The Epidemic of Social Isolation and Loneliness

If you are student of the teachings of Kenneth H. Cooper, MD, MPH , Founder and Chairman of Cooper Aerobics (based on the scientific publications from The Cooper Institute®), you also know about the cardiovascular risks of a sedentary lifestyle, poor cardiorespiratory fitness due to lack of regular exercise, systemic inflammation and low intake of nutrients such as omega-3 fatty acids and vitamin D.

Although they cannot be measured with a blood test, or easily quantified on a medical history questionnaire, two other important risk factors for cardiovascular disease are gaining attention from public health experts: social isolation and loneliness.

What is social isolation? According to the Centers for Disease Control and Prevention (CDC), “social isolation” is defined as a lack of relationships with others (an objective state of having few or infrequent social contacts). For example, someone who lives alone and has no communication with family or friends and avoids opportunities to interact with others.

“Loneliness” is defined as perceived isolation that causes distress. For example, a person may have a lot of friends and acquaintances in their neighborhood, at work or in their community, but they do not feel they have close relationships with others or may not feel a sense of belonging.

Although related, loneliness and social isolation are different entities. A person can live a relatively isolated life (living alone, not engaged in social media, few close friends) but not feel lonely. Conversely, someone else may have many friends, work colleagues and community acquaintances, but they may still feel lonely.

Social isolation and loneliness impact your health
Although these risk factors for cardiovascular disease were identified more than a decade ago, there is increasing focus in the public health sector to identify ways to reduce the risk of developing loneliness and social isolation and to rectify it in those who are currently experiencing these conditions.

Two recent examples of health advisories include the 2023 U.S. Surgeon General’s report entitled “Our Epidemic of Loneliness and Isolation” and American Heart Association’s 2022 Scientific Statement, “Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health.”

Social isolation or loneliness or both are associated with an increased risk for developing:

• Heart disease and stroke
• Type 2 diabetes
• Depression and anxiety
• Addiction
• Dementia
• Earlier death

The problem of loneliness and social isolation is a global one. In response to a World Health Organization advisory in late 2020 that identified social isolation and loneliness as priority public health problems, Meta and Gallup joined forces to survey about 1,000 people per country in 140 countries from June 2022 to February 2023. Those results, published in late 2023, showed:

• Older adults (≥ 65): 17% reported feeling very or fairly lonely
• Young adults (age 19-29): 27% reported feeling very or fairly lonely

Global results show 24% of both men and women report feeling very or fairly lonely.

The magnitude of this impact is illustrated in specific studies summarized below:

• In a meta-analysis of almost 3.5 million participants , investigators found loneliness and social isolation increase the risk for premature death by 26% and 29% respectively.
• In a meta-analysis of 181,000 participants , poor social relationships were associated with a 29% increase for the development of heart disease and 32% increased risk of developing stroke.
• In the Framingham Heart Study of almost 3,000 healthy adults , investigators found those participants who reported persistent loneliness had almost twice the risk of developing dementia compared to those who reported no loneliness.
• In a large analysis of more than 400,000 adults from the United Kingdom, investigators found that social isolation and loneliness, both independently and jointly, increased the risk of developing type 2 diabetes by about 20%.

The epidemic of loneliness and social isolation began well before the COVID pandemic and requirements for physical distancing. The Jo Cox Commission on Loneliness was established in 2016 to investigate ways to reduce loneliness in the United Kingdom . After its results were published in December 2017, British Prime Minister Theresa May created a leadership role within the government to manage a loneliness reduction strategy often referred to as the “Minister for Loneliness.”

Two surveys completed in 2018 assessed the prevalence of loneliness or social isolation in different U.S. populations.

• In a survey of 3,000 midlife and older adults performed by AARP Foundation, researchers found more than one-third (35%) of adults age 45 and older in the United States report feeling lonely.
• Cigna commissioned a national survey of more than 20,000 adults in the U.S. to quantify loneliness and factors associated with loneliness. Of these participants age 18 and older, 46% reported “sometimes or always feeling alone.”

What are risk factors for developing social isolation and loneliness?
A comprehensive review on Social Isolation and Loneliness in Older Adults was generated by the National Academies of Sciences, Engineering and Medicine in 2020. This 316-page review summarized the state of knowledge regarding the impact of these two risk factors on health, morbidity, mortality and quality of life in adults ≥ 50 years of age.

These experts identified the following risk and protective factors for social isolation and loneliness in older adults:

• Chronic diseases and conditions such as cardiovascular disease, stroke, chronic obstructive pulmonary disease and advanced heart failure
• Impairments such as deficits in communication, hearing loss or impaired mobility
• Major depression and anxiety
• Absence of family members
• Driving cessation
• Disruptive life event such as the death of a spouse, retirement or the onset of illness

The impact of marriage, grown children and interacting with pets on social isolation and loneliness depends on the quality of the relationships. Finally, feelings of loneliness can be more prevalent in single older adults because of lack of or loss of a trusted confidant or partner.

The Cigna survey also collected information about factors that may be associated with loneliness in their 20,000 survey participants, 30% of whom were age 18-34 and 55% were age 35 to 64. The following characteristics were individually associated with greater loneliness:

• Lower education
• Nonurban living
• Non-white race
• Being unemployed
• Being single and reporting lower income

Of interest, because this survey was completed online, all participants were required and able to navigate the internet. The Cigna report found loneliness to be more common among users of social media (Facebook, Snapchat, Twitter, YouTube, Pinterest).

How do social isolation and loneliness actually cause illnesses such as dementia or diabetes?
Factors that moderate and mediate the links between social isolation/loneliness and health outcomes in adults age > 50 were also identified in report issued by National Academies of Sciences, Engineering and Medicine.

• Health-related Behaviors : The presence of social isolation and loneliness can affect health-related behaviors such as smoking, physical activity and sleep quality. These behaviors can in turn impact the risk of developing multiple chronic diseases as well as overall mortality.
• Psychological Factors: Individuals with more social support has a blunted physiological response to stress. Conversely, individuals with higher levels of loneliness have an exaggerated physiological response to stress.
• Biological Factors: High levels of social isolation and loneliness are associated with high blood pressure, an increase in stress related hormones such as cortisol and systemic inflammation biomarkers such as interleukin-6 and C-reactive protein.

How can we remedy loneliness and social isolation?
In his 2023 report , the U.S. Surgeon General makes recommendations to various stakeholders to advance social connection. For individuals, his recommendations include:

• Invest time in nurturing your relationships through consistent, frequent and high-quality engagement with others. Take time each day to reach out to a friend or family member.
• Minimize distraction during conversation to increase the quality of the time you spend with others. For instance, don’t check your phone during meals with friends, important conversations and family time.
• Seek out opportunities to serve and support others , either by helping your family, co-workers, friends or strangers in your community or by participating in community service.
• Be responsive, supportive and practice gratitude . As we practice these behaviors, others are more likely to reciprocate, strengthening our social bonds, improving relationship satisfaction and building social capital.
• Reflect the core values of connection in how you approach others in conversation and through the actions you take. Key questions to ask yourself when considering your interactions with others include: How might kindness change this situation? What would it look like to treat others with respect? How can I be of service? How can I reflect my concern for and commitment to others?
• Reduce practices that lead to feelings of disconnection from others . These include harmful and excessive social media use, time spent in unhealthy relationships and disproportionate time in front of screens instead of people.
• Participate in social and community grou ps such as fitness, religious, hobby, professional and community service organizations to foster a sense of belonging, meaning and purpose.
• Be open with your health care provider about significant social changes in your life, as this may help them understand potential health impacts and guide them to provide recommendations to mitigate health risks.

If you haven’t seen your health care provider in a while, now is a good time to make an appointment. Cooper Clinic’s comprehensive preventive exam is unlike any exam of its type. Exams are customized based on age, gender, medical history, specific needs and recommendations from Cooper physicians. The exam also includes plenty of time for one-on-one consultation with your Cooper Clinic physician—as much time as needed. Unhurried, focused time with your physician helps establish a trusted relationship, allowing them to become your health advocate and champion.

For more information about Cooper Clinic or to schedule a comprehensive preventive exam, visit cooper-clinic.com or call 866.906.2667 .

Article provided by Nina B. Radford, MD, FACC , Cooper Clinic Cardiologist.