Social Relationships and Mortality Risk: A Meta-analytic Review

Abstract

In a meta-analysis, Julianne Holt-Lunstad and colleagues find that individuals' social relationships have as much influence on mortality risk as other well-established risk factors for mortality, such as smoking.

Abstract

Background

The quality and quantity of individuals' social relationships has been linked not only to mental health but also to both morbidity and mortality.

Objectives

This meta-analytic review was conducted to determine the extent to which social relationships influence risk for mortality, which aspects of social relationships are most highly predictive, and which factors may moderate the risk.

Data Extraction

Data were extracted on several participant characteristics, including cause of mortality, initial health status, and pre-existing health conditions, as well as on study characteristics, including length of follow-up and type of assessment of social relationships.

Results

Across 148 studies (308,849 participants), the random effects weighted average effect size was OR = 1.50 (95% CI 1.42 to 1.59), indicating a 50% increased likelihood of survival for participants with stronger social relationships. This finding remained consistent across age, sex, initial health status, cause of death, and follow-up period. Significant differences were found across the type of social measurement evaluated ( p<0.001); the association was strongest for complex measures of social integration (OR = 1.91; 95% CI 1.63 to 2.23) and lowest for binary indicators of residential status (living alone versus with others) (OR = 1.19; 95% CI 0.99 to 1.44).

Conclusions

The influence of social relationships on risk for mortality is comparable with well-established risk factors for mortality.

Please see later in the article for the Editors' Summary

Editors' Summary

Background

Humans are naturally social. Yet, the modern way of life in industrialized countries is greatly reducing the quantity and quality of social relationships. Many people in these countries no longer live in extended families or even near each other. Instead, they often live on the other side of the country or even across the world from their relatives. Many also delay getting married and having children. Likwise, more and more people of all ages in developed countries are living alone, and loneliness is becoming increasingly common. In the UK, according to a recent survey by the Mental Health Foundation, 10% of people often feel lonely, a third have a close friend or relative who they think is very lonely, and half think that people are getting lonelier in general. Similarly, across the Atlantic, over the past two decades there has been a three-fold increase in the number of Americans who say they have no close confidants. There is reason to believe that people are becoming more socially isolated.

Why Was This Study Done?

Some experts think that social isolation is bad for human health. They point to a 1988 review of five prospective studies (investigations in which the characteristics of a population are determined and then the population is followed to see whether any of these characteristics are associated with specific outcomes) that showed that people with fewer social relationships die earlier on average than those with more social relationships. But, even though many prospective studies of mortality (death) have included measures of social relationships since that first review, the idea that a lack of social relationships is a risk factor for death is still not widely recognized by health organizations and the public. In this study, therefore, the researchers undertake a systematic review and meta-analysis of the relevant literature to determine the extent to which social relationships influence mortality risk and which aspects of social relationships are most predictive of mortality. A systematic review uses predefined criteria to identify all the research on a given topic; a meta-analysis uses statistical methods to combine the results of several studies.

What Did the Researchers Do and Find?

The researchers identified 148 prospective studies that provided data on individuals' mortality as a function of social relationships and extracted an “effect size” from each study. An effect size quantifies the size of a difference between two groups—here, the difference in the likelihood of death between groups that differ in terms of their social relationships. The researchers then used a statistical method called “random effects modeling” to calculate the average effect size of the studies expressed as an odds ratio (OR)—the ratio of the chances of an event happening in one group to the chances of the same event happening in the second group. They report that the average OR was 1.5. That is, people with stronger social relationships had a 50% increased likelihood of survival than those with weaker social relationships. Put another way, an OR of 1.5 means that by the time half of a hypothetical sample of 100 people has died, there will be five more people alive with stronger social relationships than people with weaker social relationships. Importantly, the researchers also report that social relationships were more predictive of the risk of death in studies that considered complex measurements of social integration than in studies that considered simple evaluations such as marital status.

What Do These Findings Mean?

These findings indicate that the influence of social relationships on the risk of death are comparable with well-established risk factors for mortality such as smoking and alcohol consumption and exceed the influence of other risk factors such as physical inactivity and obesity. Furthermore, the overall effect of social relationships on mortality reported in this meta-analysis might be an underestimate, because many of the studies used simple single-item measures of social isolation rather than a complex measurement. Although further research is needed to determine exactly how social relationships can be used to reduce mortality risk, physicians, health professionals, educators, and the media should now acknowledge that social relationships influence the health outcomes of adults and should take social relationships as seriously as other risk factors that affect mortality, the researchers conclude.

Additional Information

Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000316.

• The Mental Health America Live Your Life Well page includes information about how social relationships improve both mental and physical health

• The Mental Health Foundation, a UK charity, has information on loneliness and mental health; its report “The Lonely Society?” can be downloaded from this page

• The Mayo Clinic has information on social support as a way to manage stress

• The Pew Research Foundation has information on technology and social isolation

• Wikipedia has a page on social isolation (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)