Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies

Nicole K Valtorta, Mona Kanaan, Simon Gilbody, Sara Ronzi, Barbara Hanratty, Nicole K Valtorta, Mona Kanaan, Simon Gilbody, Sara Ronzi, Barbara Hanratty

Abstract

Background: The influence of social relationships on morbidity is widely accepted, but the size of the risk to cardiovascular health is unclear.

Objective: We undertook a systematic review and meta-analysis to investigate the association between loneliness or social isolation and incident coronary heart disease (CHD) and stroke.

Methods: Sixteen electronic databases were systematically searched for longitudinal studies set in high-income countries and published up until May 2015. Two independent reviewers screened studies for inclusion and extracted data. We assessed quality using a component approach and pooled data for analysis using random effects models.

Results: Of the 35 925 records retrieved, 23 papers met inclusion criteria for the narrative review. They reported data from 16 longitudinal datasets, for a total of 4628 CHD and 3002 stroke events recorded over follow-up periods ranging from 3 to 21 years. Reports of 11 CHD studies and 8 stroke studies provided data suitable for meta-analysis. Poor social relationships were associated with a 29% increase in risk of incident CHD (pooled relative risk: 1.29, 95% CI 1.04 to 1.59) and a 32% increase in risk of stroke (pooled relative risk: 1.32, 95% CI 1.04 to 1.68). Subgroup analyses did not identify any differences by gender.

Conclusions: Our findings suggest that deficiencies in social relationships are associated with an increased risk of developing CHD and stroke. Future studies are needed to investigate whether interventions targeting loneliness and social isolation can help to prevent two of the leading causes of death and disability in high-income countries.

Study registration number: CRD42014010225.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Figures

Figure 1
Figure 1
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. CHD, coronary heart disease.
Figure 2
Figure 2
Internal validity. NA, not applicable.
Figure 3
Figure 3
Forest plot of studies investigating incident CHD. CHD, coronary heart disease.
Figure 4
Figure 4
Forest plot of studies investigating incident stroke.
Figure 5
Figure 5
(A) Contour-enhanced funnel plot, coronary heart disease studies. (B) Contour-enhanced funnel plot, stroke studies.

References

    1. Holt-Lunstad J, Smith TB, Baker M, et al. . Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci 2015;10:227–37. 10.1177/1745691614568352
    1. Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta-analytic review. PLoS Med 2010;7:e1000316 10.1371/journal.pmed.1000316
    1. Berkman LF, Glass TA. Social network epidemiology. In: Berkman LF, Kawachi I. Social Epidemiology. New York: Oxford University Press, 2014:234–89.
    1. Hawkley LC, Cacioppo JT. Loneliness matters: a theoretical and empirical review of consequences and mechanisms. Ann Behav Med 2010;40:218–27. 10.1007/s12160-010-9210-8
    1. Shankar A, McMunn A, Banks J, et al. . Loneliness, social isolation, and behavioral and biological health indicators in older adults. Health Psychol 2011;30:377–85. 10.1037/a0022826
    1. Steptoe A, Owen N, Kunz-Ebrecht SR, et al. . Loneliness and neuroendocrine, cardiovascular, and inflammatory stress responses in middle-aged men and women. Psychoneuroendocrinology 2004;29:593–611. 10.1016/S0306-4530(03)00086-6
    1. McAvay GJ, Seeman TE, Rodin J. A longitudinal study of change in domain-specific self-efficacy among older adults. J Gerontol B Psychol Sci Soc Sci 1996;51:P243–53. 10.1093/geronb/51B.5.P243
    1. Grant N, Hamer M, Steptoe A. Social isolation and stress-related cardiovascular, lipid, and cortisol responses. Ann Behav Med 2009;37:29–37. 10.1007/s12160-009-9081-z
    1. Hawkley LC, Thisted RA, Masi CM, et al. . Loneliness predicts increased blood pressure: 5-year cross-lagged analyses in middle-aged and older adults. Psychol Aging 2010;25:132–41. 10.1037/a0017805
    1. World Health Organization. Global health estimates summary tables: DALYs by cause, age and sex, by World Bank income group. 2013. (accessed 26 June 2015).
    1. Centre for Reviews and Dissemination. Systematic Reviews: CRD's guidance for undertaking reviews in health care. York, UK: University of York, 2009.
    1. PROSPERO. Loneliness and social isolation as determinants of health: a systematic review of longitudinal observational studies set in high-income countries. 2014. (accessed 22Jul 2015).
    1. Perlman D, Peplau AL. Toward a social psychology of loneliness. In: Duck S, Gilmour R. Personal relationships in disorder. London: Academic Press, 1981:31–56.
    1. de Jong Gierveld J, Van Tilburg TG, Dykstra PA. Loneliness and social isolation. In: Vangelisti A, Perlman D. Cambridge Handbook of Personal Relationships. Cambridge, UK: Cambridge University Press, 2006:485–500.
    1. World Bank. World Bank list of economies. 2014. (accessed 29 May 2015).
    1. Viswanathan M, Berkman ND, Dryden DM, et al. . Assessing risk of bias and confounding in observational studies of interventions or exposures: further development of the RTI item bank. Rockville MD, Agency for Healthcare Research and Quality (US), 2013.
    1. Stringhini S, Berkman L, Dugravot A, et al. . Socioeconomic status, structural and functional measures of social support, and mortality: the British Whitehall II Cohort Study, 1985–2009. Am J Epidemiol 2012;175:1275–83. 10.1093/aje/kwr461
    1. Pinquart M, Sörensen S, Shohov S. Risk factors for loneliness in adulthood and old age: a meta-analysis. Adv Psych Res 2003;19:111–43.
    1. Zhang J, Yu KF. What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes. JAMA 1998;280:1690–1. 10.1001/jama.280.19.1690
    1. Higgins JPT, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from
    1. André-Petersson L, Hedblad B, Janzon L, et al. . Social support and behavior in a stressful situation in relation to myocardial infarction and mortality: who is at risk? Results from prospective cohort study “Men born in 1914,” Malmo, Sweden. Int J Behav Med 2006;13:340–7. 10.1207/s15327558ijbm1304_9
    1. Eng PM, Rimm EB, Fitzmaurice G, et al. . Social ties and change in social ties in relation to subsequent total and cause-specific mortality and coronary heart disease incidence in men. Am J Epidemiol 2002;155:700–9. 10.1093/aje/155.8.700
    1. Hedblad B, Ostergren PO, Hanson BS, et al. . Influence of social support on cardiac event rate in men with ischaemic type ST segment depression during ambulatory 24-h long-term ECG recording. Eur Heart J 1992;13:433–9.
    1. Kawachi I, Colditz GA, Ascherio A, et al. . A prospective study of social networks in relation to total mortality and cardiovascular disease in men in the USA. J Epidemiol Community Health 1996;50:245–51. 10.1136/jech.50.3.245
    1. Orth-Gomér K, Rosengren A, Wilhelmsen L. Lack of social support and incidence of coronary heart disease in middle-aged Swedish men. Psychosom Med 1993;55:37–43. 10.1097/00006842-199301000-00007
    1. Reed D, McGee D, Yano K. Psychosocial processes and general susceptibility to chronic disease. Am J Epidemiol 1984;119:356–70.
    1. Reed D, McGee D, Yano K, et al. . Social networks and coronary heart disease among Japanese men in Hawaii. Am J Epidemiol 1983;117:384–96.
    1. Rosengren A, Wilhelmsen L, Orth-Gomér K. Coronary disease in relation to social support and social class in Swedish men. A 15 year follow-up in the study of men born in 1933. Eur Heart J 2004;25:56–63. 10.1016/j.ehj.2003.10.005
    1. Sykes D, Arveiler D, Salters CP, et al. . Psychosocial risk factors for heart disease in France and Northern Ireland: the Prospective Epidemiological Study of Myocardial Infarction (PRIME). Int J Epidemiol 2002;31:1227–34. 10.1093/ije/31.6.1227
    1. Eaker ED, Pinsky J, Castelli WP. Myocardial infarction and coronary death among women: psychosocial predictors from a 20-year follow-up of women in the Framingham Study. Am J Epidemiol 1992;135:854–64.
    1. Gafarov VV, Panov DO, Gromova EA, et al. . The influence of social support on risk of acute cardiovascular diseases in female population aged 25–64 in Russia. Int J Circumpolar Health 2013;72 10.3402/ijch.v72i0.21210
    1. Kuper H, Adami HO, Theorell T, et al. . Psychosocial determinants of coronary heart disease in middle-aged women: a prospective study in Sweden. Am J Epidemiol 2006;164:349–57. 10.1093/aje/kwj212
    1. Rutledge T, Linke SE, Olson MB, et al. . Social networks and incident stroke among women with suspected myocardial ischemia. Psychosom Med 2008;70:282–7. 10.1097/PSY.0b013e3181656e09
    1. Strodl E, Kenardy J. The 5-item mental health index predicts the initial diagnosis of nonfatal stroke in older women. J Womens Health (Larchmt) 2008;17:979–86. 10.1089/jwh.2007.0516
    1. Strodl E, Kenardy J, Aroney C. Perceived stress as a predictor of the self-reported new diagnosis of symptomatic CHD in older women. Int J Behav Med 2003;10:205–20. 10.1207/S15327558IJBM1003_02
    1. Avendano M, Kawachi I, Van Lenthe F, et al. . Socioeconomic status and stroke incidence in the US elderly: the role of risk factors in the EPESE study. Stroke 2006;37:1368–73. 10.1161/01.STR.0000221702.75002.66
    1. Barefoot JC, Grønbaek M, Jensen G, et al. . Social network diversity and risks of ischemic heart disease and total mortality: findings from the Copenhagen City Heart Study. Am J Epidemiol 2005;161:960–7. 10.1093/aje/kwi128
    1. Colantonio A, Kasi SV, Ostfeld AM. Depressive symptoms and other psychosocial factors as predictors of stroke in the elderly. Am J Epidemiol 1992;136: 884–94. 10.1093/aje/136.7.884
    1. Ikeda A, Iso H, Kawachi I, et al. . Social support and stroke and coronary heart disease: the JPHC study cohorts II. Stroke 2008;39:768–75. 10.1161/STROKEAHA.107.496695
    1. Nagayoshi M, Everson-Rose SA, Iso H, et al. . Social network, social support, and the risk of incident stroke: the atherosclerosis risk in communities study. Circulation 2014;129.
    1. Player MS, King DE, Mainous AG III, et al. . Psychosocial factors and progression from prehypertension to hypertension or coronary heart disease. Ann Fam Med 2007;5:403–11. 10.1370/afm.738
    1. Thurston RC, Kubzansky LD. Women, loneliness, and incident coronary heart disease. Psychosom Med 2009;71:836–42. 10.1097/PSY.0b013e3181b40efc
    1. Vogt TM, Mullooly JP, Ernst D, et al. . Social networks as predictors of ischemic heart disease, cancer, stroke and hypertension: incidence, survival and mortality. J Clin Epidemiol 1992;45:659–66. 10.1016/0895-4356(92)90138-D
    1. Berkman L, Breslow L. Health and ways of living: the alameda county study. New York: Oxford University Press, 1983.
    1. Lubben J. Assessing social networks among elderly populations. Fam Community Health 1988;11:42–52. 10.1097/00003727-198811000-00008
    1. Goodger B, Byles JE, Higganbotham N. Assessment of a short scale to measure social support among older people. Aust N Z J Public Health 1999;23: 260–5. 10.1111/j.1467-842X.1999.tb01253.x
    1. Kuper H, Marmot M, Hemingway H. Systematic review of prospective cohort studies of psychosocial factors in the etiology and prognosis of coronary heart disease. Semin Vasc Med 2002;2:267–314. 10.1055/s-2002-35401
    1. Barth J, Schneider S, von Känel R. Lack of social support in the etiology and the prognosis of coronary heart disease: a systematic review and meta-analysis. Psychosom Med 2010;72:229–38. 10.1097/PSY.0b013e3181d01611
    1. Steptoe A, Kivimäki M. Stress and cardiovascular disease: an update on current knowledge. Annu Rev Public Health 2013;34:337–54. 10.1146/annurev-publhealth-031912-114452
    1. Roest AM, Martens EJ, de Jonge P, et al. . Anxiety and risk of incident coronary heart disease: a meta-analysis. J Am Coll Cardiol 2010;56:38–46. 10.1016/j.jacc.2010.03.034
    1. Fransson EI, Nyberg ST, Heikkilä K, et al. . Job strain and the risk of stroke: an individual-participant data meta-analysis. Stroke 2015;46:557–9. 10.1161/STROKEAHA.114.008019
    1. Cohen S, Gottlieb B, Underwood L. Social relationships and health. In: Cohen S, Underwood L, Gottlieb B. Measuring and Intervening in Social Support. New York: Oxford University Press, 2000:3–16.

Source: PubMed

赞助者和合作者

医疗条件

药物干预

3
订阅