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Optimism and Life Satisfaction as Determinants for Dental and General Health Behavior—Oral Health Habits Linked to Cardiovascular Risk Factors
1 Department of Periodontology and Geriatric Dentistry, Institute of Dentistry, University of Oulu, Oulu, PL 5281, 90014 Oulun Yliopisto, Finland; Correspondence: *corresponding author, pekka.ylostalo{at}oulu.fi
Oral infections and cardiovascular diseases share common biological and behavioral risk factors. Psychosocial determinants could act as a link between general health behavior and dental health behavior. Our objective was to study optimism and life satisfaction as determinants of general and dental health behavior and to evaluate whether these are connected with cardiovascular risk factors and dental diseases. The 1966 Northern Finland Birth Cohort (N = 12,058) is a general population birth cohort. In a postal questionnaire, respondents (N = 8690) were asked about their health behavior and dental status. Cardiovascular risk factors were assessed in health examinations (N = 6033). Generalized linear regression models were used in analysis. The results showed that health orientation increases with strengthening life satisfaction and optimism. Dental health behavior and general health behavior were associated with both cardiovascular risk factors and self-reported dental diseases, which support the assumption that they share a common behavioral background.
Key Words: cardiovascular risk factors • optimism • life satisfaction • young adults • cohort study
Since the link between cardiovascular diseases (CVD) and oral diseases is deemed to be relatively weak (Beck et al., 2000), and since both these diseases share common risk factors such as potential biological risk factors (Beck et al., 2000) and behavioral risk factors such as diet, smoking, and otherwise unhealthy behavior, it is a challenging task to show the role of oral infections in the etiology of cardiovascular diseases. It is therefore not surprising that research has yielded contradictory findings in this area (DeStefano et al., 1993; Beck et al., 1996; Joshipura et al., 1996; Hujoel et al., 2001). The development of lifestyle diseases such as cardiovascular diseases and oral diseases is the result of long-term unhealthy behavior, which is difficult to control in both cross-sectional settings and in longitudinal settings among middle-aged or older study subjects. Hence, if possible, the link between cardiovascular diseases and oral diseases should be studied among younger age groups. The evidence of common behavioral etiology has recently been shown in dentistry, where it has been found that general health behavior is linked to dental health behavior to at least some degree (Payne and Locker, 1996; Sakki et al., 1998; Kawamura et al., 2001) and, consequently, to dental health status (Sakki et al., 1994, 1995). This supports the assumption that dental and general health behaviors might have some determinants in common. In addition to established socio-economic factors, several psychosocial features—such as a sense of coherence, a locus of control, self-efficacy, life satisfaction, and optimism—have been identified in health research as being connected with several health outcomes. Optimism, for example, is connected with better recovery from operations (King et al., 1998; Edgar et al., 2000), preventive health behavior (Friedman et al., 1994), and avoidance of risk behavior (Scheier and Carver, 1985), and life satisfaction with personality features, psychiatric morbidity (Koivumaa-Honkanen, 1998; Green et al., 1992), and disease mortality (Koivumaa-Honkanen et al., 2000). This study was focused on young adults, and our aim was, first, to study optimism and life satisfaction as determinants of general and dental health behaviors. Second, our aim was to study whether dental health behavior is connected to cardiovascular risk factors and whether general health behavior is connected to dental diseases. Our hypotheses were that dental health behavior and general health behavior share a common background and that both dental and general health behavior are connected to cardiovascular risk factors and dental diseases.
The 1966 Birth Cohort in Northern Finland is an unselected general population birth cohort (Rantakallio, 1988). It covers 96% of all births (N = 12,058) in the provinces of Lapland and Oulu in 1966. The present study is based on a postal questionnaire collected between 1997 and 1998, when the cohort had reached 31 years of age. In the postal questionnaire, respondents were asked about their general health and oral health, use of health services, nutrition, smoking, drinking, and amount of physical exercise. The number of eligible replies was 8690, and the response rate was 75.3%. Those who lived in Northern Finland and in the Helsinki region were invited to a health examination (N = 8463). The participation rate was 71% (N = 6033). A research plan for the 31-year follow-up of the cohort was reviewed and approved by the Ethics Committee of the Faculty of Medicine, Oulu University.
Variables The variable for dental health behavior consisted of three different items: frequency of dental check-ups (at least once in two years vs. less frequently); toothbrushing frequency (at least twice a day vs. less often); and consumption of sweets, chocolate, or soft drinks (more than twice a week vs. less often). The socio-economic status of the respondents was measured by means of the respondent’s educational level and income. Education was classified into four categories: education in university or in higher educational institutions (tertiary), vocational education, comprehensive school only (secondary), and other. Income was measured by gross income in Finnish marks (FIM) per adult member of the family. Incomes were classified into four categories (0-49,999, 50,000-99,999, 100,000-199,999, and 200,000+). Marital status was classified into two categories: married or cohabiting vs. other. Optimism was measured by means of a revised version of the Life Orientation Test (LOT-r) (Scheier et al., 1994), a measure of dispositional optimism developed by Scheier and Carver (1985). This test assesses individual differences in generalized outcome expectancies, positive expectancies being associated with optimism and negative with pessimism. In the test, respondents were asked to rate how well they agreed with 6 items across a five-point Likert-type scale ranging from 0 (strongly disagree) to 4 (strongly agree). The revised version of the test has been found to correlate with the original version by 0.95. The coefficient alpha was 0.78 for the present sample. The test scores were classified into four categories based on distribution (low optimism, 0-13; moderate optimism, 14-16; high optimism, 17-19; highest optimism, 20-24). Life satisfaction was measured by means of a question: "Are you satisfied with your life in general?" The response alternatives were: "(1) very satisfied", "(2) quite satisfied", "(3) quite dissatisfied", "(4) very dissatisfied", and "(5) don’t know" (excluded from the results). The responses of the "quite dissatisfied" and "very dissatisfied" were classed together, since there were so few of them. Self-reported oral health was determined on the basis of the following questions: "In your opinion, do you have caries in your teeth at present?" (No/Yes), "In your opinion, do your gums bleed when you brush your teeth?" (No/Yes), "In your opinion, do you have a toothache or other symptoms in your mouth at present?" (No/Yes). In the questionnaire, the respondents were asked to report the number of missing teeth they had (0, 1-5, 6-10, more than 10 but not all, all). The respondents were classified into two categories according to the number of missing teeth: those who had fewer than 6 teeth missing, and those who had lost 6 or more teeth.
Body mass index (BMI), blood pressure, and the levels of serum total cholesterol and serum triglycerides were used to measure risk for cardiovascular diseases. Blood samples were taken after an overnight fast. Serum total cholesterol, serum high-density lipoprotein (HDL) cholesterol, and serum triglycerides were determined by standard enzymatic methods. Body weight and height were measured in connection with the 31-year examination. Where the subjects’ weight or height had not been measured at the age of 31, self-reported measurements were used. The circumference of the waist was measured at the level midway between the lowest rib margin and the iliac crest. Blood pressure was measured twice with a sphygmomanometer, and the result was expressed as a mean of these two measurements. Subjects with cardiovascular risk factors involved those whose serum total cholesterol was
Statistical Methods
The results of the multivariate regression analyses are presented in Tables 1 and 2  . Education, life satisfaction, and optimism were associated with both dental and general health habits. Health orientation increases with strengthening life satisfaction and optimism, and the health-promoting effect of high education was evident in general health behavior. Overall, the effects of the explanatory variables were stronger in general health behavior than in dental behavior, and the effect of income was more evident in dental health behavior where health orientation increases with higher income. The marital status of the respondents had no significant effect on health behavior.
Determinants for both dental and general health behavior varied by gender. Among men, the effects of education, income, life satisfaction, and optimism on both dental and general behavior were of about the same magnitude. Among women, in contrast, income, life satisfaction, and optimism were the strongest determinants in dental behavior, whereas general health behavior was determined mainly by education and optimism (Tables 1 and 2  ).
The health behavior variables were cross-tabulated with self-reported dental diseases and cardiovascular risk factors. The proportion of subjects with dental diseases, elevated blood pressure, levels of serum total and HDL-cholesterol, serum triglycerides, BMI, and abdominal obesity increased as the number of unhealthy dental and general health habits rose (Tables 3 and 4
Optimism and life satisfaction were connected with healthy dental and general health behavior. Dental and general health behaviors were associated with both cardiovascular risk factors and self-reported dental diseases. Despite the statistical significance, our view is that dental health behavior does not have a direct impact on cardiovascular risk factors, but rather that the link is evidence of common behavioral etiology. Associations between dental health behavior and cardiovascular risk factors and links between general health behavior and dental diseases support the idea that health behavior should be understood as an overall unity—although differently weighted in relation to different outcomes. The connection between general health behavior and oral health behavior has in fact been previously described by Payne and Locker (1996) and Kawamura et al. (2001). The level of income was closely connected with dental health behavior, which is understandable, since the dental health behavior variable included dental check-ups. Education was associated with health behavior after adjustment for other variables, suggesting that education is an important factor involving attitudinal elements, which might improve adaptation and propensity to change behavior. Healthy behavior demands psychosocial resources such as interest in health, propensity to change behavior, and ability to follow instructions. The lack of these types of resources can be understood as an indicator of high health risks. The connection between optimism and health behavior is not surprising in the light of previous studies, since the lack of optimism is connected with passive health behavior (Lin and Peterson, 1990). Optimism has also been associated with the perception of self-efficacy (Schwarzer, 1994), which in an earlier study was linked with oral and general health behavior (Syrjälä et al., 1999). Previously, optimism has also been found to be associated with improved immunological functions (Kamen et al., 1991; Segerstrom, 1998; Brennan and Charnetski, 2000). The connection between life satisfaction and health behavior is not surprising either, since life satisfaction has been previously connected with a sense of coherence, and a strong sense of coherence is closely linked with various health outcomes (Antonovsky, 1993), including an improved immune function (Lutgendorf et al., 1999). The evidence from the impact of optimism and life satisfaction on health behavior is convincing, and their effects on health most likely mediate through health behavior, but the possibility that they might also have a direct biological effect is not to be excluded. The data used in this study consisted of an unselected general population birth cohort. The cohort members were 31 years old when the data were collected. The prevalence of serious illnesses in this age group is low, which means that they have no major effect on the life satisfaction, optimism, and socio-economic situation of the respondents. The response rate, which totaled 75.3%, was high for a mailed questionnaire. The data used in the study were collected through health examination and a mailed questionnaire, and the reliability of mailed questionnaires including questions on well-defined findings has been good in previous studies (Axelsson and Helgadottir, 1995). Regional differences in the availability of dental services in Finland are small, and the possibility for the use of public dental services or subsidized private dental health services reduces the costs of dental health services. Both these aspects made it possible for us to use dental check-ups as one item in measuring dental health behavior. Chronic periodontal infection is a suspected contributor to CVD and has previously been linked with cardiovascular risk factors such as obesity (Saito et al., 2001), hypercholesterolemia (Katz et al., 2001), and hyperlipidemia (Cutler et al., 1999). In this study, the results support the assumption that health behaviors share a common background leading to both dental diseases and CVD. This is supported by the fact that the prevalence of chronic periodontal infection in an age group as young as this is evidently low, which excludes biological explanation. Our interpretation is that some cohort members are at risk of developing periodontitis due to inferior health behavior and, at the same time, are at risk of developing cardiovascular diseases and diabetes due to established health risks such as obesity, elevated blood pressure, hyperlipidemia, and hypercholesterolemia. Our results suggest that the observed connections between oral diseases and general diseases could partly be explained by an accumulation of unhealthy habits. This accumulation is understandable, since factors such as optimism and life satisfaction are both underlying factors in dental and general health behaviors. The results showed that both unhealthy dental and general health behaviors are risk factors for both general and oral health. Thus, when the connections between oral diseases and general diseases are studied, behavioral risk factors should be emphasized in the analysis strategy.
Dr. Ylöstalo thanks the Finnish Dental Society for financial support. Ms. Ek thanks the National Well-Being at Work Programme of the Finnish Government and the Gyllenberg Foundation for financial support. Received for publication June 20, 2002. Revision received October 30, 2002. Accepted for publication November 22, 2002.
Journal of Dental Research, Vol. 82, No. 3,
194-199 (2003) This article has been cited by other articles:
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ABSTRACT
INTRODUCTION
5.2 mmol/L (200 mg/dL), serum HDL-cholesterol 
1.04 mmol/L (40 mg/dL), serum triglycerides 
