Prioritizing Social Connection Within Social Determinants of Health: Healthy People 2030 Recommendations - Rural Aging

Prioritizing Social Connection
                              Within Social Determinants of Health:
                             Healthy People 2030 Recommendations

                                        Julianne Holt-Lunstad, Ph.D
                      With Assistance from Tanner Mangum and Elizabeth Rula, Ph.D
                                                Tivity Health
                                  National Rural Aging Advisory Council

Lacking social connection1 (e.g., social isolation, loneliness) is an independent risk factor for poorer
health and premature death, while being socially connected has a strong positive influence on
psychological and physical well-being. Social determinants of health are a critical priority, yet current
Healthy People 2020 objectives do not address social isolation, loneliness, and decreased social capital.

     •    We recommend that the Social Determinants of Health objective within Healthy People 2030
          be amended to more specifically address social connection (including isolation and
          loneliness) by including specific measurable goals and metrics. Social connection needs to be
          a prominent component within Social Determinants of Health.

While Social Cohesion is identified as a key issue in the Social and Community Context domain of
Healthy People 2020, Social Determinants of Health, it is limited in scope (see definition) and currently
doesn’t include specific measurable goals.

            “Relationships are conceptualized through terms such as social cohesion, social capital, social
            networks, and social support. Social cohesion refers to the strength of relationships and the
            sense of solidarity among members of a community.”

Mounting evidence across decades of research documents a magnitude of risk associated with lacking
social connection that is comparable to many leading health determinants that receive significant public
health resources (e.g., smoking, obesity, physical inactivity, air quality). The prevalence of social
isolation exceeds the prevalence of adult smokers and is comparable to the prevalence of obesity—
pointing to both the importance and urgency of addressing this issue. Further, addressing this issue helps
us address other priorities, including reducing health disparities. Yet current objectives and goals do not
adequately recognize human social relationships as either a health determinant or health risk marker in a
manner that is comparable to that of other public health priorities.

Notably, the U.S. is lagging behind other international efforts. For example, the World Health
Organization (WHO) lists “social support networks” as a determinant of health (WHO, n.d.), and the
United Kingdom’s minister of health has established loneliness as a health priority (U.K. Department for
Work & Pensions, 2015)—including a national strategy. Other nations including Spain, Australia,
Denmark, and Portugal are also currently working on similar efforts.

  Defining terms: The effects of social relationships, or lack thereof, have been measured in a variety of ways in empirical
research. Data reveal that, just like nutrition, both quantity and quality matter when it comes to social relationships and thus
social connection is used as an umbrella term to represent a multifactorial protective factor (or social disconnection as a risk
factor)—which includes the way we socially connect via the presence or absence of others (e.g., social network size, social
capital, living alone, marital status), the functions and roles relationships provide (or are perceived to be available; e.g., social
support, loneliness), and the quality of the relationships (e.g., relationship satisfaction, conflict, strain) (1, 6).
A robust body of scientific evidence has indicated that being embedded in high-quality close relationships
and feeling socially connected to the people in one’s life significantly decreases risk for all-cause
mortality as well as a range of disease morbidities (1).
    • Social isolation and loneliness predict worse outcomes, including cardiovascular disease,
        coronary disease, stroke, and higher risk among objectively measured biomarkers of physical
        health such as hypertension, waist circumference, and body mass index across all age groups (2–
        4), among others.
    • Meta-analytic data shows that being socially connected is associated with a 50% reduced risk of
        early death (5), demonstrating a robust protective effect of being socially connected. Moreover,
        most epidemiological studies control for lifestyle factors (e.g., smoking, physical activity),
        documenting an independent influence of social relationships on mortality.

Social connection meets the key criteria for inclusion in Healthy
People 2030
Scientific evidence clearly supports the inclusion and prioritization of social connection as a key objective
within Social Determinants of Health. The protective effect of social connections, or conversely the risk
associated with lacking social connections, has been documented across numerous studies. Below is a
sample of health outcomes and data published since 2015. When available meta-analyses are listed, these
provide the most robust evidence.2

1. Evidence of an independent risk factor for Premature Mortality from all causes.
   • Multiple meta-analyses establish the independent risk of mortality stemming from few social
       connections and estimate a magnitude comparable to or exceeding most currently included core
       objectives. There are hundreds of studies with millions of participants that establish this effect (2,
       7). For example, data from more than 3.4 million participants showed that loneliness, social
       isolation, and living alone carry a greater risk of mortality than the risk associated with obesity

2. Evidence of increased risk of developing Coronary Heart Disease and Stroke, independent of
   traditional cardiovascular disease risk factors (3, 9).
       • In a meta-analysis, poor social relationships were associated with a 29% increase in risk of
            incident CHD (pooled relative risk: 1.29, 95% confidence interval (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).
       • A longitudinal study of 5,397 adults over the age of 50 found loneliness was associated with
            an increased risk of cardiovascular disease (odds ratio 1.27, 95% CI 1.01-1.57).

3. Mechanistic Evidence: Biological and behavioral mechanisms by which social connection affects the
   development and course of disease.
   • A meta-analysis of 41 studies including 73,037 participants establishes the influence of social
      support and social integration on inflammation (10), thus implicating this in inflammatory-related
      disease development and exacerbation. Chronic inflammation has been linked to diseases such as
      heart disease or stroke, some cancers, and autoimmune disorders.

  Meta-analytic data (a) provides a better estimate of the relation that exists in the population than single studies, (b) provides
estimates that are more precise because of the increased amount of data and statistical power, (c) makes it possible to examine
hypothesis testing and biases associated with publications, and (d) helps resolve inconsistencies in research and identifies
potential moderating or mediating variables.
•   Data from 61 studies with a total of 105,437 participants demonstrate a robust association
        between social support and favorable sleep outcomes (11). Importantly, sleep influences a variety
        of physical health conditions, including cardiovascular disease, weight gain and obesity, diabetes,
        metabolic syndrome, and increased risk for mortality.

4. Evidence of a dose response effect across age groups (4).
   • Data from four nationally representative longitudinal samples of the U.S. population assessed the
       prospective association of both structural and functional dimensions of social relationships (social
       integration, social support, and social strain) with objectively measured biomarkers of physical
       health (C-reactive protein, systolic and diastolic blood pressure, waist circumference, and body
       mass index) within each life stage, including adolescence and young, middle, and late adulthood,
       and compared such associations across life stages. A higher degree of social integration was
       associated with lower risk of physiological dysregulation in a dose-response manner in both early
       and later life.

Summary: Applying probabilistic causation (consistent with causal claims associated with smoking),
evidence that social disconnection increases the risk of mortality in a predictive and dose-response
manner points to the causal influence of social relationships on health outcomes and supports social
connectivity as a protective lifestyle factor.

    •   The independent directional effect of social disconnection on health risk is well established.
    •   There is also significant evidence that addressing social connections helps us address many if not
        most other HP2020 core areas (e.g., nutrition and weight status, diabetes, dementias, etc.). For
        example, a review of the evidence on social capital and health risk behaviors (12), including
        smoking, alcohol and illicit drug use, and sexual risk taking, emphasizes the importance of
        addressing social connections for other HP2030 core areas.

Reliable, nationally representative data source with baseline data no
older than 2015
To measure and track HP2030 goals specific to social connection, we can leverage existing data from
national surveys, including:
    • Health and Retirement Study (HRS)
             o Data collection began in 1990, most recent wave occurred in 2016, next wave in 2020
             o Data on social participation–social engagement, loneliness, social network, social
                integration, relationship quality, social support, social strain
    • National Longitudinal Study of Adolescent to Adult Health (Add Health)
             o Data collection began in 1994, most recent wave occurred 2016–2018
             o Family structure, social network, friend count, religious attendance, activities
                participation, school cohesion, volunteering, marital status
    • National Survey of Midlife Development in the United States (MIDUS)
             o Data collection began in 1995, most recent wave 2013–2019
             o Social integration, social support, social strain
    • National Social Life, Health, and Aging Project (NSHAP)
             o Data collection began in 2005, most recent wave 2015–2016
             o Social integration, social support, social strain
Additional data sources include:
    • BRFSS: How often do you get the social and emotional support you need?
    • PRAPARE item for health centers and provider (EMR): How often do you see or talk to people
        that you care about and feel close to?
•   ICD-10 codes Z60, Z63

Additional data provide current estimates of prevalence rates:
   • According to the Kaiser international study (2018), more than a fifth of adults in the U.S.
       (22%) say they often or always feel lonely, feel that they lack companionship, feel left out, or feel
       isolated from others; and half or more reporting loneliness say it has had a negative impact on
       their personal relationships or their physical health.
   • The 2018 Cigna Survey found that the majority of Americans are lonely (scores >43 on UCLA
       Loneliness Scale) and that Generation Z had the highest rates of loneliness.
   • Three-fourths of study participants reported moderate to high levels of loneliness
       (UCLA Loneliness Scale) (13)

 We recommend that Healthy People 2030 create specific goals to increase social connection.
 More specifically, we recommend goals to:
            • Reduce isolation, loneliness, and social strain.
            • Increase social engagement, social support, and social integration.
 These goals should represent groups across age and other demographics.

Two additional data points during the decade
    •   Social capital can be estimated via U.S. Census data. For example, more than a quarter of the
        U.S. population (27%) lives alone, over half the U.S. adult population is unmarried, and one in
        five have never married (U.S. Census Bureau, 2013). The divorce rate in the U.S. continues to
        hover around 40% of first marriages (U.S. Census Bureau, 2011).
    •   Data from the Pew Research Center shows that the average size and diversity of core discussion
        networks have declined (2009) and that the majority of Americans no longer participate in social
        groups (2011).

National importance
The 19th U.S. Surgeon General has stated that we are facing a loneliness epidemic. This is consistent with
statements made by world leaders from the UK, Europe, and World Health Organization. While exact
prevalence varies according to differing measurement approaches, data do support that a significant
portion of the population is socially disconnected in some way—and it may be increasing.

Evidence that social disconnection may be increasing
The average size of core social networks has declined by one-third since 1985, and networks have
become less diverse; they are less likely to include non-kin (Hampton, Sessions Goulet, Her, & Rainie,
2009). Average household size has decreased, and there has been a 10% increase in single-occupant
households (U.S. Census Bureau, 2011). Census data have also revealed trends in fewer children per
household and increased rates of childlessness (U.S. Census Bureau, 2011). Projections of the U.S.
population using microsimulations suggest the number of kinless Americans will continue to increase
from 2015 to 2060 (14). The combination of an aging population, smaller families, and greater mobility
reduces the ability to draw upon familial sources of informal support in old age (Rook, 2009). Decreased
community involvement is evidenced by falling rates of volunteerism (U.S. Department of Labor, Bureau
of Statistics, 2016) and an increasing percentage of Americans reporting no religious affiliation (Pew
Research Center, 2015). Given that the incidence of loneliness is known to increase with age (15) and that
social (particularly friendship) networks shrink with age (16), the prevalence of loneliness is estimated to
increase with increased population aging. Taken together, these trends suggest that Americans are
becoming less socially connected, and thus at higher risk of premature mortality.
Evidence that social connections have an equivalent or greater effect on health than other currently
prioritized core areas, including tobacco use, physical activity, nutrition, and weight status
    • Pooled effects across social relationship measures and their effect on risk for mortality is
         equivalent to smoking up to 15 cigarettes per day and exceed the effects of excessive alcohol
         consumption (>6 drinks per day), physical inactivity, and obesity (BMI >30) (5).
    • Social isolation increased the risk of inflammation by the same magnitude as physical inactivity
         in adolescence, and the effect of social isolation on hypertension exceeded that of clinical risk
         factors such as diabetes in old age (4).

Other national health efforts bolster the importance of social connections
   • Institute of Medicine has recommended that social connection/isolation be included in all
        electronic health records (EHRs) (17, 18).
   • National Academy of Sciences has a committee on the Health and Medical Dimensions of Social
        Isolation and Loneliness in Older Adults.
   • The Senate Committee on Aging has convened two congressional hearings centered on social
        isolation and loneliness and building social connections among older adults, and as a result
        introduced the Over the Counter Hearing Aid Act that was later signed into law.
   • Inclusion in U.S. Surgeon General Emotional Well-being Initiative in America.

Effective, evidence-based interventions available to achieve the
Similar to the influence of other health risk factors (e.g., hypertension, obesity, smoking, cholesterol
levels), the influence of social relationships is complex and multifactorial. Simply put, this means that
there is no single putative causal factor. Instead, there are multiple factors to intervene in. Thus, it is
challenging to design intervention that will garner effective results for all and points to the need for a
systems approach. Large-scale community preventive efforts are needed to achieve the objective,
consistent with a report from the Keck Center of the National Academies that indicated the need for
“multi-level approaches—at the individual, dyadic, family, community, and population levels.” The
National Strategy in the UK and WHO’s Health in All Policies framework may serve as models for
potential approaches.

A review of promising approaches used in the UK includes interventions aimed at supporting and
maintaining existing social relationships, supporting new social connections, and psychological
approaches. These also include approaches to target gateway services (technology, transportation) and
structural enablers (neighborhood approaches, asset-based community development, volunteering, age-
positive approaches).

Broad-based reviews of approaches to address social connectedness reveal themes in evidence-based
approaches that include telephone-based, community involvement/volunteering, online/digital solutions,
physical activity, or resilience training (19–21). Interventions that include social or educational group
activities can also reduce social isolation and loneliness (22).

Data from AARP shows that people who participate in their community through volunteering or local
civic groups are less likely to be lonely—they provide a tie-in to social and community context.

Specific examples of effective interventions:
   • Participation in a fitness program for older adults, SilverSneakers, is associated with greater
        social engagement and less loneliness. These social benefits contribute to greater self-reported
        health for members, controlling for the health benefits of physical activity (23).
•   The Carolina Abecedarian Project indicates that improvement in cognitive and social stimulation
        in early life (birth to age 5), along with early intervention in school, reduces the likelihood of
        cardiovascular and metabolic diseases in the mid-30s (28).
    •   The Nurse-Family Partnership (NFP) provides monthly nurse home visits to low-income and
        unmarried pregnant women from the prenatal period across the first two years of their children’s
        lives and is widely recognized as influencing several important maternal and child outcomes,
        including reductions in child abuse and neglect (29). Further, targeting early social relationships
        (e.g., promoting parent–child bonding consistent with attachment theory) while bolstering the
        social support mothers receive from family and friends had durable effects on both maternal and
        child health outcomes (29).

Data to help address disparities and achieve health equity
Research has revealed that prevalence of social disconnectedness (isolation or loneliness) is not evenly
distributed in the U.S. and that this social determinant of health disproportionately impacts certain
vulnerable and underserved populations.

Older Americans have been the subject of many national studies of social connection. A national study by
AARP found that 1 in 3 adults over age 45 are lonely; low income increases this rate to 1 in 2. LGBTQ
older adults were also more likely to suffer from loneliness. Physical and mental health conditions also
increase the likelihood of an individual becoming lonely or isolated as does a recent death of a spouse or
partner (24) or acting as a caregiver to a friend or family member. The National Survey of American Life
revealed that for older adults, impairment to mobility or self-care ability increases the likelihood of
isolation from friends (25).

Disparities across racial and ethnic groups are not well understood. Studies have incongruent findings
regarding differences in social isolation or loneliness in minority groups that may be explained by more
specific regional or cultural differences that are not observed in most studies (25, 26). The detrimental
health effects of social isolation can also vary across racial and ethnic groups (27).

Distinguishing disparities among minority groups or in specific regions or geographies requires a large
data set or oversampling of populations of interest. Useful data sources include BRFSS, the largest
continuously conducted health survey system, with 400,000 U.S. adult interviews each year; Add Health,
which includes ethnic and disabled samples from regionally representative schools; and the Health and
Retirement Study, which includes a minority oversample.

As an example of interracial/ethnic differences in social behaviors, the Pew Research Center found that
group participation differs according to racial and ethnic groups (30). Hispanics are least likely to be
involved in community groups, organizations for older adults, political parties, book clubs, or
performance groups.
There is a vast amount of evidence linking a lack of social connectedness to significant health risks, and a
significant portion of the U.S. population lack social connections, which places them at greater risk for
premature mortality and underlying morbidity—and the magnitude of this risk is comparable to that of
currently recognized leading health determinants. Examining potential moderating factors (e.g., gender,
age, country of origin) reveals remarkably consistent and widespread effects across the human population
(5). Changes in U.S. demographic trends further point to an exacerbation of social disconnection,
suggesting an increasing urgency. Based on the HP2030 core criteria, there is sufficient evidence to
support prioritizing social connection in public health.

Additional comments
We support retaining the following related objectives in Healthy People 2030:

         AH-3.1 Increase the proportion of adolescents who have an adult in their lives with whom they
         can talk about serious problems
         DH-17 Increase the proportion of adults with disabilities who report sufficient social and
         emotional support
         EMC-2.2 Increase the proportion of parents who use positive communication with their child

We also support a sustained focus on Older Adults (OA-2030), Social Determinants (SDOH-
2030), Dementias (DIA-2030), Disability and Health (DH-2030), and Injury and Violence
Prevention (IVP-2030).

Submitted By:
Julianne Holt-Lunstad, PhD
Tivity Health
Health eVillages
MIT AgeLab
Jefferson College of Population Health
Saint Joseph's College of Maine
Valley Area Agency on Aging
National Association of Nutrition and Aging Programs
Grantmakers in Aging
Mercy Health Care
National Rural Health Association
Healthcare Leadership Council
National Minority Quality Forum
Share Care Blue Zones
Health Intelligence Partner
The Drapin Group LLC
YMCA of Portage (Indiana)
Ashtabula County YMCA (Ohio)
YMCA of the USA
Better Medicare Alliance
Regis College
Milken Institute, Center for the Future of Aging
American College of Lifestyle Medicine
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