Healthy Happiness: Effects of Happiness On Physical Health and The Consequences For Preventive Health Care
Healthy Happiness: Effects of Happiness On Physical Health and The Consequences For Preventive Health Care
Healthy Happiness: Effects of Happiness On Physical Health and The Consequences For Preventive Health Care
This study was done for ZonMw, the Netherlands' organization for health research and
development and reported in Dutch in Veenhoven 2006j
Earlier versions of this paper were presented at the 3rd European Conference on Positive
Psychology in Braga, Portugal, July 3-6, 2006 and the 7th conference of the International Society
for Quality of Life Studies, in Grahamstown, South Africa, July 16-20
Correspondence:
Printed version :
Prof. Dr. Ruut Veenhoven Erasmus University Rotterdam, Faculty of Social Sciences,
P.O.B. 1738 3000 DR Rotterdam, Netherlands. www2.eur.nl/fsw/research/veenhoven
www.SpringerLink.com
Ruut Veenhoven
Healthy happiness
THE ISSUE
It is widely acknowledged that mental factors may influence physical functioning and
that psychological wellbeing works positively on physical health. This idea does not only
live among adherents of holistic medicine, it also has a firm root in academic psychology.
There is good evidence for the negative effects of mental distress on physical health, e.g.
of depression, anxiety and hostility and there are also indications for the beneficial effects
of positive mental states, such as positive affect (Zautra 2003).
In this context it is commonly assumed that happiness is conducive to physical
health. It is believed that happiness helps to heal the sick and that it protects people in
good healthy against getting ill. In this view, health-care should not only be concerned
with illness, it should also be concerned with wider quality-of-life. This view is reflected
in broad definitions of health, such as the World Health Organizations definition of
health as a state of general physical, mental and social wellbeing and not only the absence
of illness and defect (Seedhouse 1996:41). In this line it is also asserted that current
health education may be counter productive because it puts a damper on enjoyable things
such as smoking and drinking (Warburton 1994, 1996)
Yet there are also different notes. For instance, VanDam (1989) argues that
positive attitudes cannot stop serious illness and that the idea of fighting cancer with
happiness is a mere illusion that blames the victim. Several studies have indeed failed to
find longer survival times among happy cancer patients and some studies even report
shorter survival times (e.g. Derogatis 1979). There is also doubt about the protective
effect of happiness and even reports of greater mortality among cheerful people as a
result to their more risky lifestyles (Freedman et. al 1993). In this view healthcare is
better limited to physical health in the strict sense with too buoyant living being
discouraged.
In this paper I address this issue in two ways: First I take stock of the empirical research
on effects of happiness on physical health. I focus on longevity and assess whether happy
people live longer. This appears to be the case, though happiness does not cure serious
illness, it does appear to protect against falling ill in some way. Having established that
happiness adds to health, I next explore the consequences of this finding for public health
policy.
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Healthy happiness
more detail (Veenhoven 1984: chapter 2). Thus defined, happiness is a state of mind and
can therefore be measured using questioning techniques, among which single, direct
questions. Self-reports of happiness appear to be fairly valid, though not very precise
(Veenhoven 1984: chapter 3).
As for the concept of health, I restrict to physical health, which I define in the
narrow sense of absence of illness or defect. I do so to avoid conceptual overlap with
happiness or related attitudinal matters. Physical health can be measured objectively
using medical assessments or subjectively using self-reports. The most objective measure
of physical health is longevity2 .
2.1
Correlational studies
There is a wealth of cross-sectional studies on happiness and physical health, much of
which is summarized in the World Database of Happiness, Correlational findings on
happiness and Physical Health (WDH 2006). This research shows consistent positive
relationships.
Correlations vary between +.10 and +.40 and appear to be largely independent of
age, gender, socio-economic status and personality. The correlations tend to be higher in
patient populations than among the general public. The correlations of happiness with
self-rated health are somewhat stronger than the correlations between happiness and
heath ratings based on medical examinations, but that does not necessarily mean that the
relation with real health is weaker, since objective indicators do not capture several
relevant aspects of health (Benyamini et. al 1999). A recent cross national survey found
highly similar correlations in 46 nations, a one point difference on the 5-step self-rating
of health corresponding to a 0,6 point difference in happiness (Helliwel, 2002: 339).
These studies clearly show that there is a statistical relationship, but they do not
inform us about cause and effect. The correlations can be caused by the effect of health
on happiness rather than by effects of happiness of health. To disentangle cause and
effect we need follow-up studies.
2.2
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2.3
Healthy happiness
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Healthy happiness
2.3.1
2.3.2
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Healthy happiness
Since we have seen that happiness does not cure serious illness, this outcome
means probably that happiness protects one against falling ill. That interpretation fits
well with the fact that the effects manifest most strongly in the long-term studies.
2.4
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Healthy happiness
extend these policies also add to happiness; in other words, I look how much synergy
there is between current health promotion and the requirements for greater happiness.
Using this as a basis I then identify some ways that can be used to further happiness that
are not yet part of public health policy.
3.1
3.2
3.2.1
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Healthy happiness
jogging on mood (Biddle 2000). In this case there is synergy between the promotion of
health and happiness
Smoking: Moderate smokers appear to be no less happy than non-smokers, but heavy
smokers are. There are indications for a causal effect of happiness on smoking, a followup among American adolescents showing that earlier unhappiness predicts later smoking
(Bachman 1978), but in a recent follow-up in Russia, happiness appeared not to predict
starting or stopping smoking (Graham, 2004: 18). The available data do not tell us
whether smoking cuts back on happiness irrespective of health. So, for the time being, we
cannot rule out the possibility that smoking affect health negatively but happiness
positively, hence we are sure that synergy exists on this point.
Drinking: Moderate drinkers appear to be happier than teetotallers, the optimum being
one or two units of alcohol a day (Ventegodt 1995:180-4). As in the case of smoking,
heavy drinkers are less happy, that is people who drink five or more units of alcohol per
day. The only indication of causality is found in a five-year follow-up in Russia, in which
an increase in drinking appeared to be associated with a decline of happiness.
Unfortunately the amounts of alcohol involved are not reported (Graham 2004). As in the
foregoing case we cannot rule out that heavy drinking may be worse for your health than
for your happiness. Only in the case problem drinking is there a clear synergy.
Eating: There is a lot of research into the effects of nutrition on physical health, but
hardly any research into the effects of diet on happiness. Analysis of a health-survey in
the Netherlands showed no relationship between intake of unhealthy food-stuffs (sugar,
fats) and happiness, nor with healthy food (fruit), while consumption of meat and dairyproducts was slightly positively correlated with happiness (Aakster 1972). In a study
carried out in Denmark the researcher observed that people who often eat fast foods tend
to be somewhat less happy (Ventegodt 1995). In both cases the correlations could be
spurious or be due to a causal effect of happiness on food preference rather than the
converse. There is not much research either on the effects of how much one eats on
happiness. The available data suggest that being slightly overweight does not depress
happiness, people with Body Mass Index between 25-30 being happiest (Ventegodt 1995:
232-4). Yet again we lack data on cause and effect. All in all, no clear synergy has been
found as yet.
3.2.2
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3.2.3
Healthy happiness
4.1
4.1.1
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This policy does not involve paternalism; it does not push people into a particular
way of life, but it provides them with information for making a well-informed
autonomous decision. Paternalism would only be involved if research is manipulated or
its results communicated selectively. For instance if the observed negative effect of
parenthood on happiness is disguised (World Database of happiness, Correlational
findings on happiness and having Children, WDH 2006).
This approach to the furthering of happiness is similar to current evidence based
health-education. As in the case of happiness, we are often not sure about the
consequences of life-style choices on our health. How much drinking is too much? Is
eating raw vegetables really good for your health? We cannot answer such question on
the basis of our own experience and common wisdom is often wrong. Hence we
increasingly look to the results of scientific studies that provide us with ever more
information, and the results of which are disseminated systematically.
As yet, the information basis for such a way of furthering happiness is still small.
Although there is a considerable body of research on happiness, this research is typically
cross-sectional and does not inform us about cause and effect. What we need is panel data
that allow us to follow the effects of life-choices over time. Still another problem is that
current happiness research deals mainly with things over which we have little control,
such as personality and social background. What we need is research on things we can
choose, for example, working part-time or fulltime or raising a family or not.
Once such information becomes available, it will quickly be disseminated to the
public, though the lifestyle press and the self-help literature. It can also be included in
organized health-education, broadened to become education for living well. The
problem is not in the dissemination of knowledge, but in the production of it.
4.1.2 Training techniques for art-of-living
Happiness depends heavily on various skills for living, such as realism, determination,
social competence and having some resilience. Consequently improving such skills can
further an individuals happiness.
As yet, such attempts focus typically on repairing skill-deficits, for instance
psychotherapy in case of unrealistic beliefs and empowerment trainings for sub-assertive
individuals. Many of the interventions are provided in the context of mental health care
and are often paid for by health insurers. This supply caters to the unhappiest part of the
population. Recently there has also been a rise in techniques that aim at to strengthen the
life-skills of people without problems, in particular the Positive Psychology movement
(Seligman & Csikszentmihalyi 2000). There is less institutional support for such positive
training, but the potential audience is much greater.
In this context it would be worthwhile to invest in the development of training that
focus on the art of living. Art-of-living is the knack of leading a satisfying life, and in
particular, the ability to develop a rewarding life-style (Veenhoven 2003). This involves
various aptitudes, some of which seems to be susceptible to improvement using training
techniques. Four of these aptitudes are: 1) the ability to enjoy, 2) the ability to choose, 3)
the ability to keep developing and 4) the ability to see meaning.
Learning to enjoy:
The ability to take pleasure from life is partly in-born (trait negativity-positivity), but can
to some extent be cultivated. Learning to take pleasure from life was
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such as providing for vocational career scripts or artistic interests but people must also
make choices of their own, in particular in multiple-choice societies. Failure to involve
oneself in challenging activities may lead one into diffuse discontent or even depression,
this for example happens regularly after retirement from work. Thus another art-of-living
is to keep oneself going and developing.
Intervention would also seem possible in this case. Mere information will
probably be useful and one can also think of various ways to get people going. Once
again training techniques can build on available experience, in this case experience in
various activation programs. There is already an ample supply of growth trainings on
the peripheries of psychology but as yet little evidence for the effectiveness of such
interventions and certainly no proof of long term effects on happiness.
Helping to see meaning: Probably, but not certainly, happiness also depends on one
seeing meaning in ones life. Though it is not sure that we have an innate need for
meaningfulness as such, the idea of it provides at least a sense of coherence. Seeing
meaning in ones life requires that one develops a view of ones life and that one can see
worth in it. These mental knacks can also be strengthened and possible one can also learn
to live with the philosophical uncertainties that surround this issue. There is experience
on this matter in existential counselling and in practices such as life-reviewing (Holahan
& Wonacott 1999) and logo-therapy (Frankl 1946). As far as I know, the impact of such
interventions on happiness has yet to be investigated.
4.1.3 Professional life- counselling
If we feel unhealthy we go to a medical general practitioner, who makes a diagnosis and
either prescribes a treatment or refers us to a medical specialist. If we feel unhappy, there
is no such generalist. We have to guess about the possible causes ourselves and on that
basis consult a specialist who may be a psychologist, a marriage counsellor or a lawyer.
Professional guidance for a happier life is unavailable as yet. This is a remarkable market
failure, given the large number of people who feel they could be happier. The size of the
demand is reflected in the booming sales of self-help books and the willingness to pay for
things that promise greater happiness, such as cosmetic surgery and second homes. The
main reason is probably that the knowledge basis for such a profession is still small and
that trust in happiness counselling is undermined by the many quacks operating in this
area.
Still there seems to be a future for professional counselling for a happier life and
for related life coaching and trainings. There is demand for such services, but as yet no
proper supply. Much can be gained by developing that supply. One of the ways is to
stimulate the professionalization of current activities in that area, amongst other things by
following people who use such services to establish what interventions add to happiness
or do not. The development of professional life counselling could also profit from the
above-advised research into long-term changes in happiness following major life-choices.
4.2
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Governance
Comparative research has also revealed that happiness prospers in well-governed
countries. There are strong correlations with rule of law (r = +.53) and government
effectiveness (r=+.60). These relationships are largely independent of economic
development and appear in all regions of the world (Ott 2006)
This all suggests that greater happiness for a greater number can be achieved by policies
that aim at a decent material standard of living, the fostering of freedom and democracy
and good governance.
5
CONCLUSIONS
Happy people live longer, probably because happiness protects physical health. If so,
public health can be furthered by policies that aim at greater happiness of a great number.
Current public health policies seem only to affect happiness marginally.
Happiness can be advanced in several ways: At the individual level happiness can
be furthered by means of 1) providing information about consequences of life-choices on
happiness, 2) training in art-of-living skills, and 3) professional life-counselling. At the
level of society greater happiness for a greater number can be achieved by policies that
aim at a decent material standard of living, the fostering of freedom and democracy and
good governance. Evidence based happiness engineering requires more research.
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Table 1
Happiness and longevity: 11 follow-up studies in patient populations
Subjects
35
1 year
668
2 years
2001-2003
Aged inhabitants
nursing home:
chronically ill
193
2 years
1977-78
Aged residents
nursing home
Massachusetts, USA
30
2,5 years
6 questions about
satisfaction with life
3375
3 years
Follow-up
Measure of happiness
Control variables
Observed effect
Source
None
Negative
Dead: M = 2,01
Alive: M = 1,27
Difference: p<05
Derogatis 1979
Positive
OR = 1.4 unhappy
OR = 8,9 very unh.
No difference
Negative:
Dead: M = 27,2
Alive: M = 21,9
p<.05
Janoff-Bulman &
Marshall 1982
No effect
RR = 1,052 ns
Positive
RR = 0,92 p<.002
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Early stage
melanoma patients
Sydney, Australia
426
1-6 years
1991-1997
129
End-stage renal
disease patients
Calgary, Canada
97
Healthy happiness
Baseline disease
variables, coping style
and concerns
Negative
HR = 1,02
CI95: 1.00-1,03
4 years
No effect
HR = 0,79
r = -.08 ns
OConnor &
Vallerand 1998
4 years
Age, co-morbidity,
number of leisure
activities
No effect
r = +.00 ns
156
5 years
Happiness (MUNSH)
No effect
partial r = -.17 ns
Age, activity, religiosity,
perceived health
Questions on recent
happiness
Breast cancer
patients:
with relapse
36
7 years
345
11 years
1985-1996
Negative
1,2% explained variance
Negative
2% explained variance
Positive
B = +.20
Levy et al 1988
Biographic variables
Positive
OR = 1,99
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Table 2
Happiness and longevity: 19 follow-up studies in healthy populations
Subjects
Follow-up
Measure of happiness
Control variables
Observed effect
Source
Questions about
happiness
No effect
Goldberg e.a.
(1979)
>18 aged
Montana, Maryland,
USA
164
6-12 months
1971-74
2282
2 years
1993-94
Positive
OR4 = 2,4
400
2 years
1972-74
Rating by interviewer
Positive
OR2 = 1,8 healthy
OR2 = 2,4 ill
>65 aged
Not institutionalized
Nonamura, Japan
2274
3 years
1998-2001
No effect
After control for age,
gender, baseline health
and activity
513
3-6 years
1990/3-1996
Positive affect
(PANAS)
Positive
OR =1.3
No effect
OR =1,2 ns
(also after control for
intellectual functioning)
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> 75 aged
living in community
Tierp, Sweden
18
161
4 years
1986-1990
Self-report on single
question
Healthy happiness
Positive
among 75-84 aged
OR = 3,0 (CI95 1,3-7,1)
No effect
among > 85 aged
>70 aged
North Carolina
USA,
147
4 years
1955-1959
Question about
happiness
Positive
r = +.10
No effect
r = +.01
Palmore (1969)
>75 aged
Helsinki, Finland
491
10 years
1985-1995
Question on life
satisfaction
Positive
OR2 = 1,2
702
10 years
1991-2001
Positive
OR4 = 1,9 (CI95 1,3-2,8)
Lyyra (2006)
Positive
OR4 = 1,8 (CI95 1,2-2,7)
>65 aged
Manitoba, Canada
3128
6 years
1971-1977
No effect
503
6 years
1979-1985
Positive
OR3 = 3,4
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20-90 aged
Almeda county,
California, USA
19
6928
9 years
1965-74
26.401
1 to19 years
(average 8,5)
1984-2002
22.461
20 years
1975-1995
Healthy happiness
No effect
Question on life
satisfaction
Satisfaction index
Positive
OR3 = 2,1
45-65 aged
Heidelberg,
Germany
3055
21 years
1973-1994
None
Positive
OR4 = 19,7
Blakeslee &
Grossarth-Maticek
(2000)
>50 aged
Ohio, USA
660
23 years
1975-1998
Positive
HRb = 0,87 p<. 001
Beta = +.25 p<.001
Happy lived 7,5 years
longer
The effect of life-satisfaction becomes insignificant when baseline heath-satisfaction is also controlled. The author used health-satisfaction as an indicator of
physical health. Yet satisfaction with health is not the same as perceived state of health, one acknowledges that ones health is not too good, but still be satisfied
and this commonly observed among elderly people. Satisfaction with health is partly determined by general life-satisfaction (top down); hence control of healthsatisfaction wipes out variance in life-satisfaction.
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Positive evaluation of
life in retirement
(3 items)
Positive
partial r = +.06 p<.05
>60 aged
North Carolina
USA
270
25 years
1955-1981
6 item index
Baseline health
Positive
r = +.18
No effect after control for
baseline health
Palmore (1982)
>65 aged
Nederland
2645
28 years
1955-1983
Questions on evaluation
of life
Positive
= +.05
Nuns, USA
678
>60 years
1925-2000
Content analysis of
autobiographies written
around age 22. Count of
positive words
None
Positive
OR4 = 4,3
Happiest quartile lived 10
years longer
OR2: Odds Ratio: excess mortality of least happy (lowest half) compared to most happy subjects (highest half)
OR3: Odds Ratio: excess mortality of least happy (lowest triciel) compared to most happy subjects (highest triciel)
OR4: Odds Ratio: excess mortality of least happy (lowest quartile) compared most happy subjects (highest quartile)
HR: Hazard Ratio. Excess mortality of least happy (1 SD below mean) compared to most happy (1 SD above mean)
RR: Relative Risk: Relative risk of dying of the most happy as a function of an increase of 1 SD
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2. No measure of health is perfect. Longevity does not capture the good health of people who dye
prematurely as a result of an accident.