3

Positive Health: Resilience, Recovery, Primary Prevention, and Health Promotion

The structure of the National Institutes of Health (NIH) reflects a central focus on illness and disease. Most of the institutes are organized around major health problems (alcohol abuse and alcoholism; allergy and infectious disease; arthritis, musculoskeletal, and skin diseases; cancer; drug abuse; deafness and communication disorders; diabetes and digestive and kidney diseases; cardiovascular, lung, and blood diseases; neurological disorders and stroke; retinal and corneal disease). Among institutes with a nonspecific disease purview (aging, child health and human development, environmental health sciences, genome research, mental health, nursing), the preponderant program emphasis has also been on illness, dysfunction, and disorder.

As a much-needed counterpoint to long-standing focus on illness and disease, we urge the NIH to invest significant new resources in advancing knowledge of positive health. Such a program builds on emerging studies of resilience and resistance to adverse health outcomes (e.g., Glantz and Johnson, 1999) as well as current work on recovery from illness (e.g., Berkman et al., 1992; Leedham et al., 1995) and primary prevention (e.g., Raczynski and DiClemente, 1999; National Advisory Mental Health Council, 1998). Going beyond efforts to resist disease or recover from it, the focus on positive health also encompasses the need to understand and promote optimal human functioning. This requires attending to how and why individuals thrive and flourish (Ickovics and Park, 1998; Ryff and Singer, 1998a), qualities that embody the essence of good health, a central mandate of NIH.



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New Horizons in Health: An Integrative Approach 3 Positive Health: Resilience, Recovery, Primary Prevention, and Health Promotion The structure of the National Institutes of Health (NIH) reflects a central focus on illness and disease. Most of the institutes are organized around major health problems (alcohol abuse and alcoholism; allergy and infectious disease; arthritis, musculoskeletal, and skin diseases; cancer; drug abuse; deafness and communication disorders; diabetes and digestive and kidney diseases; cardiovascular, lung, and blood diseases; neurological disorders and stroke; retinal and corneal disease). Among institutes with a nonspecific disease purview (aging, child health and human development, environmental health sciences, genome research, mental health, nursing), the preponderant program emphasis has also been on illness, dysfunction, and disorder. As a much-needed counterpoint to long-standing focus on illness and disease, we urge the NIH to invest significant new resources in advancing knowledge of positive health. Such a program builds on emerging studies of resilience and resistance to adverse health outcomes (e.g., Glantz and Johnson, 1999) as well as current work on recovery from illness (e.g., Berkman et al., 1992; Leedham et al., 1995) and primary prevention (e.g., Raczynski and DiClemente, 1999; National Advisory Mental Health Council, 1998). Going beyond efforts to resist disease or recover from it, the focus on positive health also encompasses the need to understand and promote optimal human functioning. This requires attending to how and why individuals thrive and flourish (Ickovics and Park, 1998; Ryff and Singer, 1998a), qualities that embody the essence of good health, a central mandate of NIH.

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New Horizons in Health: An Integrative Approach Across the spectrum of inquiry on resilience, recovery, prevention, and positive health promotion, we underscore the fundamental importance of behavioral, environmental, psychological, and social factors. Research implicates these factors in the pathogenesis of multiple disease outcomes. Thus, reducing profiles of risk associated with negative behavioral, environmental, and psychosocial influences must be a key target for avoiding adverse health outcomes or delaying their onset. The positive health focus, however, calls for more, namely, the promoting of positive behavioral, environmental, and psychosocial factors viewed as protective influences in “salutogenesis ” (Antonovsky, 1987)—the etiology of optimal health and well-being. A key implication of the shift toward positive health promotion is that it will require going beyond strategies targeted at high-risk groups to broader goals of health enhancement for the population at large (Rose, 1992). In the latter context, the goal is to shift entire population distributions toward better health, not just to intervene with special groups showing high risk. From a historical perspective, we underscore the limited attention given to promotion of positive health, as contrasted with efforts to prevent, treat, or alleviate negative health outcomes. Despite the long-standing imbalance, current studies document that those with psychosocial strengths show delayed onset of symptoms as well as extended survival (e.g., Taylor et al., 2000), and the underlying mechanisms for such findings are poorly understood. Critically needed are future investigations of the physiological mechanisms (pathways) through which positive behavioral and psychosocial factors promote health, well-being, and longevity. The preceding chapter on predisease pathways describes cumulative physiological risk as illustrated by the concept of allostatic load. Focusing on positive biological mechanisms, the concept of allostasis captures the capacity of the organism to adapt over the life course to oncoming challenges, thereby preventing the unfolding of pathophysiological processes (McEwen and Stellar, 1993). Allostasis emphasizes that the internal milieu varies to meet perceived and anticipated demands. That is, systems like the hypothalamic-pituitary-adrenal (HPA) axis and the autonomic nervous system exhibit large variations that actually help maintain other homeostatic systems (e.g., pH, body temperature, oxygen tension). This maintenance of “stability through change” (i.e., allostasis) promotes adaptation and appears to be importantly linked to social and behavioral factors, although current knowledge must be greatly expanded to understand the scope of these effects and how they come about. Going beyond effective management of challenge and stress, the focus on positive health also points to the promise and potential of salubrious biobehavioral linkages. For example, recent findings on exercise and plasticity of the brain show that physical activity in rats increases BDNF, a

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New Horizons in Health: An Integrative Approach growth factor of the neurotrophin family supporting the function and survival of many neurons (Neeper et al., 1995). Exposure of adult mice to enriched environments also increases neurogenesis in the dentate gyrus (van Praag et al., 1999). This increased cell proliferation, however, involved voluntary running, not maze running or yoked swimming, thereby underscoring the fine-tuned nature of positive biobehavioral linkages. We urge that the scope of a positive health program at NIH be broad and integrative, running from molecular and cellular levels of analysis through neurophysiological systems to behavioral, environmental, and psychosocial levels of analysis. This is a call for increased support for multidisciplinary investigations that are centrally concerned with bridging between biomedical and social behavioral research. These have frequently been studied as separate realms or, when put together, have typically focused on adverse health consequences of maladaptive behaviors or on psychosocial stress and dysfunction. Comprehensive biopsychosocial understanding of how illness and disease are prevented (or delayed), as well as how positive health is promoted, is an overdue and much-needed priority, and we strongly encourage NIH to launch a new trans-institute initiative under the broad umbrella of positive health. RESILIENCE AND RESISTANCE TO DISEASE: WHO STAYS WELL AND WHY? Across NIH, there is pervasive concern for risk factors (genetic, behavioral, environmental) that predict the onset of particular disease outcomes. Scientific attention has focused disproportionately on individuals who ultimately suffer adverse health outcomes and on the etiological routes through which such effects occur. While the importance of such programs goes undisputed, we stress the concomitant need for studies of people with known risk factors who do not develop the disorder or disease in question. This resistance is usefully illustrated with samples pertaining to genetic risk. Among females with the BRCA1 gene, about 29 percent develop ovarian cancer by age 50 and 50 percent by age 85 (Ford et al., 1995). More than half do not develop the disease, despite having genetic risk. Similarly, among those with the DYT1 gene for idiopathic torsion dystonia, only about 30 percent develop the disease (Risch et al., 1995). The gene for familial dysautonomia (localized to chromosome 9Q31) is carried by 30 percent of Ashkenazi Jews, but the development of this hereditary sensory dysfunction is so sensitive to diverse environmental triggers (e.g., cumulative stress, persistent infections) that no single summary penetrance number is meaningful (Blumenfeld et al., 1993). Of those with genetic risk of primary pulmonary hypertension (25-27 region on chromosome 2q31-32), the frequency of developing the disease at some point in a lifetime is only

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New Horizons in Health: An Integrative Approach 10-20 percent (Rich, 1998). Finally, the expression of Type 1 diabetes among those with genetic susceptibility (major histocompatibility complex on chromosome 6p21 and 17 and a 14/15 base pair oligonucleotide on chromosome 11p15) is very sensitive to diet, infections, and a range of external environmental triggers (Todd, 1999). All of the above examples underscore the importance of understanding disease resistance or delay of onset in the face of high risk. Given the dominant focus on predicting disease incidence, rather than avoidance, such inquiry represents largely uncharted scientific territory. It is nonetheless essential for mapping the causal processes involved in disease resistance, particularly in the face of known risk. Behavioral and psychosocial factors (e.g., exercise, nutrition, coping strategies, optimism, social supports) are not necessarily implicated in all such instances. Other genetic factors, for example, may account for aspects of disease resistance, but even these routes need to be explicated, particularly with regard to the nature of environmentally induced gene expression. Even the most powerful environmental risk factors do not produce uniform outcomes. In studies of children growing up under adverse environmental conditions (e.g., parental psychopathology, parental alcoholism, extreme poverty), some children exhibit remarkable resilience, as evidenced by profiles of healthy development and avoidance of the disorders that characterize their parents (Garmezy, 1991; Glanz and Johnson, 1999; Rutter, 1990; Werner and Smith, 1992). These individuals have “defied others' expectations and survived or surmounted daunting and seemingly overwhelming dangers, obstacles and problems” (Leshner, 1999). Numerous protective factors have been suggested to explain such resilience (e.g., having bonds with at least one nurturing and supportive parent, receiving support from the external community, having an affectionate and outgoing temperament). Intervention studies conducted with children of poverty or those with developmental disabilities also show that significant improvements in cognitive, academic, and social outcomes can be promoted among those lacking early resources or abilities (Ramey and Ramey, 1998). A further realm for illustrating resilience pertains to the growing interest in social inequalities and health (Adler et al., 1999). A recent transinstitute initiative seeks to advance knowledge of how these effects occur by explicating the intervening behavioral, psychosocial, and neurobiological processes. Existing research shows that lower socioeconomic status (SES) increases risk for ill health, but there is extensive variability within SES groups. Not all individuals with limited life resources and opportunities have poor health; in fact, some show optimal physical and mental health. Greater scientific investment is needed to explain the behavioral, psychosocial, and biological protective factors that underlie class-related health resilience. For example, individuals with cumulative economic adversity are

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New Horizons in Health: An Integrative Approach more likely to have high allostatic load, a predictor of later-life morbidity and mortality (Seeman et al., 1997). Those from deprived economic backgrounds who had offsetting benefits of good social relations (e.g., affectional ties with parents, intimacy with spouse) are significantly less likely to exhibit the physiological indicators associated with high allostatic load (Singer and Ryff, 1999). Additional studies are needed to identify protective factors among low SES individuals who defy the odds of succumbing to ill health. Across the above examples, longitudinal studies are essential to ascertain whether observed resistance and resilience reflect higher starting baseline profiles or the influence of subsequent interventions and/or protective resources. Even more imperative is the need for investigations to establish the neurobiological mechanisms through which health protection occurs. While adverse outcomes, particularly under conditions of high risk, are avoided, it is unknown whether this reflects a reversal of neurophysiological systems, compensatory responses, or both. We underscore the potential of animal studies to advance understanding of these mechanistic questions and thereby offer critically needed complements to the above human research. For example, animals reared in emotionally impoverished environments react to stress more radically throughout their lives than those reared in enriched environments (Caldji et al., 1998). However, these effects are reversible; those exposed to inadequate nurturing in early life can, if subsequently reared by a high-licking and high-grooming foster mother, show normal functioning and healthy adult lives. Animal models add critically needed understanding of how such behavioral interventions regulate the development of neural systems. RECOVERY AND DIFFERENTIAL SURVIVAL PROCESSES Effective treatment of major health problems is a central priority across the NIH. Much existing work emphasizes differential survival rates as a function of various behavioral and pharmacological treatments. The positive health focus calls for increased inquiry across the specific disease foci on psychological, social, and behavioral factors that contribute to recovery from particular health problems and/or enhanced survival rates while living with disease. Advances in these directions are already underway, as shown by recent reports (e.g., Behavioral Research in Cardiovascular, Lung, andBlood Health and Disease by the National Heart, Lung, and Blood Institute (1998) and Basic Behavioral Science Research for Mental Health by the National Institute of Mental Health (1995). This report calls for further strides of this nature across the other institutes as well. Numerous protective resources promote recovery processes and increase survival rates. At the psychological level, mounting evidence points

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New Horizons in Health: An Integrative Approach to the importance of optimism and hope in the face of health challenge. Positive expectations have been shown to predict better health after heart transplantation (Leedham et al., 1995); optimists have also been documented to show quicker recovery from coronary bypass surgery and have less severe anginal pain than pessimists (Fitzgerald et al., 1993). In men who are HIV-positive, optimism has been shown to predict disease course and mortality. Such men who were asymptomatic and did not have negative expectations showed less likelihood of symptom development during the follow-up period (Reed et al., 1994). Importantly, HIV-positive men with unrealistically optimistic beliefs about their own survival actually lived longer (Reed et al., 1994). Those who were able to find meaning in their loss of a close partner maintained CD-4 T helper cells over the follow-up period and were less likely to die (Bower et al., 1998). Thus, optimism and meaning are resources that may preserve not only mental but also physical health (Scheier and Carver, 1992; Taylor et al., 2000). On the other hand, unrealistic optimism in specific situations may encourage actions that create unwanted risks of injury and disease (e.g., Avis et al., 1989; Svenson, 1978; Weinstein, 1998), and these possibilities must also be part of future agendas. Other factors contributing to differential survival profiles include social and emotional support. Group psychotherapy programs that promote social support and emotional expression among women with breast cancer show multiple effects: reductions in anxiety and depression as well as increased survival time and lower rates of recurrence (Spiegel et al., 1998; Spiegel and Kimerling, in press). Survival after myocardial infarction also has been significantly associated with emotional support, even after controlling for severity of disease, comorbidity, and functional status (Berkman et al., 1992). The negative role of emotional factors in survival processes has been demonstrated with anger in the context of coronary heart disease (Kawachi et al., 1996) and depression among postmyocardial infarction patients (Frasure-Smith et al., 1993). Future studies are needed to document the replicability and pervasiveness of these effects. Recent research shows that promoting the positive can help prevent relapse of depression, a central challenge for clinicians involved in the treatment of this disorder (Fava et al., 1998; Fava, 1999). This is particularly relevant to the residual phase of depression, when major debilitating symptoms have subsided but well-being is not fully regained. During this period the risk for relapse is especially high. To promote full recovery, “well-being therapy” was implemented—a cognitive behavioral approach designed to increase awareness of and participation in positive aspects of daily life. Those participating in treatment showed dramatically higher remission profiles over a two-year period compared to those receiving standard clinical treatment. This underscores the need to promote positive

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New Horizons in Health: An Integrative Approach psychosocial and emotional experience as a key route to sustained recovery from depression. Finally, relevant to the challenge of living with chronic disease, we call for additional emphasis on quality of life. Current approaches accentuate basic mobility and self-care capacities, along with effective management of treatment side effects (e.g., with medications for lowering cholesterol or blood pressure). In addition to clinical management of disease, a positive health approach would also include higher levels of functioning and well-being (e.g., self-esteem, efficacy and mastery, quality ties to others, purpose in life). Current psychosocial assessment tools have much to offer regarding enrichment of quality of life indicators and thereby to studies of health-related quality of life on survival. We endorse the report of the National Heart, Lung, and Blood Institute (1998, p. 19), which states that “health-related quality of life is a relatively new area of behavioral research. Nevertheless, it is likely to assume growing importance as the medical community and public increasingly recognize that patient's abilities to participate in life's major activities are an essential component of medical evaluation and decision-making.” Of critical research significance, however, is whether enriched quality of life slows disease progression and thereby delays mortality. These are important targets for future inquiry. ADVANCING THE SCIENCE OF PRIMARY PREVENTION The concern of positive health extends beyond efforts to increase survival vis-à-vis disease; it also includes efforts to reduce the likelihood of adverse health outcomes via primary prevention. Compared to curative approaches, preventive medicine has received notably little attention (Rose, 1992). Prevention is not a science with a confirmed tradition (Raczynski and DiClemente, 1999, pp. 3-11) but rather a newly emerging, multidisciplinary field of inquiry involving the behavioral and social sciences as well as public health, medical, and other allied disciplines. We strongly endorse the need to advance the science of primary prevention, that is, the knowledge base on which prevention programs are built. As a model for expanding preventive programs across the institutes of NIH, we draw attention to a recent National Advisory Mental Health Council report entitled Priorities for Prevention Research at the NIMH (1998). The report discussed basic biological, psychological, and sociocultural factors (and their interactive influences) involved in preventing mental disorders as well as relapse, comorbidity, disability, and adverse family consequences of severe mental illness. Among the core scientific recommendations were the needs to strengthen the epidemiological foundations of prevention research, stimulate early intervention studies in childhood, broaden the populations targeted for prevention research, support long-

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New Horizons in Health: An Integrative Approach term follow-up in prevention studies, and build prevention research capacities through training grants. These priorities provide much-needed direction across other institutes as well. Scientifically, prevention research has been overwhelmingly focused on the need to change behavior, specifically maladaptive behaviors that increase risk for disease. Extensive work has examined changing behaviors related to tobacco use (Winders et al., 1999), obesity and nutrition (Spear and Reinold, 1999), physical activity (Sanderson and Taylor, 1999), and alcohol and drug abuse (Schumacher and Milby, 1999). Behavioral changes needed to prevent specific health outcomes, such as cardiovascular disease (Raczynski et al., 1999), cancer (Reynolds et al., 1999), pulmonary disorders (Kohler et al., 1999), and HIV/AIDS (DiClemente et al., 1999) have also been studied. Prevention research has encompassed the life span (Albee and Gulotta, 1997; Millstein et al., 1993), including early interventions for children at risk, fostering resilient outcomes in children of divorce, promoting life skills training for adolescents at risk, and developing adult programs to promote reemployment following job loss. These prevention endeavors bring to the fore issues of responsibility —that is, does the individual or the collective bear responsibility for enacting effective behavior change (Fischhoff, 1992)? Depending on the response, some programs have focused competence promotion and education at the individual level, including helping individuals make effective choices regarding their own health and well-being (Clemen, 1991; Dawes, 1988; Fischhoff et al., 1997), while others have addressed broader issues of environmental support and community organization (Albee and Gullotta, 1997). Prevention is thus a formidable challenge of wide scope, influenced not just by virus, gene, and physiological processes but also by individuals' cognitions, emotions, and behaviors, all of which exist within particular environmental, interpersonal, economic, and cultural contexts. Clearly, advancing the science of primary prevention is a multidisciplinary task. The committee recommends that NIH usher in a new era of prevention research, spanning all institutes and targeted at a refined understanding of these complex connections. For example, adverse health consequences follow from numerous behavioral and psychosocial factors (problem drinking, smoking, sedentary lifestyles, poor stress management), and yet notably limited progress has been made in understanding why only one in four Americans exercises regularly or why the prevalence of smoking (especially among teenagers) remains unacceptably high (National Heart, Lung, and Blood Institute, 1998). Much prior work rested on the belief that informed individuals would make good behavioral choices: teach people about the dangers of smoking and they will not smoke; teach people about the danger of drugs and they will not use them; teach people about the importance of exercise and nutrition, and they will stay fit and eat properly. Unfortu-

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New Horizons in Health: An Integrative Approach nately the relationships between information, education, and prevention are not clear-cut or direct (Rothman and Kiviniemi, 1999). With regard to the science of primary prevention, it is also important to recognize the role of individuals as active agents, shaping their environment, evaluating the appropriateness of public policies and medical recommendations, following or abandoning therapeutic protocols, self-medicating with over-the-counter drugs, and so on. The effectiveness of programs designed to reduce health-risk behaviors or increase health-promoting behaviors depends on the interplay of individuals ' beliefs, values, affective responses, and social interactions (Fischhoff, 1999; Merz et al., 1993). The creation of the NIH Council of Public Representatives reflects a commitment to improve interactions between the individuals' decisions and advances in biomedical research (Institute of Medicine, 1998). These activities should be encouraged and extended. For example, at the same time that basic science is documenting the life-extending benefits of caloric restriction (Weindruch, 1996) and clarifying the genetic mechanisms through which these effects occur (Lee et al., 1999), there is an epidemic of obesity (Mokdad et al., 1999). The prevalence of obesity in the general population increased from 12.0 percent in 1991 to 17.9 percent in 1998, an increase observed in all states and both sexes. By the most stringent definition, more than half of U.S. adults aged 20 and over are considered overweight and nearly one-quarter are clinically obese (Wickelgren, 1998). While the experts may disagree as to whether the central health threat is increase in body fat per se or lack of physical activity, there is no disagreement that major behavioral and environmental change is needed to correct this increase in obesity (Hill and Peters, 1998; Taubes, 1998), estimated to cost more than $70 billion annually in direct and indirect health care costs (Wickelgren, 1998). Understanding how to redirect individuals' investment in diet interventions that have little chance of success or that increase health risks is part of this agenda. Comparative cost-benefit analyses of prevention-versus treatment-oriented approaches, across multiple health problems, also constitutes an important future research direction. Cast more broadly, the etiology and persistence of health-compromising behaviors together should become a key research priority at NIH. Far greater attention must be given to factors such as the personal motivation, values, skills, and intellectual resources needed to change behavior and to whether surrounding contexts and environments support the needed behavioral change. These issues call for a new era of scientific studies of why maladaptive behaviors are so intransigent, particularly when knowledge of related health risks is widely available, and what can be done to modify these behaviors. Like our science, individuals may need a better understanding of health-promoting processes in addition to those associated with

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New Horizons in Health: An Integrative Approach risk (National Research Council, 1989; Woloshin and Schwartz, 1999). Thus, increased dissemination to the larger public of effective prevention strategies must be a key NIH priority. NEW DIRECTIONS IN POSITIVE HEALTH PROMOTION While primary prevention is the cornerstone of good public health, the most proactive version of positive health is the promotion of optimal health behaviors and sustaining supportive environments. The distinction between primary prevention and positive health promotion is usefully illustrated with an intervention program designed to teach “life skills” to high-risk adolescents (Danish, 1997). This project rests on the observation that “to be successful in life, it is not enough to know what to avoid; one must also know how to succeed. For this reason, our focus is on teaching youth ‘what to say yes to' as opposed to ‘just say no'” (p. 292). The Going for the Goal (GOAL) program views early adolescence as an appropriate time to teach life skills, promotes interventions that simultaneously increase health-enhancing behaviors and decrease health-compromising behaviors, recognizes that those who do not have positive future expectations are at risk for engaging in health-compromising behaviors, and realizes that teaching skills is a critical route to changing behavior and cognition. Using a peer-teaching model, high school-aged adolescents teach life skills to both older and younger peers, emphasizing how to formulate and pursue positive life goals, including learning how to surmount obstacles to goal attainment. Since 1992, GOAL has been implemented in many cities. Students participating in the program achieve more of the goals they set, have better school attendance, and report fewer health-compromising behaviors (e.g., getting drunk, smoking cigarettes, violence) compared with those in control groups. In addition to positive health promotion via life skills training, we reiterate the health significance of optimism and hope as well as of social and emotional support. While these are relatively new areas of inquiry, emerging evidence shows that such factors promote longer-term survival for those suffering from specific health challenges (see above), and these effects may be of even wider significance for the general population. Optimists and adults with low anxiety have lower ambulatory blood pressure and more positive moods than pessimistic and anxious adults (Räukkönen et al., 1999). Individuals growing up with feelings of warmth and closeness with parents had, 35 years later, decreased incidence of diagnosed diseases in midlife (coronary artery disease, hypertension, duodenal ulcers, alcoholism; Russek and Schwartz, 1997). Other recent advances in the social and behavioral sciences, such as studies of emotion coaching in parents (Gottman et al., 1996), positive emotions (Fredrickson, 1998), purpose and meaning (Wong and Fry, 1998), coping and problem solving (Thoits, 1994),

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New Horizons in Health: An Integrative Approach thriving and flourishing (Ickovics and Park, 1998; Ryff and Singer, 1998a,b), represent diverse topics ripe for connection with biomedical studies, where their health-promoting effects can be fully investigated. Perhaps the most extensive documentation of salubrious effects following from the social realm pertains to social relationships/social support and health. Epidemiological studies have mapped contributions of the social ties and integration to host resistance, reduced morbidity, and delayed mortality (Berkman, 1995; Cassel, 1976; House et al., 1988). Subsequent experimental studies and interventions have elaborated the beneficial effects of quality social interaction (e.g., Cohen et al., 1997; Spiegel, 1993). More recently, health behaviors and outcomes have been linked to religion and spirituality (Ellison and Levin, 1998; Koenig et al., 1998). Responsive to these findings, the National Institute on Aging has put forth a new program initiative on the connections between religion, spirituality, and health. Five newly funded centers for mind/body interactions will also carry forward the science of optimal health-promoting linkages between psychological factors and biology. Some evidence exists that there are already trends toward positive health in some segments of the population. For example, recent population-level studies of the elderly show declining rates of disability among current cohorts of aged individuals (Manton et al., 1997; Singer and Manton, 1998). Even among older persons showing high disease burden, it has been shown that many do not become disabled (Guralnik et al., 1993). Other scientific research documents the capacities of many older persons to maintain or regain health status and functional capacities in the face of later-life challenges (LaCroix et al., 1993; Ryff et al., 1998; Staudinger et al., 1995). Thus, an emergent literature documents the growing prevalence of resilience in later life; however, the current work does not clarify the factors (behavioral, psychosocial, environmental, genetic) that contribute to the maintenance of functional capacities, health, and well-being in old age. Critically needed across all these topics are entire new programs of research on the neurobiological mechanisms underlying the health benefits ensuing from behavioral and psychosocial influences. What are the actual processes (e.g., neural circuitry, endocrine and immune function) through which behavioral (e.g., nutrition, exercise, stress management) and psychosocial (optimism, purpose, coping, quality social ties) factors convey their health-promoting effects? This is a call to advance what is known about the “physiological substrates of flourishing” (Ryff and Singer, 1998a,b). Such inquiry has begun, for example, in studies linking social supports to physiological processes (Seeman, 1996; Uchino et al., 1996). These efforts have tended, however, to focus on the endocrinological and immunological correlates of relational conflict, or caregiving demands (Kiecolt-Glaser et al., 1996, 1997), not relational strengths. Thus, there is major need for new

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New Horizons in Health: An Integrative Approach studies linking the positive aspects of social relationships (attachment, affection, intimacy) to the mechanisms that underlie good health (Ryff and Singer, 2000). Animal research provides valuable models for such explication of the mechanisms that connect positive social relations to health (Carter, 1998; Uvnäs-Moberg, 1997, 1998). In sum, we urge NIH to embark on new programs of positive health promotion that will dramatically expand the scope of the above inquiries as well as related initiatives linking various behavioral (e.g., exercise, nutrition) and psychosocial (e.g., hope, meaning, support) to neurogenesis (Gould et al., 1997), anabolic systems and growth factors (Epel et al., 1998), and gene expression (Lee et al., 1999). The potential long-term payoff of early benefits following from these factors is critically important. That is, accompanying this call for greater emphasis on predisease pathways is a parallel need to advance knowledge of pathways of health promotion. Longitudinal studies are imperative to achieve this end. POSITIVE HEALTH AND THE COUNCIL OF PUBLIC REPRESENTATIVES The core objectives of the positive health focus are directly responsive to the input provided by the Council of Public Representatives (COPR), which brings public views to NIH activities, programs, and decisions (see Executive Summary). The strong message from COPR, speaking for the general public, was that NIH should do more to help people create and lead healthy lives. Many perceive NIH as focused on curing disease rather than on promoting quality living, optimal families, supportive work environments, and healthy communities. They also called for more information about how the general public can take more responsibility for its own health care. The behavioral and psychosocial research initiatives described under positive health are very much in the spirit of these messages from the general public. We have outlined multiple new directions at NIH for promoting optimal health via positive health behaviors (nutrition, exercise, stress management), quality social relationships, and strong psychological resources. These are core domains of ever-expanding knowledge in the social and behavioral sciences, but there is great need for linking them to ongoing biomedical programs across the institutes. The integration of these realms with an explicit focus on primary prevention and positive health promotion is a key route to improving the health of the U.S. population. RECOMMENDATIONS We urge NIH to promote new trans-institute programs to clarify the role of behavioral, environmental, and psychosocial factors in promoting

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New Horizons in Health: An Integrative Approach optimal health. Such work should be targeted toward the general population and not focused solely on at-risk groups. Specifically, we recommend that NIH: target new research on the neurobiological mechanisms (e.g., allostasis, neurogenesis, anabolic systems, and growth factors) through which positive behavioral and psychosocial factors (e.g., exercise, enriched environments, quality social relationships, psychological well-being) influence health; establish new priorities focused on the etiology (at genetic, behavioral, and environmental levels) of disease resistance, particularly in the contexts of known risk; increase support for the study of protective resources (optimism, meaning and purpose, social and emotional support, and related neurobiological mechanisms) that promote recovery and increased survival rates; initiate new investigations that will advance knowledge of resilience in the face of life adversity, giving particular emphasis to longitudinal studies; advance the science of primary prevention, giving particular attention to overcoming persistent maladaptive behaviors (e.g., drinking, smoking, sedentary lifestyles, poor stress management); develop new population-based initiatives, implemented at local community levels, that promote health via the teaching of positive life practices and the provision of environmental supports to sustain them. REFERENCES Adler NE , Marmot M , McEwen BS , Stewart J. 1999 “Socioeconomic status and health in industrialized nations: Social, psychological, and biological pathways” Annals of the New York Academy of Sciences , 896 , entire issue . Albee GW , Gullotta TP. 1997 Primary Prevention Works ( Thousand Oaks CA : Sage Publications ). Antonovsky A. Unraveling the Mysteries of Health: How People Manage Stress and Stay Well ( San Francisco CA : Jossey-Bass Publishers ). Avis NE , Smith KW , McKinlay JB. 1989 “Accuracy of perceptions of heart attack risk” American Journal of Public Health 79 : 1608-1612 . Berkman LF. 1995 “The role of social relations in health promotion” Psychosomatic Medicine 57 : 245-254 . Berkman LF , Leo-Summers L , Horwitz RI. 1992 “Emotional support and survival after myocardial infarction” Annals of Internal Medicine 117 : 1003-1009 . Blumenfeld A , Slaugenhaupt SA , Axelrod FB , Lucente DE , Maayan C , Leibert CB , Ozelius L , Trofatter JA , Haines JL , Breakfield XO , Gusella JF. 1993 “Localization of the gene for familial dysautonomia on chromosome 9 and definition of DNA markers for genetic diagnosis” Nature Genetics .

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