The Biggest Threat to Women’s Health: Loneliness

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Mental Health

The Biggest Threat to Women’s Health: Loneliness

A Q&A with Dr. Julianne Holt-Lunstad explores the dreadful loneliness epidemic and how to fight it 

By Lori Miller Kase

Study after study examining what brings people happiness reveals that it’s not success or wealth, but our relationships, says Julianne Holt-Lunstad, PhD, professor of psychology and neuroscience at Brigham Young University. Social connection is not only a driver of happiness, she noted in a recent lecture at Harvard University’s Lee Kum Sheung Center for Health and Happiness, but is also crucial to our overall health. Research shows that people who are lonely or isolated not only have a higher risk of depression, but also of heart disease, cancer, and dementia… even an increased susceptibility to respiratory infections like COVID-19. So, how do we deal with loneliness? 

Earlier this year, Surgeon General Vivek H. Murthy issued an advisory calling attention to the “loneliness epidemic” in this country, and the threat it poses to public health. Isolation became a new normal for many during the pandemic; yet even post-pandemic, loneliness persists. At any one moment, according to a recent report, 1 out of 2 Americans feels lonely. For midlife women, major transitions like becoming an empty nester for the first time or getting divorced are common triggers for loneliness. And while the last thing a lonely woman needs is the added stress of worrying that her loneliness may be compromising her health, being proactive about alleviating loneliness can actually improve both your mental and physical well-being. 

CoveyClub recently had the opportunity to speak with Dr. Holt-Lunstad, a leading expert on the health implications of loneliness, and lead scientific editor for the Surgeon General’s Advisory. Dr. Holt-Lunstad directs the Social Connection and Health Lab at Brigham Young, is the founding scientific chair for the US Foundation for Social Connection, and serves as a regular guest lecturer for the Harvard TH Chan School of Public Health’s “Loneliness and Public Health” course. Here, Dr. Holt-Lunstad reveals just what isolation can do to your health — and how to combat loneliness and build better social connections.

CoveyClub: Let’s cut to the chase. What are the health effects of isolation and loneliness? 

Dr. Holt-Lunstad: Generally speaking, studies show that having more and better relationships are associated with better health outcomes, and having fewer and poor quality relationships are associated with poor outcomes. Research shows that loneliness impacts both physical and mental health, though we have the most evidence on cardiovascular outcomes and depression. Loneliness has also been linked to cognitive health, with studies looking at Alzheimer’s disease, dementia more broadly, and mild cognitive impairment as well. It has also been linked to more short term kinds of acute respiratory illnesses and susceptibility to cold and flu viruses, suggesting an impact on immune functioning. Some of the more robust evidence links loneliness to mortality — and this is looking at mortality from all causes and includes disease-related mortality.

CoveyClub: How did the global pandemic exacerbate existing problems of isolation and loneliness? 

Dr. Holt-Lunstad: There were already concerning trends, a variety of indicators that would suggest that Americans were becoming less socially connected, spending more time alone, less time with family, less time with friends, less time in their communities. If you look at the  American Time Use Survey, time spent alone was increasing while time spent with others was decreasing, and you saw that happening well before the pandemic. But of course the pandemic made it even worse — that slope got even steeper. We probably found ways, in essence, to have adapted to that situation, ways of spending time in isolation that were comfortable and convenient. And so, we can’t predict the future, but it’s possible that because of that we may not see things getting better. They could potentially get worse. 

CoveyClub: Can you talk about your work with the Surgeon General’s Advisory, and highlight the advisory’s findings? Anything new to report?

Dr. Holt-Lunstad: As the lead scientific editor, I worked very closely with the office of the Surgeon General in drafting it. It really lays out the evidence to point to how this is relevant to public health, how it impacts the health and safety and well-being and prosperity and resilience of both individuals and communities. It goes beyond just raising awareness of these concerns — it also includes evidence pointing to how being more socially connected both as individuals and communities is associated with better outcomes. The last part of the report is a framework for a national strategy to advance social connection, with six pillars to help build more socially connected individuals, communities, and a nation. 

In response to this, a few bills have been proposed. Senators Chris Murphy [D-Connecticut] and Bob Casey [D-Pennsylvania] just introduced a bill focused on addressing social isolation and loneliness in older adults, and Congressmen Mike Flood [R- Nebraska] and David Trone [D-Maryland] recently introduced a bipartisan bill to measure the scope of the loneliness and isolation public health crisis. One of the reasons we recommend for national measurement is that while we have lots of surveys measuring loneliness, as well as isolation and other aspects of social connection, they may not be measuring them consistently. One study might ask “How frequently do you feel lonely?” and another might ask “How lonely do you feel?” You can get different kinds of responses when you ask the questions differently. If loneliness is not being measured consistently, it’s hard to know if it is really 50 percent of Americans who are lonely or 30 percent. And it’s hard to know if things are getting better or worse. 

CoveyClub: Often, major life changes like having an empty nest for the first time, or even divorce, are drivers of loneliness and isolation for midlife women. Can you discuss the problem of loneliness and isolation in this population in particular? How might women at this stage of life take steps to alleviate feelings of loneliness and foster more social connection?

Dr. Holt-Lunstad: Just knowing that various life transitions can put people at greater risk for loneliness and isolation, just recognizing that and taking steps proactively ahead of time to prevent that can help. We know that people are getting messages consistently of how they have to plan financially for retirement — but not for how they should plan emotionally for retirement. Consider planning ahead to be an empty nester: Build up your social network ahead of time so that you have a variety of strong relationships in addition to your children who are leaving home. In that time you should also be building those relationships with your children so that when they do leave home there’s continued communication. Strengthening those relationships earlier on can help maintain them at a distance. But if you have also built up your social network ahead of time, you’ll be able to draw on other kinds of relationships that may be more proximate when you no longer have your kids at home.

Oftentimes, people have a hard time building new relationships later in life. There is actually a study that just came out on friendship in older adults and its link to health and how important friendships are for this population. It has data on almost 13,000 adults from The Health and Retirement Study, and looked at 35 different health and psychological outcomes. The study found that friendship in older adults contributed to better health behaviors, as well as improved physical and mental health. 

loneliness epidemic

CoveyClub: So how do you suggest that midlife and older women go about building up their social network, establishing new friendships? 

Dr. Holt-Lunstad: One recommendation if you’re trying to build new relationships would be to join or become active in some kind of group. Of course the type of group will differ for different people, but the one advantage that a group can provide is that most groups — whether a faith-based group or a fitness group or a book club — provide some kind of regular contact. Relationships take time to develop and to nurture. Groups may meet monthly or weekly or daily, but because of the regularity of contact, you can start to make friends in the group. Also, if you find a group that you feel a sense of affinity to, it can also provide a sense of belonging, a feeling of being a part of something bigger. You could also nurture your existing relationships, prioritizing them, investing more time in them. Recommendations around how to nurture these relationships might include responsiveness and reaching out to others. Far too often we expect other people to reach out to us, invite us to the party, invite us to lunch. We have the power to initiate those kinds of interactions. 

There is a great deal of research that shows that both volunteering and supporting and helping others is associated with reduced loneliness. So as we look around and think about how we reach out to others, whether in a more formal support sort of situation like volunteering or simply by saying hello to your neighbors and seeing what you can do to help, that can not only reduce your loneliness, but help you start to build social bonds. We saw this with the “Kindness Challenge,” a multi-country, randomized, controlled trial where we had people do small acts of kindness. They could choose what they felt most comfortable with, whether checking in on a neighbor, or helping them out with their dog or their yard. After four weeks, those who were randomly assigned to do the kindness challenge compared to those in the control group were significantly less likely to report loneliness. We did see reductions in loneliness as well. We also found that in the time before the intervention even started, people who knew at least six of their neighbors were significantly less likely to report loneliness. After the intervention, we found that people who actually did the kindness challenge were more likely to know at least six of their neighbors.

CoveyClub: Speaking of knowing your neighbors, you mentioned in your talk at Harvard that more connected communities, in which people know one another, are likely to respond to and recover from natural disasters better than those without social connection — and that increased social connection is going to be even more crucial as we respond to climate change and more frequent extreme weather events. Can you touch on this? 

Dr. Holt-Lunstad: Yes, and this is one of the things we highlighted in the Surgeon General’s Advisory as well. We need to make efforts to get to know our neighbors. Not only is it just good for our mental well-being, but when it comes to resiliency from various crises — wildfires to earthquakes to flooding, you name it — our neighbors are often, just due to proximity, more likely to be the first responders relative to trained professionals, and so actually knowing your neighbors in some cases could be a matter of life and death.

CoveyClub: Biologically speaking, how is it that social connection impacts our physiology? 

Dr. Holt-Lunstad: Theoretically, humans are a social species, and being part of a group is adaptive to survival throughout human history. So neuroscientists have argued that our brains have adapted to expect social proximity, so that social is considered the neuro-default, our resting state. The optimal state is when we are social — when we are alone or not with trusted others, our brain, and subsequently our bodies, have to be more active. Cognitively, we need to be far more alert to potential threats, we might have to handle on our own whatever those threats might be (i.e. the challenges of everyday life), which takes more effort, more mental energy, as well as the kind of physical energy that is thought to activate various systems in the body. A cascade of cortisol, the stress-related hormone, for example, comes with cardiovascular changes, increases in inflammation, and other kinds of biological adaptations to meet the demands and so this can, if sustained over time, put wear and tear on the body.

There are multiple pathways through which social connection affects our bodies — biological, psychological, behavioral, etc. Clear pathways have been identified, for example, that show how lacking social connection is linked to increased inflammation, and chronic inflammation has been linked to cardiovascular disease, to depression, to dementia — to all of these physical, mental and cognitive health outcomes. Loneliness also affects health by causing changes in  the gut microbiome, or heart rate variability, or blood pressure, or antibody response. Feeling lonely from time to time is not necessarily a bad thing. It’s actually adaptive, like hunger or thirst, a biological drive that motivates us to reconnect socially, just like hunger motivates us to meet a biological need. It’s only when it becomes sustained long-term that it is a problem. 

CoveyClub: You noted in your talk that research suggests a social gradient or continuum — and that each unit of increase in social connection brings with it additional reduction in risk. So interesting! Can you explain?

Dr. Holt-Lunstad: I’m drawing upon two different papers. One is looking at four national representative data sets across the life course — starting from adolescence through older age — and looks across various indicators of health and found that dose response effect. The other paper is a review across social species, including humans, and looking across a variety of different social outcomes, maps this out and finds a gradient effect. They both find that any increase in social connection is associated with an additional decrease in health risk. Social aspects considered included perceived emotional support, tangible support, whether subjects have people they can go to for guidance or support or a favor. (So, not only do you have people in your life, but can you count on them.) 

CoveyClub: You’ve mentioned a link between loneliness and mortality. So you’re saying that more socially connected people actually live longer? How exactly do you measure this?

Dr. Holt-Lunstad: What we typically do in these studies is follow people over years — often decades — and look at the percentage of people who are alive or dead at the follow-up. In my meta-analysis on loneliness, isolation and living alone, loneliness increased risk of mortality by 26 percent, isolation by 29 percent and living alone by 32 percent. In one of my studies, people who were more socially connected had a 50 percent increased likelihood of survival. 

CoveyClub: So as we age, and strive to prevent the chronic diseases often associated with aging by focusing on preventive health strategies like good nutrition, exercise, sleep and stress reduction, are you suggesting that we add social connection to the list? Would you say that research suggests that this deserves equal weight?

Dr. Holt-Lunstad: Yes! Is this an easy parameter to control? Some people balk at this because they think it’s too challenging. They are all challenging. Some behaviors are more modifiable than others, and with social connection we also have to be really concerned about not increasing the stigma associated with this risk factor. That was something we saw a lot in the efforts around obesity. There is robust evidence showing that people who live alone are at increased risk for mortality, but at the same time, we can’t tell people you shouldn’t live alone, because there could be reasons outside their control of why they live alone. It’s something very difficult to modify and we don’t want to add stigma or shame to anyone whose circumstances put them in that way. In many cases we need systemic levels of change to address some of these issues. 

In the advisory, we talk about how we can increase social connection on a societal level, borrowing from the idea of how the [World Health Organization] WHO and [Centers for Disease Control and Prevention] CDC have this “health in all policies” framework. They recognize that our policies often have health implications. Just like we would evaluate the economic or environmental impact of our policies, we need to consider the social impact of our policies. Just like you might consider, for example, the environmental impacts of working remotely, we have to consider the social impact as well. Too many people think, “What are you going to do? Legislate good friends?” But really, it’s about evaluating the impacts of our policies and revising policies that may have a detrimental social impact or present huge barriers to social connection — as well as considering newer policies that may help our ability to connect socially.  

On the individual level, one of the things I do is I say to my friends, “Let’s go for a walk or a hike” instead of “Let’s go out for lunch.” Not only is it a time to get together and connect, but you’re being physically active — you’re exercising with a friend. 

CoveyClub: Based on all your research, and your work with the Surgeon General’s Advisory, would you like to leave us with any other general advice for midlife women regarding social connection? 

Dr. Holt-Lunstad: We need to start prioritizing it. It’s really easy for us to think of it as something nice to have, but not necessarily essential. But given how strong the evidence is, it really is important for our health, for our length of life, our quality of life, our functionality, so many different outcomes. So, especially as we age, social connection can be incredibly important not only in navigating those life changes, but just like with all these other lifestyle factors, how well we are doing on them in midlife can predict equally our quality and quantity of life. We really need to start prioritizing social connection so that we can have longer and healthier lives, because it’s linked to both of them. And even if we do experience little bumps and we’re not as healthy as we’d like, having others to support us through those challenges is going to make those outcomes better — and help us to cope with them.

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