numerous studies report significant associations between optimism or pessimism and various health outcomes including cardiovascular disease ( cvd ) , coronary heart disease ( chd ) , myocardial infarction , and cancer ; most report that optimism is protective whereas pessimism is associated with increased risk of disease [ 16 ] . the few clinical studies that examined the association between optimism or pessimism and mortality report less consistent results . for example , a study of 238 us male and female cancer patients aged 30 years and older suggested that pessimism was a mortality risk factor only for younger patients , while a predominantly male french cohort of 101 cancer patients , aged 35 to 81 years , reported greater risk of death for pessimistic as compared to optimistic patients one year after diagnosis . a recent study by chang et al . showed statistically significant sex differences in the reporting of psychological outcomes : men were more inclined to report positive psychological outcomes for self rather than for others and also more likely to report negative psychological outcomes for others rather than for self . only two population - based studies have reported the association of optimism or pessimism with mortality . among 97,253 women aged 50 to 79 years from women 's health initiative who were followed up by mail for eight years , optimism was associated with a reduction of 14% for total , 24% for cvd , and 30% for chd - related mortality after adjusting for traditional and lifestyle risk factors such as age , hypertension , bmi , smoking , alcohol use , and physical activity . the arnhem elderly study of 999 dutch men and women aged 65 to 85 years followed up for nine years reported protective effects of optimism on all - cause and cvd mortality in men after adjusting for risk factors , including lifestyle and medical history , whereas , after adjusting for the same risk factors in women , the protective effect of optimism was found only for cvd mortality . analysis of a 15-year follow - up of men only from the zutphen study showed that optimism was associated with lower risk of cardiovascular death   as well as healthier lifestyle and dietary habits , suggesting that lower levels of optimism may influence behavioral choices leading to cardiovascular death . however , there has been no us population - based study of both older men and women who were followed up for 1012 years . the purpose of this report was to examine the association of optimism and pessimism with all - cause and cause - specific mortality in the rancho bernardo study , a large population - based sample of community - dwelling older men and women . given the associations of optimism and pessimism with multiple diseases and the inconsistency in the literature relating to mortality , it is important to determine how optimism and pessimism are associated with mortality and whether there are sex differences in these associations . between 1972 and 1974 , the rancho bernardo heart and chronic disease study enrolled 82% ( n = 6629 ) of residents aged 30 to 79 years from the southern california community of rancho bernardo . these participants have been followed up with periodic clinic visits and yearly mailed surveys ; death certificates were obtained for all decedents . between 1999 and 2002 , 463 men and 678 women ( n = 1141 ) participated in a follow - up research clinic visit . in 1999 , a mailed survey including the life orientation test - revised ( lot - r ) questionnaire used to assess optimism and pessimism was mailed to all participants . participants for this study were members of the rancho bernardo cohort who attended the 19992002 clinic visits , responded to the 1999 mailed lot - r questionnaire , and were followed up through 2012 . after excluding the 78 men and 145 women ( n = 223 ) who did not complete the lot - r questionnaire , 8 men and 21 women ( n = 29 ) missing two or more lot - r responses , 10 men and 2 women ( n = 12 ) younger than age 50 at the time of this clinic visit , and 1 woman missing a death certificate , there remained a total of 367 men and 509 women ( n = 876 ) who formed the cohort for this report . participants were followed up through 2012 , the last year for which complete mortality data was available ; at that time , 102 men and 96 women ( n = 198 ) were deceased ; 265 men and 413 women ( n = 678 ) were alive ( figure 1 ) . this study was approved by the human research protections program at the university of california , san diego . all participants gave written informed consent prior to participation . at the 19992002 clinic visit , height and weight were measured in participants wearing light clothing without shoes and used for calculation of body mass index ( bmi , kg / m ) as an estimate of obesity . waist circumference was measured at the bending point and hip girth was measured at the widest point for calculation of waist - hip ratio ( whr ) as an estimate of central adiposity . two blood pressure measures were obtained 5 minutes apart by a nurse trained in the hypertension detection and follow - up program ( hdfp ) protocol after participants had been seated quietly for five minutes , using the average of the two systolic and diastolic measures . a trained interviewer used a standardized interview to obtain information on current marital status ( no / yes ) , cigarette smoking history ( never / past / current ) , and exercise 3 or more times per week ( no / yes ) . alcohol use during an average week ( grams / week ) was calculated based on the number of beers and glasses of wine and drinks of hard liquors and liqueurs per week . participants were asked about their medical history including physician 's diagnosis of hypertension , diabetes , heart attack , transient ischemic attack ( tia ) , stroke , angina , and cancer . participants were also queried about current medication use including antihypertensives and angina treatment and cholesterol - lowering and diabetes medications . current medications were validated by a nurse who examined pills and containers brought to the clinic for that purpose . the medical outcomes short - form health survey ( sf-12 ) is a 12-item , self - report measure of functional health and well - being from the participant 's point of view . this scale has been reported to have test - retest ( 2-week ) correlations of 0.89 and 0.76 , respectively , for the 12-item physical component summary and the 12-item mental component summary . in 1999 , a mailed survey included the life orientation test - revised ( lot - r ) , a widely used , 10-item , validated questionnaire assessing dispositional optimism that consists of 3 items assessing optimism , 3 items assessing pessimism , and 4 filler items . the total lot - r score takes into account the relative contributions of optimism and pessimism whereas all of the subscales only assess a single dimension . an example of an optimism question is ,  in uncertain times , i usually expect the best  and an example of a pessimism question is ,  if something can go wrong for me , it will  . this scale has been reported to have internal reliability of 0.78 and test - retest reliability of 0.79 at 28 months . internal consistency for total lot - r in this sample was 0.73 based on cronbach 's  coefficient . in addition to the total lot - r score , the authors also separately examined the 3 optimism items ( optimism subscale ) and the 3 pessimism items ( pessimism subscale ) to determine whether there were differences across these subscales and the total score . death certificates were obtained for all decedents and cause of death was coded by a certified nosologist using the international classification of disease , ninth revision ( icd-9 ) . cancer deaths included codes 140239 , cvd deaths included codes 401414 , 426438 , and 440448 , and chd deaths included codes 410414 . total lot - r score was calculated by reverse scoring the three optimism items and adding this value to the sum of the three pessimism items to obtain a score ranging from 0 to 24 ; higher total lot - r scores indicate greater optimism . a separate subscale score for optimism was calculated by summing the three reverse scored optimism items and a separate subscale score for pessimism was calculated by summing the scores for the three pessimism items . for both optimism and pessimism subscales , if one item was unanswered , it was given the mean value of the two answered optimism or pessimism items ; higher scores indicated greater optimism or pessimism . the total lot - r score measures the balance of optimism versus pessimism whereas the optimism subscale measures optimism only and the pessimism subscale measures pessimism only . based on data distributions , total lot - r scores were divided into quartiles and the subscales were each divided into tertiles . descriptive statistics were calculated and reported as rates for categorical data and means (  standard deviations ) for continuous data . comparisons were performed for categorical variables using chi - square tests and for continuous variables using independent t - tests . lot - r scores were divided into quartiles of increasing optimism based on the total sample ( 015 , 16 - 17 , 18 - 19 , and 2024 ) ; comparisons between quartiles were made for age , behaviors such as exercise , alcohol use , smoking , and other potential confounders using age - adjusted univariate logistic regression for categorical variables and age - adjusted univariate linear regression for continuous variables . because all analyses yielded similar results for men and women , variables for which differences between quartiles were obtained where p < 0.20 were included as covariates in later multivariable analyses . forward stepwise cox proportional hazard models were used to assess the association between continuous total lot - r score and each of four main mortality outcomes : all - cause , cancer , cvd , and chd mortality . for variables that did not meet the proportional hazards assumption ( p value  0.05 ) , the time / variable interaction term time was measured from date of 19992002 clinic visit to date of last contact or date of death . model 1 examined the unadjusted associations of total lot - r score with each mortality outcome . model 4 included model 3 variables with average alcohol use per week , smoking status , whr , and exercise added . model 5 included model 4 variables plus angina , cholesterol - lowering , and diabetic medications . all analyses were conducted using sas version 9.2 ( sas institute , nc ) ; p value  0.05 was considered statistically significant . the sample size of 876 participants had greater than 80% statistical power for detecting an association with 95% confidence . table 1 shows descriptive statistics for men and women combined and separately for each sex . average age was 74.1  9.7 years ( men 74.3  9.3 years and women 74.1  10.1 years ) . compared to women , men had significantly higher average alcohol consumption per week ( 50.6  g versus 79.6  g , p < 0.001 , resp . ) and higher rates of medication use for angina ( p = 0.001 ) , cholesterol ( p < 0.001 ) , and diabetes ( p = 0.02 ) . participants were followed up for up to 12 years for an average of 8.1 years . there were no significant differences in total lot - r score or optimism and pessimism subscale scores between men and women ( p = 0.99 ) . during follow - up there were 198 deaths due to all causes , 49 due to cancer , 62 due to cvd , and 22 due to chd . all - cause mortality and chd mortality were significantly higher in men than in women ( 27.8% versus 18.9% , p < 0.001 , and 4.4% versus 1.2% , p = 0.04 ) . there were no significant sex differences in cancer ( 6.5% versus 4.9% , p = 0.85 ) or cvd mortality ( 8.4% versus 6.1% , p = 0.76 ) . age and age - adjusted comparisons of covariates by quartile of lot - r scores for men and women combined are presented in table 2 . there were significant differences in age by quartile of total lot - r ; those with the highest quartile had the lowest mean age while those with the lowest quartile had the highest mean age ( p  0.001 ) . there were significant differences by quartile of total lot - r in rates of smoking ( p = 0.05 ) , use of cholesterol - lowering medications ( p = 0.02 ) , and average alcohol use per week ( p = 0.02 ) . figures 2(a)2(c ) show unadjusted comparisons of all - cause , cancer , cvd , and chd mortality percentages by quartile of total lot - r and by tertiles of optimism and pessimism subscales scores . all - cause , cvd , and chd mortality decreased with increasing quartile of total lot - r ( figure 2(a ) ) and increasing tertile of optimism subscale score ( figure 2(b ) ) . there were significant differences for all - cause , cancer , and chd mortality between the lowest and highest quartiles of total lot - r and significant differences between the lowest and highest tertiles of the optimism subscale scores for cancer and chd deaths . conversely , chd mortality increased with increasing tertile of pessimism subscale ( figure 2(c ) ) , with significant differences between the lowest and highest tertile of pessimism subscale for all - cause mortality . table 3 shows the associations of total lot - r and optimism and pessimism subscale scores with mortality , after adjusting for covariates . prior to adjusting for covariates , there were significant associations between total lot - r score and lower rates of all - cause ( p = 0.002 ) , cvd ( p = 0.004 ) , and chd mortality ( p = 0.003 ) . after adjusting for age , odds of chd mortality were 15% lower for those with higher optimism ( hr = 0.85 , 95% ci = 0.74 , 0.97 ) , a difference that remained significant after further adjustment for sex , alcohol use , smoking status , waist - hip ratio ( whr ) , exercise status , and use of angina treatment and cholesterol - lowering and/or diabetic medications ( hr = 0.86 , 95% ci = 0.75 , 0.99 ) . associations of total lot - r with all - cause and cvd mortality became nonsignificant after adjustment for age . there were no significant associations between total lot - r and cancer mortality either before or after adjustment for covariates . similar patterns were found for the optimism subscale score , which was significantly associated with decreased risk of chd before and after adjustment for age , sex , alcohol use , smoking status , whr , exercise status , and use of angina , cholesterol - lowering , and/or diabetic medications ( hr = 0.77 , 95% ci = 0.61 , 0.99 ) . the optimism subscale score was not significantly associated with all - cause , cancer , or cvd mortality . the pessimism subscale score also was not associated with odds of all - cause or cause - specific mortality after adjusting for age and/or other covariates . in both sexes , higher optimism , whether based on total lot - r score or based on optimism subscale score , was associated with 14% and 23% lower risk , respectively , of chd mortality . although participants with higher optimism had healthier lifestyle behaviors , these associations were independent of age , sex , lifestyle variables ( alcohol use , smoking status , obesity , and exercise ) , and medication use ; adjustment for these variables did not alter the results . after adjustment for covariates there was no association of optimism with cvd , all - cause , or cancer mortality and no association of pessimism with all - cause or cause - specific mortality . results of this study are important , as , to our knowledge , this is the largest population - based us study of optimism and mortality that includes both older men and women . these results are in accord with those from women 's health initiative , which reported a significant association between higher levels of optimism based on total lot - r and a 30% reduction in chd mortality for white women after adjusting for age and other potential confounders . however , our study included both sexes and found similar reductions of ~14% for chd mortality for analyses including both men and women and in other analyses stratified by sex . in contrast to results from women 's health initiative , our study did not find an association between higher levels of optimism and reduced odds of all - cause and cvd mortality , nor was pessimism associated with increased odds of cancer mortality as shown in some prior clinical studies [ 6 , 7 ] . however , participants in our study were older , had higher socioeconomic status , and had health insurance compared to previous studies . associations of pessimism with poor outcomes disappeared after adjusting for age and other covariates , suggesting a relatively large role of age and lifestyle factors on all - cause or cvd deaths . our results also differed from both the arnhem elderly study where optimism was protective for all - cause and cvd mortality and the zutphen study where optimism was protective for cvd mortality , but this is most likely due in part to the fact that scales other than the lot - r were used to assess dispositional optimism [ 911 ] . results of this study have clinical utility as they suggest that a personality characteristic , namely , optimism , is protective against chd mortality . the biological and psychological mechanism of action between optimism , pessimism , and mortality are complex and not fully understood . our participants with higher optimism scores had healthier behaviors ; those in the highest optimism quartile were younger , drank less per week , smoked less , and exercised more , and a greater proportion were married compared to participants in the three lower optimism quartiles . thus , optimism may exert indirect effects on health via a healthier lifestyle or marital status . however , optimism also had an effect on health independent of lifestyle and other covariates . participants in the highest optimism quartile also had lower systolic blood pressure and lower rates of hypertension , diabetes , and heart disease , and fewer reported taking medications for hypertension , angina , and cholesterol . others have shown that optimism is associated with lower levels of inflammation   and stress and negative emotions [ 18 , 19 ] . thus , it is plausible that optimism exerts a beneficial effect by improved physiologic parameters such as reduced inflammation   or biological side effects of stress ( such as hypertension , diabetes , and heart disease ) , and negative emotions , thereby contributing to reduced mortality in more optimistic persons [ 18 , 19 ] . while recent studies have shown associations between increased levels of inflammatory biomarkers and increased risk of chd [ 20 , 21 ] , it is not clear if this is unique to chd or applies to cvd in general . given the older age of our study participants , it is conceivable that an association of optimism or pessimism with mortality was missed because participants had died before the follow - up assessment . comparisons showed that those who did not complete the mailed survey had a higher proportion of men ( 65% ) , fewer married individuals ( 63.7% versus 70.2% ) , and lower rates of exercise ( 64.1% versus 72.1% ) and drank on average less alcohol per week ( 53.9  g versus 67.2  g ) . self - reported responses on the lot - r introduce the possibility of misreporting . due to the small number of cases in each analyzed mortality subgroup , we can not exclude the possibility that low power may have reduced the ability to detect differences in mortality , although the association of optimism with reduced chd mortality argues against this . participants from the rancho bernardo study are white and middle - class with relatively good access to healthcare . thus , these results may not be generalizable to different ethnicities , lower socioeconomic status , or limited healthcare . on the other hand , this homogeneity means that the associations of optimism and pessimism with mortality may be less confounded by these differences . a major strength of this study includes its prospective design with follow - up for mortality over 1012 years . in conclusion , participants with higher optimism had healthier behaviors , but optimism was associated with reduced risk of chd mortality independent of age , sex , and behaviors including alcohol use , smoking status , obesity , exercise , and medication use . these associations suggest similar direct and indirect effects of optimism on chd mortality in men and women . additional studies including both men and women with longer follow - up are necessary to further explore both sex and cause - specific nature of these associations .
purpose . to examine the associations of optimism and pessimism with all - cause , cardiovascular disease ( cvd ) , coronary heart disease ( chd ) , and cancer mortality in a population - based sample of older men and women followed 12 years . methods . 
 367 men and 509 women aged 50 from the rancho bernardo study attended a 19992002 research clinic visit when demographic , behavioral , and medical history were obtained and completed a 1999 mailed survey including the life orientation test - revised ( lot - r ) . 
 mortality outcomes were followed through 2012 . results . 
 average age at baseline was 74.1 years ; during follow - up ( mean = 8.1 years ) , 198 participants died , 62 from cvd , 22 from chd , and 49 from cancer . 
 total lot - r , optimism and pessimism scores were calculated . 
 participants with the highest optimism were younger and reported less alcohol use and smoking and more exercise . 
 cox proportional hazard models showed that higher total lot - r and optimism , but not pessimism scores , were associated with reduced odds of chd mortality after adjusting for age , sex , alcohol , smoking , obesity , physical exercise , and medication ( hr = 0.86 , 95% ci = 0.75 , 0.99 ; hr = 0.77 , 95% ci = 0.61 , 0.99 , resp . ) . 
 no associations were found for all - cause , cvd , or cancer mortality . 
 conclusions . 
 optimism was associated with reduced chd mortality in older men and women . 
 the association of positive attitudes with mortality merits further study .