Professor Glenn Levine on Optimism and the Heart
Professor Glenn Levine chaired the team which wrote the American Heart Association Scientific Statement: "Psychological Health, Well-Being, and the Mind-Heart-Body Connection (January 2021). Glenn N. Levine, M.D., FAHA is a master clinician and professor of medicine at Baylor College of Medicine and chief of the cardiology section at the Michael E. DeBakey VA Medical Center in Houston. Glenn joined Victor Perton in The Centre for Optimism's Optimism Cafe to talk about the report and his optimism.
Victor Perton: Glenn Levine, what makes you optimistic?
Glenn Levine: "Let me address that first by what actually makes me optimistic and the things that lead me to be optimistic. I have learned or at least trained myself to try to focus on the positive and positive things and try to get enough control of my mind and how it thinks to not focus on the negatives. And that clearly sets up a general more optimistic attitude.
"If you ask about the thing that makes me optimistic, it is the fact that we can learn to be less pessimistic and more optimistic by appreciating the things around us rather than the things that we don't have."
Victor Perton: Do you want to tell us a little bit about how you started the American Heart Association project to create the scientific statement and how you got that group of great scientists together to reach world-leading conclusions?
Glenn Levine: "The genesis of this is I was asked by one of the world's most famous cardiologists Valentin Fuster to give a talk at about a 2000 person symposium on psychological health, of which at the time I knew nothing. So I quickly had to become an expert on this. I was amazed about how much good quality data connected psychological health, both negative and positive to heart health and cardiovascular risk. And as we outlined in our scientific statement, there really is a good amount of data.
"Negative psychological health is associated with and plausibly leads to increased cardiovascular risk and worst outcome.
"And on the flip side, there is really neat data in pretty well-done studies that positive psychological health, including happiness, optimism, and gratitude, is associated with better cardiac outcomes, including decreased mortality. That really amazed me.
"Because of these findings, I thought we needed to get out to the world some of these findings and the importance of us as cardiologists and healthcare providers, to really focus not only on things like blood pressure, cholesterol and diabetes but actually on the patient's psychological health.
"So we asked the AHA to commission the scientific statement which they did.
"We spent about six months preparing the statement, it went under reviews and here we are today, and we are extraordinarily gratified by the end product. And we're hoping that this serves to get the message out that psychological health and things like optimism really matter to heart health."
Victor Perton: "It's a great read: I shared it in a global optimism conversation this morning. We've included the studies from Harvard, The American Military, and Boston University on longevity on our Centre for Optimism website. There's good evidence from Vienna around sleep and optimism, excellent material on slowing dementia through an optimistic mindset.
"So from your perspective, from the group that you chaired, what's the evidence, what are the conditions in which optimism plays a role in either being preventative or slowing down the onset of degenerative diseases?"
Glenn Levine: If I talk about optimism and other facets of positive psychological health again, including gratitude, a sense of purpose and things of that nature, the first thing that became clear to us and some of the psychiatrists and psychologists on the panel was clear to point out, is that these are not just the opposite side of the coin. It's not pessimism or optimism. It's not depression or neurotic happiness, but these are actually distinct states, above just being neutral. So optimism is more than just the lack of pessimism. Happiness is more than just a lack of depression. So these are distinct entities.
"And what we find, again and again, is in people who have these positive psychological factors including optimism and others, the associations are really really profound, less risk of heart attack, and less risk of cardiovascular mortality.
"And in some cases overall a greater likelihood of long-term survival and these are not studies published in obscure journals. These are studies published in the leading national and international journals, and they're well-done studies at that. So we are pretty convinced the evidence is real."
Victor Perton: One of the things that struck me in the Harvard medical school comments is they think declining levels of optimism is a public health issue. That the increased levels of pessimism in the world is caused in part by constant 24 by seven bad news. I recently interviewed the lead scientist at Morneau Shepell, a leading well-being company. They talked about the same influence of the "news" factor.
Do you think there's a public health purpose now or need to help people understand what makes them optimistic and that connection between optimism and good health?
Glenn Levine: "Yes, I think it's more important than ever. Certainly, the timing of when this scientific statement came out, now 10 months into COVID could not have been better. Clearly, people are more isolated, they're more depressed, they're staying in longer, there is incredible economic stress that people are undergoing. So there are certainly more than ever challenges to maintaining an optimistic attitude. And so I think it's more important than ever to emphasize the potential benefits of optimism as well as some possible ways that people can potentially be calm, more optimistic, happier with their lives and have a better outlook on the future.
Victor Perton: One of the most exciting parts of your scientific study is you share the scientific explanations for why positive states of mind improve heart health. Do you want to share that with us?
Glenn Levine: This is a vital part of our investigation because if we just found random associations, that's nice, but that really doesn't take things to the next level. What I think is important is figuring out, are these just statistical associations that we see or is there what we call "biologically plausibility"? Whereas negative states lead to increased cardiac risk and decreased prognosis and positive states like optimism and happiness can contribute to decreased risk.
"There are multiple potential pathways. Those consist of things like biologic pathways, particularly things like inflammation, sympathetic and parasympathetic tone and other factors. There are obviously psychological and behavioural things.
"Are people who are happier and more optimistic versus pessimistic and depressed, are those people more likely to take their medicines? The answer is undoubted, yes.
"Are they more likely to care about the future, be interested in the future and so go for preventive screening and follow up on their appointments? The answer is certainly yes.
"Are they more likely to not smoke or try to stop smoking? Are they more likely to exercise regularly? Are they more likely to watch their weight or watch their diabetes? And the answer is certainly yes.
"And when you take this to the next step, well what can we see and what do we see? Less smoking, potentially lower blood pressure, potentially better glucose management, potentially watching your diet, so you don't give yourself too much salt intake and heart failure.
"All these things, biologically plausibility lead to decreased cardiac risk. So you're probably less likely to develop heart disease.
"Then there the people who already have heart disease where we get into the area of secondary prevention. We want them to take the meds, we want them to stop smoking, we want them to follow up to control their blood pressure.
"Again, what is suspected, and there's data to support this, positive, optimistic people are more likely to do these things than depressed people or those with negative feelings and emotions.
"So we think there's a pretty good chain we've put together.
"And for those who look at the publication, we've put together a nice figure that really sums up how we think all these things fit in from just associations to actual causative mechanisms and how they can actually lead to less risk of developing heart disease or dying from heart disease.
Victor Perton: Absolutely brilliant! I sent your scientific statement to my own general practitioner in Melbourne. I've sent it to the doctors who are members of The Centre for Optimism.
One of the exciting things I've found in your report was the suggestion that there are some excellent questions that both the clinician and the reception staff can use.
At The Centre for Optimism, our central purpose is to ask people what makes them optimistic. And we've asked that of people like you, presidents and prime ministers and people digging ditches in India.
What are those questions that you think doctors should be asking of their patients, but more importantly, that reception staff should be asking as the people come in?
Glenn Levine: "The questions that we suggest along those lines are certainly if you are speaking with a patient who's not taking their medicines, who's just telling you they feel tired all the time, they don't feel like doing anything, but there's not really a clear physiologic reason. They're not in heart failure, they don't have heart blockages. Certainly, that should lead one to be concerned. Are they depressed? Are they down? Are they pessimistic?
"And simple questions like reflecting and saying, "I'm getting the sense that you seem a little bit down or depressed. Do you want to talk about that a little bit?"
"The key is not to ask challenging questions, but the key is to ask very open-ended and sympathetic questions, acknowledging that they may not be in the best of states, empathizing with that and sort of opening the door without pushing them to see if they want to discuss this more.
"And I think what you find is that many patients are actually relieved that someone is asking about these things when you do this.
"All of us are not psychologists. All of us are not psychiatrists. All of us are not comfortable or familiar with putting people on the many different available drugs, but certainly, this opens the door for discussion and potentially referral if needed to mental health practitioners.
"In addition, though to drugs, we know of many programs that focus on decreasing stress and increasing your appreciation of the positive.
"Indeed, those I think are fair game to mention to patients even at our level as a non-psychologists or non-psychiatrist practitioners.
"Would you be interested in some good programs that are focused on improving your optimism or your happiness, or decreasing your level of stress, or things like mindfulness and meditation programs that get you better understanding how you're thinking and subsequently allow you to better focus and control your thinking, doing things like, thinking about the positives and the good things in life, rather than just endlessly ruminating about past events or things in the future you're worried about that are in all likelihood, never even going to happen."
Victor Perton: We love those programs.
"On the question side, one of the interventions we do is to get people to stop asking "how are you?” In Australia, typically we say, "Good day. How are you?" And the answer is 50% of the time, "not bad" or "not too bad." So it's a wasted question, wasted answer. I train people instead of saying, how are you to ask instead "what's the best thing happening?", or "what's the best thing in your day?"
"On interventions: I saw the Vienna Medical School last year commended "my best self" the imagining exercise where you think of yourself in a year all going well, write for 10 minutes and then contemplate it and do that every six months or so.
"Another proven intervention is to use gratitude journals last thing in the evening and read them first thing in the morning.
"We've also produced an animated course on the "Habits of an Optimist" We say to people "smile", just as you do Glen. Just smiling at strangers with people, laughing every day, reading humour, all of these things are so uplifting.
"And when I look at what you do, you're a professor, you're a doctor, and you find time to engage in pet rescue and dog rescue. I saw in your past writings your associations between pet care and good health.
"So what are your tips and tricks? What do you do to keep yourself optimistic? What can people learn from a master clinician and teacher like you on keeping more optimistic?
Glenn Levine: Well, I'll tell you for about the last 10 years I've been doing meditation, something that surprises me because I was about the most type-A interventional cardiologist, not sort of a granola-eating, tree-hugging kind of guy in the world. But I got into it. I find it great, as far as remaining mindful and really learning how to focus myself on the now, on appreciating what's going now, and then just not getting bogged down by negative things, but thinking about the positive things down the road.
"It has given me much better control of my mind than most of us have because most of us were so worried about the past or worry about the future. And that has really been my trick.
"You mentioned pets. There was actually some good data that dogs are great for decreasing the negatives in psychological health and improving the positives. And we have three rescues, and I've had rescue dogs my whole life. So those are some of the tricks that I use.
"Perhaps one of the wisest things I heard is an Eastern saying "we can make ourselves happy or we can make ourselves sad, it takes an equal amount of energy to do either and the choice is up to us."
"And so in essence, what it tells us is we can sit here, and we can actually impact our happiness and optimism by what we think about. And it takes no more effort than sitting here and ruminating about negative thoughts or worrying about the what may or may not happen in the future or kicking ourselves for something that happened 20 years ago. It's a really interesting approach that I really endorse and would suggest to others."
Victor Perton: "Meditation is so powerful. I've recorded a few myself. The Buddhist compassion (loving-kindness) meditation, which is said to be three or 4,000 years old, this notion of sending out healing thoughts to those that you love, to those who you're friendly with, then you send it of course to people who are probably enemies. But the interesting thing is when I've done it with big groups of men, the most challenging thing is actually getting them to have self-compassion. Do you find that in the people you work with? I think blokes often have a hard time being compassionate to themselves, they've always been hard on themselves."
Glenn Levine: "The "loving-kindness meditation" is one of the big four meditations. I will confess it, it's not my favourite meditation. I have practised it a little bit. It's suitable for some, probably not everyone's cup of tea. But it is interesting, and it is good, and if you do it enough, you actually can change your feelings.
And I think it's precisely true what you say, it is a lot easier to be kinder to someone you know or even don't know. And I think the true mental health experts will probably say that the most challenging thing is for people to actually try to be kind to themselves. And that's, I think one of the big themes in a lot of some of the Eastern philosophies that I've read about, but it really is a challenge.
Victor Perton: Lastly Glenn, at your Baylor Medical school, are you producing a generation of optimistic doctors?
Glenn Levine: "We are working on it. We're working on it. I think there's light at the end of the tunnel."
Victor Perton: "A beautiful phrase. On behalf of The Centre for Optimism, I want to thank you and your team. Whatever we can do to support your cause over the decades to come, we make that commitment to you, Glenn. So thank you for joining us today in The Optimism Cafe.
Glenn Levine: "Victor, thank you for inviting me, and I must say, I love what you're doing. This is great. This is what the world needs more of. And probably after 10 months of COVID, we need it even more than ever. So on behalf of myself and my colleagues, thank you and your group as well."
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