Abstract
Social isolation and loneliness are increasing public health concerns and have been associated with increased risk of cardiovascular disease (CVD) among older adults. To examine the associations of social isolation and loneliness with incident CVD in a large cohort of postmenopausal women and whether social support moderated these associations. This prospective cohort study, conducted from March 2011 through March 2019, included community-living US women aged 65 to 99 years from the Women's Health Initiative Extension Study II who had no history of myocardial infarction, stroke, or coronary heart disease. Social isolation and loneliness were ascertained using validated questionnaires. The main outcome was major CVD, which was physician adjudicated using medical records and included coronary heart disease, stroke, and death from CVD. Continuous scores of social isolation and loneliness were analyzed. Hazard ratios (HRs) and 95% CIs for CVD were calculated for women with high social isolation and loneliness scores (midpoint of the upper half of the distribution) vs those with low scores (midpoint of the lower half of the distribution) using multivariable Cox proportional hazards regression models adjusting for age, race and ethnicity, educational level, and depression and then adding relevant health behavior and health status variables. Questionnaire-assessed social support was tested as a potential effect modifier. Among 57 825 women (mean [SD] age, 79.0 [6.1] years; 89.1% White), 1599 major CVD events occurred over 186 762 person-years. The HR for the association of high vs low social isolation scores with CVD was 1.18 (95% CI, 1.13-1.23), and the HR for the association of high vs low loneliness scores with CVD was 1.14 (95% CI, 1.10-1.18). The HRs after additional adjustment for health behaviors and health status were 1.08 (95% CI, 1.03-1.12; 8.0% higher risk) for social isolation and 1.05 (95% CI, 1.01-1.09; 5.0% higher risk) for loneliness. Women with both high social isolation and high loneliness scores had a 13.0% to 27.0% higher risk of incident CVD than did women with low social isolation and low loneliness scores. Social support was not a significant effect modifier of the associations (social isolation × social support: r, -0.18; P = .86; loneliness × social support: r, 0.78; P = .48). In this cohort study, social isolation and loneliness were independently associated with modestly higher risk of CVD among postmenopausal women in the US, and women with both social isolation and loneliness had greater CVD risk than did those with either exposure alone. The findings suggest that these prevalent psychosocial processes merit increased attention for prevention of CVD in older women, particularly in the era of COVID-19.
Highlights
In the US, cardiovascular disease (CVD) is the leading cause of death in women[1] and accounts for approximately 1 in every 5 deaths among women.[2]
The Hazard ratios (HRs) for the association of high vs low social isolation scores with CVD was 1.18, and the HR for the association of high vs low loneliness scores with CVD was 1.14
Social support was not a significant effect modifier of the associations. In this cohort study, social isolation and loneliness were independently associated with modestly higher risk of CVD among postmenopausal women in the US, and women with both social isolation and loneliness had greater CVD risk than did those with either exposure alone
Summary
In the US, cardiovascular disease (CVD) is the leading cause of death in women[1] and accounts for approximately 1 in every 5 deaths among women.[2] there have been marked decreases in CVD mortality among both men and women, data suggest slowing of these decreases in CVD incidence and mortality among women.[3] Social isolation and loneliness are prevalent psychosocial processes among adults[4] and have been shown to be associated with increased risk of CVD among older adults.[5] More than one-fourth of adults aged 65 or older are socially isolated, and one-third of adults aged 45 or older report being lonely.[6] Of note, there is increasing evidence that both social isolation and loneliness are associated with CVD risk factors such as increased blood pressure,[7] higher cholesterol levels, obesity, smoking,[8,9] physical inactivity,[10,11] and poor diet quality.[12] Whereas social isolation is the objective measure of social interactions and relationships, loneliness is the subjective feeling of being socially isolated.[6,13] The experiences of social isolation and feelings of loneliness have been shown to be mildly correlated[14]; they are distinct constructs, and research has shown that social isolation and loneliness are associated with different adverse outcomes of health and well-being.[14,15,16,17]
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