A randomized controlled trial of positive-affect induction to promote physical activity after percutaneous coronary intervention

The effects of optimism and gratitude on adherence, functioning and mental health following an acute coronary syndrome

OBJECTIVE

This study examined the effects of optimism and gratitude on self-reported health behavior adherence, physical functioning and emotional well-being after an acute coronary syndrome (ACS).

METHODS

Among 156 patients, we examined associations between optimism and gratitude measured 2 weeks post-ACS and 6-month outcomes: adherence to medical recommendations, mental and physical health-related quality of life (HRQoL), physical functioning, depressive symptoms and anxiety. Multivariable linear regression models were used, controlling for increasing levels of adjustment.

RESULTS

Optimism [β=.11, standard error (S.E.)=.05, P=.038] and gratitude (β=.10, S.E.=.05, P=.027) at 2 weeks were associated with subsequent self-reported adherence to medical recommendations (diet, exercise, medication adherence, stress reduction) at 6 months in fully adjusted models. Two-week optimism and gratitude were associated with improvements in mental HRQoL (optimism: β=.44, S.E.=.13, P=.001; gratitude: β=.33, S.E.=.12, P=.005) and reductions in symptoms of depression (optimism: β=-.11, S.E.=.05, P=.039; gratitude: β=-.10, S.E.=.05, P=.028) and anxiety (optimism: β=-.15, S.E.=.05, P=.004; gratitude: β=-.10, S.E.=.05, P=.034) at 6 months.

CONCLUSION

Optimism and gratitude at 2 weeks post-ACS were associated with higher self-reported adherence and improved emotional well-being 6 months later, independent of negative emotional states. Optimism and gratitude may help recovery from an ACS. Interventions promoting these positive constructs could help improve adherence and well-being.

Effects of Optimism and Gratitude on Physical Activity, Biomarkers, and Readmissions After an Acute Coronary Syndrome: The Gratitude Research in Acute Coronary Events Study

BACKGROUND

Positive psychological constructs, such as optimism, are associated with beneficial health outcomes. However, no study has separately examined the effects of multiple positive psychological constructs on behavioral, biological, and clinical outcomes after an acute coronary syndrome (ACS). Accordingly, we aimed to investigate associations of baseline optimism and gratitude with subsequent physical activity, prognostic biomarkers, and cardiac rehospitalizations in post-ACS patients.

METHODS AND RESULTS

Participants were enrolled during admission for ACS and underwent assessments at baseline (2 weeks post-ACS) and follow-up (6 months later). Associations between baseline positive psychological constructs and subsequent physical activity/biomarkers were analyzed using multivariable linear regression. Associations between baseline positive constructs and 6-month rehospitalizations were assessed via multivariable Cox regression. Overall, 164 participants enrolled and completed the baseline 2-week assessments. Baseline optimism was significantly associated with greater physical activity at 6 months (n=153; β=102.5; 95% confidence interval, 13.6-191.5; P=0.024), controlling for baseline activity and sociodemographic, medical, and negative psychological covariates. Baseline optimism was also associated with lower rates of cardiac readmissions at 6 months (n=164), controlling for age, sex, and medical comorbidity (hazard ratio, 0.92; 95% confidence interval, [0.86-0.98]; P=0.006). There were no significant relationships between optimism and biomarkers. Gratitude was minimally associated with post-ACS outcomes.

CONCLUSIONS

Post-ACS optimism, but not gratitude, was prospectively and independently associated with superior physical activity and fewer cardiac readmissions. Whether interventions that target optimism can successfully increase optimism or improve cardiovascular outcomes in post-ACS patients is not yet known, but can be tested in future studies.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01709669.

Positive Affect and Health Behaviors Across 5 Years in Patients With Coronary Heart Disease: The Heart and Soul Study

OBJECTIVES

Positive psychological states are linked to superior health and longevity, possibly due to behavioral factors. We evaluated cross-sectional and 5-year associations between positive affect and health behaviors in patients with coronary heart disease (CHD).

METHODS

Outpatients with CHD reported positive affect, physical activity, sleep quality, medication adherence, cigarette smoking, and alcohol use at baseline (n = 1022) and 5 years later (n = 662). Covariates in regression analyses included demographics, cardiac disease severity, and depressive symptoms.

RESULTS

At baseline, higher positive affect (per 1 standard deviation) was associated with better health behaviors: physical activity (odds ratio [OR] = 1.52, 95% 95% confidence interval [CI] = 1.30-1.77, p < .001), sleep quality (OR = 1.24, 95% CI = 1.04-1.48, p = .015), medication adherence (OR = 1.46, 95% CI = 1.12-1.90, p = .005), and nonsmoking (OR = 1.29, 95% CI = 1.06-1.57, p = .012), but was unrelated to alcohol use. Baseline positive affect did not predict health behaviors at follow-up, accounting for baseline behaviors. However, increases in positive affect across 5 years co-occurred with improvements in physical activity (B = 0.023, standard error [SE] = 0.008, p = .002), sleep quality (B = 0.011, SE = 0.005, p = .039), and medication adherence (B = 0.014, SE = 0.004, p < .001), but not smoking status (OR = 1.07, 95% CI = 0.73-1.55, p = .74).

CONCLUSIONS

Positive affect was associated with health behaviors among patients with CHD. Efforts to sustain or enhance positive affect may be promising for promoting better health behaviors.

Is Knowledge Level of Coronary Heart Disease and Risk Factors Among Post-Percutaneous Coronary Intervention Patients Adequate?

BACKGROUND

Percutaneous coronary intervention (PCI) is now commonly used in the treatment of coronary heart disease. However, shorter hospital stays after intervention may affect patients' knowledge and subsequent required lifestyle changes.

OBJECTIVE

The aim of this study is to investigate participants' risk factor profile, knowledge of coronary heart disease, and the influence of demographic and risk factors on this knowledge.

METHODS

This prospective, cross-sectional 1-site study recruited both elective and emergency PCI patients postdischarge. The questionnaire collected data on demographics, risk factor profile, and coronary heart disease knowledge as measured on the Bergman Heart Disease Knowledge Questionnaire. Bivariate and multivariate analyses were used to analyze the influence of 11 risk and sociodemographic factors on knowledge.

RESULTS

The response rate was 67% (n = 84). The sample was mostly male and aged 65.79 ± 9.9 years, and 59% had an elective PCI. Risk factor burden was high; 2 or more risk factors were seen in 66% of participants. Mean knowledge score overall was 51%, with the highest score achieved in the risk factor domain (61%). Lowest scores were in the medical and symptoms domains (both 46%). Neither the bivariate nor the multivariate analyses were significant. A large proportion of patients believed that coronary heart disease was no longer a concern for them after PCI.

CONCLUSIONS

As expected, the risk factor profile of post-PCI patients was high. However, their knowledge levels and awareness were unrelated to risk factor profile and poor in comparison with studies in other cardiac patients. This, in addition to the short stay in hospital and the low attendance of this cohort at cardiac rehabilitation, identifies this group of patients as a priority for further targeted education. Innovations are needed to increase knowledge and begin behavioral change predischarge after PCI. This should include target and goal setting for lifestyle change to avail of this critical education opportunity.

A Systematic Review Exploring the Social Cognitive Theory of Self-Regulation as a Framework for Chronic Health Condition Interventions

Background

Theory is often recommended as a framework for guiding hypothesized mechanisms of treatment effect. However, there is limited guidance about how to use theory in intervention development.

Methods

We conducted a systematic review to provide an exemplar review evaluating the extent to which use of theory is identified and incorporated within existing interventions. We searched electronic databases PubMed, PsycINFO, CENTRAL, and EMBASE from inception to May 2014. We searched clinicaltrials.gov for registered protocols, reference lists of relevant systematic reviews and included studies, and conducted a citation search in Web of Science. We included peer-reviewed publications of interventions that referenced the social cognitive theory of self-regulation as a framework for interventions to manage chronic health conditions. Two reviewers independently assessed articles for eligibility. We contacted all authors of included studies for information detailing intervention content. We describe how often theory mechanisms were addressed by interventions, and report intervention characteristics used to address theory.

Results

Of 202 articles that reported using the social cognitive theory of self-regulation, 52% failed to incorporate self-monitoring, a main theory component, and were therefore excluded. We included 35 interventions that adequately used the theory framework. Intervention characteristics were often poorly reported in peer-reviewed publications, 21 of 35 interventions incorporated characteristics that addressed each of the main theory components. Each intervention addressed, on average, six of eight self-monitoring mechanisms, two of five self-judgement mechanisms, and one of three self-evaluation mechanisms. The self-monitoring mechanisms ‘Feedback’ and ‘Consistency’ were addressed by all interventions, whereas the self-evaluation mechanisms ‘Self-incentives’ and ‘External rewards’ were addressed by six and four interventions, respectively. The present review establishes that systematic review is a feasible method of identifying use of theory as a conceptual framework for existing interventions. We identified the social cognitive theory of self-regulation as a feasible framework to guide intervention development for chronic health conditions.

Social network characteristics associated with weight loss among black and hispanic adults

OBJECTIVE

To examine social network member characteristics associated with weight loss.

METHODS

A cross-sectional examination included egocentric network data from 245 Black and Hispanic adults with BMI ≥ 25 kg/m(2) enrolled in a small change weight loss study. The relationships between weight loss at 12 months and characteristics of helpful and harmful network members (relationship, contact frequency, living proximity, and body size) were examined.

RESULTS

There were 2,571 network members identified. Mean weight loss was -4.8 (±11.3) lbs. among participants with network help and no harm with eating goals vs. +3.4 (±7.8) lbs. among participants with network harm alone. In a multivariable regression model, greater weight loss was associated with help from a child with eating goals (P = 0.0002) and coworker help with physical activity (P = 0.01). Weight gain was associated with having network members with obesity living in the home (P = 0.048) and increased network size (P = 0.002).

CONCLUSIONS

There was greater weight loss among participants with support from children and coworkers. Weight gain was associated with harmful network behaviors and having network members with obesity in the home. Incorporating child and coworker support and evaluating network harm and the body size of network members should be considered in future weight loss interventions.

Design and baseline data from the Gratitude Research in Acute Coronary Events (GRACE) study

BACKGROUND

Positive psychological constructs, especially optimism, have been linked with superior cardiovascular health. However, there has been minimal study of positive constructs in patients with acute coronary syndrome (ACS), despite the prevalence and importance of this condition. Furthermore, few studies have examined multiple positive psychological constructs and multiple cardiac-related outcomes within the same cohort to determine specifically which positive construct may affect a particular cardiac outcome.

MATERIALS AND METHODS

The Gratitude Research in Acute Coronary Events (GRACE) study examines the association between optimism/gratitude 2weeks post-ACS and subsequent clinical outcomes. The primary outcome measure is physical activity at 6months, measured via accelerometer, and key secondary outcome measures include levels of prognostic biomarkers and rates of nonelective cardiac rehospitalization at 6months. These relationships will be analyzed using multivariable linear regression, controlling for sociodemographic, medical, and negative psychological factors; associations between baseline positive constructs and subsequent rehospitalizations will be assessed via Cox regression.

RESULTS

Overall, 164 participants enrolled and completed the baseline 2-week assessment; the cohort had a mean age of 61.5+/?10.5years and was 84% men; this was the first ACS for 58% of participants.

CONCLUSION

The GRACE study will determine whether optimism and gratitude are prospectively and independently associated with physical activity and other critical outcomes in the 6months following an ACS. If these constructs are associated with superior outcomes, this may highlight the importance of these constructs as independent prognostic factors post-ACS.

Variability Modifies Life Satisfaction's Association With Mortality Risk in Older Adults

Greater life satisfaction is associated with greater longevity, but its variability across time has not been examined relative to longevity. We investigated whether mean life satisfaction across time, variability in life satisfaction across time, and their interaction were associated with mortality over 9 years of follow-up. Participants were 4,458 Australians initially at least 50 years old. During the follow-up, 546 people died. After we adjusted for age, greater mean life satisfaction was associated with a reduction in mortality risk, and greater variability in life satisfaction was associated with an increase in mortality risk. These findings were qualified by a significant interaction such that individuals with low mean satisfaction and high variability in satisfaction had the greatest risk of mortality over the follow-up period. In combination with mean life satisfaction, variability in life satisfaction is relevant for mortality risk among older adults. Considering intraindividual variability provides additional insight into associations between psychological characteristics and health.

Relationships between positive psychological constructs and health outcomes in patients with cardiovascular disease: A systematic review

Depression and anxiety are well-known to be associated with adverse health outcomes in cardiac patients. However, there has been less work synthesizing the effects of positive psychological constructs (e.g., optimism) on health-related outcomes in cardiac patients. We completed a systematic review of prospective observational studies using established guidelines. A search of PubMed and PsycINFO databases from inception to January 2014 was used to identify articles. To be eligible, studies were required to assess effects of a positive psychological construct on subsequent health-related outcomes (including mortality, rehospitalizations, self-reported health status) in patients with established heart disease. Exploratory random effects' meta-analyses were performed on the subset of studies examining mortality or rehospitalizations. Seventy-seven analyses from 30 eligible studies (N=14,624) were identified. Among studies with 100 or more participants, 65.0% of all analyses and 64.7% of analyses adjusting for one or more covariates reported a significant (p<.05) association between positive psychological constructs and subsequent health outcomes. An exploratory meta-analysis of 11 studies showed that positive constructs were associated with reduced rates of rehospitalization or mortality in unadjusted (odds ratio=.87; 95% confidence interval [.83, .92]; p<.001) and adjusted analyses (odds ratio=.89; 95% confidence interval [.84, .91]; p<.001); there was little suggestion of publication bias. Among cardiac patients, positive psychological constructs appear to be prospectively associated with health outcomes in most but not all studies. Additional work is needed to identify which constructs are most important to cardiac health, and whether interventions can cultivate positive attributes and improve clinical outcomes.

Small Changes and Lasting Effects (SCALE) Trial: the formation of a weight loss behavioral intervention using EVOLVE

Background

Obesity is a major health problem that disproportionately affects Black and Hispanic adults. This paper presents the rationale and innovative design of a small change eating and physical activity intervention (SC) combined with a positive affect and self-affirmation (PA/SA) intervention versus the SC intervention alone for weight loss.

Methods

Using a mixed methods translational model (EVOLVE), we designed and tested a SC approach intervention in overweight and/ or obese African American and Hispanic adults. In Phase I, we explored participant’s values and beliefs about the small change approach. In Phase II, we tested and refined the intervention and then, in Phase III we conducted a RCT. Participants were randomized to the SC approach with PA/SA intervention vs. a SC approach alone for 12 months. The primary outcome was clinically significant weight loss at 12 months.

Results

Over 4.5 years a total of 574 participants (67 in Phase I, 102 in Phase II and 405 in Phase III) were enrolled. Phase I findings were used to create a workbook based on real life experiences about weight loss and to refine the small change eating strategies. Phase II results shaped the recruitment and retention strategy for the RCT, as well as the final intervention. The RCT results are currently under analysis.

Conclusion

The present study seeks to determine if a SC approach combined with a PA/SA intervention will result in greater weight loss at 12 months in Black and Hispanic adults compared to a SC approach alone.

Positive Psychological Interventions for Patients with Type 2 Diabetes: Rationale, Theoretical Model, and Intervention Development

Most patients with type 2 diabetes (T2D) have suboptimal adherence to recommended diet, physical activity, and/or medication. Current approaches to improve health behaviors in T2D have been variably effective, and successful interventions are often complex and intensive. It is therefore vital to develop interventions that are simple, well-accepted, and applicable to a wide range of patients who suffer from T2D. One approach may be to boost positive psychological states, such as positive affect or optimism, as these constructs have been prospectively and independently linked to improvements in health behaviors. Positive psychology (PP) interventions, which utilize systematic exercises to increase optimism, well-being, and positive affect, consistently increase positive states and are easily delivered to patients with chronic illnesses. However, to our knowledge, PP interventions have not been formally tested in T2D. In this paper, we review a theoretical model for the use of PP interventions to target health behaviors in T2D, describe the structure and content of a PP intervention for T2D patients, and describe baseline data from a single-arm proof-of-concept (N = 15) intervention study in T2D patients with or without depression. We also discuss how PP interventions could be combined with motivational interviewing (MI) interventions to provide a blended psychological-behavioral approach.

Life satisfaction and use of preventive health care services

OBJECTIVE

Although a growing body of research shows that life satisfaction is linked with enhanced health behaviors and physical health, no study has examined life satisfaction's association with use of preventive health care services. From prior research the authors hypothesized that people with higher life satisfaction would be more proactive in taking care of their health, hence more likely to use preventive health care services.

METHOD

Multiple logistic regression models were used to examine the association between life satisfaction and preventive services. Participants were drawn from the Health and Retirement Study, a prospective and nationally representative panel study of adults (age >50). Participants' use of preventive services was collected over 2 years of follow-up.

RESULTS

In models adjusting for sociodemographic factors, each standard deviation increase in life satisfaction was associated with a higher likelihood that people would obtain a cholesterol test. Further, women with higher life satisfaction were more likely to obtain a mammogram-x-ray or pap smear and also regularly check their breasts for lumps, whereas men were more likely to obtain a prostate exam.

CONCLUSION

Higher life satisfaction was associated with higher use of several preventive services. A growing body of randomized controlled trials targeting life satisfaction has shown that levels of life satisfaction are modifiable. Thus, if these findings are replicated, life satisfaction may provide an important target for interventions aimed at enhancing preventive behaviors and health.

Development of a positive psychology intervention to improve adherence in adolescents with type 1 diabetes

INTRODUCTION

Novel interventions are needed to improve adherence to treatment in adolescents with type 1 diabetes. In this article, we describe the development, feasibility, and acceptability of a positive psychology intervention for this population.

METHOD

Adolescents and their parents (n = 39) were randomly assigned to either a positive psychology intervention or an attention control group. Quantitative and qualitative data were collected on feasibility and acceptability. Descriptive and content analysis methods were used.

RESULTS

Recruitment was successful, participation and satisfaction were high in both groups, and retention was excellent over 6 months. In the positive psychology group, adolescents and their parents noted benefits related to increased positive communication and thinking more about diabetes care. We also identified challenges to implementation.

DISCUSSION

Although more research is indicated, a positive psychology framework emphasizing positive emotions and strengths, rather than problems, may be beneficial to adolescents living with a complex chronic illness.

Depression, coronary artery disease, and physical activity: how much exercise is enough?

PURPOSE

The mechanisms by which depressive symptoms negatively affect clinical outcomes in patients with coronary artery disease (CAD) remain poorly understood. Previous interventions that have attempted to treat depressive symptoms in patients with CAD to improve their clinical outcomes have been disappointing. Our objectives were, among a cohort of CAD patients, to evaluate the impact of depressive symptoms over time, controlling for comorbidity, in determining both successful long-term lifestyle change (ie, increased physical activity), and cardiovascular morbidity and mortality outcomes. In addition, we examined the impact of physical activity changes over time on 2 known mediators of cardiovascular morbidity: parasympathetic tone and inflammation.

METHODS

Clinical data were previously collected (2004-2006) from 242 elective/urgent coronary angioplasty patients who participated in a prospective randomized controlled trial evaluating the efficacy of a behavioral intervention versus an educational control to motivate physical activity over 12 months. Exclusion criteria included: (1) inability to walk; (2) enrollment in other risk-reduction trials; (3) non-English speaking; and (4) lack of cardiologist's permission to increase physical activity. Participants were assessed every 2 months for interval clinical events and physical activity. In addition, biomarkers were collected at baseline and at 12 months in a subset of 54 participants; these biomarkers included low-frequency heart rate variability (lfHRV), high-frequency heart rate variability (hfHRV), serum C-reactive protein, interleukin-6, and salivary cortisol.

FINDINGS

The mean age of participants was 63 years and 30% were female. Overall, 37% had high depressive symptoms at baseline. Patients with high depressive symptoms who achieved an increase in physical activity of ≥336 kilocalories(kcal)/week by 12 months had significantly lower rates of cardiovascular morbidity/mortality (5.1% vs. 21.3%; odds ratio [OR], 0.20, [95% CI, 0.04-0.98]; P = 0.03). In a multivariate model examining cardiovascular morbidity/mortality in patients with high depressive symptoms, an increase in physical activity of ≥336 kcal/week reduced the risk of new cardiovascular morbidity/mortality (OR, 0.11 [95% CI, 0.02-0.81]; P < 0.03), and comorbidity increased the risk (OR, 1.58 [95% CI, 1.18-2.13]; P = 0.002). In a generalized structural equation model, increasing physical activity by ≥336 kcal/week decreased the risk of complications, and comorbidity increased the risk. Furthermore, increasing physical activity (≥336 kcal/week) predicted an increase in hfHRV, a marker of parasympathetic tone, and the increase in hfHRV predicted a reduction in the proinflammatory mediators interleukin-6 and C-reactive protein.

IMPLICATIONS

This study found a threshold in physical activity in CAD patients with depressive symptoms that is associated with a decrease in cardiovascular morbidity and mortality. Exercise maintenance at this level may improve clinical outcomes via enhanced parasympathetic tone and decreased inflammation. ClinicalTrials.gov identifier: NCT00248846.

The psychology of change: self-affirmation and social psychological intervention

People have a basic need to maintain the integrity of the self, a global sense of personal adequacy. Events that threaten self-integrity arouse stress and self-protective defenses that can hamper performance and growth. However, an intervention known as self-affirmation can curb these negative outcomes. Self-affirmation interventions typically have people write about core personal values. The interventions bring about a more expansive view of the self and its resources, weakening the implications of a threat for personal integrity. Timely affirmations have been shown to improve education, health, and relationship outcomes, with benefits that sometimes persist for months and years. Like other interventions and experiences, self-affirmations can have lasting benefits when they touch off a cycle of adaptive potential, a positive feedback loop between the self-system and the social system that propagates adaptive outcomes over time. The present review highlights both connections with other disciplines and lessons for a social psychological understanding of intervention and change.

Check it! A randomized pilot of a positive psychology intervention to improve adherence in adolescents with type 1 diabetes

PURPOSE

The purpose of the current study was to pilot-test a positive psychology intervention to improve adherence to diabetes management in adolescents with type 1 diabetes.

METHODS

A total of 39 adolescents (ages, 13-17 years) with type 1 diabetes and their caregivers were randomized to a positive psychology intervention (n = 20) or an attention control (education) intervention (n = 19). The intervention condition used positive psychology exercises (eg, gratitude, self-affirmation), small gifts, and parent affirmations to boost positive affect. Outcomes included frequency of blood glucose monitoring, quality of life, and glycemic control.

RESULTS

No main effects for treatment were observed at the 6-month follow-up. However, there was a significant association between adolescents' levels of positive affect and measures of adherence, including self-report and meter downloads of glucose monitoring.

CONCLUSIONS

The results from the current study support the assertion that positive affect in the context of diabetes education is an important factor to consider in adolescents with type 1 diabetes.

Positive psychological states and health behaviors in acute coronary syndrome patients: A qualitative study

Positive psychological states are linked to superior cardiac outcomes, possibly mediated through increased participation in health behaviors. Trained study staff conducted in-depth semi-structured interviews in the hospital and 3 months later for 34 patients diagnosed with an acute coronary syndrome. These interviews focused on positive psychological states, cardiac health behaviors, and their connection; the interviews were transcribed and independently coded using directed content analysis. Both optimism and positive affect were associated with completion of physical activity and healthy eating in a bidirectional manner. In contrast, gratitude, while common, was infrequently linked to completion of health behaviors.

A yoga intervention for type 2 diabetes risk reduction: a pilot randomized controlled trial

BACKGROUND

Type 2 diabetes is a major health problem in many countries including India. Yoga may be an effective type 2 diabetes prevention strategy in India, particularly given its cultural familiarity.

METHODS

This was a parallel, randomized controlled pilot study to collect feasibility and preliminary efficacy data on yoga for diabetes risk factors among people at high risk of diabetes. Primary outcomes included: changes in BMI, waist circumference, fasting blood glucose, postprandial blood glucose, insulin, insulin resistance, blood pressure, and cholesterol. We also looked at measures of psychological well-being including changes in depression, anxiety, positive and negative affect and perceived stress. Forty-one participants with elevated fasting blood glucose in Bangalore, India were randomized to either yoga (n = 21) or a walking control (n = 20). Participants were asked to either attend yoga classes or complete monitored walking 3-6 days per week for eight weeks. Randomization and allocation was performed using computer-generated random numbers and group assignments delivered in sealed, opaque envelopes generated by off-site study staff. Data were analyzed based on intention to treat.

RESULTS

This study was feasible in terms of recruitment, retention and adherence. In addition, yoga participants had significantly greater reductions in weight, waist circumference and BMI versus control (weight -0.8 ± 2.1 vs. 1.4 ± 3.6, p = 0.02; waist circumference -4.2 ± 4.8 vs. 0.7 ± 4.2, p < 0.01; BMI -0.2 ± 0.8 vs. 0.6 ± 1.6, p = 0.05). There were no between group differences in fasting blood glucose, postprandial blood glucose, insulin resistance or any other factors related to diabetes risk or psychological well-being. There were significant reductions in systolic and diastolic blood pressure, total cholesterol, anxiety, depression, negative affect and perceived stress in both the yoga intervention and walking control over the course of the study.

CONCLUSION

Among Indians with elevated fasting blood glucose, we found that participation in an 8-week yoga intervention was feasible and resulted in greater weight loss and reduction in waist circumference when compared to a walking control. Yoga offers a promising lifestyle intervention for decreasing weight-related type 2 diabetes risk factors and potentially increasing psychological well-being.

TRIAL REGISTRATION

ClinicalTrials.gov Identified NCT00090506.

Promoting patient uptake and adherence in cardiac rehabilitation

BACKGROUND

Cardiac rehabilitation is an important component of recovery from coronary events but uptake and adherence to such programs are below recommended levels. In 2010, our Cochrane review identified some evidence that interventions to increase uptake of cardiac rehabilitation can be effective but there was insufficient evidence to provide recommendations on intervention to increase adherence. In this review, we update the previously published Cochrane review.

OBJECTIVES

To determine the effects, both harms and benefits, of interventions to increase patient uptake of, or adherence to, cardiac rehabilitation.

SEARCH METHODS

We performed an updated search in January 2013 to identify studies published after publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 12, 2012), MEDLINE (Ovid), EMBASE (Ovid), CINAHL EBSCO, Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Thomson Reuters), and National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)) on The Cochrane Library (Issue 4, 2012). We also checked reference lists of identified systematic reviews and randomised controlled trials (RCTs) for additional studies. We applied no language restrictions.

SELECTION CRITERIA

Adults with myocardial infarction, coronary artery bypass graft, percutaneous transluminal coronary angioplasty, heart failure, angina, or coronary heart disease eligible for cardiac rehabilitation and RCTs or quasi-randomized trials of interventions to increase uptake or adherence to cardiac rehabilitation or any of its component parts. We only included studies reporting a primary outcome.

DATA COLLECTION AND ANALYSIS

At least three authors independently screened titles and abstracts of all identified references for eligibility and obtained full papers of potentially relevant trials. At least two authors checked the selection. Three authors assessed included studies for risk of bias.

MAIN RESULTS

The updated search identified seven new studies (880 participants) of interventions to improve uptake of cardiac rehabilitation and one new study (260 participants) of interventions to increase adherence. When added to the previous version of this review, we included 18 studies (2505 participants), 10 studies (1338 participants) of interventions to improve uptake of cardiac rehabilitation and eight studies (1167 participants) of interventions to increase adherence. We assessed the majority of studies as having high or unclear risk of bias. Meta-analysis was not possible due to multiple sources of heterogeneity. Eight of 10 studies demonstrated increased uptake of cardiac rehabilitation. Successful interventions to improve uptake of cardiac rehabilitation included: structured nurse- or therapist-led contacts, early appointments after discharge, motivational letters, gender-specific programs, and intermediate phase programs for older patients. Three of eight studies demonstrated improvement in adherence to cardiac rehabilitation. Successful interventions included: self monitoring of activity, action planning, and tailored counselling by cardiac rehabilitation staff. Data were limited on mortality and morbidity but did not demonstrate a difference in cardiovascular events or mortality except for one study that noted an increased rate of revascularization in the intervention group. None of the studies found a difference in health-related quality of life and there was no evidence of adverse events. No studies reported on costs or healthcare utilization.

AUTHORS' CONCLUSIONS

We found only weak evidence to suggest that interventions to increase the uptake of cardiac rehabilitation are effective. Practice recommendations for increasing adherence to cardiac rehabilitation cannot be made. Interventions targeting patient-identified barriers may increase the likelihood of success. Further high-quality research is still needed. 

The impact of positive affect on health cognitions and behaviours: a meta-analysis of the experimental evidence

Several reviews suggest that positive affect is associated with improved longevity, fewer physical symptoms, and biological indicators of good health. It is possible that positive affect could influence these outcomes by promoting healthful cognitions and behaviours. The present review identified conceptual pathways from positive affect to health cognitions and behaviour, and used random effects meta-analysis to quantify the impact of positive affect inductions (versus neutral affect conditions) on these outcomes. Literature searches located 54 independent tests that could be included in the review. Across all studies, the findings revealed no reliable effects on intentions (d+ = -.12, 95% CI = -.32 to .08, k = 15) or behaviour (d+ = .15, 95% CI = -.03 to .33, k = 23). There were four reliable effects involving specific cognitions and behaviours, but little clear evidence for generalised benefits or adverse effects of positive emotions on health-related cognitions or actions. Conclusions must be cautious given the paucity of tests available for analysis. The review offers suggestions about research designs that might profitably be deployed in future studies, and calls for additional tests of the impact of discrete positive emotions on health cognitions and behaviour.

An online positive affect skills intervention reduces depression in adults with type 2 diabetes

Positive affect predicts improved glycemic control and longevity in adults with type 2 diabetes. We tested DAHLIA, a self-paced online intervention for type 2 diabetes that teaches positive affect skills such as savoring, gratitude, and acts of kindness. Participants (n=49) were randomized to the 5-week DAHLIA course or an emotion-reporting waitlist control. DAHLIA was understood and accepted by participants and showed good retention (78%). At post-intervention, DAHLIA participants showed a significantly greater decrease in depression than controls (-4.3 vs. +0.6 points on the CES-D, p =.05). Secondary analyses found that this effect was considerably stronger in intervention recipients recruited online than those recruited in person. Intervention recipients recruited online also showed significantly increased positive affect, reduced negative affect, and reduced perceived stress. There were no effects on measures of diabetes-specific efficacy or sense of burden, or preliminary measures of health behaviors. This successful feasibility and efficacy trial provides support for a larger trial focusing more specifically on health behavior.

Examining Relationships between Multiple Health Risk Behaviors, Well-Being, and Productivity

Traditionally, the concept of health promotion has emphasized the reduction of health risk behaviors to reduce disease and impairment. Well-being research expands this focus to include positive constructs such as thriving, productivity, life-evaluation, and emotional and physical health. The objective of the present study was to examine the relationships between health risk behaviors and specific measures of individual well-being. Participants ( N = 790) from 49 states completed a one-time online assessment that included the Life-Evaluation Index, Emotional and Physical Health Ladders, the Health Risk Intervention Assessment, and the Work Productivity and Activity Improvement Questionnaire for General Health. Life Evaluation and physical and emotional health were all inversely related to the number of health risk behaviors, with higher well-being scores associated with lower number of risk behaviors. Across the three Life Evaluation categories (Suffering, Struggling, and Thriving) the number of health risk behaviors decreased, productivity loss decreased, and emotional and physical health increased. The results add to previous research on how reducing multiple health risk behaviors can be combined with well-being, i.e., an emphasis on increasing life-evaluation, emotional and physical health, better functioning, and productivity.

Developing self-management education in coronary artery disease

We describe a three-step approach to develop and evaluate a novel coronary artery disease (CAD) self-management educational workbook. First, we conducted interviews using grounded theory methods with a diverse CAD cohort (n = 61) to identify needs and perceptions. Second, we developed the workbook, incorporating themes that emerged from the qualitative interviews. Finally, 225 people with CAD used the workbook in a longitudinal study and we evaluated their use of and experience with the workbook at 12 months. 12-month evaluation data revealed that the workbook: provided practical health information; enhanced behavior-specific self-efficacy; and reinforced that healthy behaviors decrease risk. Participants who read the workbook had greater within-patient increases in physical activity at 12-months compared with non-readers (p = 0.093) and among Black/Hispanic participants, workbook readers' increases were significant (592 vs. -645 kilocalories per week, p = 0.035). A self-management educational workbook developed using qualitative methods can provide relevant, disease-specific health information for patients with CAD.

Mediators and moderators of behavior change in patients with chronic cardiopulmonary disease: the impact of positive affect and self-affirmation

Among patients with chronic cardiopulmonary disease, increasing healthy behaviors improves outcomes, but such behavior changes are difficult for patients to make and sustain over time. This study aims to demonstrate how positive affect and self-affirmation improve health behaviors compared with a patient education control group. The patient education (PE control) patients completed a behavioral contract, promising to increase their physical activity or their medication adherence and received an educational guide. In addition to the contract and guide, the positive affect/self-affirmation intervention (PA intervention) patients also learned to use positive affect and self-affirmation to facilitate behavior change. Follow-up was identical. In 756 patients, enrolled in three randomized trials, the PA intervention resulted in increased positive affect and more success in behavior change than the PE control (p < .01). Behavior-specific self-efficacy also predicted success (p < .01). Induction of positive affect played a critical role in buffering against the adverse behavioral consequences of stress. Patients who experienced either negative psychosocial changes (p < .05) or interval negative life events (p < .05) fared better with the PA intervention than without it. The PA intervention increased self-efficacy and promoted success in behavior change by buffering stress.

Life satisfaction and frequency of doctor visits

OBJECTIVE

Identifying positive psychological factors that reduce health care use may lead to innovative efforts that help build a more sustainable and high-quality health care system. Prospective studies indicate that life satisfaction is associated with good health behaviors, enhanced health, and longer life, but little information about the association between life satisfaction and health care use is available. We tested whether higher life satisfaction was prospectively associated with fewer doctor visits. We also examined potential interactions between life satisfaction and health behaviors.

METHODS

Participants were 6379 adults from the Health and Retirement Study, a prospective and nationally representative panel study of American adults older than 50 years. Participants were tracked for 4 years. We analyzed the data using a generalized linear model with a gamma distribution and log link.

RESULTS

Higher life satisfaction was associated with fewer doctor visits. On a 6-point life satisfaction scale, each unit increase in life satisfaction was associated with an 11% decrease in doctor visits--after adjusting for sociodemographic factors (relative risk = 0.89, 95% confidence interval = 0.86-0.93). The most satisfied respondents (n = 1121; 17.58%) made 44% fewer doctor visits than did the least satisfied (n = 182; 2.85%). The association between higher life satisfaction and reduced doctor visits remained even after adjusting for baseline health and a wide range of sociodemographic, psychosocial, and health-related covariates (relative risk = 0.96, 95% confidence interval = 0.93-0.99).

CONCLUSIONS

Higher life satisfaction is associated with fewer doctor visits, which may have important implications for reducing health care costs.

Positive psychological characteristics in diabetes: a review

Positive psychological characteristics, such as optimism, self-efficacy, and resilience, have been increasingly associated with improved outcomes in medically ill individuals. However, there has been minimal systematic review of these characteristics and their associations with outcomes in people with diabetes. We aim to review these associations, their potential mediating mechanisms, and the evidence supporting interventions targeting these qualities. In people with diabetes, positive psychological characteristics are significantly associated with improved glycemic control, fewer complications, and reduced rates of mortality. Potential mechanisms mediating these associations include behavioral factors (e.g., improved treatment adherence), reduced inflammation, and improved neuroendocrine and autonomic functioning. Most psychosocial treatments in this population have focused on improving self-efficacy and resilience; such interventions may improve quality of life, well-being, and diabetes self-care. While untested in diabetes, interventions to boost other positive characteristics have been effective in other medically ill patients and may warrant further study in this cohort.

Combining self-affirmation with the extended parallel process model: the consequences for motivation to eat more fruit and vegetables

There is potential for fruitful integration of research using the Extended Parallel Process Model (EPPM) with research using Self-affirmation Theory. However, to date no studies have attempted to do this. This article reports an experiment that tests whether (a) the effects of a self-affirmation manipulation add to those of EPPM variables in predicting intentions to improve a health behavior and (b) self-affirmation moderates the relationship between EPPM variables and intentions. Participants (N = 80) were randomized to either a self-affirmation or control condition prior to receiving personally relevant health information about the risks of not eating at least five portions of fruit and vegetables per day. A hierarchical regression model revealed that efficacy, threat × efficacy, self-affirmation, and self-affirmation × efficacy all uniquely contributed to the prediction of intentions to eat at least five portions per day. Self-affirmed participants and those with higher efficacy reported greater motivation to change. Threat predicted intentions at low levels of efficacy, but not at high levels. Efficacy had a stronger relationship with intentions in the nonaffirmed condition than in the self-affirmed condition. The findings indicate that self-affirmation processes can moderate the impact of variables in the EPPM and also add to the variance explained. We argue that there is potential for integration of the two traditions of research, to the benefit of both.

Self-affirmation and motivational interviewing: integrating perspectives to reduce resistance and increase efficacy of alcohol interventions

To promote efforts at reducing problematic alcohol use and improving health outcomes, the present review proposes an integration of a social psychological approach - self-affirmation theory - with a clinical psychology intervention - motivational interviewing. Motivational interviewing (MI) is a popular empirically-designed treatment approach that has shown moderate success at reducing drinking and improving health, especially with resistant drinkers. Experiments informed by self-affirmation theory have found that people exhibit reduced defensiveness to threatening health messages and increased intentions to reduce alcohol consumption when affirmed. This review focuses on the mechanisms by which self-affirmation reduces resistance and how these mechanisms are complementary to the MI approach. Further, the review outlines suggestions for conducting and integrating self-affirmation into a MI intervention and provides recommendations for future empirical research.

A brief self-affirmation study to improve the experience of minority patients

BACKGROUND

There is evidence that Black patients may experience stereotype threat--apprehension about being negatively stereotyped--in healthcare settings, which might adversely affect their behavior in clinical encounters. Recent studies conducted outside of healthcare have shown that a brief self-affirmation intervention, in which individuals are asked to focus on and affirm their valued characteristics and sources of personal pride, can reduce the negative effects of stereotype threat on academic performance and on interpersonal communication.

METHODS

This randomised controlled trial examined whether a self-affirmation (SA) intervention would decrease the negative effects of stereotype threat (negative mood, lower state self-esteem, greater perceptions of racial discrimination) and increase communication self-efficacy among Black primary care patients. Self-affirmation was induced by having patients complete a 32-item values affirmation questionnaire.

RESULTS

Patients in the SA condition had lower levels of performance self-esteem and social self-esteem than patients in the control. There were no differences between the SA and the control groups on negative mood, communication self-efficacy, and perceptions of discrimination.

CONCLUSIONS

Our SA intervention lowered state self-esteem among Black patients. Future research is needed to determine the type of SA task that is most effective for this population.

Exercise Mediates the Association Between Positive Affect and 5-Year Mortality in Patients With Ischemic Heart Disease

Background—

Positive affect has been associated with better prognosis in patients with ischemic heart disease, but the underlying mechanisms remain unclear. We examined whether positive affect predicted time to first cardiac-related hospitalization and all-cause mortality, and whether exercise mediated this relationship in patients with established ischemic heart disease.

Methods and Results—

The sample comprised 607 patients with ischemic heart disease from Holbæk Hospital, Denmark. In 2005, patients completed the Global Mood Scale (GMS) to assess positive affect and a purpose-designed question on exercise. Data on mortality and hospitalization were collected from Danish national registers for the period 2006–2010. Adjusted Cox and logistic regression were used to analyze the mediation model. Because no significant association between positive affect and cardiac-related hospitalization was found, we constructed no mediation model for hospitalization. Importantly, patients with high positive affect had a significantly reduced risk of all-cause mortality (hazard ratio, 0.58; 95% confidence interval, 0.37–0.92; unadjusted analysis) and were more likely to exercise (odds ratio, 1.99; 95% confidence interval, 1.44–2.76; unadjusted analysis; odds ratio, 1.48; 95% confidence interval, 1.03–2.13; adjusted analysis). When controlling for positive affect and other relevant variables, patients engaged in exercise were less likely to die during follow-up (hazard ratio, 0.50; 95% confidence interval, 0.31–0.80; P =0.004). Importantly, exercise acted as a mediator in the relationship between positive affect and mortality.

Conclusions—

Patients with higher levels of positive affect were more likely to exercise and had a lower risk of dying during 5-year follow-up, with exercise mediating the relationship between positive affect and mortality. Interventions aimed at increasing both positive affect and exercise may have better results with respect to patients’ prognosis and psychological well-being than interventions focusing on 1 of these factors alone.

Translating basic behavioral and social science research to clinical application: the EVOLVE mixed methods approach

OBJECTIVE

To describe a mixed-methods approach to develop and test a basic behavioral science-informed intervention to motivate behavior change in 3 high-risk clinical populations. Our theoretically derived intervention comprised a combination of positive affect and self-affirmation (PA/SA), which we applied to 3 clinical chronic disease populations.

METHOD

We employed a sequential mixed methods model (EVOLVE) to design and test the PA/SA intervention in order to increase physical activity in people with coronary artery disease (post-percutaneous coronary intervention [PCI]) or asthma (ASM) and to improve medication adherence in African Americans with hypertension (HTN). In an initial qualitative phase, we explored participant values and beliefs. We next pilot tested and refined the intervention and then conducted 3 randomized controlled trials with parallel study design. Participants were randomized to combined PA/SA versus an informational control and were followed bimonthly for 12 months, assessing for health behaviors and interval medical events.

RESULTS

Over 4.5 years, we enrolled 1,056 participants. Changes were sequentially made to the intervention during the qualitative and pilot phases. The 3 randomized controlled trials enrolled 242 participants who had undergone PCI, 258 with ASM, and 256 with HTN (n = 756). Overall, 45.1% of PA/SA participants versus 33.6% of informational control participants achieved successful behavior change (p = .001). In multivariate analysis, PA/SA intervention remained a significant predictor of achieving behavior change (p < .002, odds ratio = 1.66), 95% CI [1.22, 2.27], controlling for baseline negative affect, comorbidity, gender, race/ethnicity, medical events, smoking, and age.

CONCLUSIONS

The EVOLVE method is a means by which basic behavioral science research can be translated into efficacious interventions for chronic disease populations.

When it hurts, a positive attitude may help: association of positive affect with daily walking in knee osteoarthritis. Results from a multicenter longitudinal cohort study

OBJECTIVE

While depressive symptoms and knee pain are independently known to impede daily walking in older adults, it is unknown whether positive affect promotes daily walking. This study investigated this association among adults with knee osteoarthritis (OA) and examined whether knee pain modified this association.

METHODS

This study is a cross-sectional analysis of the Multicenter Osteoarthritis Study. We included 1,018 participants (mean ± SD age 63.1 ± 7.8 years, 60% women) who had radiographic knee OA and had worn a StepWatch monitor to record their number of steps per day. High and low positive affect and depressive symptoms were based on the Center for Epidemiologic Studies Depression Scale. Knee pain was categorized as present in respondents who reported pain on most days at both a clinic visit and a telephone screening.

RESULTS

Compared to respondents with low positive affect (27% of all respondents), those with high positive affect (63%) walked a similar number of steps per day, while those with depressive symptoms (10%) walked less (adjusted β -32.6 [95% confidence interval (95% CI) -458.9, 393.8] and -579.1 [95% CI -1,274.9, 116.7], respectively). There was a statistically significant interaction of positive affect by knee pain (P = 0.0045). Among the respondents with knee pain (39%), those with high positive affect walked significantly more steps per day (adjusted β 711.0 [95% CI 55.1, 1,366.9]) than those with low positive affect.

CONCLUSION

High positive affect was associated with more daily walking among adults with painful knee OA. Positive affect may be an important psychological factor to consider for promoting physical activity among people with painful knee OA.

The adaptive neuroplasticity hypothesis of behavioral maintenance

Physical activity is a seemingly simple and clinically potent method to decrease morbidity and mortality in people with coronary heart disease (CHD). Nonetheless, long-term maintenance of physical activity remains a frustratingly elusive goal for patients and practitioners alike. In this paper, we posit that among older adults with CHD, recidivism after the initiation of physical activity reflects maladaptive neuroplasticity of malleable neural networks, and people will revert back to learned and habitual physical inactivity patterns, particularly in the setting of stress or depression. We hypothesize that behavioral interventions that successfully promote physical activity may also enhance adaptive neuroplasticity and play a key role in the maintenance of physical activity through the development of new neuronal pathways that enhance functional ability in older adults. Conversely, without such adaptive neuroplastic changes, ingrained maladaptive neuroplasticity will prevail and long-term maintenance of physical activity will fail. In this paper we will: (1) describe the enormous potential for neuroplasticity in older adults; (2) review stress and depression as examples of maladaptive neuroplasticity; (3) describe an example of adaptive neuroplasticity achieved with a behavioral intervention that induced positive affect in people with CHD; and (4) discuss implications for future work in bench to bedside translational research.