Introduction Emotional Longevity:
Toward a New Definition
of Health
The greatest compliment I have ever received came from my mother, in her last words, on the last day of her life. She said, "You are becoming just like me."
As a son I've often pondered the meaning and significance of what she said, as I've pondered her long and vital life. What did it mean to be just like her? I will perhaps never fully understand the meaning she intended by her statement, but I do know that my mother possessed many characteristics worthy of emulation. Among the most impressive was the harmony of her moods, where anger or fear were rarely evident and sadness was short-lived, but where contentment, joy, and happiness were nearly ever present, even when external circumstances were less than uplifting.
As a psychologist and a health researcher, I have also pondered how science could uncover what contributed to my mother's emotional symmetry, and her longevity, and make it available for everyone. To uncover in a sense what it means to be truly whole, in body, mind, and spirit, and package it for all. Although this is a tall order for science, I think we are actually getting close-closer than we've ever been before. This book is about a new revolution in health science that is getting us there, and in doing so is literally transforming what it means to be healthy and demonstrating how we can enhance the quality and length of our lives.
These days when you hear about a revolution in health science, you are in all probability hearing about the genetics revolution, and for good reason. Genetics has already transformed biological science and has the promise to change the practice of medicine. But health science is also experiencing another revolution-one that is less publicized but is, in some respects, as complex and profound as the recent breakthroughs in genetics. This other revolution, like the one in genetics, is fueled by rigorous scientific methodology and advanced statistical analyses. But, unlike the genetics revolution, this one can be brilliantly illuminated in the lives of everyday people. People who have the kinds of lives most of us strive for-lives that are happy, fulfilled, confident, mentally engaged, and vital. These are people who are able to hold off sickness until the very end of long lives and who do not suffer through years of chronic illness. If illness comes, these are people who recover faster or who, like my mother, are able to maintain a sense of emotional and psychological well-being, and perhaps even grow from the experience.
My mother, Lois Anna Jones Anderson, died in 1992 at the age of seventy-eight. Although she was ultimately claimed by cancer, the arc of her life and her senior years were characterized by strong health and vigor. For nearly fifty years she and my father served as copastors of a sizable Baptist church in North Carolina, making her one of the first women leaders of a large Southern congregation. Though leading a congregation was not always heaven on earth, my mother reveled in the rich and rewarding life of the church. It provided her an intellectual outlet, where she prepared weekly sermons and Bible-study lessons. Her personal relationships were broad and deep, not only with members of the church but also with many people in the community. These people provided her with a vast network of mutual support. My mother also had a very keen mind and loved to read on a variety of topics, but she especially loved books on spiritual matters. When she married my father, she had only finished high school, but she valued education so much that she squeezed in college courses between church duties and raising a family. She earned a bachelor's and a master's degree and was ultimately awarded an honorary doctorate in theology.
My mother's life was not perfect, and she had her share of negative experiences. At the age of eight, she was devastated by the death of her own mother. Two years later her younger sister died of an infection after accidentally sticking a pencil in her eye. While still coping with those deaths, she lost the security of her home in Norfolk, Virginia, when her father abruptly moved the family to New York City. She suffered several miscarriages trying to have children. Much later in life my mother coped with several debilitating chronic illnesses in the family, from Alzheimer's disease in two sisters and a brother to my father's coma following a heart attack, which left him in a deep vegetative state for eighteen months. When my father died, my mother took over the reins of the two-thousand-member church alone, at the age of seventy. This was to be another trying time for her. As many historians have documented, women leaders in the church are often met with strong opposition. My mother had been a full partner with my father, providing spiritual guidance and counsel to all church members. Yet, without my father's presence, a few vocal male leaders of the congregation could not adjust to a woman at the helm. These men spearheaded a very bitter and ugly revolt, which severely divided the church. To end the turmoil, my mother, after much thought and prayer, relinquished her leadership and graciously resigned. In essence, saving the church meant losing the defining element of her life: that of a church leader at the institution she helped build, nurture, and strengthen.
It was during times of trauma and challenge that I was most impressed with my mother. She always faced obstacles with a combination of dignity, faith, wisdom, optimism, and quiet confidence. She seemed to rise above circumstances that would leave most of us reeling. In fact, it was during her ultimate battle with cancer that her remarkable attributes were most clearly manifest.
By any measure my mother had achieved what has come to be known as "successful aging," defined as experiencing minimal disease or disability until the end of life, a high level of mental and physical functioning, and an engagement in life.1 She enjoyed a high quality of life-even in the presence of untoward circumstances-something we would all like to achieve. But is her experience realistic for most of us? Is it really possible to avoid the sickness and disability thought to inevitably accompany old age? Can we hope to achieve or maintain physical, mental, and emotional health as we grow older? Is it possible to have a positive outlook on life and experience happiness in the presence of negative life circumstances?
Science has progressed to a point where I believe that the answer to these questions is unequivocally "Yes!" New research is uncovering not only the dimensions of successful aging but also the elements of a larger phenomenon that I call emotional longevity. Although the expression may appear at first to connote long-lasting emotions, my meaning is very different. "Emotional longevity" is a symbolic rather than literal expression, meant to signal a departure from traditional ways of thinking about longevity. In the past we have thought of longevity, either implicitly or explicitly, as determined primarily by biology, but the phrase "emotional longevity" symbolizes a shift in emphasis away from an exclusive focus on biology. It serves to highlight the essence of the new way of thinking about longevity and health, an essence characterized by connections-connections between biology and social relationships; between biology and beliefs and behavior; and between biology and emotions. Science is now documenting these and other connections and showing us that attaining physical and mental health and longevity involves much more than being biologically sound, and even more than staying physically fit and eating a proper diet. Emotional longevity is the idea that these connections, between biological and nonbiological factors,2 occurring across the life span, are what ultimately determine our health, the quality of our lives, and how long we live.
This book is about the science that has uncovered these connections and how they affect our health. It is also about people, like my mother, whose lives illustrate the new scientific findings, which together are changing our views on what it means to be healthy.
SO WHAT DOES IT MEAN TO BE HEALTHY?
The traditional answer to this question is fairly straightforward: Being healthy means an absence of disease. With no diagnosis or symptoms, traditional medical science gives us a clean bill of health. This does not mean that well-known risk factors for disease are ignored; cigarette smoking, high cholesterol, and obesity do raise concern. But in the absence of a diagnosable illness, we are still considered "healthy." Yet the absence of disease, even the absence of traditional risk factors, can be misleading.
Are We Missing Something?
In this book I discuss research that tracks large groups of individuals, often for years, who are free of disease. Invariably a certain percentage of these individuals die prematurely from illnesses that were not predicted based on their age, initial health, or established risk factors. If we define health simply as the absence of disease or traditional biological or behavioral risk factors, we are obviously missing something important. But what? One answer could legitimately come from genetics, since we know that certain illnesses have a strong genetic component. Yet future genetic tests will likely leave a large gap in the ability to accurately predict longevity and will further serve to highlight the need to encompass nonbiological aspects of disease.
For example, identical twins, because they share the same genetic structure, are at the same genetic risk for illness. Yet even twins vary tremendously in their experience of health problems such as cancer, heart disease, Alzheimer's disease, schizophrenia, Parkinson's disease, hypertension, and rheumatoid arthritis.3 Here is a case in point: A study of the prevalence of cancer in twins, involving over 44,000 pairs of twins, was recently published in the New England Journal of Medicine.4 The study was designed to estimate the relative importance of heritable and environmental factors in causing cancer. While genetic factors were clearly associated with different types of cancer in this study, they had less impact than environmental factors. The researchers noted that "inherited genetic factors make a minor contribution to susceptibility to most types" of cancer and "that the overwhelming contributor to the causation of cancer...was the environment."
Something other than genes alone or, more likely, something working in conjunction with genes, is determining whether one twin gets sick while his/her genetically identical sibling stays well. Animal studies have demonstrated that social, behavioral, and environmental factors can actually determine whether genes are expressed-that is, whether they are turned on or off. For example, stress has been shown to cause symptoms of diabetes, such as hyperglycemia, in animals that are genetically susceptible to diabetes. Animals not exposed to stress conditions were less likely to develop hyperglycemia or diabetes, even though they were genetically prone to the disorder.5
One thing is certain: Individuals determined to be at genetic risk for illness will be very motivated to do whatever is in their power to remain healthy. In the absence of gene therapies or gene-specific drugs, we will have to look for other avenues, including nonbiological ones, to keep people healthy. Health researchers are on a search for the missing components, the other nongenetic factors, that determine our health. This is a search that goes beyond even the well-known "lifestyle" factors such as diet, exercise, and smoking.
The fact that we are missing important dimensions of what constitutes health is also starkly illustrated in studies on something called self-rated health. Participants in these studies, who are of the same age, are asked to rate their health on a scale of one to five, where one is "excellent" and five is "poor." Results show that people who are free of disease, symptoms, and risk factors, but who nevertheless rate their own health as "fair or poor," are likely to die at an earlier age than individuals who rate their health as "good or excellent."6 What does this mean? Why would a self-rating of poor health predict premature death in the absence of disease, symptoms, or risk factors? Were these participants tapping in to other dimensions of their own health? What was it that they sensed was awry? We can assume that they were not "sensing" a poor genetic makeup. More plausibly they were tapping in to other dimensions of health, dimensions that over time may alter their biology, leading to premature death. This book describes many remarkable studies that have not only identified these dimensions but have also conclusively linked them with biological functioning in the short term (e.g., immune and cardiovascular functioning) and with illness and longevity over the long term.
The experience of people with specific illnesses such as heart disease, cancer, or AIDS also highlights the need to broaden our definition of the determinants of health and longevity. People with such illnesses experience a wide range of outcomes. Some recover completely, with no sign of observable illness. Others, even though they continue to have the illness, are able to live productive or fulfilling lives. Yet for others the disease continues its negative progression, often leading to severe disability and death. Still others become emotionally debilitated by their illnesses. You might even say that some people with an illness are "healthier" than others with the same diagnosis. Heart disease is a perfect example. Among people who suffer heart attacks of similar severity, some recover with minimal physical impairment. Others become significantly disabled, unable to resume many previous activities. Many others go on to have subsequent heart attacks or die from the disorder sooner than their counterparts. These differences among heart patients often arise even when there are no differences in age, gender, race or ethnicity, risk factors, cardiovascular pathology, or their level of participation in rehabilitation programs. What these studies suggest, then, is that among the medically ill there are important determinants of longevity that go beyond medical features of a disease. A patient's prognosis may depend on more than the usual laundry list of biological or behavioral characteristics.
A New Definition of Health
What, then, determines the wide differences in longevity among the physically healthy and those with medical illnesses? What are the missing pieces? Over the last decades science has been inching closer to identifying these pieces. In fact, health research has come to a watershed that indicates a need to transform our previous notions and that is, in essence, leading to a new definition of health.
Specifically, the new definition of health holds that health is multifaceted and includes six fundamental dimensions, the missing pieces. As depicted in Figure 1, these dimensions include:
* Biological well-being-biology in the figure
* Psychological and behavioral well-being-thoughts & actions in the figure
* Environmental and social well-being-environment & relationships in the figure
* Economic well-being-personal achievement & equality in the figure
* Existential/religious/spiritual well-being-faith & meaning in the figure
* Emotional well-being-emotions in the figure
Your biological status is very important, but your health is more than that alone. It has a psychological and behavioral dimension that takes into account the well-known lifestyle factors ("actions") such as physical activity, diet, and smoking but also includes less recognized factors such as our expectations, explanations, and beliefs ("thoughts"); and how we respond to traumatic experiences. There is an environmental and social dimension that includes characteristics of the physical environments in which we live (e.g., level of pollution, type of housing, neighborhood safety), and our relationships with others, on both an interpersonal and societal level. The economic dimension includes not only our educational attainment and income level, but also the notion of economic equality-degree of economic difference between the most and the least well off in society. The existential/religious/spiritual dimension relates to, among other things, our beliefs and actions that help us foster a sense of meaning in our lives. For many people, meaning is fostered through religious or spiritual activities, but may also be developed through a variety of other pursuits. The final dimension, emotional well-being, involves the degree to which we experience both negative and positive emotional states. As you will read later, I believe this emotional dimension is an essential part of the "connective tissue" that links the other elements to physical well-being and longevity.
Do we really gain anything by adding these additional dimensions under the rubric of health? I argue that we do, since our lives-how we feel about our existence in general-depend in large part on our emotional, social, economic, and spiritual well-being. When we are saddened or afraid, when we are socially isolated or lonely, or when we are having financial difficulties, our lives are substantially less fulfilling. Many of the largest pharmaceutical companies now include quality-of-life measures to evaluate the effectiveness of their drugs that include emotional and psychological well-being, not just whether the patients are biologically better off.7 There is a growing recognition that a life that is less emotionally, psychologically, and socially fulfilling is a less healthy life. And the World Health Organization (WHO) agrees. In its definition of health, WHO includes social, psychological, and physical well-being as important components.8
You may ask, "What is really new about this expanded, multidimensional view of health?9 Isn't this just a repackaging of the old idea of holistic health?" This redefinition does indeed have some similarity with the concept of holistic health. Both share a core philosophy that health and illness are determined by many factors, not just the biological ones. But unlike the concept of holistic health, the new definition of health comprises dimensions that stem from, and are substantiated by, the highest standards of scientific research, research that has identified what I believe are six dimensions as the key determinants of health and longevity. It is this foundation in rigorous scientific methodology that sets the new definition of health apart from the philosophically similar idea of holistic health. In the former, notions about health and longevity are accepted or rejected based on the outcome of carefully designed studies. In the latter, scientific verification is less critical than are intuitive appeal and personal experience. Not that intuitive appeal and personal experience are unimportant. In fact, they are often the first phase of the scientific process. I personally enjoy a certain type of yoga, which I am convinced helped me heal an injury, but I have no scientific proof. However, I continue to practice it and believe that it helps me. By contrast, the dimensions of the new definition of health, and specific elements of each, have passed both the intuitive and the scientific tests. As you will see in subsequent chapters, however, intuitive and everyday beliefs about nonbiological dimensions of health are not always complete or accurate.
Research now conclusively shows that the more comprehensive, multidimensional, and expanded view of health described in this book is the most scientifically accurate one and will help us improve the understanding, treatment, and prevention of disease. Using the new definition, health is not defined as just the absence of disease, and sickness is not defined by deficiencies in any dimension of health. One of the criticisms of the WHO definition of health is that it defines health as the "complete state of physical, mental, and social well-being." Many scientists took issue with the word "complete" because it implied that if you are not experiencing 100 percent mental or social well-being (regardless of how it is defined), then you might be considered sick.10 By such standards a majority of the world's population could be considered under the weather. My view of the new definition of health is that the dimensions should be viewed not diagnostically but, rather, prognostically. That is, deficiencies in any of the dimensions should not be labeled illness but should be looked at as (1) something that might increase or decrease overall quality and enjoyment of life and (2) something that might increase or decrease risk for actual disease. The first one is obvious. Having diminished emotional, social, psychological, or existential well-being is clearly not desirable and therefore can effect day-to-day experiences of life. The second one is less obvious and is the focus of this book. Dimensions of the new definition of health contain specific elements that are powerful determinants of longevity. Some of these elements increase risk for disease, while others protect health. As I pointed out earlier, having deficiencies in any of the elements does not represent illness, but it does represent warnings-signals that there is more we can do to optimize our health or avoid or recover from disease.
A theme of this new way of thinking about health is that of interconnectedness. Few illnesses that we suffer arise from biological processes alone, but instead from the interplay between our biological makeup, our social and physical environment, our thoughts and behavior, and our emotions.11 This interplay determines in large part who gets sick, who stays well, and who recovers from, adapts to, or survives illnesses. Consider these facts about the six dimensions of health:
l Each of the dimensions and its related elements is strongly and unequivocally linked to physical illness and longevity. Because of this, they all must now be considered crucial aspects of any definition of health.
* The dimensions are linked to one another, such that changes in one can precipitate changes in the others. In particular, changes in biological status (e.g., immune-system functioning) can be produced by changes in each of the other dimensions. Emotional, psychological, social, and spiritual well-being all have profound effects on the biological mechanisms that lead to illnesses.
* Health is often determined by an accumulation of risk and protective factors from across several of the dimensions.
These three facts about the six dimensions of health are very important because they help us get away from a kind of either/or thinking about physical illnesses. That is, either my illness is due to a "real" biological cause, which means I can exclude nonbiological causes, or it's "all in my head" because an acceptable biological cause can't be found. In this book, you will learn that our thoughts, our relationships, and our emotions have real biological consequences and need to be part of our health profile as much as biological lab tests. In fact, biological and nonbiological risks for illness may work in combination. A great illustration of this combined effect is the research on ulcers, which is recounted by Dr. Robert Sapolsky in his classic book, Why Zebras Don't Get Ulcers. For decades, a good deal of research had shown a connection between stress and ulcers. Because of this kind of research, it became common knowledge among physicians and the public that ulcers could be caused by stress. Then, in the 1980s, it was discovered that a bacterium called Helicobacter pylori, or H. pylori, was associated with 85 percent to 100 percent of ulcers. The high prevalence of H. pylori in ulcer patients, coupled with the fact that treatment of the bacterium with antibiotics could cure the problem, led to a widespread rejection of the stress hypothesis for ulcers. A bacterium was in, and stress was out. Many biomedical scientists and physicians now say things like "We once thought ulcers were caused by stress, but now we know they are caused by bacteria" in the same tone as saying "We used to think the Earth was flat, now we know it is round."
But a closer look at the data provides a different picture. First, according to Sapolsky, up to 15 percent of people who get ulcers are not infected with H. pylori at all. More remarkably, although most people who have ulcers also have H. pylori, only about 10 percent of people infected with H. pylori actually get an ulcer. So if you get a certain type of ulcer, you are likely infected with H. pylori. But just because you are infected with H. pylori does not necessarily mean you will get an ulcer. The same can be said about stress. Just because you experience a great deal of stress does not mean you will get an ulcer-most people under intense stress don't get ulcers. But what is most fascinating about the ulcer research is that it now appears that ulcers are actually caused by a combination of stress and H. pylori. According to Sapolsky, in the presence of major life stressors, the addition of a small amount of bacteria inevitably leads to ulcers. On the other hand, in the presence of lots of bacteria, it takes only a small amount of stress to cause an ulcer. Of course, ulcers can be caused by many other things, not just stress and bacteria. But the point here is that factors within both the biological and nonbiological dimensions can combine to affect health outcomes.
THE EMERGENCE OF A NEW HEALTH SCIENCE
Three pivotal scientific trends, developing mainly within the last two decades, have fueled the expanded view of health, resulting in a new approach to health science. The first trend is the growth and increased methodological sophistication of research on nonbiological aspects of disease. Although there has long been an interest among social and behavioral scientists in factors such as stress, emotions, and social relationships and their connections to health, until recently this research has not met the highest scientific standards. Because of this, its acceptance within the medical establishment, such as in large medical centers and at the National Institutes of Health, was minimal. However, since the early 1980s there has been a proliferation of studies on the nonbiological elements of health that use the most rigorous research methods. These include (1) better measurement of concepts such as social relationships, stress, and depression, (2) longitudinal (i.e., long-term) studies to track the health of large populations over time, (3) randomized controlled trials to evaluate interventions, and (4) more sophisticated statistical analyses of study data.
The second trend has been more theoretical and philosophical in nature. It is the trend toward a clearer understanding and articulation of the manifold connections between our biological makeup, our psychological and emotional characteristics, and our social environments. The new view of health goes one step further than the concept that nonbiological factors are important to health. In the new view of health, these various dimensions are not truly separable. They are in fact inextricably connected, with each having the ability to influence, and be influenced by, the others. Nothing is purely social, biological, psychological, and so forth. No one element of health is self-contained-the status of each is multiply determined, even the status of our immune, cardiovascular, and neuroendocrine systems and the expression of our genes.
The third trend is a product of the first two: the rise of what is called interdisciplinary research, the sine qua non of the new health science.12 Interdisciplinary research occurs when scientists from different disciplines, with expertise in the different aspects of health, combine their expertise to illuminate new connections between the various dimensions. Perhaps the most exciting type of interdisciplinary research has been between scientists trained in the behavioral and social sciences and those trained in the biological sciences. Scientists with backgrounds in psychology, sociology, anthropology, and public health are working with those trained in immunology, oncology, cardiology, and genetics. To those who are not health scientists, this may not seem like a major accomplishment, but the historic chasm between these fields has been oceanic. Social and behavioral scientists and biomedical scientists have largely ignored each other's research, even if they were all interested in the same health problem. When they did pay attention to one another, it usually consisted of one camp's criticizing the other as "soft science" and "irrelevant" to health, or "reductionistic" and "narrow." Very little real communication usually occurred across this chasm.
But all this is changing. The chasm is being bridged. Research in the health sciences is approaching a critical mass of social, behavioral, and biological scientists who are working together, making unprecedented discoveries, and changing the terrain of health science. This interdisciplinary research is the heart and soul of the new health science. What they are finding is intriguing and often surprising. This book chronicles some of the most important and fascinating findings of these studies.
Each chapter of this book describes a small sample of some of the most exciting, innovative, and cutting-edge research that provides clear illustrations of the six dimensions of the new definition of health and their connections with one another. I say "small sample" of research because the explosion of science in this field makes it impossible to describe everything. So I picked topics within each dimension of health that I thought were exemplary. In this book, you will learn that your physical health and longevity can be affected by:
* your expectations about the future
* how you explain things that happened in your past
* your friendships and social ties
* your education and income
* the degree of control you have in your work
* traumatic experiences you have never disclosed
* your ability to find meaning in negative life experiences
* your experience of three key emotions
These and other topics featured in this book do more than shed light on and provide a scientific basis for the new definition of health. The studies I will describe to you often confirm or refute proverbial wisdom about what is healthy and what is not. Is it always good to look on the bright side? Does every cloud have a silver lining? Is venting emotions the best way to handle pent-up distress? Are the health benefits of marriage as good for the goose as for the gander? Is it best always to be realistic, to see things clearly and accurately? The answers to these and other questions might surprise you.
Finally, but of equal importance, is the fact that this book is about more than science. It is also about people. People whose lives put a human face on the amazing discoveries I will share. Some of these people you might recognize, such as entrepreneur Wally "Famous" Amos, Parade magazine editor Walter Anderson, author and poet Maya Angelou, television professional Linda Ellerbee, Duke University basketball coach Michael Krzyzewski, and former Atlanta mayor and U.S. ambassador to the United Nations Andrew Young. Others may be unfamiliar to you, but they have equally compelling stories. Their lives exemplify how the new dimensions of health can be used to achieve a high quality of life and overall emotional and physical well-being.
--from Emotional Longevity: What Really Determines How Long We Live by Dr. Norman B. Anderson with P. Elizabeth Anderson, Copyright © 2003 by Norman B. Anderson, published by Viking Press, a member of Penguin Group (USA) Inc., all rights reserved, reprinted with permission from the publisher.