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      Social Relationships and Mortality Risk: A Meta-analytic Review

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          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.

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          Most cited references198

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          Stress, social support, and the buffering hypothesis.

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            Impact of Psychological Factors on the Pathogenesis of Cardiovascular Disease and Implications for Therapy

            Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Pathophysiological mechanisms underlying the relationship between these entities and CAD can be divided into behavioral mechanisms, whereby psychosocial conditions contribute to a higher frequency of adverse health behaviors, such as poor diet and smoking, and direct pathophysiological mechanisms, such as neuroendocrine and platelet activation. An extensive body of evidence from animal models (especially the cynomolgus monkey, Macaca fascicularis) reveals that chronic psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Evidence from monkeys also indicates that psychosocial stress reliably induces ovarian dysfunction, hypercortisolemia, and excessive adrenergic activation in premenopausal females, leading to accelerated atherosclerosis. Also reviewed are data relating CAD to acute stress and individual differences in sympathetic nervous system responsivity. New technologies and research from animal models demonstrate that acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. In the presence of underlying atherosclerosis (eg, in CAD patients), acute stress also causes coronary vasoconstriction. Recent data indicate that the foregoing effects result, at least in part, from the endothelial dysfunction and injury induced by acute stress. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals. Current data link sympathetic nervous system hyperresponsivity to accelerated development of carotid atherosclerosis in human subjects and to exacerbated coronary and carotid atherosclerosis in monkeys. Thus far, intervention trials designed to reduce psychosocial stress have been limited in size and number. Specific suggestions to improve the assessment of behavioral interventions include more complete delineation of the physiological mechanisms by which such interventions might work; increased use of new, more convenient "alternative" end points for behavioral intervention trials; development of specifically targeted behavioral interventions (based on profiling of patient factors); and evaluation of previously developed models of predicting behavioral change. The importance of maximizing the efficacy of behavioral interventions is underscored by the recognition that psychosocial stresses tend to cluster together. When they do so, the resultant risk for cardiac events is often substantially elevated, equaling that associated with previously established risk factors for CAD, such as hypertension and hypercholesterolemia.
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              Social support and patient adherence to medical treatment: a meta-analysis.

              In a review of the literature from 1948 to 2001, 122 studies were found that correlated structural or functional social support with patient adherence to medical regimens. Meta-analyses establish significant average r-effect sizes between adherence and practical, emotional, and unidimensional social support; family cohesiveness and conflict; marital status; and living arrangement of adults. Substantive and methodological variables moderate these effects. Practical support bears the highest correlation with adherence. Adherence is 1.74 times higher in patients from cohesive families and 1.53 times lower in patients from families in conflict. Marital status and living with another person (for adults) increase adherence modestly. A research agenda is recommended to further examine mediators of the relationship between social support and health.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                PLoS Med
                PLoS
                plosmed
                PLoS Medicine
                Public Library of Science ( San Francisco, USA )
                1549-1277
                1549-1676
                July 2010
                July 2010
                27 July 2010
                : 7
                : 7
                Affiliations
                [1 ]Department of Psychology, Brigham Young University, Provo, Utah, United States of America
                [2 ]Department of Counseling Psychology, Brigham Young University, Provo, Utah, United States of America
                [3 ]Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
                University of Cambridge, United Kingdom
                Author notes

                ICMJE criteria for authorship read and met: JHL TS JBL. Agree with the manuscript's results and conclusions: JHL TS JBL. Designed the experiments/the study: TS. Analyzed the data: JHL TS JBL. Collected data/did experiments for the study: JHL TS JBL. Wrote the first draft of the paper: JHL TS. Contributed to the writing of the paper: JHL TS JBL.

                Article
                09-PLME-RA-3646R2
                10.1371/journal.pmed.1000316
                2910600
                20668659
                ae3c3e06-a820-4f5d-8956-126bed569aac
                Holt-Lunstad et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                Page count
                Pages: 1
                Categories
                Research Article
                Public Health and Epidemiology/Social and Behavioral Determinants of Health

                Medicine
                Medicine

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