Effects of Objective and Perceived Social Isolation on Cardiovascular and Brain Health: A Scientific Statement From the American Heart Association

The impact of social isolation and loneliness on cardiovascular disease risk factors: a systematic review, meta-analysis, and bibliometric investigation

Data on the association between social isolation, loneliness, and risk of incident coronary heart disease (CVD) are conflicting. The objective of this study is to determine the relationship between social isolation and loneliness, and the risk of developing cardiovascular disease (CVD) in middle age and elderly using meta-analysis. The purpose of the bibliometric analysis is to systematically evaluate the existing literature on the relationship between social isolation, loneliness, and the risk of developing cardiovascular disease (CVD) in middle-aged and elderly individuals. A comprehensive search through four electronic databases (MEDLINE, Google Scholar, Scopus, and Web of Science) was conducted for published articles that determined the association between social isolation and/or loneliness and the risk of developing coronary heart disease from June 2015 to May 2023. Two independent reviewers reviewed the titles and abstracts of the records. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline to conduct the systematic review and meta-analysis. Data for the bibliometric analysis was obtained from the Scopus database and analyzed using VOSviewer and Bibliometrix applications. Six studies involving 104,511 patients were included in the final qualitative review and meta-analysis after screening the records. The prevalence of loneliness ranged from 5 to 65.3%, and social isolation ranged from 2 to 56.5%. A total of 5073 cardiovascular events were recorded after follow-up, ranging between 4 and 13 years. Poor social relationships were associated with a 16% increase in the risk of incident CVD (Hazard Ratio of new CVD when comparing high versus low loneliness or social isolation was 1.16 (95% Confidence Interval (CI) 1.10-1.22). The bibliometric analysis shows a rapidly growing field (9.77% annual growth) with common collaboration (6.37 co-authors/document, 26.53% international). The US leads research output, followed by the UK and Australia. Top institutions include University College London, Inserm, and the University of Glasgow. Research focuses on "elderly," "cardiovascular disease," and "psychosocial stress," with recent trends in "mental health," "social determinants," and "COVID-19". Social isolation and loneliness increase the risk of and worsen outcomes in incident cardiovascular diseases. However, the observed effect estimate is small, and this may be attributable to residual confounding from incomplete measurement of potentially confounding or mediating factors. The results of the bibliometric analysis highlight the multidimensional nature of CVD research, covering factors such as social, psychological, and environmental determinants, as well as their interplay with various demographic and health-related variables.

The impact of loneliness on mental and physical health outcomes: An umbrella review

Loneliness and related constructs associated with isolation are public health problems with increasing prevalence. The aim of this umbrella was to collate and grade evidence analyzing actual and subjective loneliness as a health risk factor. Following prospective registration, a systematic search was conducted in Pubmed, Embase, Scopus, Web of Sciences, psycoINFO and Cochrane Library until August 2023. Systematic reviews assessing the association between actual and subjective loneliness with adverse health outcomes were selected. Risk of bias was evaluated using AMSTAR-2 tool. Data were tabulated and synthesis was narrative. A total of 13 systematic reviews was selected (four included meta-analysis). The methodological quality was critically low in 10 reviews (76.92%) and low in 3 (23.08%). Results showed that loneliness was related to poor well-being and increase the risk of negative mental and physical health. The available data suggested but did not allow the confirmation of a causal association. Most constructs of loneliness seem to be related to mental and physical health conditions. A preventive strategy ought to be recommended, especially for vulnerable populations.

Social Disconnectedness in Individuals with Cardiovascular Disease: Associations with Health Literacy and Treatment Burden

BACKGROUND

Knowledge is limited on associations between social disconnectedness (i.e. loneliness and social isolation), health literacy and perceived treatment burden in individuals with cardiovascular disease (CVD). However, understanding these associations may be important for clinical practice.

METHODS

This study used cross-sectional self-reported data from the 2017 Danish health and morbidity survey entitled 'How are you?', investigating the associations of loneliness and social isolation with low health literacy and high treatment burden in individuals with CVD (n = 2521; mean age = 65.7 years).

RESULTS

Logistic regression analysis showed that loneliness and social isolation were associated with low health literacy in terms of difficulties in 'understanding health information' (loneliness: adjusted odds ratio (AOR) = 1.32, 95% confidence intervals (CI) [1.16, 1.50]; social isolation: AOR = 1.47, 95% CI [1.24, 1.73]) and 'engaging with healthcare providers' (loneliness: AOR = 1.53, 95% CI [1.37, 1.70]; social isolation: AOR = 1.21, 95% CI [1.06, 1.40]) and associated with high treatment burden (loneliness: AOR = 1.49, 95% CI [1.35, 1.65]; social isolation: AOR = 1.20, 95% CI [1.06, 1.37]).

CONCLUSIONS

Our findings show that loneliness and social isolation coexisted with low health literacy and high treatment burden in individuals with CVD. These findings are critical as socially disconnected individuals experience more health issues. Low health literacy and a high treatment burden may potentially exacerbate these issues.

Evaluation of Changes in Social Isolation and Loneliness with Incident Cardiovascular Events and Mortality

BACKGROUND

It remains unknown how the patterns of change of social isolation and loneliness are associated with the onset of cardiovascular disease (CVD) and mortality. We aimed to investigate the longitudinal association of changes in social isolation and loneliness with incident CVD, all-cause mortality, CVD mortality and subsequent cardiac function.

METHODS

This prospective cohort study included 18,258 participants aged 38-73 years who participated in visit 0 (2006-2010) and visit 1 (2012-2013) using UK Biobank (mean age 57.1, standard deviation [SD] 7.4; 48.7% males). Social isolation or loneliness was categorized into four patterns: never, transient, incident, and persistent. Incident CVD, all-cause and CVD mortality were ascertained through linkage data. Cardiac function was assessed by cardiovascular magnetic resonance imaging in a subsample (N = 5188; visit 2, since 2014).

RESULTS

Over a median follow-up of 8.3 (interquartile range [IQR] 8.1-8.6) years, compared with never social isolation, persistent social isolation was associated with the higher risk of incident CVD (hazard ratio [HR] 1.17, 95% confidence interval [CI] 1.03-1.33), all-cause (1.42, 1.12-1.81) and CVD (1.53, 1.05-2.23) mortality. Likewise, persistent loneliness was strongly associated with the greater risk of incident CVD (1.13, 1.00-1.27), all-cause (1.28, 1.02-1.61) and CVD mortality (1.52, 1.06-2.18).

CONCLUSIONS

Persistent social isolation and loneliness posed a substantially higher risk for incident CVD, all-cause and CVD mortality, and cardiac dysfunction than other patterns. Persistent social isolation and loneliness, along with an increasing cumulative score, are associated with lower cardiac function.

A translational neuroscience perspective on loneliness: Narrative review focusing on social interaction, illness and oxytocin

This review addresses key findings on loneliness from the social, neurobiological and clinical fields. From a translational perspective, results from studies in humans and animals are included, with a focus on social interaction, mental and physical illness and the role of oxytocin in loneliness. In terms of social interactions, lonely individuals tend to exhibit a range of abnormal behaviors based on dysfunctional social cognitions that make it difficult for them to form meaningful relationships. Neurobiologically, a link has been established between loneliness and the hypothalamic peptide hormone oxytocin. Since social interactions and especially social touch regulate oxytocin signaling, lonely individuals may have an oxytocin imbalance, which in turn affects their health and well-being. Clinically, loneliness is a predictor of physical and mental illness and leads to increased morbidity and mortality. There is evidence that psychopathology is both a cause and a consequence of loneliness. The final section of this review summarizes the findings from social, neurobiological and clinical perspectives to present a new model of the complex construct of loneliness.

Prognostic Value of Objective Social Isolation and Loneliness in Older Patients With Heart Failure: Subanalysis of FRAGILE-HF and Kitasato Cohort

BACKGROUND

Social factors encompass a broad spectrum of nonmedical factors, including objective (social isolation [SI]) and perceived (loneliness) conditions. Although social factors have attracted considerable research attention, information regarding their impact on patients with heart failure is scarce. We aimed to investigate the prognostic impact of objective SI and loneliness in older patients with heart failure.

METHODS AND RESULTS

This study was conducted using the FRAGILE-HF (Prevalence and Prognostic Value of Physical and Social Frailty in Geriatric Patients Hospitalized for Heart Failure; derivation cohort) and Kitasato cohorts (validation cohort), which included hospitalized patients with heart failure aged ≥65 years. Objective SI and loneliness were defined using the Japanese version of Lubben Social Network Scale-6 and diagnosed when the total score for objective and perceived questions on the Lubben Social Network Scale-6 was below the median in the FRAGILE-HF. The primary outcome was 1-year death. Overall, 1232 and 405 patients in the FRAGILE-HF and Kitasato cohorts, respectively, were analyzed. Objective SI and loneliness were observed in 57.8% and 51.4% of patients in the FRAGILE-HF and 55.4% and 46.2% of those in the Kitasato cohort, respectively. During the 1-year follow-up, 149 and 31 patients died in the FRAGILE-HF and Kitasato cohorts, respectively. Cox proportional hazard analysis revealed that objective SI, but not loneliness, was significantly associated with 1-year death after adjustment for conventional risk factors in the FRAGILE-HF. These findings were consistent with the validation cohort.

CONCLUSIONS

Objective SI assessed using the Lubben Social Network Scale-6 may be a prognostic indicator in older patients with heart failure. Given the lack of established SI assessment methods in this population, further research is required to refine such methods.

Social Isolation, Loneliness, and Cardiovascular Mortality: The Role of Health Care System Interventions

PURPOSE OF REVIEW

The world is proliferating rapidly, with science and technology advancing at an incredible rate. These advances have, however, ushered in an age with a rise in social isolation (SI) and loneliness. SI is an objective term that refers to lacking social contact or support. On the other hand, loneliness is subjective and refers to feeling alone or isolated. These concepts are rapidly gaining prominence mainly due to their negative impact on the physical and psychological health of the population, mainly through behavioural modifications that encompass substance abuse, decreased physical activity and unhealthy food habits, and poor sleep hygiene. This review summarizes the pathophysiology, evaluates the evidence behind impact of SI on cardiovascular mortality, and interventions to overcome SI.

RECENT FINDINGS

Through proposed mechanisms, such as activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis, both SI and loneliness have strong evidence linking them to cardiovascular morbidity and mortality. A systematic review and meta-analysis of 90 prospective cohort studies including 2,205,199 individuals reported that SI was independent predictor of cardiovascular mortality with a point estimate of 1.34 (95% confidence interval:1.25-1.44). The evidence so far is compelling and necessitates urgent action with the implementation of strict policies to tackle this issue. As healthcare professionals, it becomes even more critical to remain vigilant, recognize this insidious pandemic, and take appropriate action.

Sociodemographic Heterogeneity in the Associations of Social Isolation With Mortality

Importance

There are limited data on whether the vulnerabilities and impacts of social isolation vary across populations.

Objective

To explore the association between social isolation and mortality due to all causes, cardiovascular diseases (CVD), and malignant neoplasms focusing on heterogeneity by sociodemographic factors.

Design, Setting, and Participants

This cohort study used a moderator-wide approach to examine the heterogeneity in the association of social isolation with all-cause, CVD, and malignant neoplasm mortality using baseline data from the Japan Gerontological Evaluation Study in 2010 and 2011. Eligible participants were adults aged 65 years or older without heart disease, stroke, cancer, or impaired activity of daily living across 12 Japanese municipalities. Follow-up continued until December 31, 2017, identifying 6-year all-cause, cardiovascular disease (CVD), and malignant neoplasm mortality. Logistic regression assessed effect modification by age, gender, education, income, population density, marital status, and employment on mortality associations. Data analysis was performed from September 13, 2023, to March 17, 2024.

Exposure

Social isolation, determined by a 3-item scale (scores of 2 or 3 indicating isolation) was the primary exposure variable.

Main Outcomes and Measures

Six-year all-cause, CVD, and malignant neoplasms mortality.

Results

This study included 37 604 older adults, with a mean (SD) age of 73.5 (5.9) years (21 073 women [56.0%]). A total of 10 094 participants (26.8%) were classified as experiencing social isolation. Social isolation was associated with increased all-cause (odds ratio [OR], 1.20 [95% CI, 1.09-1.32]), CVD (OR, 1.22 [95% CI, 0.98-1.52]), and malignant neoplasm mortality (OR, 1.14 [95% CI, 1.01-1.28]). Stratified analysis showed associations of social isolation with all-cause and malignant neoplasm mortality among people with high income (highest tertile all cause: OR, 1.27 [95% CI, 1.06-1.53]; malignant neoplasm: OR, 1.27 [95% CI, 1.02-1.60]), living in areas with high population density (highest tertile all cause: OR, 1.47 [95% CI, 1.26-1.72]; malignant neoplasm: OR, 1.38 [95% CI, 1.11-1.70]), not married (all cause: OR, 1.33 [95% CI, 1.15-1.53]; malignant neoplasm: OR, 1.25 [95% CI, 1.02-1.52]), and retirees (all cause: OR, 1.27 [95% CI, 1.14-1.43]; malignant neoplasm: OR, 1.27 [95% CI, 1.10-1.48]). Formal testing for effect modification indicated modification by population density and employment for all-cause mortality and by household income and employment for neoplasm mortality.

Conclusions and Relevance

Social isolation was associated with increased risks of all-cause, CVD, and malignant neoplasm mortality, with associations varying across populations. This study fills an important gap in research on social isolation, emphasizing its varied associations across demographic and socioeconomic groups.

Loneliness, Methamphetamine Use, and Cardiovascular Risk Factors Among Sexual Minority Men in the COVID-19 Era

BACKGROUND

Important gaps exist in our understanding of loneliness and biobehavioral outcomes among sexual minority men (SMM), such as faster HIV disease progression. At the same time, SMM who use methamphetamine are approximately one-third more likely than non-users to develop cardiovascular disease. This study examined associations of loneliness, stimulant use, and cardiovascular risk in SMM with and without HIV.

METHOD

Participants were enrolled from August 2020 to February 2022 in a 6-month prospective cohort study. The study leveraged self-report baseline data from 103 SMM, with a subset of 56 SMM that provided a blood sample to measure markers of cardiovascular risk.

RESULTS

Loneliness showed negative bivariate associations with total cholesterol and LDL cholesterol in the cardiometabolic subsample (n = 56). SMM with methamphetamine use (t(101) = 2.03, p < .05; d = .42) and those that screened positive for a stimulant use disorder (t(101) = 2.07, p < .05; d = .46) had significantly higher mean loneliness scores. In linear regression analyses, negative associations of loneliness with LDL and total cholesterol were observed only among SMM who used methamphetamine.

CONCLUSION

We observed lower cholesterol in SMM reporting loneliness and methamphetamine use. Thus, in addition to the observed associations of loneliness with cholesterol, there are important medical consequences of methamphetamine use including cardiovascular risk, higher HIV acquisition risk and progression, as well as stimulant overdose death. This cross-sectional study underscores the need for clinical research to develop and test interventions targeting loneliness among SMM with stimulant use disorders.

Non-alcoholic fatty liver disease and coexisting depression, anxiety and/or stress in adults: a systematic review and meta-analysis

Background

Non-alcoholic fatty liver disease (NAFLD) is a common chronic liver disease, affecting 25-30% of the general population globally. The condition is even more prevalent in individuals with obesity and is frequently linked to the metabolic syndrome. Given the known associations between the metabolic syndrome and common mental health issues, it is likely that such a relationship also exists between NAFLD and mental health problems. However, studies in this field remain limited. Accordingly, the aim of this systematic review and meta-analysis was to explore the prevalence of one or more common mental health conditions (i.e., depression, anxiety, and/or stress) in adults with NAFLD.

Methods

PubMed, EBSCOhost, ProQuest, Ovid, Web of Science, and Scopus were searched in order to identify studies reporting the prevalence of depression, anxiety, and/or stress among adults with NAFLD. A random-effects model was utilized to calculate the pooled prevalence and confidence intervals for depression, anxiety and stress.

Results

In total, 31 studies were eligible for inclusion, involving 2,126,593 adults with NAFLD. Meta-analyses yielded a pooled prevalence of 26.3% (95% CI: 19.2 to 34) for depression, 37.2% (95% CI: 21.6 to 54.3%) for anxiety, and 51.4% (95% CI: 5.5 to 95.8%) for stress among adults with NAFLD.

Conclusion

The present findings suggest a high prevalence of mental health morbidity among adults with NAFLD. Given the related public health impact, this finding should prompt further research to investigate such associations and elucidate potential associations between NAFLD and mental health morbidity, exploring potential shared underlying pathophysiologic mechanisms.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42021288934.

Perceived stress from social isolation or loneliness among clinical and non-clinical healthcare workers during COVID-19

BACKGROUND

Workplace social isolation and loneliness have been found to result in a decline in job satisfaction and an increase in burnout among working individuals. The COVID-19 pandemic exacerbated feelings of loneliness and social isolation among healthcare workers. The majority of research on healthcare worker experiences is conducted in siloes which does not reflect the shared experiences of interprofessional teams. The purpose of this study is to understand stress from social isolation or loneliness across the entire clinical and non-clinical healthcare team over the course of the pandemic.

METHODS

Data was acquired using a cross-sectional survey distributed to healthcare workers once a year at a large academic medical center in the Southeastern United States during the COVID-19 pandemic (2020-2022). Information pertaining to job role, work location, and demographic factors was collected. Participants were also asked to assess individual well-being and resilience, in addition to reporting stress derived from various sources including job demands and social isolation or loneliness. Descriptive statistics and bivariate analyses were conducted to assess the association between stress from social isolation or loneliness and individual characteristics.

RESULTS

Stress from social isolation or loneliness was found to decrease over the survey period across all measured variables. Trainees and physician-scientists were found to report the highest rates of this stressor compared to other job roles, while Hospital-Based ICU and Non-ICU work locations reported the highest rates of loneliness and social isolation stress. Younger workers and individuals from marginalized gender and racial groups were at greater risk for stress from social isolation or loneliness.

CONCLUSIONS

Given the importance of social connections for well-being and job performance, organizations have a responsibility to create conditions and mechanisms to foster social connections. This includes establishing and reinforcing norms of behavior, and developing connection mechanisms, particularly for groups at high risk of loneliness and social isolation.

Comprehensively evaluating the relationships between marital status and other family factors with cardiovascular disease and long-term overall mortality in the elderly: a study of 48 510 Chinese individuals

BACKGROUND

Marital status is associated with cardiovascular disease (CVD) incidence and overall mortality, yet limited research on this topic in elderly individuals is available. Our aim was to comprehensively assess the impact of marital status and other family factors on CVD incidence and long-term mortality among elderly people.

METHODS

Data from the Chinese Longitudinal Healthy Longevity Survey (2002/2005/2008-2018) for participants aged ≥60 years were analysed. A cross-sectional study initially examined the correlation between spouses, offspring, living arrangements, and CVD using logistic regression. Subsequently, a retrospective cohort study investigated the long-term associations of these factors with overall mortality via Kaplan-Meier and Cox regression analyses.

RESULTS

The study involved 48 510 subjects (average age: 87 years). The cross-sectional analysis revealed a correlation between living with a spouse and an increased incidence of heart disease (adjusted OR 1.27, 95% CI 1.04-1.55) and cerebrovascular disease/stroke (adjusted OR 1.26, 95% CI 1.11-1.42). According to the retrospective cohort analysis, living with a spouse significantly reduced overall mortality (adjusted HR 0.84, 95% CI 0.80-0.87), irrespective of marital relationship quality. Conversely, living with offspring (adjusted HR 1.12, 95% CI 1.08-1.16), having more children (adjusted Pnonlinearity = 0.427) or cohabitants (adjusted Pnonlinearity < 0.0001) were associated with increased overall mortality.

CONCLUSION

In the elderly population, being married and living with a spouse were not significantly associated with a decrease in CVD incidence but were associated with a reduction in long-term overall mortality. Living with offspring, having more children, or having a larger family size did not replicate the protective effect but indicated greater overall mortality.

Promise of Lifestyle Medicine for Heart Disease, Diabetes Mellitus, and Cerebrovascular Diseases

The burden of noncommunicable chronic diseases has relevant and negative consequences to persons, health care systems, and economies worldwide. Chronic diseases are the leading cause of disability and mortality and are responsible for 90% of health care expenditure. The most common chronic diseases are diabetes mellitus (DM), cardiovascular disease, and cerebrovascular disease (stroke and vascular cognitive impairment). Modifiable risk factors (MRFs) for these conditions include hypertension, hyperlipidemia, smoking, poor diet, and low-physical activity; with hypertension being the most prevalent MRF. Most MRFs can be successfully targeted through lifestyle medicine (LSM), which is a medical specialty that addresses the root causes of chronic diseases through its primary, secondary, and tertiary preventative approaches. Lifestyle medicine comprises 6 pillars (nutrition, physical activity, sleep health, stress reduction, social connections, and substance use) which through various behavioral approaches, focus on regular physical activity, healthy eating, good quality and quantity sleep, and meaningful social connections coupled with the reduction of stress and substance use. This paper will briefly review the evidence and promise of individual LSM pillars in addressing the underlying MRFs of DM, cardiovascular and cerebrovascular disease (specifically stroke and vascular cognitive impairment). Lifestyle medicine holds a great promise for comprehensive and much improved population health. However, the adoption of LSM at the societal scale requires a multifaceted approach and widespread integration would galvanize a paradigm shift to prevent, treat or reverse chronic diseases from the root causes and achieve health equity.

Sex-based trajectories of health system use in lonely and not lonely older people: A population-based cohort study

BACKGROUND

There is growing interest in understanding the care needs of lonely people but studies are limited and examine healthcare settings separately. We estimated and compared healthcare trajectories in lonely and not lonely older female and male respondents to a national health survey.

METHODS

We conducted a retrospective cohort study of community-dwelling, Ontario respondents (65+ years) to the 2008/2009 Canadian Community Health Survey-Healthy Aging. Respondents were classified at baseline as not lonely, moderately lonely, or severely lonely using the Three-Item Loneliness Scale and then linked with health administrative data to assess healthcare transitions over a 12 -year observation period. Annual risks of moving from the community to inpatient, long-stay home care, long-term care settings-and death-were estimated across loneliness levels using sex-stratified multistate models.

RESULTS

Of 2684 respondents (58.8% female sex; mean age 77 years [standard deviation: 8]), 635 (23.7%) experienced moderate loneliness and 420 (15.6%) severe loneliness. Fewer lonely respondents remained in the community with no transitions (not lonely, 20.3%; moderately lonely, 17.5%; and severely lonely, 12.6%). Annual transition risks from the community to home care and long-term care were higher in female respondents and increased with loneliness severity for both sexes (e.g., 2-year home care risk: 6.1% [95% CI 5.5-6.6], 8.4% [95% CI 7.4-9.5] and 9.4% [95% CI 8.2-10.9] in female respondents, and 3.5% [95% CI 3.1-3.9], 5.0% [95% CI 4.0-6.0], and 5.4% [95% CI 4.0-6.8] in male respondents; 5-year long-term care risk: 9.2% [95% CI 8.0-10.8], 11.1% [95% CI 9.3-13.6] and 12.2% [95% CI 9.9-15.3] [female], and 5.3% [95% CI 4.2-6.7], 9.1% [95% CI 6.8-12.5], and 10.9% [95% CI 7.9-16.3] [male]).

CONCLUSIONS

Lonely older female and male respondents were more likely to need home care and long-term care, with severely lonely female respondents having the highest probability of moving to these settings.

Efficacy of an Internet-based self-help intervention with human guidance or automated messages to alleviate loneliness: a three-armed randomized controlled trial

Loneliness is a prevalent and stigmatized phenomenon associated with adverse (mental) health outcomes. However, evidence-based interventions to alleviate loneliness are scarce. This randomized controlled trial (ClinicalTrials.gov-ID: NCT04655196) evaluated the efficacy of an internet-based cognitive behavioral self-help intervention (ICBT) to reduce loneliness by comparing two intervention groups with guidance or automated messages against a waitlist control group. Adults (N = 243) suffering from loneliness were recruited from the general public and then randomly assigned (2:2:1) to a 10-week ICBT with human guidance (GU) or automated messages (AM) or to a waitlist control group (WL). Loneliness, assessed with the UCLA-9, was the primary outcome. Outcomes were assessed at baseline and 10 weeks (post) and analyzed using mixed-effects models. The pooled intervention conditions resulted in lower loneliness scores at post-assessment than the WL (Cohen's d = 0.57, 95% CI [0.25; 0.89]) and reduced depressive symptoms, social anxiety, social avoidance behavior, and rejection sensitivity (d = 0.32-0.52). The GU group had lower loneliness scores at post-assessment than the AM group (d = 0.42, 95% CI [0.13; 0.70]). ICBT effectively alleviated loneliness, and guidance increased the reduction in loneliness compared to automated messages. Alleviating loneliness with ICBT further seems to reduce the overall burden of psychopathological symptoms.

Dynamics of Perceived Social Isolation, Secondary Conditions, and Daily Activity Patterns Among Individuals With Stroke: A Network Analysis of Ecological Momentary Assessment Data

OBJECTIVE

To assess contemporaneous and temporal dynamics of perceived social isolation (PSI), secondary conditions, and daily activity patterns in individuals post-stroke.

DESIGN

Longitudinal observational study using ecological momentary assessment (EMA) as a real-time assessment of an individual's lived experiences. We conducted dynamic network analyses to examine longitudinal associations among EMA variables.

SETTINGS

Home and Community.

PARTICIPANTS

202 individuals with mild-to-moderate chronic stroke (median age=60 years; 45% women; 44% black; 90% ischemic stroke; median NIHSS score=2; N=202).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

EMA questions measured PSI, secondary conditions (pain, tiredness, stress, anxiety, worthlessness, difficulty concentrating, and cheerfulness), and daily activity patterns (being at home, being alone, and participating in productive activities).

RESULTS

The median EMA response rate was 84%. The contemporaneous model showed that PSI was associated with being home, alone, and all symptoms except pain. The temporal model revealed a pathway indicating that feelings of worthlessness predicted PSI (regression coefficient=0.06, P=.019), followed by stress (regression coefficient=0.06, P=.024), and then by being not at home (regression coefficient=-0.04, P=.013).

CONCLUSION

Implementing dynamic network analyses on EMA data can uncover dynamic connections among PSI, secondary conditions, and daily activity patterns after stroke. This study found a significant temporal association between PSI and negative emotions. Feeling isolated was followed by feeling stressed, which was followed by a tendency to be out of home, indicating adaptive behaviors in individuals with stroke. These findings highlight the importance of engaging in out-of-home or outdoor activities to mitigate PSI and negative emotions.

Does social connection mediate the association between neuroticism and cognition? Cross-sectional analysis of the Canadian Longitudinal Study on Aging

OBJECTIVES

This study tested the association between neuroticism and six cognitive measures, and examined the potential mediating roles of social connection (social isolation and loneliness) among middle-aged and older adults.

METHODS

This cross-sectional study was a secondary analysis of the Canadian Longitudinal Study on Aging (CLSA) Comprehensive Cohort, a sample of Canadians aged 45-85 years at baseline. Respondents with data collected at the first follow-up, between 2015 and 2018, were included (n = 27,765). Structural equation modelling was used to assess the association between neuroticism and six cognitive measures (Rey Auditory Verbal Learning Test immediate recall and delayed recall, Animal Fluency Test, Mental Alternation Test, Controlled Oral Word Association Test and Stroop Test interference ratio), with direct and indirect effects (through social isolation and loneliness). All analyses were stratified by sex, including females (n = 14,133) and males (n = 13,632).

RESULTS

In unadjusted models, there was evidence of associations between neuroticism and all cognitive measures, except the Stroop Test interference ratio, suggesting higher neuroticism was associated with lower scores on memory and executive function tests. In the models of these other five outcomes, there was consistent evidence of indirect effects (through social isolation and loneliness) and, in some cases, direct effects. The results are discussed in context with limitations, including the use of cross-sectional design and alternative hypotheses to explain the association between personality and cognition.

CONCLUSION

Among middle-aged and older adults, for both males and females, the findings suggest that the association between neuroticism and cognitive outcomes may be mediated by aspects of social connection.

Social Determinants of Health and Disparities in Hypertension and Cardiovascular Diseases

High blood pressure causes over 10 million preventable deaths annually globally. Populations in low- and middle-income countries suffer the most, experiencing increased uncontrolled blood pressure and cardiovascular disease (CVD) deaths. Despite improvements in high-income countries, disparities persist, notably in the United States, where Black individuals face up to 4× higher CVD mortality than White individuals. Social determinants of health encompass complex, multidimensional factors linked to an individual's birthplace, upbringing, activities, residence, workplaces, socioeconomic and environmental structures, and significantly affect health outcomes, including hypertension and CVD. This review explored how social determinants of health drive disparities in hypertension and related CVD morbidity from a socioecological and life course perspective. We present evidence-based strategies, emphasizing interventions tailored to specific community needs and cross-sector collaboration to address health inequalities rooted in social factors, which are key elements toward achieving the United Nations' Sustainable Development Goal 3.4 for reducing premature CVD mortality by 30% by 2030.

Factors associated with perceived social isolation among veterans with spinal cord injury and disorders: Cross sectional survey

CONTEXT/OBJECTIVE

Examine demographics, injury characteristics, objective measures of social isolation and health factors that are associated with perceived social isolation (PSI) among Veterans with spinal cord injury and disorders (SCI/D).

DESIGN

Cross-sectional survey.

SETTING

The Veterans Health Administrations (VHA) SCI/D system of care.

PARTICIPANTS

Veterans with SCI/D who have used the VHA health care system.

INTERVENTION

Not applicable.

OUTCOMES MEASURES

We assessed unadjusted associations of high PSI (above population mean) vs low (normative/below population mean), and multivariable logistic regression for independent associations with PSI.

RESULTS

Out of 1942 Veterans with SCI/D, 421 completed the survey (22% response rate). Over half (56%) had PSI mean scores higher than the general population. Among the objective measures, having a smaller social network size was associated with increased odds of high PSI (OR 3.59, P < .0001); additionally, for health factors, having depression (OR 3.98, P < 0.0001), anxiety (OR 2.29, P = 0.009), and post-traumatic stress (OR 2.56, P = 0.003) in the previous 6 months, and having 4 or more chronically occurring secondary conditions (OR 1.78, P = 0.045) was associated with increased odds of high PSI. The most commonly identified contributors to feelings of PSI included mobility concerns (63%), having a SCI/D (61%), and concerns about being a burden on others (57%).

CONCLUSIONS

Factors such as social network size may be used to identify individuals with SCI/D at risk for PSI. Additionally, by identifying mental health problems, presence of multiple chronically occurring secondary conditions, and Veteran-identified contributors of PSI, we can target these factors in a patient-centered interventions to identify and reduce PSI.

Educational Attainment and Lifetime Risk of Cardiovascular Disease

Importance

Education is a social determinant of health. Quantifying its association with lifetime cardiovascular disease (CVD) risk has public health importance.

Objective

To calculate lifetime risk estimates of incident CVD and CVD subtypes and estimate years lived with and without CVD by education.

Design, Setting, and Participants

Included community-based cohort studies with adjudicated cardiovascular events used pooled individual-level data from 1985 to 2015 of 6 prospective cohort studies. The study team assessed the association between education and lifetime CVD risk with modified Kaplan-Meier and Cox models accounting for competing risk of noncardiovascular death. The study team estimated years lived with and without CVD by education with the Irwin restricted mean and the utility of adding educational attainment to CVD risk assessment. Participants (baseline 40 to 59 years old and 60 to 79 years old) were without CVD at baseline and had complete education, cardiovascular risk factors, and prospective CVD outcomes data. Data were analyzed from January 2022 to September 2022.

Exposures

Educational attainment (less than high school, high school completion, some college, or college graduate).

Main outcome and measures

Cardiovascular events (fatal and nonfatal coronary heart disease, heart failure, and stroke; CVD-related deaths; and total CVD encompassing any of these events).

Results

There were 40 998 participants (23 305 female [56.2%]) with a mean (SD) age of 58.1 (9.7) years for males and 58.3 (9.9) years for females. Compared with college graduates, those with less than high school or high school completion had higher lifetime CVD risks. Among middle-aged men, the competing hazard ratios (HRs) for a CVD event were 1.58 (95% CI, 1.38-1.80), 1.30 (95% CI, 1.10-1.46), and 1.16 (95% CI, 1.00-1.34) in those with less than high school, high school, and some college, respectively, compared with those with college completion. Among women, these competing HRs were 1.70 (95% CI, 1.49-1.95), 1.19 (95% CI, 1.05-1.35), and 0.98 (95% CI, 0.83-1.15). Individuals with higher education had longer duration of life prior to incident CVD. Education provided limited contribution toward enhancing CVD risk prediction.

Conclusions and relevance

Lower education was associated with lifetime CVD risk across adulthood; higher education translated to healthy longevity. Educational policy initiatives may associate with long-term health benefits.

Social isolation and risk of disability in older adults: Effect modification of metabolic syndrome

PURPOSE

Delaying the onset of disabilities is a social challenge, especially in an aging society. Social isolation (SI) and metabolic syndrome (MetS) can coexist and pose the risks of disability onset. However, their interaction is not proven in older adults. Therefore, this study investigated whether SI combined with MetS exacerbates disability onset in older adults.

MATERIALS AND METHODS

A total of 3,738 community-dwelling older adults underwent a health check-up. After baseline assessments, we followed them up to assess disability incidence for five years. SI was defined as a condition in which two or more of the following measures were met: domestic isolation, less social contact, and social disengagement. MetS was defined according to the criteria of the International Diabetes Federation. We used Cox proportional hazard regression used to identify the interaction effect of SI and MetS on the risk of disability onset after adjusting for potential confounding factors.

RESULTS

Multivariate Cox proportional hazard regression showed a significant interaction effect of SI and MetS on disability onset. In the subgroup analysis stratified by MetS status, SI was identified as a risk factor for disability onset only in the MetS group, but not in the non-MetS group.

CONCLUSIONS

This five-year longitudinal study showed that the co-occurrence of SI and MetS increased the risk of disability onset in older adults. This indicates that the assessment of MetS in socially isolated older adults is important for healthcare providers to delay the onset of disabilities.

Social isolation, loneliness and subsequent risk of major adverse cardiovascular events among individuals with type 2 diabetes mellitus

Background

Individuals with type 2 diabetes mellitus (T2DM) are more vulnerable to social disconnection compared with the general population; however, there are few relevant studies investigating this issue.

Aims

To investigate whether social isolation or loneliness may be associated with subsequent risk of developing major adverse cardiovascular events, whether these associations vary according to fatal and non-fatal outcomes and how behavioural, psychological and physiological factors mediate these associations.

Methods

This longitudinal analysis included data from 19 360 individuals with T2DM at baseline (2006-2010) from the UK Biobank. Social isolation and loneliness were measured using self-report questionnaires. The study outcomes included the first events of myocardial infarction (MI) or stroke (n=2273) and all-cause (n=2820) or cardiovascular disease-related mortality through linked hospital data or death registries.

Results

Over a median follow-up of 12.4 years (interquartile range (IQR): 11.6-13.3 years), participants who were more socially isolated (most social isolation vs least social isolation) experienced increased risks for all-cause (hazard ratio (HR) : 1.33, 95% confidence interval (CI): 1.19 to 1.47) and cardiovascular disease (HR: 1.36, 95% CI: 1.17 to 1.59) mortality but not first MI or stroke. Loneliness (yes vs no) was associated with a greater risk for a composite of incident MI or stroke (HR: 1.37, 95% CI: 1.19 to 1.57) but not mortality. Social isolation was associated with fatal MI and stroke, whereas loneliness was associated with non-fatal MI and stroke. The significant associations of social isolation and loneliness with outcomes were mainly mediated by behavioural factors (mediating proportion: 17.8%-28.2% and 17.6%-17.8%, respectively).

Conclusions

Among individuals with T2DM, social isolation and loneliness are associated with a greater risk of developing major adverse cardiovascular events, with differences in both risks stratified according to fatal and non-fatal events and underlying mediating factors.

Association of cumulative loneliness with all-cause mortality among middle-aged and older adults in the United States, 1996 to 2019

Loneliness is a growing public health concern worldwide. We characterized the association between cumulative loneliness and subsequent all-cause mortality, using data from 9,032 participants aged 50+ in the population-based US Health and Retirement Study (HRS) from 1996 to 2019. Loneliness status (yes; no) was measured biennially from 1996 to 2004, and we categorized the experience of cumulative loneliness over the 8-y period as never, one time point, two time points, and ≥three time points. A multivariable-adjusted age-stratified Cox proportional hazards regression model was fitted to examine the association between cumulative loneliness from 1996 to 2004 and all-cause mortality from 2004 to 2019. Excess deaths due to each category of cumulative loneliness were calculated. Compared to those who never reported loneliness from 1996 to 2004, participants experiencing loneliness at one time point, two time points, and ≥three time points respectively had 1.05 (95% CI: 0.96 to 1.15), 1.06 (95% CI: 0.95 to 1.19), and 1.16 (95% CI: 1.02 to 1.33) times higher hazards of mortality from 2004 to 2019 (P trend = 0.01). These results correspond to 106 (95% CI: 68 to 144), 202 (95% CI: 146 to 259), and 288 (95% CI: 233 to 343) excess deaths per 10,000 person-years, for those experiencing loneliness at each of one, two, or ≥three time points from 1996 to 2004. Cumulative loneliness in mid-to-later life may thus be a mortality risk factor with a notable impact on excess mortality. Loneliness may be an important target for interventions to improve life expectancy in the United States.

Social isolation from childhood to mid-adulthood: is there an association with older brain age?

BACKGROUND

Older brain age - as estimated from structural MRI data - is known to be associated with detrimental mental and physical health outcomes in older adults. Social isolation, which has similar detrimental effects on health, may be associated with accelerated brain aging though little is known about how different trajectories of social isolation across the life course moderate this association. We examined the associations between social isolation trajectories from age 5 to age 38 and brain age assessed at age 45.

METHODS

We previously created a typology of social isolation based on onset during the life course and persistence into adulthood, using group-based trajectory analysis of longitudinal data from a New Zealand birth cohort. The typology comprises four groups: 'never-isolated', 'adult-only', 'child-only', and persistent 'child-adult' isolation. A brain age gap estimate (brainAGE) - the difference between predicted age from structural MRI date and chronological age - was derived at age 45. We undertook analyses of brainAGE with trajectory group as the predictor, adjusting for sex, family socio-economic status, and a range of familial and child-behavioral factors.

RESULTS

Older brain age in mid-adulthood was associated with trajectories of social isolation after adjustment for family and child confounders, particularly for the 'adult-only' group compared to the 'never-isolated' group.

CONCLUSIONS

Although our findings are associational, they indicate that preventing social isolation, particularly in mid-adulthood, may help to avert accelerated brain aging associated with negative health outcomes later in life.

The association between loneliness or social isolation and food and eating behaviours: A scoping review

Loneliness or social isolation and food/eating behaviours have important health consequences and there are rationales for why they could interact. Loneliness and dietary behaviours are recognised as health determinants and targets for interventions at individual, group and population levels. However, there are currently no research reviews investigating associations between these areas. This scoping review synthesized evidence investigating loneliness or social isolation and food/eating behaviours in people aged over 16 years in high-income countries. A systematic search of five databases from 2000 was conducted using predetermined search terms. Dissertation database and backwards citation searches were also conducted. Full text screening of 254 articles/theses resulted in inclusion of three qualitative and 26 quantitative studies, with eight conducted in COVID-19 lockdowns. Almost all studies reported a relationship between loneliness/social isolation and eating behaviours usually considered harmful such as low fruit and vegetable intake and lower diet quality. Qualitative research also supports the detrimental influence of loneliness or social isolation on eating. Study quality was considered, and interpretation and comparison of results was complicated by use of varying methods. Better awareness and understanding of the relationship between these complex aspects of health is needed to inform the development of interventions and practice of nutrition and mental health practitioners, policymakers, researchers and end-users.

Post-Stroke Brain Health Monitoring and Optimization: A Narrative Review

Significant advancements have been made in recent years in the acute treatment and secondary prevention of stroke. However, a large proportion of stroke survivors will go on to have enduring physical, cognitive, and psychological disabilities from suboptimal post-stroke brain health. Impaired brain health following stroke thus warrants increased attention from clinicians and researchers alike. In this narrative review based on an open timeframe search of the PubMed, Scopus, and Web of Science databases, we define post-stroke brain health and appraise the body of research focused on modifiable vascular, lifestyle, and psychosocial factors for optimizing post-stroke brain health. In addition, we make clinical recommendations for the monitoring and management of post-stroke brain health at major post-stroke transition points centered on four key intertwined domains: cognition, psychosocial health, physical functioning, and global vascular health. Finally, we discuss potential future work in the field of post-stroke brain health, including the use of remote monitoring and interventions, neuromodulation, multi-morbidity interventions, enriched environments, and the need to address inequities in post-stroke brain health. As post-stroke brain health is a relatively new, rapidly evolving, and broad clinical and research field, this narrative review aims to identify and summarize the evidence base to help clinicians and researchers tailor their own approach to integrating post-stroke brain health into their practices.

Social Networks and Cardiovascular Disease Events in the Jackson Heart Study

Background Cardiovascular disease (CVD) disproportionately affects Black adults. Greater social networks (SNs), or social connectedness, may lower the risk of CVD events. This study determined the association of SNs and incident CVD and tested mediation by depressive symptoms, hypertension control, and diabetes control. Methods and Results We used the Social Network Index at exam 1 (2000-2004) to develop a continuous standardized SN score and binary categories (high versus low) among participants in the Jackson Heart Study (n=4686; mean age, 54.8 years). Surveillance of coronary heart disease, stroke, and heart failure events occurred after exam 1 (2005 for HF) until 2016. Using Cox proportional hazards regression, we estimated the association of SNs and CVD events by sex and tested the mediation of depressive symptoms, hypertension control, and diabetes control. Models adjusted for age, education, health behaviors, CVD comorbidities, and depressive symptoms. Among women, the SN score was associated with a lower hazard of stroke, coronary heart disease, and heart failure after full adjustment (hazard ratio [HR], 0.78 [95% CI, 0.64-0.95]; HR, 0.79 [95% CI, 0.71-0.88]; and HR, 0.78 [95% CI, 0.66-0.92], respectively). SN scores were also associated with a lower hazard of coronary heart disease in men (HR, 0.84 [95% CI, 0.75-0.94]) after full adjustment. High versus low SNs were associated with a lower hazard of coronary heart disease and heart failure among women after full adjustment. There was no evidence of mediation by depressive symptoms, diabetes control, and hypertension control. Conclusions Higher SNs may lower the risk of CVD events, especially in women.

angptl4 gene expression as a marker of adaptive homeostatic response to social isolation across the lifespan in zebrafish

Social isolation has detrimental health effects, but the underlying mechanisms are unclear. Here, we investigated the impact of 2 weeks of isolation on behavior and gene expression in the central nervous system at different life stages of zebrafish. Results showed that socially deprived young adult zebrafish experienced increased anxiety, accompanied by changes in gene expression. Most gene expression patterns returned to normal within 24 hours of reintroduction to a social environment, except angptl4, which was upregulated after reintroduction, suggesting an adaptive mechanism. Similarly, aging zebrafish displayed heightened anxiety and increased central nervous system expression of angptl4 during isolation, but effects were reversed upon reintroduction to a social group. The findings imply that angptl4 plays a homeostatic role in response to social isolation, which varies across the lifespan. The study emphasizes the importance of social interactions for psychological well-being and highlights the negative consequences of isolation, especially in older individuals. Further research may unravel how social isolation affects angptl4 expression and its developmental and aging effects.

Social isolation and loneliness: Undervalued risk factors for disease states and mortality

Social isolation and loneliness are two common but undervalued conditions associated with a poor quality of life, decreased overall health and mortality. In this review, we aim to discuss the health consequences of social isolation and loneliness. We first provide the potential causes of these two conditions. Then, we explain the pathophysiological processes underlying the effects of social isolation and loneliness in disease states. Afterwards, we explain the important associations between these conditions and different non-communicable diseases, as well as the impact of social isolation and loneliness on health-related behaviours. Finally, we discuss the current and novel potential management strategies for these conditions. Healthcare professionals who attend to socially isolated and/or lonely patients should be fully competent in these conditions and assess their patients thoroughly to detect and properly understand the effects of isolation and loneliness. Patients should be offered education and treatment alternatives through shared decision-making. Future studies are needed to understand the underlying mechanisms better and to improve the treatment strategies for both social isolation and loneliness.

PROTOCOL: In-person interventions to reduce social isolation and loneliness: An evidence and gap map

This is the protocol for an evidence and gap map. The objectives are as follows: This EGM aims to map available evidence on the effects of in-person interventions to reduce social isolation and/or loneliness across all age groups in all settings.

The Social Worker in The Care of The Stroke Patient

As a leading cause of death and long-term disability, stroke care is a complex endeavor, requiring a coalition of healthcare professionals. As part of a multi-disciplinary team, social workers help the patient to reach individual goals and facilitate their return to and stability in their community at their highest possible functional, social, and economic level.

The mediating effect of stigma between self-perceived burden and loneliness in stroke patients

Introduction

Stroke patients may experience reduced socialization and feelings of isolation due to post-stroke sequelae such as impaired motor function and cognitive deficits. Factors associated with loneliness need to be explored to develop targeted interventions. However, little is known about the impact of self-perceived burden and illness stigma on loneliness in this population.The aim of this study was to explore the mediating effect of stigma on self-perceived burden and loneliness in stroke patients.

Methods

The cluster random sampling method was adopted to select 1028 stroke patients from the neurology department of third-grade A hospitals and second-grade A hospitals in 5 cities of Henan Province from May 2022 to August 2022. A general data questionnaire, self-perceived burden scale, stroke stigma scale, and loneliness scale were used to investigate. The structural equation model was used to analyze the mediating effect of stigma between self-perceived burden and stigma.

Results

The loneliness of stroke patients was positively correlated with self-perceived burden and stigma. The results of the mediation analysis showed that stigma played a complete mediating role between self-perceived burden and loneliness.

Discussion

The results of the study revealed the relationship between self-perceived burden, stigma, and loneliness in stroke patients. Stigma mediated the relationship between self-perceived burden and loneliness in this population.Stigma should be emphasized as an important modifiable psychological factor that affects loneliness of stroke patients.

One-Year Survival after Cardiac Surgery in Frail Older People-Social Support Matters: A Prospective Cohort Study

There are increasing rates of cardiac surgery in the elderly. Frailty, depression, and social vulnerability are frequently present in older people, and should be considered while assessing risk and providing treatment options. We aimed to analyse the impact of clinically relevant variables on survival at one year, and identify areas of future intervention. We performed a prospective cohort study at a University Hospital, with a sample of 309 elective cardiac surgery patients 65 years old and over. Their socio-demographic and clinical variables were collected. Frailty prevalence was 61.3%, while depression was absent in the majority of patients. Mortality was 1.6% and 7.8% at 30 days and 12 months, respectively. After Kaplan-Meier analysis, severe frailty (p = 0.003), severe depression (p = 0.027), pneumonia until 30 days (p = 0.014), and re-operation until 12 months (p = 0.003) significantly reduced survival, while social support increased survival (p = 0.004). In the adjusted multivariable Cox regression model, EuroSCORE II (HR = 1.27 [95% CI 1.069-1.499] p = 0.006), pneumonia until 30 days (HR = 4.19 [95% CI 1.169-15.034] p = 0.028), re-intervention until 12 months (HR = 3.14 [95% CI 1.091-9.056] p = 0.034), and social support (HR = 0.24 [95% CI 0.079-0.727] p = 0.012) explained time until death. Regular screening for social support, depression, and frailty adds relevant information regarding risk stratification, perioperative interventions, and decision-making in older people considered for cardiac surgery.

Adverse Childhood Experiences, Social Isolation, Job Strain, and Cardiovascular Disease Mortality in U.S. Older Employees

Stress is a key driver of cardiovascular disease (CVD), yet the contribution of psychosocial stressors to the development of CVD has not been systematically examined in United States (U.S.) populations. The objective of this study was to assess prospective associations of adverse childhood experiences (ACEs), social isolation, and job strain with CVD mortality. Data were from the large, nationally representative, population-based Health and Retirement Study (HRS). ACEs, social isolation and job strain were assessed using validated survey instruments at baseline between 2006-2008, and death information was followed up through 2018. Cox proportional hazards regression models were used to examine prospective associations of ACEs, social isolation, and job strain with CVD mortality among 4046 older employees free from CVD at baseline. During 42,149 person-years of follow-up time, 59 death cases of CVD were reported. After adjustment for covariates, ACEs and job strain were significantly associated with increased risk of CVD mortality (aHR and 95% CI = 3.67 [1.59, 8.48] and 2.24 [1.21, 4.11], respectively), whereas social isolation demonstrated an inflated but nonsignificant association (aHR and 95% CI = 1.62 [0.72, 3.66]). These findings highlight the role of psychosocial exposures as novel and clinically relevant risk factors for CVD.

Childhood Obesity and Cardiovascular Disease Risk

PURPOSE OF REVIEW

The global epidemic of youth-onset obesity is tightly linked to the rising burden of cardiometabolic disease across the lifespan. While the link between childhood obesity and cardiovascular disease is established, this contemporary review summarizes recent and novel advances in this field that elucidate the mechanisms and impact of this public health issue.

RECENT FINDINGS

The review highlights the emerging data supporting the relationship between childhood adverse events, social determinants of health, and systemic and institutional systems as etiological factors. We also provide updates on new screening and treatment approaches including updated nutrition and dietary guidelines and benchmarks for pediatric obesity screening, novel pharmacological agents for pediatric obesity and type 2 diabetes such as glucagon-like 1 peptide receptor agonists, and we discuss the long-term safety and efficacy data on surgical management of pediatric obesity. The global burden of pediatric obesity continues to rise and is associated with accelerated and early vascular aging especially in youth with obesity and type 2 diabetes. Socio-ecological determinants of risk mediate and moderate the relationship of childhood obesity with cardiometabolic disease. Recognizing the importance of neighborhood level influences as etiological factors in the development of cardiovascular disease is critical for designing effective policies and interventions. Novel surgical and pharmacological interventions are effective pediatric weight-loss interventions, but future research is needed to assess whether these agents, within a socio-ecological framework, will be associated with abatement of the pediatric obesity epidemic and related increased cardiovascular disease risk.

Associations of a biopsychosocial frailty phenotype with all-cause dementia, Alzheimer's disease, vascular dementia, and other dementias: the Italian PRoject on the Epidemiology of Alzheimer's disease (IPREA)

Frailty is a critical intermediate status of the aging process including physical, cognitive, and psychosocial domains/phenotypes. We operationalized a new biopsychosocial frailty construct, estimating its impact on the odds of all-cause dementia, Alzheimer's disease (AD), vascular dementia (VaD), and other dementias in 2838 older individuals from the population-based Italian PRoject on the Epidemiology of Alzheimer's disease (IPREA). Biopsychosocial frailty operationalization was based on the results of a previous comprehensive geriatric assessment and the presence of physical frailty. In this cross-sectional study, participants with biopsychosocial frailty showed an increased odds ratio of all-cause dementia [odds ratio (OR): 5.55, 95% confidence interval (CI): 3.72-8.28, p < 0.001], in particular for probable AD (OR: 3.62, 95% CI: 1.55-8.45, p < 0.001), probable VaD (OR: 10.05, 95% CI: 5.05-19.97, p < 0.001), and possible VaD (OR: 17.61, 95% CI: 6.42-48.32, p < 0.001). No statistically significant association was found between this biopsychosocial frailty phenotype and possible AD (OR: 2.84, 95% CI: 0.81-9.97, p = 0.09) or other dementias (OR: 1.77, 95% CI: 0.75-0.21, p = 0.19). In conclusion, in a large cohort of Italian older individuals, a biopsychosocial frailty model was associated to all-cause dementia, probable AD, and probable and possible VaD. In the next future, other large and prospective population-based studies evaluating the association between the biopsychosocial frailty phenotype and incident all-cause dementia, AD, and VaD are needed, addressing also potential bias and confounding sources.

The relationship between social isolation, social support, and loneliness with cardiovascular disease and shared risk factors: A narrative review

BACKGROUND

Cardiovascular disease (CVD) is the greatest contributor to global morbidity and mortality. Poor social health plays a critical role in CVD incidence. Additionally, the relationship between social health and CVD may be mediated through CVD risk factors. However, the underlying mechanisms between social health and CVD are poorly understood. Certain social health constructs (social isolation, low social support and loneliness) have complicated the characterisation of a causal relationship between social health and CVD.

AIM

To provide an overview of the relationship between social health and CVD (and its shared risk factors).

METHOD

In this narrative review, we examined published literature on the relationship between three social health constructs (social isolation, social support, and loneliness) and CVD. Evidence was synthesised in a narrative format, focusing on the potential ways in which social health affects CVD, including shared risk factors.

RESULTS

The current literature highlights an established relationship between social health and CVD with a likelihood for bi-directionality. However, there is speculation and varied evidence regarding how these relationships may be mediated through CVD risk factors.

CONCLUSIONS

Social health can be considered an established risk factor for CVD. However, the potential bi-directional pathways of social health with CVD risk factors are less established. Further research is needed to understand whether targeting certain constructs of social health may directly improve the management of CVD risk factors. Given the health and economic burdens of poor social health and CVD, improvements to addressing or preventing these interrelated health conditions would have societal benefits.

A Middle-Range Theory of Social Isolation in Chronic Illness

Chronic illnesses and social isolation are major public phenomena that drive health and social policy worldwide. This article describes a middle-range theory of social isolation as experienced by chronically ill individuals. Key concepts include social disconnectedness, loneliness, and chronic illness. Antecedents of social isolation include predisposing factors (e.g., ageism and immigration) and precipitating factors (e.g., stigma and grief). Outcomes of social isolation include psychosocial responses (e.g., depression and quality of life), health-related behaviors (i.e., self-care), and clinical responses (e.g., cognitive function and health service use). Possible patterns of social isolation in chronic illness are described.

Solo With Cancer

This essay describes the author’s experience with a socially isolated patient who declined cancer treatment because he had no one to help him after transarterial radioembolization therapy.

Influence of the Social Environment on Ideal Cardiovascular Health

Background The environment plays a large role in the health of individuals; however, more research is needed to better understand aspects of the environment that most influence health. Specifically, our study examines how the social environment influences cardiovascular health (CVH). Methods and Results The social environment was characterized using measures of belonging and life and work stress in individuals, as well as nationally derived measures of marginalization, deprivation, economic status, and community well-being in neighborhoods. CVH was defined by the American Heart Association's Cardiovascular Health Index-a summed score of 7 clinical and behavioral components known to have the greatest impact on CVH. Data were obtained from the Canadian Community Health Survey 2015 to 2016 and multiple national data sources. Multilevel regression models were used to analyze the associations between CVH and the social environment. Overall, 27% of Canadians reported ideal CVH (6-7 score points), 68% reported intermediate CVH (3-5 score points), and 5% reported poor CVH (0-2 score points). The neighborhood environment contributed up to 7% of the differences in CVH between individuals. Findings indicated that residing in a neighborhood with greater community well-being (odds ratio [OR], 1.33 [95% CI, 1.26-1.41]) was associated with achieving higher odds of ideal CVH, while weaker community belonging (OR, 0.67 [95% CI, 0.62-0.72]) and residing in a neighborhood with greater marginalization (OR, 0.87 [95% CI, 0.82-0.91]) and deprivation (OR, 0.67 [95% CI, 0.64-0.69]) were associated with achieving lower odds of ideal CVH. Conclusions Aspects of individual-level social environment and residing in a neighborhood with a more favorable social environment were both independently and significantly associated with achieving ideal CVH.

Sex Differences in the Evaluation and Treatment of Stroke

There are differences in the prevalence and strength of risk factors in women, along with sex-specific risk factors such as pregnancy. Women have a higher lifetime risk of stroke compared to men, with worse outcomes including higher rates of death and disability. We have made strides in the identification of sex-specific risk factors but with the paucity of sex-specific end points in clinical trials, stroke treatment and research are hindered.

Support Needs and Coping Strategies in Non-Alcoholic Fatty Liver Disease (NAFLD): A Multidisciplinary Approach to Potential Unmet Challenges beyond Pharmacological Treatment

Non-alcoholic fatty liver disease (NAFLD) is the most frequently occurring chronic liver disease, affecting approximately 25–30% of the adult general population worldwide. NAFLD reflects excess hepatic accumulation of fat in the absence of increased alcohol intake, and, due to its close association with obesity, is frequently referred to as the ‘hepatic manifestation’ of metabolic syndrome. Indeed, a high percentage of individuals with NAFLD present with a combination of the cardio-metabolic comorbidities that are associated with the metabolic syndrome. In addition to its well-established link with the metabolic syndrome and increased risk for cardiovascular disease, NAFLD has also been associated with certain mental health issues (e.g., depression and stress). Although this link is now being increasingly recognized, there are still unmet needs regarding the holistic management of patients with NAFLD, which could further contribute to feelings of social isolation and loneliness. The latter conditions are also increasingly reported to pose a substantial risk to overall health and quality of life. To date, there is limited research that has explored these issues among patients with NAFLD, despite existing data which indicate that perceived loneliness and isolation may pose an additional health risk. Notably, many features associated with NAFLD have been related to these concepts, such as perceived stigma, fatigue, stress, and confusion regarding this diagnosis. As such, this review aimed to assess such potential problems faced by patients with NAFLD, and to explore the possibility of unmet support needs which could lead to perceived social isolation. Moreover, the importance of a compassionate approach towards such patients is discussed, together with potential coping strategies. Future research directions and the need for a multidisciplinary approach are also highlighted.

Risk Factors Associated with Preventable Hospitalisation among Rural Community-Dwelling Patients: A Systematic Review

Potentially preventable hospitalisations (PPHs) are common and increase the burden on already stretched healthcare services. Increasingly, psychosocial factors have been recognised as contributing to PPHs and these may be mitigated through greater attention to social capital. This systematic review investigates the factors associated with PPHs within rural populations. The review was designed, conducted, and reported according to PRISMA guidelines and registered with Prospero (ID: CRD42020152194). Four databases were systematically searched, and all potentially relevant papers were screened at the title/abstract level, followed by full-text review by at least two reviewers. Papers published between 2000-2022 were included. Quality assessment was conducted using Newcastle-Ottawa Scale and CASP Qualitative checklist. Of the thirteen papers included, eight were quantitative/descriptive and five were qualitative studies. All were from either Australia or the USA. Access to primary healthcare was frequently identified as a determinant of PPH. Socioeconomic, psychosocial, and geographical factors were commonly identified in the qualitative studies. This systematic review highlights the inherent attributes of rural populations that predispose them to PPHs. Equal importance should be given to supply/system factors that restrict access and patient-level factors that influence the ability and capacity of rural communities to receive appropriate primary healthcare.

Affective Neuroscience of Loneliness: Potential Mechanisms underlying the Association between Perceived Social Isolation, Health, and Well-Being

Loneliness, or the subjective feeling of social isolation, is an important social determinant of health. Loneliness is associated with poor physical health, including higher rates of cardiovascular disease and dementia, faster cognitive decline, and increased risk of mortality, as well as disruptions in mental health, including higher levels of depression, anxiety, and negative affect. Theoretical accounts suggest loneliness is a complex cognitive and emotional state characterized by increased levels of inflammation and affective disruptions. This review examines affective neuroscience research on social isolation in animals and loneliness in humans to better understand the relationship between perceptions of social isolation and the brain. Loneliness associated increases in inflammation and neural changes consistent with increased sensitivity to social threat and disrupted emotion regulation suggest interventions targeting maladaptive social cognitions may be especially effective. Work in animal models suggests the neural changes associated with social isolation may be reversible. Therefore, ameliorating loneliness may be an actionable social determinant of health target. However, more research is needed to understand how loneliness impacts healthy aging, explore the role of inflammation as a potential mechanism in humans, and determine the best time to deliver interventions to improve physical health, mental health, and well-being across a diverse array of populations.