Addressing the Epidemic of Loneliness and Social Isolation for Cardiovascular Health

Loneliness and social isolation have recently been recognized as significant factors influencing the prognosis and management of cardiovascular disease (CVD), with profound effects on mortality and morbidity as well as poor health behaviors.1,2 According to the US Surgeon General, lacking social connection is considered as dangerous as smoking up to 15 cigarettes a day.3 In 2023, the Surgeon General's Advisory declared the United States faces an epidemic of loneliness and social isolation and urged our country to focus on the healing effects of social connection and community.3 In the Advisory, loneliness is described as a "subjective distressing experience that results from perceived isolation or inadequate meaningful connection," whereas social isolation is referred to as "objectively having few social relationships, social roles, and infrequent social interactions."3 Although social isolation and loneliness are related, they signify different concepts. Acknowledging the distinction between loneliness and social isolation will lead to more accurate identification, targeted research approaches, and effective interventions that can impact health policy and clinical guidelines. Loneliness and social isolation are also associated with public health concerns such as increased healthcare utilization and costs, increased mental health challenges, and negative impact on health behaviors (eg, poor diet, lack of physical activity, lack of self-care, smoking, and alcohol consumption).4 This article seeks to present the scope of this epidemic as well as clinical and research implications for cardiovascular nurses. According to recent reports, there is a growing prevalence of loneliness with estimates ranging from 35% and 47% of US adults feeling lonely, whereas one-fourth of adults 65 years and older report being socially isolated.5–7 Research has identified certain populations have reported feeling lonely or socially isolated. Sociodemographic characteristics such as race and ethnicity, sexual orientation, gender identity, socioeconomic status, and social status (eg, immigrants, incarcerated individuals) or place of residence (eg, rural and underresourced settings) place individuals at risk for loneliness or social isolation.8 One survey described Gen Z (adults aged 18–22 years) as the loneliest generation; thus, attention to loneliness and social isolation must be provided across age groups.6 However, a meta-analysis of 75 longitudinal studies conducted in Asia, Australia, Europe, and North America (N = 83 679) found no significant relationship between age and loneliness.9 The investigators also did not find evidence for interindividual differences in loneliness to differ across different parts of the world, across birth cohorts, or between females and males.9 In contrast, they found that changes in loneliness were related to individual experiences.9 Other research has shown that people are more likely to feel lonely and experience social isolation because of factors such as living alone, losing family and friends, having a low socioeconomic status, and managing chronic physical or mental health conditions.1,3,5 Adults who report being socially isolated experience increased morbidity and premature all-cause mortality.1 Specifically, adults experiencing poor social relationships, whether it is from social isolation or loneliness, have a 29% increased risk of incident coronary heart disease and a 32% increased risk of stroke.2 Similarly, in adults living with heart failure, there was a 68% increased risk of hospitalization and almost a 4-fold increased risk of death (hazard ratio, 3.74) for those with high perceived social isolation.10 A systematic review and meta-analysis examined 13 studies that showed perceived or objective social isolation was associated with a 55% greater risk of hospital readmission in patients with heart failure (odds ratio, 1.55; 95% confidence interval, 1.39–1.73; P < .001).11 Another recent large study of diverse postmenopausal women found socially isolated women had a higher risk of incident heart failure hospitalization compared with nonisolated women (hazard ratio, 1.23; 95% confidence interval, 1.08–1.41).12 This association was not mediated by greater depressive symptoms, nor was the association explained by race and ethnicity nor age at baseline.12 Clinical Implications Currently, there are no guidelines for screening and treating loneliness. Healthcare professionals need to be aware of the implications of loneliness and be able to distinguish it from other mental health challenges such as depression, anxiety, or posttraumatic stress disorder. Multiple intervention programs involve increasing social contact for those experiencing loneliness, but it is important to point out the limitations of such programs. First, such programs must consider social and cultural differences that influence how loneliness is perceived and treated. Second, many of these programs are not financially sustainable and are resource heavy. Finally, social intervention programs typically use a one-size-fits-all model, although interventions for loneliness may vary widely based on the individual. Overall, there is much work to be done in this burgeoning area of research, and more attention must be placed on individuals with CVD.4 Nurses play an integral part in identifying and addressing loneliness among adults with CVD because nursing continues to be the most trusted profession and the foundation of healthcare systems. Special attention should be made to those who are most susceptible to loneliness such as those residing in rural areas, those living alone, and vulnerable populations living with chronic physical or mental health conditions.3 Combating loneliness in older adults to address CVD morbidity and mortality requires a multifaceted approach that tackles social, emotional, and environmental factors. Here are some strategies to consider: Community engagement: Encourage older adults to participate in community activities such as clubs, volunteer work, intergenerational programs, or hobby groups to foster social connection and a sense of belonging.13 Digital technology: Educate older adults on how to use technology such as smartphones, social media, or video chat apps to stay connected with family and friends, especially if they are physically isolated.14 Transportation services: If transportation is a barrier to receive care, recommend home-based cardiac rehabilitation programs for individuals who qualify.15 Furthermore, for individuals who are homebound, many home-visiting programs can be extremely beneficial in providing social interaction. Physical activity: Encourage participation in group exercise. For older adults, the SilverSneakers program offers community-based in-person or online classes and has been linked to increased physical activity and self-rated health as well as decreased social isolation and loneliness.16 Individual or group therapy: Screen and advocate for individuals who may benefit from critical interventions (eg, social cognitive behavioral therapy) to improve loneliness or other mental health conditions, which are linked to cardiovascular health.17 Research Implications A significant body of research has identified the predictors and outcomes of loneliness and social isolation to date, although much remains to be understood in terms of effective interventions to reduce health risk. Our understanding of loneliness and social isolation to date is largely limited to cross-sectional studies. No previous intervention studies have sought to reduce the adverse impact of social isolation or loneliness on cardiovascular health outcomes. Thus, it is vital for the research community to test hypothesized mechanisms of loneliness and social isolation and implement theory-driven longitudinal research studies to intervene on the growing epidemic of loneliness and social isolation. In addition, there are a limited number of studies on loneliness compared with social isolation,18 as well as fewer studies pertaining to coronary heart disease compared with heart failure. Although it is true that nurses are known for their compassion and dedication to their patients' holistic health journey, they are also adept at addressing the needs of an evolving society. The loneliness epidemic presents a new challenge for nurses to rally and rise once again as their patients' champions. Because nurses are represented in every health sector and in the community, they have the opportunity to cultivate a culture of connection through empathy and inclusivity to thereby promote cardiovascular health by addressing loneliness and social isolation.