BMJ Open is committed to open peer review. As part

0 downloads 0 Views 1MB Size Report
Sep 5, 2017 - We also post the versions of the paper that were used during peer ... If you have any questions on BMJ Open's open peer review process ... Sociocultural Ancillary Study (SCAS). Journal: BMJ Open. Manuscript ID bmjopen-2017-019434 ..... married/living with a partner], healthcare insurance status [has ...
BMJ Open is committed to open peer review. As part of this commitment we make the peer review history of every article we publish publicly available. When an article is published we post the peer reviewers’ comments and the authors’ responses online. We also post the versions of the paper that were used during peer review. These are the versions that the peer review comments apply to. The versions of the paper that follow are the versions that were submitted during the peer review process. They are not the versions of record or the final published versions. They should not be cited or distributed as the published version of this manuscript. BMJ Open is an open access journal and the full, final, typeset and author-corrected version of record of the manuscript is available on our site with no access controls, subscription charges or payper-view fees (http://bmjopen.bmj.com). If you have any questions on BMJ Open’s open peer review process please email [email protected]

BMJ Open

The Association of Disposition Optimism and Life’s Simple 7’s Cardiovascular Health Index: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study (SCAS)

rp Fo Journal:

Manuscript ID Article Type:

Date Submitted by the Author:

bmjopen-2017-019434 Research 05-Sep-2017

ee

Complete List of Authors:

BMJ Open

w

ie

ev

rr

Hernandez, Rosalba; University of Illinois at Urbana Champaign, School of Social Work González, Hector M. ; Michigan State University, Department of Epidemiology & Biostatistics Tarraf, Wassim Moskowitz, Judith Carnethon, Mercedes; Northwestern University, Department of Preventive Medicine Gallo, Linda; San Diego State University, Department of Psychology Penedo, FJ; Northwestern University, Department of Medical Social Sciences Isasi, Carmen; Albert Einstein College of Medicine, Department of Epidemiology and Population Health Ruiz, John Arguelles, William Buelna, Christina Davis, Sonia Gonzalez, Franklyn McCurley, Jessica Wu, Donghong Daviglus, Martha; University of Illinois at Chicago, Institute of Minority Health Research

Keywords:

Cardiovascular medicine

ly

Secondary Subject Heading:

on

Primary Subject Heading:

Mental health, Cardiovascular medicine, Epidemiology

MENTAL HEALTH, Coronary heart disease < CARDIOLOGY, EPIDEMIOLOGY

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 1 of 23

The Association of Disposition Optimism and Life’s Simple 7’s Cardiovascular Health Index: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) Sociocultural Ancillary Study (SCAS)

Running title: Hernandez et al.; Optimism and Cardiovascular Health

Rosalba Hernandez,1 Hector M. González,2 Wassim Tarraf,3 Judith T. Moskowitz,4 Mercedes R. Carnethon,5 Linda C. Gallo,6 Frank J. Penedo,4 Carmen R. Isasi,7 John M. Ruiz,8 William Arguelles,9 Christina Buelna,10 Sonia Davis,11 Franklyn Gonzalez,11 Jessica L. McCurley,12 Donghong Wu,13 and Martha L. Daviglus5,13

School of Social Work, University of Illinois at Urbana-Champaign, Chicago, USA; 2Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, USA; 3Wayne State University, Institute of Gerontology, Detroit, USA; 4Medical Social Sciences, Northwestern University, Chicago, USA; 5Department of Preventive Medicine, Northwestern University, Chicago, USA; 6Department of Psychology, San Diego State University, San Diego, USA; 7Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, USA; 8Department of Psychology, University of Arizona, Tucson, USA; 9Department of Psychology, University of Miami, Coral Gables, USA; 10Office of Institutional Effectiveness, Southwestern College, Chula Vista, USA; 11 Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA; 12Clinical Psychology, San Diego State University/University of California, San Diego, USA; 13Institute for Minority Health Research, University of Illinois at Chicago, Chicago, USA

w

ie

ev

rr

ee

1

rp Fo

Word Count: 3,000

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

Address for Correspondence: Rosalba Hernandez, PhD School of Social Work University of Illinois at Urbana-Champaign 1010 W. Nevada Street, Urbana, IL Tel: 217-300-1049 Fax: 217-244-5220 Email: [email protected] 1

For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

Abstract Objectives: Mounting evidence links positive psychological functioning to restorative health processes and favorable medical outcomes. However, very little is known about the relationship between optimism, an indicator of psychological functioning, and the American Heart Association (AHA)-defined concept of cardiovascular health (CVH), particularly in Hispanics/Latinos of diverse backgrounds. To address limitations of existing literature, the current study investigated the association between dispositional optimism and cardiovascular

rp Fo

health in a heterogeneous sample of Hispanics/Latinos residing in the US. Design: Crosssectional study. Participants and setting: Data was analyzed from 4,919 adults ages 18-75 of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) parent study and the Sociocultural Ancillary Study. Main outcome measures: Optimism was assessed using the 6item Life-Orientation Test-Revised (range from 6-30). AHA classification standards were used

ee

to derive an additive CVH score with operationalization of indicators as Ideal, Intermediate, and Poor. The overall CVH score included indicators of diet, body mass index, physical activity,

rr

cholesterol, blood pressure, fasting glucose, and smoking status. Multivariate linear and logistic regressions were used to examine associations of optimism with CVH (Life’s Simple 7s), after

ev

adjusting for socio-demographic factors and depressive symptoms. Results: Each increase in the optimism total score was associated with a greater cardiovascular health score [β=0.03 per unit

ie

increase, 95% CI=0.01, 0.05]. When modeling tertiles of optimism, participants with moderate

w

[β=0.24, 95%CI=0.06, 0.42] and high [β=0.12, 95%CI=0.01, 0.24] levels of optimism displayed greater CVH scores when compared to their least optimistic peers. Conclusions: The current

on

study offers preliminary evidence for an association between optimism and CVH in a large heterogeneous group of Hispanic/Latino adults. Our study adds scientific knowledge of

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 2 of 23

psychological assets that may promote cardiovascular health and suggests a novel therapeutic target for consideration. Future studies are needed to explore causality and potential mechanism underlying the relationship between positive emotion and heart health.

Keywords: psychological well-being, dispositional optimism, Hispanics/Latinos, cardiovascular health, health disparities

2 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 3 of 23

Strengths and limitations of this study  This is one of the few studies to examine the link between dispositional optimism and the seminal concept of cardiovascular health which focuses on maintenance and promotion of favorable behavioral health practices and biological attributes.  The strength of this study is exploration of the association between emotional well-being and cardiac-related health in a large heterogeneous sample of Hispanic/Latino adults that afforded the power to examine effect modification by country of origin.  Our study contributes to existing literature and suggests that dispositional optimism may be a novel therapeutic target for consideration when attempting to promote cardiovascular health among Hispanic/Latino adults, regardless of age, sex, or Hispanic/Latino country of origin.  We acknowledge the inherent limitation associated with cross-sectional designs and endorse longitudinal studies and randomized trials to ascertain hypotheses regarding causation and temporality of the association.  Because dietary intake and physical activity were assessed through self-report, measurement error and misclassification bias were possible.

w

ie

ev

rr

ee

rp Fo

ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

3 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

The American Heart Association (AHA) has called for the inclusion of depression as a cardiovascular disease (CVD) risk factor, joining the ranks of traditional markers such as diabetes and hypertension, to underscore the impact of emotional well-being on cardiovascular health [1]. In parallel to the AHA’s recommendation, the field of health and medicine has broadened its focus from the deleterious health effects of negative psychological constructs to a positive orientation that focuses on psychological attributes such as happiness, optimism, and life

rp Fo

purpose [2, 3]. Dispositional optimism, i.e., the overarching expectation that positive things will occur in the future, is highly correlated with positive emotion and has emerged as a well-being indicator of particular salience for cardiac-related health [4, 5]. Independent of major CVD risk

ee

factors, dispositional optimism consistently emerges as a cardioprotective factor and is independently associated with favorable lipid profiles [6], reduced circulation of inflammatory

rr

markers, lower rates of hospital readmission after coronary artery bypass graft surgery, reduced

ev

all-cause and cardiac-related mortality [7, 8], and reduced odds for incident heart disease [9]. Notably, a majority of studies on the cardio-protective influence of positive emotion

ie

focus on disease states, deficits, and disability and fail to consider the seminal concept of

w

cardiovascular health [i.e., Life’s Simple 7s (LS7s)] which focuses on maintenance and

on

promotion of favorable behavioral health practices and biological attributes. Favorable profiles of cardiovascular health are related to increased longevity, better cognitive functioning,

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 4 of 23

compressed extant morbidity, greater CVD-free survival, and reduced odds for incident acute cardiovascular events [10]. Only one study has explored the relationship between optimism and positive cardiovascular health (LS7). In participants of the Multi-ethnic Study of Atherosclerosis (MESA), Hernandez et al. (2015) found two times greater odds of having Ideal cardiovascular health for adults in the highest quartile of optimism when compared to least optimistic peers,

4 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 5 of 23

independent of plausible confounds [11]. However, that study was not able to explore whether the association was present among Hispanics/Latinos of diverse backgrounds. Major theories informing the concept of psychological well-being in the US draw heavily from Western-centric perspectives, which often neglect culturally bound frameworks. Indeed, cultural attributes could result in divergent conceptions of psychological attributes and subsequent nonequivalent associations with physical health.

rp Fo

To address limitations of existing literature, the current study investigated the association between dispositional optimism and cardiovascular health in a heterogeneous sample of Hispanics/Latinos residing in the US. We hypothesized that greater levels of optimism would be

ee

associated with more favorable cardiovascular health profiles with variance in the stability and magnitude of the association based on important sociodemographic factors.

METHODS

ie

Study population and data source

ev

rr

Participants include Hispanic/Latino adults (ages 18 to 74 years; N = 5,313) enrolled in the

w

Hispanic Community Health Study/Study of Latinos (HCHS/SOL) parent study and the

on

Sociocultural Ancillary Study (SCAS) [12, 13]. The HCHS/SOL is a large community-based multi-center cohort study that seeks to identify risk and protective factors for chronic disorders

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

and to quantify patterns of morbidity and mortality in a heterogeneous group of Hispanic/Latino adults. Details of the recruitment and study protocol for HCHS/SOL [12] and SCAS [13] have been previously published. Briefly, study enrollment for HCHS/SOL occurred from 2008 to 2011 across four US regions (New York; Illinois; California; Florida) and included a total of 16,415 adults between the ages of 18-74 years. The sample included adults reporting heritage

5 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

from Mexico, Cuba, Puerto Rico, the Dominican Republic, and Central or South America. Participants were selected using a two-stage area household probability sampling approach. The SCAS consists of a subsample of 5,313 participants in the original HSHS/SOL cohort with the aim of exploring socioeconomic, cultural, and psychosocial influences on health. SCAS assessments were completed by enrollees within 9 months of their initial baseline HCHS/SOL exam. Studies were approved by the Institutional Review Boards at the data coordinating center

rp Fo

and at each field center where all subjects gave written consent. The final sample for the current study was limited to participants with available scores for measures of optimism and across indicators needed to compute the cardiovascular health score

ee

(i.e., n = 4,919 or 92.6% of the original SCAS sample). Participants excluded from analysis tended to be older and not married or living with a partner, and reported lower socioeconomic

rr

status and inferior emotional and physical health.

ie

Study measures

ev

Dispositional Optimism. Collected as part of SCAS, the Life Orientation Test-Revised

w

(LOT-R) was used to assess dispositional optimism [14]. The LOT-R is a self-administered

on

questionnaire with possible scores ranging from 6 (least optimistic) to 30 (most optimistic) and includes items such as, “In uncertain times, I usually expect the best.” The scale includes 3

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 6 of 23

positively worded items, 3 negatively worded items, and 3 filler items (excluded from analysis), all rated on a 5-point Likert-type scale with response options ranging from I agree a lot to I disagree a lot. As recommended by scale developers, main analyses treated the full-scale LOT-R as a unidimensional scale pooling all 6 items to generate a composite score. In addition to treating the optimism score as a continuous measure, tertiles were created based on the

6 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 7 of 23

distribution of scores to test for possible threshold effects (as clinically-based cutoffs are unavailable). Given debate on the factorial structure of the LOT-R, second-order analyses examined optimism and pessimism subscales by parsing negatively and positively worded items. Cardiovascular Health: Life’s Simple 7 (LS7). AHA specifications [15] were used to define and operationalize indicators of cardiovascular health for smoking, diet, physical activity, body mass index (BMI), fasting plasma glucose, serum cholesterol, and blood pressure (see

rp Fo

González et al. 2016) [16]. Indicators were coded using a 3-category scheme of Poor (0), Intermediate (1), or Ideal (2) (see Table 1). A total CVH score was computed by summing the seven indicators to derive a score ranging from 0 to 14, with higher scores indicative of better

ee

CVH [15]. An LS7 index (range 0-7) was also considered based on the sum of Ideal criteria. Lastly, a dichotomous LS7 CVH cut-point (≥4 Ideal Indicators) was generated that has been

rr

previously linked with cardio-protection and reduced 20-year incidence of coronary heart disease [10, 17-19].

ev

Protocols to capture cardiovascular health (i.e., LS7) indicators have been described in

ie

depth elsewhere [12]. Briefly, former and current smoking status was self-reported. Two 24-hour

w

dietary recalls were used to evaluate dietary intake and considered 5 food categories of

on

fruits/vegetables, fish, grains, sweetened beverages, and sodium. Physical activity was determined through self-report using a modified version of the Global Physical Activity

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

Questionnaire (GPAQ) which taps into domains related to work, transport, and leisure [20, 21]. The biomarkers considered were body mass index (BMI), total cholesterol, fasting blood glucose, and blood pressure. BMI, measured as kg/cm2, was calculated from staff-ascertained measures of weight (nearest 0.1 kg) and height (nearest centimeter). After a 12-hour fast, blood was drawn to obtain lipid profiles and fasting glucose values. Total cholesterol was measured

7 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

using a cholesterol oxidase enzymatic method whilst the hexokinase enzymatic method was employed when measuring fasting blood glucose (Roche Diagnostics, Roche Diagnostics, Indianapolis, IN). Three systolic and diastolic blood pressure readings were taken with participants in a seated position; mean values were obtained by averaging across all 3 readings. Self-reported medication use was considered when identifying those with pre-existing diabetes, hypercholesterolemia, and hypertension. Information across CVH indicators was obtained during

rp Fo

the HCHS/SOL baseline assessment (2008-2011). Covariates. Covariates included baseline age, sex [male, female], educational attainment [less than high school (HS), HS graduate/general education degree (GED), greater than HS],

ee

income [$50,000, not reported], marital status [married/living as married/living with a partner], healthcare insurance status [has health insurance, does not have

rr

health insurance], nativity/immigration status, language preference for HCHS/SOL interview

ev

[English vs. Spanish], and Hispanic/Latino heritage group (Mexican, Cuban, Puerto Rican, Dominican, Central American, South American, or other). Additionally, self-reported physical

ie

health was considered as measured using the Physical Health Composite Scale of the 12-item

w

Short Form Health Survey (SF-12) [22]. Finally, prevalent coronary heart disease (CHD) at

on

baseline and depressive symptoms (Center for Epidemiologic Studies-Depression Scale [CESD]) [23] were considered as covariates.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 8 of 23

Statistical Methods Complex survey-specific procedures were performed across analyses to properly account for sample weights and the 2-stage sampling design involving clustering and stratification procedures [12, 24]. Descriptive characteristics are presented by tertiles of optimism. Group

8 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 9 of 23

differences in participant characteristics across optimism tertiles were examined using an F-test or χ-test as appropriate. The association of optimism and CVH was examined using multivariate linear and logistic regression. Observations with missing data were excluded from analyses. The first set of regression models treated the independent variable as a continuous score ranging from 6 (least optimistic) to 30 (most optimistic) with modeling of a 1-unit increase in optimism. Three separate

rp Fo

models were constructed using three CVH scoring methods, i.e., continuous (0-14 and 0-7) and dichotomous (≥4 Ideal). Model 1 was unadjusted. Model 2 adjusted for age, sex, Hispanic/Latino heritage, marital status, education, income, insurance status, nativity/immigration status, and

ee

language of interview. Model 3 was additionally adjusted for self-rated physical health, prevalent CHD, and depressive symptoms. Analyses were replicated with treatment of optimism as a

rr

categorical (tertiled) variable to assess possible discontinuous effects (low: ≤21; moderate: 22 to

ev

≤25; high: ≥26) with the lowest tertile of optimism serving as the reference category. Sensitivity analyses testing the association of optimism and CVH were performed using logistic quantile

ie

regression to account for possible characterization of CVH as a bounded outcome [25].

w

Effect modification was also explored to inform whether stratified analyses were

on

warranted through inclusion of interaction terms testing the stability of adjusted associations between optimism and cardiovascular by age, sex, and Hispanic/Latino background. Finally,

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

second-order analyses treated the LOT-R as a bi-dimensional scale with subscales of optimism and pessimism. Data analysis was conducted using SAS 9.4. Parameter estimators of logistic quantile regression models and corresponding 95% confidence intervals were estimated using bootstrap simulations.

9 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

RESULTS Sample Characteristics Table 2 presents participant characteristics according to level of optimism. Participants ranged in age from 18 to 74 years (M = 42.3, SE=0.4) with an approximate equal distribution by sex (54.6% female). The largest Hispanic/Latino group comprised those of Mexican heritage (37.4%) followed by those identifying as Cuban (20.1%), Puerto Rican (15.5%), Dominican

rp Fo

(11.5%), and Central (7.4%) and South American (4.7%). Overall, 32.5% had less than a high school education and 46.4% reported an annual income below $20,000. P-values presenting between-subject differences across demographic factors are presented by tertile of optimism

ee

(Table 2). Participants categorized as most optimistic tended to be older, reported being married and/or living with a partner, and displayed greater socioeconomic standing as quantified by

rr

education and income. Differences in optimism were also evident by heritage group.

ev

Specifically, a greater proportion of Cuban and Central American participants were in the highest optimism tertile as opposed to the lowest tertile, whereas this finding was reversed for those of

ie

Mexican and Puerto Rican heritage. Compared to their less optimistic peers, more favorable

w

profiles among the most optimistic were evident for symptoms of depression. Table 2 also

on

presents the bivariate association between tertiles of optimism and extant number of Ideal CVH indicators. Results suggest a gradient in the distribution of Ideal LS7 criteria across tertiles of

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 10 of 23

optimism with lower levels of optimism associated with fewer Ideal LS7s.

Association of Optimism and Cardiovascular Health As effect modification was not evident by sex, age, or Hispanic/Latino heritage group, Table 3 presents pooled estimates for the associations of optimism and CVH with optimism

10 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 11 of 23

treated as a continuous variable. In the unadjusted model, each unit increase in optimism was associated with a higher cardiovascular health score (β = 0.03, 95% CI =0.01, 0.06). This relationship was robust to inclusion of covariates capturing demographic factors, health status, and depressive symptoms. Similar findings were evident across the distinct operationalization of CVH (0-7 continuous index and 4+ Ideal LS7s). For instance, each unit increase in optimism was related to 3% higher odds of meeting Ideal criteria across four or more CVH metrics (4+ Ideal

rp Fo

LS7s; OR 1.03, 95% CI =1.01, 1.06). Table 4 presents the β-estimates and associated confidence intervals for the association of optimism tertiles and CVH, with the least optimistic group serving as the referent category. In

ee

multivariate models and when compared to least optimistic peers, persons with mid- and highlevels of optimism displayed greater cardiovascular health scores when treating CVH as a

rr

continuous indicator (0-14 and 0-7 continuous indices). Specifically, mid-levels of optimism

ev

were associated with greater CVH scores using the 0 to14 scaling (β=0.24, 95% CI=0.06, 0.42) and high-levels of optimism were related to greater CVH on the 0 to 7 scale (β=0.12, 95%

ie

CI=0.01, 0.24). Associations were robust to adjustment for demographic factors, physical health

w

status, and depressive symptoms. Statistically significant findings were not replicated when

on

treating CVH as a dichotomous outcome (i.e., presence of ≥4 Ideal indicators vs < 4). Sensitivity analysis using logistic quantile regression resulted in identical findings as

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

above. Finally, second-order analyses were conducted to explore the association of the optimism and pessimism subscales with cardiovascular health. Associations of the LOT-R and cardiovascular health were largely driven by the negatively worded items (β = -0.03, p = 0.03), this is in contrast to non-significant findings for the 3-item cluster of positively worded items (β = 0.01, p = 0.45) (not shown).

11 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

DISCUSSION Limited research has investigated plausible psychosocial antecedents of favorable CVH despite its association with reduced risk of cardiac and all-cause mortality. In the first study to include Hispanics/Latinos of diverse heritage backgrounds, we found that higher optimism scores were associated with better cardiovascular health with no evidence of effect modification by age, sex, or country of origin. Conversely, few Hispanics/Latinos with low optimism met the

rp Fo

criteria for Ideal CVH. Our findings were not markedly affected by other factors measured that serve as plausible confounders (e.g., prevalent CHD, depressive symptoms). In order to achieve the AHA’s Strategic Impact Goals of improved cardiovascular health and reduced cardiac-

ee

related mortality by 20% by 2020 [15], novel and calculated strategies targeting vulnerable populations are needed to promote and maintain Ideal CVH across the lifespan.

rr

Our results are consistent with previous studies demonstrating the protective health

ev

effects of psychological well-being [11, 26]. For instance, a number of observational studies have examined the association between psychological well-being and longevity with the bulk of

ie

published research indicating that constructs such as optimism, positive affect, life satisfaction,

w

and happiness are associated with longer life, independent of the effects of negative constructs

on

(e.g., depression, anxiety) [26-28]. Psychological well-being also appears to be related to lower risk of illness onset and slower disease progression across a number of different samples and

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 12 of 23

chronic conditions (e.g., cancer, HIV) [29, 30].

Although the well-being indicator of optimism has received much attention in the field of cardiovascular epidemiology in the last decade, inconsistent findings remain evident. Some studies document a cardioprotective influence [11, 31] while others report null findings [32]. As speculated by Kruse and Sweeny (2017) [33], it is plausible that optimism displays

12 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 13 of 23

heterogeneous effects based on individual properties of the clinical marker under study and underlying biological context. Clinical markers most closely interconnected with stress physiology and dependent on patient-led self-care behavior may be particularly susceptible to the influences of positive emotion. Despite divergence in the literature, the current study of the HCHS/SOL cohort replicates previous findings of MESA investigators [11] where high levels of optimism were found to be associated with favorable cardiovascular health. Even though a small

rp Fo

effect size was evident, at the population level even modest differences in CVH scores can translate into a significant reduction in subsequent deaths as effects compound over time. Future studies will want to consider the mechanism through which optimism influences

ee

the indices used to construct the CVH score. A multi-pronged process is hypothesized to underlie the pathway through which psychological well-being protects against incidence and progression

rr

of subclinical and clinical disease, i.e., through promotion of healthy behaviors, augmentation of

ev

restorative biological processes, and increased psychosocial and coping resources [34, 35]. For instance, in both healthy populations and those with existing chronic illness, evidence links

ie

favorable psychological well-being with enhanced exercise regularity, smoking abstinence [36],

w

a more prudent diet [37, 38], and increased medication regimen adherence. Nonetheless, more

on

research is needed to elucidate important mediators, moderators, and confounders of the relationship between positive psychological well-being and cardiovascular health.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

The present study has multiple strengths. It is the first to examine the association of optimism and CVH in a large sample of diverse Hispanics/Latinos. This allowed for examination of effect modification by Hispanic/Latino group, yielding no apparent interaction of heritage with optimism when regressed upon CVH metrics. The study was also statistically powered to adjust for important confounders unique to the Hispanic/Latino population, including

13 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

acculturation and nativity status. Standardized approaches were used to obtain objective measures across health factors, e.g., cholesterol. Study limitations, however, should be considered when interpreting our findings. Because dietary intake and physical activity were assessed through self-report, measurement error and misclassification bias were possible. As with all cross-sectional studies, there is an inability to make definitive inferences about causality. Longitudinal studies are needed to establish causality and ascertain hypotheses regarding

rp Fo

temporality of the association.

Even though optimism and other indicators of emotional well-being appear to be linked with cardiovascular health, there remains a critical scientific gap as we do not yet know whether

ee

(or how) interventions to cultivate emotional well-being may help reduce cardiovascular disease risk. Recent work testing targeted inventions to boost emotional well-being has demonstrated

rr

benefits in clinical populations and settings (e.g., HIV+ patients). Moskowitz et al. (2017) found

ev

that an intervention to boost positive emotion resulted in reduced viral load in patients recently diagnosed as HIV positive. A focused intervention to improve emotional well-being may hold

ie

promise as a novel therapeutic target for promotion of cardiovascular health. Based on our

w

current findings, prevention strategies through modification of emotional well-being may be a

on

potential avenue in helping to reach AHA’s goal to increase cardiovascular health by 20% by 2020 [15]. As evidence suggests that 40% of individual variance in emotional well-being is

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 14 of 23

determined by intentional activities under direct human volition [39], current evidence, in conjunction with implementation of randomized trials will further aid in determining whether successful alteration of emotional well-being favorably impacts heart health. In conclusion, the field of health psychology is shifting away from a narrow, ill-being focus on negative psychological states toward a broader view that includes psychological well-being as well.

14 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 15 of 23

Acknowledgements Rosalba Hernandez is funded by the National Heart, Lung, and Blood Institute (NHLBI) through award number 1K01HL130712-01A1. The Hispanic Community Health Study/Study of Latinos was carried out as a collaborative study supported by contracts from the National Heart, Lung, and Blood Institute (NHLBI) to the University of North Carolina (N01-HC65233), University of Miami (N01-HC65234), Albert Einstein College of Medicine (N01-HC65235), Northwestern University (N01-HC65236), and San Diego State University

rp Fo

(N01-HC65237). The following Institutes/Centers/Offices contribute to the HCHS/SOL through a transfer of funds to the NHLBI: National Center on Minority Health and Health Disparities, the National Institute of Deafness and Other Communications Disorders, the National Institute of

ee

Dental and Craniofacial Research, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute of Neurological Disorders and Stroke, and the Office of Dietary

rr

Supplements. The authors thank the staff and participants of HCHS/SOL for their important

ev

contributions. A complete list of staff and investigators has been provided by Sorlie P., et al. in Ann Epidemiol. 2010 Aug; 20: 642-649 and is also available on the study website

ie

http://www.cscc.unc.edu/hchs/.

w

Contributors DW and RH researched data. HMG, WT, JTM, MRC, LCG, FJP, CRI, JMR, WA,

on

CB, SD, FG, and JLM reviewed/edited the full manuscript. MLD researched data, contributed to discussion, and extensively reviewed/edited the manuscript. RH wrote the manuscript.

ly

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

Competing interests The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Participant consent Obtained. Ethics approval IRB at each collaborating institution.

15 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

Provenance and peer review Not commissioned; internal peer review process. Data sharing statement The data and computer code used for this analysis reside at UNC Chapel Hill. The HCHS/SOL fully supports data sharing with outside investigators through processes internal to the study, based on a Data and Materials Distribution Agreement (DMDA) to protect the confidentiality and privacy of the HCHS/SOL participants and their families.

rp Fo

Alternatively, de-identified HCHS/SOL data are publically available at BioLINCC and dbGaP for the subset of the study cohort that authorized general use of their data at the time of informed consent.

w

ie

ev

rr

ee ly

on

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 16 of 23

16 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 17 of 23

References 1.

2. 3. 4.

5. 6. 7.

9.

13.

17.

18. 19. 20.

ly

16.

on

15.

w

14.

ie

12.

ev

11.

rr

10.

ee

8.

Lichtman, J.H., et al., Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: systematic review and recommendations a scientific statement from the American Heart Association. Circulation, 2014. 129(12): p. 1350-1369. Labarthe, D.R., et al., Positive Cardiovascular Health: A Timely Convergence. Journal of the American College of Cardiology, 2016. 68(8): p. 860-867. Labarthe, D.R., From Cardiovascular Disease to Cardiovascular Health A Quiet Revolution? Circulation-Cardiovascular Quality and Outcomes, 2012. 5(6): p. E86-E92. DuBois, C.M., et al., Relationships between positive psychological constructs and health outcomes in patients with cardiovascular disease: a systematic review. International journal of cardiology, 2015. 195: p. 265-280. DuBois, C.M., et al., Positive Psychological Attributes and Cardiac Outcomes: Associations, Mechanisms, and Interventions. Psychosomatics, 2012. 53(4): p. 303-318. Boehm, J.K., et al., Relation between optimism and lipids in midlife. Am J Cardiol, 2013. 111(10): p. 1425-31. Anthony, E.G., D. Kritz-Silverstein, and E. Barrett-Connor, Optimism and Mortality in Older Men and Women: The Rancho Bernardo Study. Journal of aging research, 2016. 2016. Giltay, E.J., et al., Dispositional optimism and all-cause and cardiovascular mortality in a prospective cohort of elderly dutch men and women. Archives of General Psychiatry, 2004. 61(11): p. 1126-1135. Boehm, J.K. and L.D. Kubzansky, The heart's content: the association between positive psychological well-being and cardiovascular health. Psychological bulletin, 2012. 138(4): p. 655. Ford, E.S., K.J. Greenlund, and Y. Hong, Ideal cardiovascular health and mortality from all causes and diseases of the circulatory system among adults in the United States. Circulation, 2012. 125(8): p. 987-95. Hernandez, R., et al., Optimism and cardiovascular health: multi-ethnic study of atherosclerosis (MESA). Health behavior and policy review, 2015. 2(1): p. 62-73. Sorlie, P.D., et al., Design and Implementation of the Hispanic Community Health Study/Study of Latinos. Annals of Epidemiology, 2010. 20(8): p. 629-641. Gallo, L.C., et al., The Hispanic community health study/study of Latinos sociocultural ancillary study: Sample, design, and procedures. Ethnicity & disease, 2014. 24(1): p. 77. Scheier, M.F., et al., The life engagement test: Assessing purpose in life. Journal of behavioral medicine, 2006. 29(3): p. 291-298. Lloyd-Jones, D.M., et al., Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction The American Heart Association's Strategic Impact Goal Through 2020 and Beyond. Circulation, 2010. 121(4): p. 586-613. González, H.M., et al., Cardiovascular health among diverse Hispanics/Latinos: Hispanic Community Health Study/Study of Latinos (HCHS/SOL) results. American heart journal, 2016. 176: p. 134-144. Folsom, A.R., et al., Community Prevalence of Ideal Cardiovascular Health, by the American Heart Association Definition, and Relationship With Cardiovascular Disease Incidence. Journal of the American College of Cardiology, 2011. 57(16): p. 1690-1696. Laitinen, T.T., et al., Ideal Cardiovascular Health in Childhood and Cardiometabolic Outcomes in AdulthoodClinical Perspective. Circulation, 2012. 125(16): p. 1971-1978. Rasmussen-Torvik, L.J., et al., Ideal Cardiovascular Health Is Inversely Associated With Incident Cancer The Atherosclerosis Risk in Communities Study. Circulation, 2013. 127(12): p. 1270-+. LaMonte, M.J., et al., Physical activity, physical fitness, and Framingham 10-year risk score: the cross-cultural activity participation study. J Cardiopulm Rehabil, 2001. 21(2): p. 63-70.

rp Fo

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

BMJ Open

17 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

BMJ Open

21.

22. 23. 24. 25. 26. 27. 28.

30.

33.

38. 39.

ly

37.

on

36.

w

35.

ie

34.

ev

32.

rr

31.

ee

29.

Arredondo, E.M., et al., Physical activity levels in US Latino/Hispanic adults: Results from the Hispanic Community Health Study/Study of Latinos. American journal of preventive medicine, 2016. 50(4): p. 500-508. Ware, J.E., M. Kosinski, and S.D. Keller, A 12-item short-form health survey - Construction of scales and preliminary tests of reliability and validity. Medical Care, 1996. 34(3): p. 220-233. Radloff, L.S., The CES-D scale A self-report depression scale for research in the general population. Applied psychological measurement, 1977. 1(3): p. 385-401. LaVange, L.M., et al., Sample design and cohort selection in the Hispanic Community Health Study/Study of Latinos. Annals of epidemiology, 2010. 20(8): p. 642-649. Bottai, M., B. Cai, and R.E. McKeown, Logistic quantile regression for bounded outcomes. Statistics in medicine, 2010. 29(2): p. 309-317. Pressman, S.D. and S. Cohen, Does positive affect influence health? Psychological bulletin, 2005. 131(6): p. 925. Chida, Y. and A. Steptoe, Positive psychological well-being and mortality: a quantitative review of prospective observational studies. Psychosomatic medicine, 2008. 70(7): p. 741-756. Howell, R.T., M.L. Kern, and S. Lyubomirsky, Health benefits: Meta-analytically determining the impact of well-being on objective health outcomes. Health Psychology Review, 2007. 1(1): p. 83-136. Trudel-Fitzgerald, C., et al., Taking the tension out of hypertension: a prospective study of psychological well being and hypertension. Journal of hypertension, 2014. 32(6): p. 1222-1228. DuBois, C.M., et al., Relationships between positive psychological constructs and health outcomes in patients with cardiovascular disease: A systematic review. International Journal of Cardiology, 2015. Boehm, J.K., et al., A Prospective Study of Positive Psychological Well-Being and Coronary Heart Disease. Health Psychology, 2011. 30(3): p. 259-267. Boehm, J.K., et al., The prospective association between positive psychological well-being and diabetes. Health Psychol, 2015. 34(10): p. 1013-1021. Kruse, E. and K. Sweeny, Comment: Well-Being Can Improve Health By Shaping Stress Appraisals. Emotion Review, 2017. Ryff, C.D., B.H. Singer, and G.D. Love, Positive health: Connecting well-being with biology. Philosophical Transactions-Royal Society of London Series B Biological Sciences, 2004: p. 1383-1394. Sin, N.L., J.T. Moskowitz, and M.A. Whooley, Positive affect and health behaviors across 5 years in patients with coronary heart disease: the heart and soul study. Psychosomatic medicine, 2015. 77(9): p. 1058-1066. Carvajal, S.C., et al., Psychosocial determinants of the onset and escalation of smoking: crosssectional and prospective findings in multiethnic middle school samples. Journal of adolescent health, 2000. 27(4): p. 255-265. Shepperd, J.A., J.J. Maroto, and L.A. Pbert, Dispositional optimism as a predictor of health changes among cardiac patients. Journal of research in personality, 1996. 30(4): p. 517-534. Kelloniemi, H., E. Ek, and J. Laitinen, Optimism, dietary habits, body mass index and smoking among young Finnish adults. Appetite, 2005. 45(2): p. 169-176. Lyubomirsky, S., K.M. Sheldon, and D. Schkade, Pursuing happiness: The architecture of sustainable change. Review of General Psychology, 2005. 9(2): p. 111-131.

rp Fo

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

Page 18 of 23

18 For peer review only - http://bmjopen.bmj.com/site/about/guidelines.xhtml

Page 19 of 23

Table 1. Definitions for the 3-category indicator of Cardiovascular Health, per AHA specifications Cardiovascular HealthLS7 Indicators 3 health behaviors Diet* Physical activity

Smoking

Poor

Intermediate

Ideal

0-1 None

2-3 1-149 min/wk moderate, or 1-74 min/wk vigorous, or 1-149 min/wk combined intensity Former smoker who quit ≤ 12 months ago

4-5 ≥150 min/wk moderate, or ≥75 min/wk vigorous, or ≥150 min/wk combined intensity Never smoked or quit > 12 months ago

Current smoker

4 biological markers BMI (kg/m2) Blood pressure (mm Hg)

≥30 or