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Optimistic Attitudes Protect Against Progression of Carotid Atherosclerosis in Healthy Middle-Aged Women

From the Departments of Psychiatry (K.A.M.), Epidemiology (K.S.-T.), and Psychology (L.H.K.), University of Pittsburgh, Pittsburgh, Pennsylvania; and the Department of Psychology (K.R.), Helsinki, Finland.

Address correspondence and reprint requests to Karen A. Matthews, PhD, University of Pittsburgh, 3811 O’Hara Street, Pittsburgh, PA 15213. E-mail: matthewska{at}upmc.edu

	ABSTRACT

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OBJECTIVE: Optimistic people report a higher quality of life, engage in more active coping and adopt more health-promoting behaviors than people low in optimism, ie, pessimism. We evaluated whether pessimists are more likely to show progression in carotid disease than optimists.

METHODS: A total of 209 middle-aged healthy premenopausal women enrolled in an epidemiological study of cardiovascular risk factors and had carotid scans 10.4 years and 13.5 years later when they were at least 5 years postmenopausal. Women completed the Life Orientation Test (LOT), a measure of pessimistic and optimistic attitudes, at study entry and at the time of the first carotid scan. Analyses evaluated the association of LOT scores and change in carotid intima medial thickness (IMT) across 3 years.

RESULTS: Multiple linear regression analyses showed that the higher the pessimism scores at study entry, the greater the increase in mean IMT (ß = 0.17, p < .007). A comparison of those in the lowest quartile of LOT scores (most optimistic) with those in the other three quartiles showed that the most optimistic group had less progression than the remaining more pessimistic women (mean percent increase = 1.3 and 6.0 for mean IMT, F = 15.4, p < .001). Women who were chronically optimistic at study entry and at the first carotid scan (bottom quartiles at both times) had less progression in mean IMT than did those who were chronically pessimistic (top quartiles at both times).

CONCLUSIONS: Optimistic women are less likely to show progression of carotid disease in mid-life than are pessimists.

Key Words: women, • optimism, • cardiovascular disease, • carotid disease, • psychosocial.

Abbreviations: LOT = Life Orientation Test;; IMT = intima medial thickness;; HWS = Healthy Women Study;; DBP = diastolic blood pressure;; SBP = systolic blood pressure;; HDL-C = high-density lipoprotein cholesterol;; BMI = body mass index;; HT = hormone therapy;; ANCOVA = analyses of covariance.

	INTRODUCTION

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A widespread belief is that optimistic people make the best of things. However, it is only recently that scientific evidence has accumulated to document that is the case. Optimism is defined as expectations of positive outcomes, whereas pessimism is defined as expectations of negative outcomes. Although some theorists view these dimensions as distinctive, most studies operationalize optimism-pessimism as a single continuum ranging from highly optimistic to highly pessimistic. Measuring optimism-pessimism in this way yields scores that are stable over time and across different contexts (1). Hereafter, we use the term, optimists and pessimists, to refer to persons who score at the extremes of a single continuum.

In well-controlled studies, optimistic patients do better following a variety of medical interventions. For example, optimistic patients who undergo coronary artery bypass surgery have higher quality of life post surgery, eg, greater work satisfaction, more positive mood, and better sleep, adjusted for standard medical covariates, relative to their more pessimistic counterparts (2–5). Optimistic pregnant women report less depressive symptoms and anxiety during and following pregnancy than do pessimists and optimistic women who receive a negative pregnancy test following in vitro fertilization are less distressed than are pessimists (6,7). Optimists report better adjustment following surgery and radiation therapy for different types of cancers (8,9).

The reasons that optimists do well after medical interventions may be in part due to differences in ways optimists and pessimists cope with adversity. For example, among women who receive a diagnosis of early stage breast cancer, optimists report coping by accepting the reality of the situation, placing a positive outlook on the situation, trying to relieve the situation with humor, where pessimists use denial (refusal to accept the reality of the situation) and disengagement (10). Optimists before bypass surgery report seeking out and requesting information about what their physicians require of them in the coming months, making plans for their future, and setting goals for their recovery (2). The proactive coping of optimists is apparent in their health behavior. Optimists have greater success in lowering levels of dietary intake of saturated fat, reducing body fat, and increasing exercise in a cardiac rehabilitation program than pessimists (11). Even among those with no particular health problems, optimists report more health-promoting behaviors than do pessimists (12,13).

Given the pattern of findings that optimists report a higher quality of life, engage in more proactive coping, and adopt more health-promoting behaviors, it is likely that optimists are in better physical health than pessimists, other things being equal. In contrast to the literature on mental health, the literature on optimism, pessimism, and physical health is small: Among bypass patients, optimists are less likely than pessimists to be rehospitalized in the next 6 months for coronary events, adjusting for medical covariates (14). Among breast cancer patients, optimists are more likely to survive after 8 months than are pessimists, particularly among the younger patients (15). Among head and neck cancer patients, optimists are more likely than pessimists to be living 1 year later (16). The purpose of the present investigation is to evaluate whether optimists and pessimists differ in their risk for progression of carotid disease in a healthy sample of middle-aged women. Analyses included controls for the biological and life-style predictors of carotid disease (eg, smoking, low HDL, high pulse pressure) (17).

	METHOD

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Study Population
The 209 participants in this paper were women enrolled in the Healthy Women Study (HWS) when premenopausal and who had repeated carotid ultrasound scans 10.4 and 13.5 years later when they were 5 and 8 years postmenopausal. HWS is an ongoing prospective study of the changes in behavioral and biological characteristics of women during the peri- and postmenopausal years. In 1983 to 1984, 541 participants (90% white) were recruited from a random sample of licensed drivers in Allegheny County, Pennsylvania (18). They were 42 to 50 years of age at study entry; menstruating within the past 3 months and not taking hormone therapy (HT); diastolic blood pressure (DBP) < 100 mm Hg; not surgically menopausal; not diagnosed with diabetes or with hypertension; and not taking thyroid, lipid-lowering, or psychotropic medications. The Institutional Review Board at the University of Pittsburgh approved this project and all gave informed consent. The women underwent baseline clinic examinations and returned cards monthly to indicate whether they had menstruated. After 12 successive months without menstruating, the women returned for a follow-up examination, and then again every several years thereafter.

The carotid ultrasound measures were added to the protocol for women who were evaluated at 5 and 8 years postmenopause starting in 1993 (n = 380) and were repeated an average 3.0 years later (SD = 0.7; range 0.9–5.4; n = 209). After a period of time, scheduling for second examinations was terminated so money could be used to finance other tests. Compared with women who had one examination, women who had two carotid examinations were younger (mean (SD) = 58.0(1.6) vs. 59.3(2.3), p < .001), had become menopausal at a later age (mean (SD) = 52.6(2.2) vs. 51.7(3.0), p < .001), and had lower systolic blood pressure (SBP) (mean (SD) = 118.0(15.2) vs. 123.7(20.8), p < .002) at the time of the first scan. No differences existed in other baseline study variables between women with and without a second scan (p > 0.07).

Measurement of Carotid Arteries
B-mode ultrasound scans of the carotid artery were obtained by certified sonographers using a scanner with a 5 MHz linear array imaging probe. Certified readers (19) measured the average intima medial thickness (IMT) across 1-cm segments of the near and far walls of the distal common carotid artery and the far wall of the carotid bulb and the internal carotid artery on both right and left sides. Measures from each location were then averaged to produce an overall measure of average IMT and the maximal IMT measure from each of the five locations were also averaged. We used a modified computerized reading program developed for the Cardiovascular Health Study (20). Readers were blind to women’s psychosocial scores or the results of prior scans. The protocol called for informing women if they had significant stenosis and alterations of blood flow. Very few women were so informed.

Reproducibility of IMT was assessed in five women who underwent two ultrasound examinations within 2 weeks. Each time, the women were scanned by two separate sonographers and each scan was scored by two readers. When accounting for sonographer and reader variation, the intraclass correlation was 0.86 for average IMT. In another reliability study that included 15 men and women, similar findings were obtained, i.e., 88% of the variability was due to the participant, <2% to the reader, and sonographer and visit variability < 1% (19). Pearson correlations were 0.99 between readers, 0.96 between sonographers, and 0.90 between visits.

Measure of Optimism/Pessimism
Optimism-pessimism was measured using the Life Orientation Test (LOT; 1). The LOT consists of 8 items that evaluate respondents’ generalized expectations of negative (4 items) and positive (4 items) outcomes. Sample items include, "In uncertain times, I usually expect the best," "If something can go wrong for me, it will." The respondents were asked to rate the extent to which they agreed with the items on a 4-point scale ranging from not at all like me (0) to a lot like me (3). Subsequent to reverse-scoring the items reflecting positive outcome expectations, the items were summed, a higher score reflecting more pessimistic life orientation and a lower score more optimistic orientation. Previous studies have established good construct validity and good internal reliability for the LOT (21). The LOT was administered at study entry and at the time of the first carotid scan.

Measurement of Other Relevant Data
Blood draw was collected in the morning after a 12-hour fast. Glucose was analyzed by enzymatic assay (Yellow Springs Glucose Analyzer, Yellow Springs, OH). Triglycerides and total high-density lipoprotein cholesterol (HDL-C) were measured in the lipid laboratory of the University of Pittsburgh Graduate School of Public Health, which has been certified by the Centers of Disease Control and Prevention, Atlanta, GA. Waist circumference was measured at the smallest circumference. SBP was measured three times on two occasions 2 hours apart with a random zero muddler sphygmomanometer, with the final overall reading being the average of the last two readings of these two assessments. Height and weight were measured and body mass index (BMI) was calculated.

Use of HT and medications for hypertension or hyperlipidemia were assessed via self-report. Cigarette smoking was measured by current status of smoking (yes/no), and alcohol intake by the amount of alcohol per day converted into grams of absolute alcohol (g/day). The Paffenbarger Activity Questionnaire was used to measure kilocalories per week spent in leisure-time activity. Beck Depression Inventory (22) was used to measure depressive symptoms.

Statistical Analyses
Multiple linear regression analyses tested whether higher LOT (more pessimistic) scores measured at study entry and at the time of the first carotid scans predicted change in mean and maximum IMT during 3 years. Univariate analyses of covariance (ANCOVA) were used to illustrate the findings by using percent change of mean and maximum IMT as the dependent variables and quartiles of LOT scores 10.4 years before and at the time of the first carotid scans as the grouping variables. Polynomial contrasts tested if the difference in percent change according to the pessimism quartiles was linear, quadratic, or cubic. Finally, ANCOVA was used to test if women who scored at the bottom quartile of LOT scores both at study entry and at the first carotid scans (most optimistic) differed from women who scored at the top quartile at both examinations (most pessimistic) in progression of carotid atherosclerosis during 3 years. All analyses of change in carotid measures were adjusted statistically for their initial values; age at the time of the LOT measurement; duration in time from the LOT measurement to the first carotid scans; and/or duration in time between the carotid scans. Additional multiple linear regressions were conducted with biological, life-style, and medication use as additional covariates in separate models due to missing data. Because of the association between pessimism and depressive symptoms (BDI and LOT scores correlated 0.36 at baseline), analyses were conducted with Beck Depression Scores as the predictor variable.

	RESULTS

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Table 1 shows the mean values of carotid measures at the first and second carotid scans. Mean IMT increased an average of 0.032 mm (t = 6.85, p < .0001) and maximum IMT an average of 0.014 mm (t = 1.93, p < .054) over the 3-year interval, which is about the change observed in other studies of women (17). Table 2 presents the behavioral and biological covariates according to the pessimism quartiles. The level of triglycerides differed significantly between the groups (p < .02), such that the level was highest and variation largest in the third quartile of LOT scores. Use of hypertensive medication was most frequent in the most pessimistic group (p < .02). There were no other significant differences between the pessimism groups.

Predictors of Progression of IMT
Of the behavioral and biological covariates, the following predicted the progression of carotid atherosclerosis in our sample: current smoker status (p < 0.03), higher SBP level at the first scan (p < .01 for mean IMT, p < .07 for maximum IMT), and longer duration in time between the first and second carotid scans (p < 0.001).

Pessimism measured at study entry predicted an increase in mean IMT (beta = 0.17, t = 2.71, p < .007). Association with maximum IMT was not significant in the linear regression analysis (beta = 0.10, t = 1.62, p < .11). Similar results were obtained including both adventitial diameter and pessimism into the same model. When women were categorized into quartiles based on the sample distribution of pessimism scores measured at study entry, ANCOVA revealed significant linear effects of pessimism on percentage of the increase in both mean (linear contrast, F = 3.29, p < .002) and maximum (linear contrast, F = 2.86, p < .025) IMT (Figure 1). The quadratic trend approached statistical significance for mean IMT (p < .06). A comparison of the lowest quartile (most optimistic) with the other three quartiles showed that the most optimistic group had less progression (mean percent increase = 1.3 for mean and –0.25 for maximum IMT) than the remaining more pessimistic women (mean percent increase = 6.0 for mean and 3.1 for maximum IMT; F = 15.4, p < .001 and F = 5.6, p < .02 respectively).

View larger version (32K): [in this window] [in a new window]   Figure 1. Percent increase in IMT during 3 years according to quartiles of LOT scores at study entry 10.4 years earlier where highest quartile is most pessimistic and the lowest quartile is most optimistic. Linear trend, p < .002; quadratic trend, p < .06.

View larger version (30K): [in this window] [in a new window]   Figure 2. Percent increase in IMT during 3 years in women who were in lowest quartile of LOT scores at study entry and 10.4 years later (chronically optimistic) and in women who were in the highest quartile of LOT scores at study entry and 10.4 years later (chronically pessimistic); ANCOVA, p < .023. Optimists’ mean change in maximum IMT was –0.001.

Beck Depression scores measured at baseline or at the first scan as a continuous or categorical variable were unrelated to initial mean or maximal IMT or to progression in mean or maximal IMT (p > 0.28). A comparison between women with chronically elevated depression scores (highest quartile at both time points) versus low depression scores (lowest quartile at both time points) was nonsignificant (p > 0.18).

Comment
The purpose of this study was to test whether optimistic women were likely to show less progression of carotid disease than pessimists in a healthy sample of women. Indeed, the hypothesis was confirmed. Across a 3-year period, optimists were less likely to increase in carotid IMT than were pessimists. Indeed, the optimists (those in the lowest quartile of scores at study entry) showed virtually no increase in carotid IMT over the 3 years. These findings remained statistically significant in separate analyses adjusting for the relevant biological, life-style, and medication status covariates. Beck Depression Inventory scores were not related to carotid disease in this sample, suggesting that optimistic attitudes are a unique predictor of carotid disease.

The study has several limitations. First, the study sample is unique in that it is largely a group of white healthy middle-aged women. Thus, the findings cannot be generalized to a more diverse sample of women, women in later stages the etiology of carotid disease, or men. On the other hand, the study used a well-characterized sample that had repeated and detailed measurements throughout the course of the study. Second, the concurrent association of optimism and carotid disease at the first scan was not significant, suggesting that optimistic attitudes at the time of treatment may be less useful as a diagnostic indicator and more useful for prognosis among initially healthy women. The associations between pessimism and adventitial diameter in the common carotid at the initial carotid examination suggest that carotid vessels of pessimistic women may be dilating. Dilation of the carotid arteries can be an adaptive response to restore shear stress, and, then, in attempt to maintain tensile stress constant, lead to subsequent changes in IMT (23). If so, this would serve to mask temporarily an association between pessimism and IMT at the first examination but allow us to observe the increase in IMT that we observed later between examinations.

The better health of the optimists shown in the present analysis contributes to a growing literature extending the benefits of optimistic attitudes from mental health, health-related quality of life, and health behaviors to physical health outcomes (24). While the mechanisms for the association cannot be established in this analysis, a number of possibilities are plausible. First, consistent with prior studies on health behaviors, optimists may be more engaged with promoting their health and be more likely to adopt health care recommendations (11–13). Second, even when facing the same level of psychological stress as pessimists, optimists may show less neuroendocrine and cardiovascular responsivity, resulting in lower sheer stress affecting the endothelium. Third, optimists may have less atherogenic levels of other novel risk factors not measured in our project, e.g., lipid particles, C- reactive protein, or ambulatory blood pressure. Indeed, we have shown in a different sample that optimists have lower ambulatory blood pressure during the workday than do pessimists (25).

In conclusion, the present study shows that, relative to pessimists, optimists are protected from progression of carotid disease across a 3-year period in mid-life. Indeed, optimists showed virtually no progression of disease. To our knowledge, this is the only study to demonstrate the association of progression of subclinical disease and optimistic attitudes in men or women.

	ACKNOWLEDGMENTS

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Supported by HL 28266, HL 65111, and HL 65112.

Received for publication January 21, 2004.

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