Consistent with other research employing Social Network Index components 1516we weighted each component equally with a score of 0 least isolated or 1 most isolated. Differences in associations between social isolation and mortality risk by sex and by race were assessed using likelihood ratio tests that compared models with and without cross-product terms for social isolation score continuous or individual components dichotomous and sex or race.
Understanding associations of social isolation components with mortality can identify dimensions of isolation that may exert more or less influence on health. Social isolation is associated with higher mortality in studies comprising mostly white adults, yet associations among black adults are unclear. Death certificates were obtained to verify reported deaths and to assess information on the cause of death.
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As an additional metric to evaluate the linear trend across the entire distribution of the social isolation score, P values for trends were determined using a continuous variable for the score. Because social isolation was assessed only at baseline and may have changed during follow-up, we compared associations between social isolation score and risk of all-cause mortality during the first — and second — 15 years of follow-up, among all race-sex subgroups combined. Being unmarried was associated with all-cause mortality—particularly for men—and with CVD and cancer mortality, consistent with literature indicating that unmarried persons—especially men—have poorer health and greater mortality risk than married persons Berkman et al.
Addressing social isolation may facilitate improved health outcomes. Association of components of a social isolation score with all-cause mortality, by race and sex, in the Cancer Prevention Study II cohort, United States, — The models stratified the data on age in single yearsand were adjusted for smoking status, education, body mass index, history of diabetes, and all other social isolation components. Schoenbach et al. In this prospective cohort study, we evaluated whether associations of social isolation with all-cause, cardiovascular disease, and cancer mortality differed by race and sex.
The prevalence of social isolation differs across population subgroups 36yet evidence on its association with mortality across subgroups is limited.
Some studies, comprising mostly white adults, have suggested that the association between social isolation and all-cause mortality may be similar for women and men 1011although other studies have suggested that social isolation is more deleterious for men 1 Many studies examining sex differences have been hindered by limited statistical power 13 — 16and the literature lacks robust evidence on the association between social isolation and mortality by race and sex.
Additionally, findings from research examining sex differences in the association between social isolation and mortality have been inconsistent. At completion of the follow-up, vital status was known for Subsequently, linkage to the National Death Index was used to identify deaths from September through December and deaths among the 21, participants lost to follow-up between and Person-years of follow-up were computed as the amount of time from completion of the baseline questionnaire to the date of death, age 90 years for men or 95 years for women, or December 31, whichever came first.
Further, the marital status component of the social isolation measure did not for unmarried persons who were living with a ificant other.
Multivariable-adjusted models additionally included dummy variables, including dummy-coding of missing data for variables with missing data. In a recent meta-analytical review, Holt-Lunstad et al. Research on site-specific cancer mortality may provide additional insights. Table 3. In the era of precision medicine, multiple influences on health—including social factors—are expected to be increasingly considered in clinical care, and addressing social isolation is aligned with this more holistic approach.
All analyses were performed using SAS, version 9.
Liu 6 studied 9, older adults and found the association between social isolation and all-cause mortality to be weakest among white men and strongest among black women. Using CPS-II data, we compared associations of social isolation with all-cause, cardiovascular disease CVDand cancer mortality among sex-race subgroups. Overall, race seemed to be a stronger predictor of social isolation score than sex, as both white men and white women were more likely to be in the least isolated category than black men and black women. This association was stronger during the first 15 years of follow-up than during the second 15 years e.
However, the study was not without limitations.
Seeking to help fill existing research gaps, this study found that social isolation was associated with higher mortality risk for all of the race-sex subgroups studied. Dozens of subsequent studies using various social isolation measures have examined associations with overall mortality, with weighted mean effect sizes between 1.
The associations of individual components of the social isolation score mutually adjusted with all-cause mortality were also assessed.
Vital status was determined using 2 approaches. Research has found black-white differences in the health-protective associations of religious involvement with protective associations being stronger among blacks 7 — 9 and of social contacts with protective associations being stronger among whites 9. Because of limited statistical power for analyses of CVD and cancer mortality in black men and women, the social isolation scores of 3 and 4 were combined for all race-sex subgroups for these mortality outcomes.
Lack of interpersonal connections seems particularly detrimental. There was no difference in association between social isolation and all-cause mortality by smoking status Web Table 2. With one exception 13other studies have found no association between social isolation and cancer mortality among men 1623 Reynolds and Kaplan 16 reported a 2. Subgroup differences in the influence of specific social isolation components were identified.
Because smoking is a major cause of death that is also associated with social isolation, in sensitivity analyses we compared the associations between social isolation score and mortality risk among never, former, and current smokers, using likelihood ratio tests comparing models with and without cross-product terms for social isolation score and smoking status. Participants completed a mailed, 4- self-administered questionnaire on demographic, medical, occupational, anthropometric, lifestyle, and behavioral factors, including components of social isolation.
Research is needed to examine why different types of social linkages have different associations with mortality within population subgroups. We computed P values for multiplicative interactions using likelihood ratio tests that compared models with and without cross-product terms for social isolation score and each of the 2 follow-up periods.
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Participants who reported being married were ased a score of 0; those who reported being single, separated, divorced, or widowed were ased a score of 1. However, the extent to which these racial differences persist using a measure of social isolation i.
Overall, each component of the social isolation score was associated with all-cause mortality and CVD mortality Table 3. Adjustment for alcohol intake, aspirin use, employment status, vegetable intake, red and processed meat intake, family history of cancer, physical activity, and postmenopausal hormone use among women had a negligible influence on risk; therefore, these factors were not included in the models.
Major strengths of this study were its large sample which overcame the power limitations of studiesits prospective de, and the availability of data on several components of social isolation.
Because this attenuation over time may have been due to increasing misclassification of social isolation during the later years of follow-up, all other analyses were based on the first year follow-up period. In age-adjusted analyses, they found that men and women who were the most isolated had 2. Notably, Liu 6 found that when combined with having diabetes mellitus, the mortality risk for the least socially connected black women and men was 3 times higher than that for well-connected black women and men.
In addition to the relatively low complexity of such approaches e. Similarly to studies 56current findings indicate that a composite measure of social isolation is a robust predictor of mortality risk among men, women, blacks, and whites.
Lastly, weighting each social isolation component equally in the social isolation score might not precisely reflect the relative importance of certain components e.
Persistent challenges in intervening on modifiable clinical risk factors such as obesity make approaches based on social isolation promising if efficacy can be established. Such findings can inform unanswered questions about the role of social isolation in mortality in these subgroups and might be useful in identifying and intervening with patients who are vulnerable to premature death.
This approach is similar to that used in other studies in which this variable was coded on the basis of frequency distributions 6 The 5-point social isolation score exposure was the sum of scores for the 4 individual components and ranged from 0 for least isolated to 4 for most isolated.
Lacking involvement in groups seems to be detrimental as well. Comparable studies examining race-sex subgroup differences are lacking. All models adjusted for race and single year of age using the stratified Cox procedure. Two other studies of social isolation and mortality reported findings for both blacks and whites.
These findings lend support to the growing assertion 3313738 that attending to social as well as clinical risk factors holds promise for reducing mortality in the United States. However, weighting is not advised unless a strong, a priori conceptual rationale exists 34and our intent for this study was to utilize a parsimonious social isolation measure.
Although research confirming mechanisms is needed, social isolation is hypothesized to influence health via multiple pathways, including psychological e. In our study, data on social isolation were not updated over time, and self-reported data are subject to misclassification, although there is no reason to expect that inaccurate reporting of social isolation information would be strongly related to future mortality risk.
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Research is needed to identify effective social isolation interventions that can be adopted in clinical or other settings. Alcaraz, W. Ryan Diver, Alpa V. Patel, Lauren R. Teras, Victoria L. To our knowledge, this was the largest study to date on associations between social isolation and mortality in multiple race-sex subgroups in a nationwide US cohort.
Social isolation was positively associated with all-cause and CVD mortality in the 4 race-sex subgroups examined and with cancer mortality in white men and women only. CI, confidence interval; HR, hazard ratio. Further, findings indicated that black women who attend religious services infrequently are at greater risk of all-cause mortality compared with other race-sex subgroups. Table 1. Identifying and intervening with socially isolated adults could improve health outcomes. In the few studies that examined social isolation and CVD mortality by sex only 15 or among men only 132324none found an association.
In all race-sex subgroups, the proportion of current smokers increased and the proportion of persons with at least a high school education decreased with increasing social isolation Table 2.