Cardiovascular Disease’s Lonely Hearts Club

Humans are naturally social. Earlier this year, in a public advisory statement by Dr. Vivek Murthy, the US Surgeon General, social loneliness and isolation were quoted as profound risks to human health and well-being.¹ The lack of social connection predisposes to greater risk of premature death, similar to smoking 15 cigarettes a day,² and increased risk of heart disease by approximately 29%.³ The importance of psychosocial factors including perceived loneliness and social isolation for cardiovascular health has been a focus in guideline and scientific statements issued by the American Heart Association and European Society of Cardiology.^4,5 Social support is broadly defined as a “network of family, friends, neighbours, and community members.”⁶ A comprehensive social support system is one that nurtures and supports emotional health, tangibility, information resources, and companionship. The quality of social relations over the quantity leads to decreased cardiovascular risk.⁷ The term “perceived support” is the subjective judgment of a subject in perceiving the availability of their social network to supply functional support during times of need. This may differ from the actual social support made available to or received by a subject in the past. In this month’s issue of the American Journal of Cardiology, Datta et al⁸ describe the relation of perceived social support with the cardiovascular risk factors in younger US adults.

The self-reported data of 19,827 adults from the 2021 National Health Interview Survey were analyzed. The National Health Interview Survey is a nationally representative survey that provides self-reported data (response rate in 2021, ~50.9%) for the US civilian noninstitutionalized population. The study cohort was divided into 4 groups depending on frequency of receiving support as reported by respondents: “always,” “usually,” “sometimes,” and “rarely or never.” The authors then estimated a binomial logistic regression to assess the odds of having the primary outcome (defined as presence of 1 of the 4 cardiovascular risk factors: hypertension, high cholesterol, diabetes, or obesity). The relative risk of having multiple cardiovascular risk factors was also assessed using multinominal logistic regression estimations by level of perceived social support. The models were adjusted for social support, sociodemographic correlates (gender, age group, race and ethnicity, marital status, employment status, nativity, insurance coverage, urban/rural residence, US census bureau region fixed effects), and education income (using educational attainment and household income). They found that in study participants, 56.7% had always, 25% had usually, 11.4% had sometimes, and 6.9% had rarely/never received social and emotional support. The subjects who “rarely/never” received social support had greater risk for hypertension 1.42 (95% confidence interval [CI] 1.20 to 1.67), high cholesterol 1.39 (95% CI 1.18 to 1.65), and diabetes 1.53 (95% CI 1.22 to 1.91) than did those “always” receiving support. The adjusted relative risks of having ≥3 cardiovascular risks for subjects “rarely/never” receiving support were 1.91 times (95% CI 1.49 to 2.46) those of subjects “always” receiving support. Taken together, these findings and the study by Datta et al⁸ add to the growing body of published research that suggests that social support is a critical component of cardiovascular health.

This study has several strengths. It provides information in younger adults about a social attribute that is important for mitigating cardiovascular risk factor and preventing disease. Reports have noted a disturbing trend of increasing prevalence of cardiovascular risk factors and disease in younger adults.^9,10 More importantly, this population was found to have the most rapid decrease in life expectancy in the United States.¹¹ Early measures of cardiovascular health in young adulthood persist throughout life.¹² Hence, this population represents an opportunity to decrease cumulative risk exposure and cardiovascular disease risk over time. The authors highlight a need to explore and better understand mechanisms linking social support and cardiovascular health. They call attention to processes such as impacts on health behaviors (smoking, exercise), and greater self-awareness of cardiovascular risk factors, along with emotional and social stress. The detrimental effects of lack of social support have been well reported;^{3,4,9,13–19} however, studies describing the mechanistic link between the impact of psychosocial factors and adverse cardiovascular health are scarce. A complex multidirectional relation among loneliness, social isolation, and mortality was described through a systematic review and meta-ethnography by Hodgson et al.¹³ The authors proposed a conceptual framework to develop holistic interventions to target interdependent factors aiming to improve outcomes of patients with loneliness and social isolation.

The present study provides a platform for researchers, policy makers, and public health stakeholders to exert joint efforts to combat the social risk in younger adults. Interventions to improve the quantity and quality of social interactions have received growing attention and focus. For example, social prescribing programs are increasingly being adopted.²⁰ Although the formal definition of social prescribing is currently under way, led by an expert consensus through a Delphi study protocol,²¹ social prescribing is an integrated approach that enables healthcare professionals to refer patients to nonclinical services in the community to improve health and well-being.²⁰ Along with social prescribing, there are additional resources and strategies for promoting social support and changing subjects’ perception of the support system. This may require individualized case-by-case approaches to improve social skills, increase social contact, and/or address maladaptive social cognition.^22,23 In this era of digital health, we have unique tools to provide psychosocial support to improve behavioral functioning and improve the cardiovascular health of our patients.²⁴ The widespread availability of internet services has opened new avenues such as patient-education websites (http://www.heart.org and http://www.cardiosmart.org), social media platforms, and artificial intelligence-large language models search engines to explore cutting-edge resources for patient informational support, bringing patient communities together and filling the gaps in patient-physician interaction. The issue of “digital divide” contributing to greater burden of cardiovascular risk factors and disease and higher cardiovascular and all-cause death rates has been reported.²⁵ The US counties with lesser broadband access had worse outcomes than did those with large broadband access. Moreover, because the field of cardiology dynamically evolves, cross-sectioning with other disciplines such as oncology, that is, cardio-oncology, addressing social disparities is of paramount importance,²⁶ especially given the increasing burden of cardiovascular risk factors and disease in such patients.²⁷

To increase awareness around the risks related to inadequate social cohesion in cardiovascular health, assessment of social support and incorporation into standard clinical care are required. We thank the authors of this study for considering a neglected problem that is the soul of cardiovascular health. There is a growing need for healthcare systems to evaluate and develop strategies to improve social support for patients who are vulnerable and lonely. These efforts are expected to improve both mental and cardiovascular health to reduce the preventable burden of cardiovascular disease.