadelphia, Pennsylvania
- ↵∗Reprint requests and correspondence:
Dr. Darwin R. Labarthe, Department of Preventive Medicine, Northwestern Feinberg School of Medicine, 680 North Lake Shore Drive, Suite 1400, Chicago, Illinois 60611.
Two concepts, positive health and cardiovascular health, have emerged recently from the respective fields of positive psychology and preventive cardiology. These parallel constructs are converging to foster positive cardiovascular health and a growing collaboration between psychologists and cardiovascular scientists to achieve significant improvements in both individual and population cardiovascular health. We explore these 2 concepts and note close similarities in the measures that define them, the health states that they aim to produce, and their intended long-term clinical and public health outcomes. We especially examine subjective health assets, such as optimism, that are a core focus of positive psychology, but have largely been neglected in preventive cardiology. We identify research to date on positive cardiovascular health, discuss its strengths and limitations thus far, and outline directions for further engagement of cardiovascular scientists with colleagues in positive psychology to advance this new field.
Two seminal concepts, positive health and cardiovascular health (CVH), have developed recently in parallel, and are converging to engender a new field of positive cardiovascular health (1,2). This report presents key features of both positive health and CVH, indicates points where interventions to improve psychological functioning may alter the life course of cardiovascular health and disease, highlights current evidence linking positive psychological factors to the risk of developing cardiovascular conditions, and outlines directions for further research in which cardiovascular scientists and positive psychologists can collaborate to advance this new field.
Positive psychology arose from the field of psychology and was launched with the millennial issue of American Psychologist in 2000 (Figure 1), following a critical assessment of the preceding half-century of psychology that concluded, “The exclusive focus on pathology that has dominated so much of our discipline results in a model of the human being lacking the positive features that make life worth living” (3). Positive psychology sought to “see a science and profession that will come to understand and build the factors that allow individuals, communities, and societies to flourish.” By 2005, research on positive psychology was active and growing, exploring such concepts as optimism, purpose in life, positive emotions, and psychological well-being (4). In 2008, Seligman (1) noted that, similar to psychological research, epidemiological and biomedical research had also focused predominantly on deficits, disease, and disability. He proposed extending the concept of positive psychology to a more general one of positive health.
CVH is a logical outgrowth of preventive cardiology, with its ultimate origin in cardiology (Figure 1), and is central to the 2020 Strategic Impact Goal of the American Heart Association, published in 2010: “By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%” (2). Adoption of this new focus on CVH, beyond that on cardiovascular disease (CVD) alone, has been called a “quiet revolution.” It promises to have a positive effect on health care, health policy, and health economics by promoting and preserving high levels of CVH from childhood to middle age and beyond (5). Published data demonstrating associations between CVH and subsequent cardiovascular and other health outcomes is substantial, and has expanded greatly, especially since 2010 (6–13).
To explore what positive health might mean in practical terms, Seligman (1) proposed the cardiovascular domain as the initial focus, in view of the prevalence of cardiovascular conditions and their importance for clinical practice, health policy, and health care costs. The present authors undertook this exploration and found that the lines of development of CVH and positive health are converging into a new scientific field focusing on positive CVH. Positive CVH will provide a new perspective on how to achieve the goals of promoting, preserving, and restoring CVH at individual and population levels and reducing the population health burden of CVD-related disability, deaths, social disparities, and costs.
Developmental Parallels and Convergence
Comparison of conceptual models of positive health and CVH reveals both close similarities and notable differences (Figure 2).
In Figure 2, positive health is defined in terms of the following 3 categories of attributes or assets: biological (i.e., superior physiological functioning), functional (i.e., capacity to perform one’s role), and subjective (i.e., positive psychological feelings) (1). Examples are maximal oxygen uptake, ability to carry out work and family roles effectively, and optimism, respectively. Favorable status for each attribute represents a high degree of physical health, functional capacity, or psychological health; favorable status across multiple attributes jointly constitutes positive health (ongoing research is assessing separate vs. joint effects of these attributes). Positive health, itself a desirable outcome, is associated with greater longevity, better quality of life (QoL), more favorable prognosis in acute illness, improved mental health, and relative savings in health care expenditures.
In the lower panel of Figure 2, CVH is defined in terms of 7 specific metrics, corresponding to 2 of the 3 categories of attributes for positive health: biological and behavioral (used here as equivalent to functional, as discussed earlier) (2). The biological metrics are 3 CVH factors (blood pressure, blood levels of total cholesterol, and fasting plasma glucose). The functional ones are 4 CVH behaviors (smoking, physical activity, diet, and body mass index). An individual’s status for each metric is graded as ideal, intermediate, or poor, in accordance with explicit criteria, and is graded separately for children (<20 years of age) and adults. Rating each metric as at an ideal, intermediate, or poor level (2, 1, or 0 points, respectively) yields a composite CVH score ranging from 14 (most favorable) to 0 (poorest). Ideal CVH metrics and overall score (i.e., a score of 2 on most metrics) have consistently been found to be associated with greater longevity, increased CVD-free survival, compression of morbidity, improved health-related QoL, lower incidence of acute cardiovascular events, preservation of cognitive function, and relative savings in health care costs (6–13).
Close parallels between CVH and positive health are readily apparent. As a prototype for positive health, CVH encompasses the biological and behavioral/functional attributes of positive health via the health behaviors and health factors that are its defining metrics. The conceptual similarities between CVH and positive health, and the urgent need to reduce the high cost and substantial burden of cardiovascular conditions in terms of impaired quality and lost years of life, suggest the value and promise of synthesizing these concepts to create a new model of positive CVH.
Figure 2 also highlights the lack of subjective health metrics for CVH, although such factors (e.g., optimism, life satisfaction, positive emotions, and purpose in life) are essential attributes for positive health (1). Moreover, positive health lacks a clear metric or composite score, a key feature of CVH. One candidate instrument is the PERMA questionnaire, assessing Positive emotion, Engagement, Relationships, Meaning, and Accomplishment, introduced by Seligman (14) as providing an aggregate measure of psychological well-being. A shorter instrument on the basis of the PERMA questionnaire could be incorporated in population sample surveys, such as NHANES (National Health and Nutrition Examination Surveys) and the BRFSS (Behavioral Risk Factor Surveillance System), to generate new data sources for subjective health metrics and enable a more comprehensive assessment of CVH. At the same time, positive health might gain from development of a composite score, expanding from PERMA to include overall physical health, and perhaps including the health-related QoL or Healthy Days measures that are already considered as secondary metrics for CVH.
It may be useful to assess how the various components of positive health and CVH inter-relate. Might the enhancement of positive psychological functioning move people and populations closer to ideal CVH? The Central Illustration is a schematic representation of how positive psychology interventions might be applied across the cardiovascular continuum.
The continuum of cardiovascular health and disease extends throughout the life course from conception to death, as depicted in the Central Illustration. The distribution of levels of CVH shifts adversely from ideal to intermediate to poor, from childhood through adulthood, due to unfavorable changes in CVH behaviors, CVH factors, or both (Central Illustration, red arrows on the left) (15). Further progression to an overt cardiovascular event or diagnosis (Central Illustration, red arrow at the center) constitutes (by definition) an irreversible transition in states beyond CVH to CVD (1). Ultimately, death follows, whether due to CVD or another cause, with or without initial survival and subsequent recurrence of CVD events (Central Illustration, red arrows on the right).
Points on the cardiovascular continuum are identified where positive psychology interventions could alter trajectories of CVH by:
1. Promoting healthy gestation, development, and aging; these will encourage and preserve ideal CVH from the beginning of life;
2. Driving favorable change in CVH metrics: enabling remedial approaches to reverse progressive decline in CVH;
3. Facilitating effective acute and long-term case management and rehabilitation: improving outcomes of first or recurrent acute events and QoL among those who survive them; and
4. Supporting palliative and end-of-life care; ameliorating the conditions of incapacitating or terminal disease.
Point 1 uniquely identifies the strategy of primordial prevention, with the goal “to promote and preserve ideal CVH from the beginning of life” (a more positive paraphrase of “primordial prevention” than the more familiar one, “prevention of risk factors in the first place”) (16). This strategy is fundamental to sustained population-wide improvement in CVH throughout the life course for future generations. It also harmonizes with the recently increased focus on primordial prevention in policy statements on CVH promotion and CVD prevention (2,4,16,17).
Points 2 to 4 identify the further, remedial strategies, each with a goal to arrest, reverse, or ameliorate already compromised CVH, or the consequences of CVD. These approaches may appear merely to reflect the long-familiar primary and secondary prevention of CVD. But, in the context of positive CVH, they bear an important new implication: each of these 3 focal points includes opportunities for intervening in psychological functioning that could enhance, or even supplant conventional approaches.
The need for more effective interventions is apparent. The persistent challenges to remedial strategies for achieving national goals in CVD prevention are extensively documented (2,17). Even the Million Hearts Initiative, a national program launched in 2010 to boost such indicators as control of hypertension and cholesterol (2 of the 3 biological CVH metrics) to 65% at the population level, would still at best leave one-third of affected individuals at continued high risk (18). If effective positive psychology interventions become established through positive CVH, and become reimbursable clinical preventive services through innovative reimbursement mechanisms, the effect of such remedial approaches might be greatly enhanced. A critical question, then, is whether the state of the science supports positive associations of subjective health attributes with CVH and CVD and whether interventions on subjective health attributes improve CVH and reduce CVD and stroke mortality.
The State of the Science
Recent systematic reviews have critically evaluated published reports regarding associations between subjective health (or positive psychological functioning) and cardiovascular behaviors, risk factors, and outcomes; intervention studies in this arena have been reviewed as well. Three systematic reviews and 2 meta-analyses indicate important relationships between positive psychological factors and health, and specifically CVH and CVD (19–23). Current evidence suggests that:
1. A variety of measurement tools, mainly self-report questionnaires, are used to quantify subjective health assets (19).
2. Rigorous observational epidemiological studies, which used longitudinal study designs, used hard health outcomes, and restricted samples to healthy subjects who were initially CVD-free, found significant effects of positive psychological functioning, even with adjustment for traditional CVD risk factors and psychological factors including depression (21,24–27). Associations have been found with CVH behaviors and factors, and with CVD events.
3. Several theoretical models suggest how such factors may influence health (19,28–32).
4. Interventions to improve positive psychological functioning have been successful in healthy persons; they have yet to be evaluated adequately in relation to cardiovascular outcomes, but are considered promising (20,21,23).
Optimism is a leading candidate for further research, as it has been examined in prospective, longitudinal studies that account rigorously for confounding, evaluate effect modification, and demonstrate highly consistent favorable associations with cardiovascular endpoints, including a lower risk of CVD (33–37). Although defined somewhat differently between studies, optimism can be characterized generally as, “the expectation that good events will be plentiful in the future and bad events are rare” (33). It is often assessed using the Life Orientation Test-Revised, a 6-item scale ranging from maximal optimism to maximal pessimism, which illustrates a type of scale that could be developed or more widely used for other positive health assets (20).
In addition to the studies cited previously (26,27) other reported findings include associations of higher optimism with:
• Lower incidence of CVD in the Veterans Administration Normative Aging Study (34).
• Reduced CVD and total mortality in the Elderly Dutch Men and Women Study (35).
• Reduced coronary and all-cause mortality in the Women’s Health Initiative (38).
• Reduced incidence of heart failure in men and women from the Health and Retirement Study and Multi-Ethnic Study of Atherosclerosis (36,39,40).
These studies strongly support the interpretation that optimism protects directly against CVD. First, their findings hold after adjusting for traditional risk factors, such as obesity, smoking, excessive alcohol use, high cholesterol, and hypertension; these factors have been previously hypothesized to be related to optimism in their own right, and as potential mediators of the effect of optimism on reduced CVD risk. Second, the relationship persists after taking psychological problems, such as depression or perceived stress, into account. Third, similar results are found when optimism is assessed in different ways. Fourth, associations of optimism with CVD demonstrate a dose-response gradient. Fifth, the effect size in reducing risk is remarkably consistent across studies.
Three likely mechanisms through which optimism and other subjective health assets might influence clinical CVD are:
• Promoting acquisition and maintenance of healthy life-styles (e.g., eating a balanced diet, exercising regularly) (39,41).
• Promoting acquisition and maintenance of a broader set of social and psychological factors known to be protective against CVD (e.g., social support) (39,42).
• Affecting relevant biological processes directly (e.g., immune system effects, gene expression, lipid levels, heart rate variability, and other aspects of autonomic function) (41,43–47).
For a schematic representation of postulated mechanistic links between subjective factors and cardiovascular disease, see Boehm and Kubzansky (19). These and other cited relationships are plausible, but remain to be tested empirically; further investigation of optimism and other aspects of positive health is needed to understand associations with CVH and CVD and to increase the potential for effective intervention.
With respect to interventions to strengthen optimism and their effects on CVH or CVD, insights are provided by several recent reports, for example, several small, short-term studies, and 3 reviews (48–53). Burton et al. (48), in 2009, presented the design of a resilience-training program to promote heart health in a general population by improving self-reported well-being and reducing depression. Five mediating variables were to be assessed: positive emotions, cognitive flexibility, social support, life meaning, and active coping (48). A pilot study of meditation-based stress management demonstrated acceptance of a 4-week intervention among patients with or at high risk of CVD, with reported reductions in depression and perceived stress (49). Outcomes of acute cardiovascular events were the target of a positive psychology telemedicine intervention addressing optimism, kindness, and gratitude in a small pilot trial (50).
DuBois et al. in 2012 (51) reviewed research on positive psychology interventions and cardiac outcomes, and called for further research to distinguish the most promising attributes to target with intervention. Whether maximal effect requires combining such interventions with established approaches to behavior change also needed clarification. They considered this work to have potential “to open up a new line of clinically-relevant work in psychosomatic medicine that could lead to improved well-being and health for the large number of patients who have cardiovascular illness” (51).
A further review examined the relation between interventions to promote positive psychological well-being (PPWB) and the practice of health behaviors (52). A pattern was suggested whereby PPWB appears to foster healthier behavior, which, in turn, enhances PPWB, in a virtuous cycle. It was concluded, “If future research confirms that PPWB does in fact increase the likelihood that individuals engage in healthy behaviors, then well-being may be a useful target for primordial intervention and, ultimately, contribute to a reduction in risk of CVD” (52).
In a meta-analysis of 39 studies of positive psychological interventions, few specific to cardiovascular conditions, Bolier et al. (53) found that, overall, such interventions could be effective in improving psychological well-being and, perhaps, in reducing depression. They posit that positive psychology interventions could have public health applicability, but called for further research to include more rigorous studies, more diverse populations and cultures, higher standards for reporting on trials, and cost-effectiveness. These several reports set the stage for discussing the next period of research.
Directions for Further Research
To build this new field effectively, it will be important to overcome several limitations (19). Historically, dominance of biological variables as contributors to near-term cardiovascular risk has led to models and interpretations of available data that subordinate subjective factors to biological factors. Even when they have been considered, subjective assets have often been represented by poor or limited measures, making it difficult to detect true associations with cardiovascular-related outcomes. Reports published to date have largely been on the basis of opportunistic, post hoc analyses of such limited data. Moreover, subjective assets have been studied in isolation from one another, precluding investigation of their independent contributions to outcomes of interest. Many study populations have been too small or specialized to yield generalizable findings. Importantly, cross-sectional or short-term studies limit inferences about temporality of mechanisms or causal relationships. Finally, studies at the individual level of observation have shed little light on population-level relationships of interest.
From this stage in the science of positive CVH, further research could take several directions. These may best be considered as complementary, rather than alternative paths and should include the following: 1) methodological studies to further validate and standardize instruments to measure subjective health assets; 2) population studies using such instruments to establish distributions of these assets among diverse populations and their associations with CVH metrics and other health indicators; 3) mechanistic studies to elucidate relationships between these assets and functional and biological ones that may (or may not) be critical intermediate factors in altering health outcomes; 4) intervention studies to determine efficacy, effectiveness, cost-effectiveness, and practical feasibility of intervention on subjective health assets in clinical practice; 5) modeling studies to forecast the potential clinical and public health effect of effective positive health interventions for CVH and other major chronic conditions; and 6) policy studies to evaluate the social, political, and economic implications of positive health and its potentially transforming effects on health care and health systems.
Each of these paths will require identifying specific research questions or hypotheses; developing interdisciplinary collaborations; and finding appropriate laboratory, clinical, and population settings. Bridging the disciplines of preventive cardiology and positive psychology will be necessary. The case for allocating resources to support the work must be taken to leading research agencies. To gain experience from practice, financial mechanisms will be needed to support implementation of clinical interventions. Ultimately, evidence on the basis of research and practice can lead to recommendation of such interventions by the U.S. Preventive Services Task Force and Community Preventive Services Task Force, thereby making them reimbursable preventive services under terms of the Affordable Care Act (54).
To begin addressing this agenda, a Positive Cardiovascular Health Research Workshop was convened in mid-2015, with 27 scientists from 11 institutions, representing preventive cardiology, positive psychology, and other disciplines. The Workshop proposed 4 research projects and inaugurated the Positive Cardiovascular Health Research Network, linking 43 interested investigators.
The Workshop highlighted abundant opportunities to develop innovative research in this new field. Young investigators in cardiology can readily find interested collaborators through the Network via the corresponding author of this paper (D.R.L.).
The continuum of cardiovascular conditions from ideal CVH to cardiovascular mortality across the life course presents multiple points of intervention where positive psychology could make a meaningful contribution. Thus, the cardiovascular domain is especially opportune for exploring the meaning of positive health and how it may be operationalized and promoted. Already, a considerable body of evidence addresses associations among subjective health attributes, or positive psychological characteristics, and cardiovascular health behaviors, factors, and outcomes (19). Experience with positive psychology interventions to address cardiovascular conditions is more limited, but has begun to accrue (20). We believe that, on balance, between substantial supportive research to date and the acknowledged need for further research, the new field of positive cardiovascular health holds great promise and has the potential to develop novel approaches to building CVH at the patient and population levels.
Potential benefits of positive psychology interventions are described at each of the 4 points shown in the Central Illustration, in terms of CVH and CVD outcomes. These include the possibility of truly achieving primordial prevention, a fundamental long-range strategy for promotion and preservation of ideal CVH to middle age and beyond. Remedial approaches may offer additional improvement in cardiovascular outcomes, QoL, and reduction of health care costs to the end of life. Contributions to remedial approaches can be anticipated as well, regaining some measure of CVH or ameliorating consequences of CVD, once present. Realizing this potential will require implementing and evaluating positive psychology interventions in practice, both as further research informs practice and as practice itself provides new evidence.
We urge investigators to join the effort in expanding research in positive CVH, building on directions for further research outlined in this paper, and connecting with an existing multidisciplinary network of interested cardiovascular scientists, psychologists, and others. We look forward to increasing collaborations and accelerated progress in this new field.
Support for this publication was provided by the Robert Wood Johnson Foundation's Pioneer Portfolio through a Positive Health grant, titled “Exploring Concepts of Positive Health,” to the Positive Psychology Center of the University of Pennsylvania (Dr. Seligman is the director). Dr. Labarthe received support from this source through a subcontract from the University of Pennsylvania to Northwestern University Feinberg School of Medicine. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- cardiovascular disease
- cardiovascular health
- positive psychological well-being
- quality of life
- Received May 28, 2015.
- Revision received February 26, 2016.
- Accepted March 25, 2016.
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