Dr. Julianne Holt-Lunstad is a professor of psychology and neuroscience at Brigham Young University. She is a loneliness and social isolation expert whose research focuses on the longterm health effects of social connections. And she has made the remarkable finding that being socially isolated carries the same health risk as smoking 15 cigarettes a day. And it’s more predictive of early death than the effects of air pollution or physical inactivity. We recognize today that the U.S. and a number of other developed nations are facing a loneliness epidemic. And Dr. Holt-Lunstad’s years of research on this issue are ahead of its time.
KEEPING SENIORS CONNECTED
Dr. Julianne Ho…: Lacking social connections, whether it be through social isolation, or loneliness, or poor quality relationships. This can increase your risk for premature mortality from all causes.
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Bill Frist: Now let’s turn to the episode. Dr. Julianne Holt-Lunstad is a professor of psychology and neuroscience at Brigham Young University. She is a loneliness and social isolation expert whose research focuses on the longterm health effects of social connections. And she has made the remarkable finding that being socially isolated carries the same health risk as smoking 15 cigarettes a day. And it’s more predictive of early death than the effects of air pollution or physical inactivity.
Bill Frist: We recognize today that the U.S. and a number of other developed nations are facing a loneliness epidemic. And Dr. Holt-Lunstad’s years of research on this issue are ahead of its time. I’m your host, Senator Bill Frist. Welcome to A Second Opinion.
Bill Frist: Julianne, I did four years of medical school, five years of general surgical residency, a couple of years in the transplant world, a couple of years in cardiac surgery. A lot of medical training, have had tens of thousands of patients. And I’ll have to admit that in my review of systems in my past medical history and the family history, when I take a history, I never said, “Are you lonely?” Nobody told me I should. Now tell me about this loneliness. Where did it come from? What is this isolation thing? Was I trained wrong and should I have been asking different questions?
Dr. Julianne Ho…: Well, there’s lots to say about that. And first of all, maybe just directly asking someone whether they’re lonely or not might not get you the kind of information you need. And it’s unfortunate because there’s a lot of stigma around loneliness. So a lot of people may not necessarily admit that they’re lonely even if they are. So we’re still working on what the right questions to ask might be, but we certainly have robust data that the extent to which someone is socially connected or lack those connections can have just as much of an effect on your patient’s health and outcomes as some of the other things that you probably regularly ask your patients about and that are included in the medical history. Whether it be their physical activity or whether they smoke or not, getting their blood pressure. All of these kinds of things are important. And I don’t want to dismiss them in any way, but the social factors are just as important.
Bill Frist: And we weren’t, the whole point obviously is that if we’re looking for risk factors for our health and wellbeing, unless you’re putting it together as a provider, as a physician or a diagnostician or a psychologist, you’re missing a big component. So the bottom line is that isolation and loneliness is a risk factor for what?
Dr. Julianne Ho…: For premature mortality.
Bill Frist: For death.
Dr. Julianne Ho…: Yeah. Yeah. It also is a risk factor for various cardiovascular outcomes. Given that that is your background. But other outcomes as well. So in fact, lacking social connections, whether it be through social isolation, or loneliness, or poor quality relationships. This can increase your risk for premature mortality from all causes. And it’s independent of smoking status. It’s independent of exercise and diet.
Dr. Julianne Ho…: So in order to establish this evidence, because of course our relationships encourage us to eat better or perhaps encourage us to exercise or to quit smoking. So that’s certainly one way in which relationships might impact that. From the time we’re little, we have people encouraging us to eat our vegetables, to wear our seat belts, to look both ways before we cross the street. Right?
Dr. Julianne Ho…: But the important part is, is that even over and above the influence that our relationship can have on these kinds of behaviors, it has an independent effect. So when we were doing our analyses to establish this effect, we wanted to make sure that we controlled for those things. Because we didn’t want people to say, “Well, it’s really just because people who are more socially connected are less likely to smoke, or are less likely to do this or that.” And really all we need to be concerned about are those behaviors. Why do we need to measure relationships? So this effect is over and above the effect that those have.
Bill Frist: Yeah. So it’s an independent predict or risk factor for premature death. Can you quantify that for our listeners? In your research, have you tried to quantify that at all to make it really sink in?
Dr. Julianne Ho…: Yeah. So in my first meta analysis, we looked across all measures of social relationships. And averaged across these, what we found was that those who were more socially connected had a 50% increased odds of survival. So what that means is that they were 50% more likely to be alive at the followup. So people were followed over years, often decades.
Dr. Julianne Ho…: But I knew that people were going to say, “Okay, 50%. What does that mean?” [crosstalk] But we hear all the time on the news, the latest health finding of, “This week, eggs are good for us and this week eggs are bad for us.” Or whether an aspirin is good or not. And I think the general public has a hard time understanding how to weigh the kinds of evidence that we’re constantly bombarded with.
Dr. Julianne Ho…: So it was really important for me when I did this, because this was a synthesis of all the available data worldwide. This isn’t just one study.
Bill Frist: A real meta analysis?
Dr. Julianne Ho…: Yes. Yeah. It was important for me to be able to provide some kind of benchmark that the average person could understand, and know just how seriously they need to take this for their health. But also the medical community. Because I also knew that the medical community wasn’t adequately recognizing this either.
Bill Frist: Yeah. And again, isolation is kind of a soft issue. Again, in medicine, you’re trying to be sort of real analytical and get all the data and all. So again, even our listeners right now in our conversation probably saying, “Loneliness and isolation, it’s still sort of this soft nebulous thing.”
Dr. Julianne Ho…: Yeah, or relationships. It’s kind of this touchy feely.
Bill Frist: Take me there.
Dr. Julianne Ho…: Fuzzy sort of, yeah. So what we found was we benchmarked it relative to the kinds of things we take very seriously, like smoking. Alcohol consumption. Physical inactivity, obesity, air pollution. And what we found was that for instance, the one that is often cited is-
Bill Frist: And it’ll be the one that everybody remembers. They haven’t heard it yet, but they’ll remember aft er this engagement.
Dr. Julianne Ho…: Lacking social connections was equivalent to smoking up to 15 cigarettes per day. And it was comparable and if not exceeding, so greater than basically all of the others. So one thing I do need to clarify though is, so remember that’s averaged across all of the indicators.
Dr. Julianne Ho…: So when I did my second meta analysis, we looked specifically at social deficits. This included social isolation, loneliness, and living alone. Those also were established as independent risk factors for mortality, but not quite as robust as the indicators of social connection. So this was roughly more around 30% increased risk. So it’s loneliness and isolation and living alone don’t quite get to the the smoking part, but still exceed obesity, physical inactivity, and air pollution-
Bill Frist: Exceed obesity?
Dr. Julianne Ho…: Yeah.
Bill Frist: Or greater impact. Independent impact. So say the smoking the cigarettes one more time.
Dr. Julianne Ho…: So lacking social connection carries a similar risk to smoking up to 15 cigarettes per day.
Bill Frist: And that’s what everybody’s going to remember. But that’s okay. Our whole conversation, if you remember that, you can hang everything else on that. And then walk through the three again so I’ll understand.
Dr. Julianne Ho…: Loneliness, social isolation, and living-
Bill Frist: So what do they mean?
Dr. Julianne Ho…: Let’s define these. Because these are often used interchangeably and they can often be correlated, but they actually can represent different life experiences.
Dr. Julianne Ho…: So social isolation is defined as really being more objective in terms of having few relationships or infrequent social contact. Whereas loneliness is really more of a subjective indicator. It’s your perception. So it’s defined as the discrepancy between one’s actual level of connection and one’s desired level of connection.
Dr. Julianne Ho…: So depending on those expectations, that can differ very much between people. Right? So while being isolated can certainly increase your risk of loneliness, you can be lonely but not isolated. So people often report feeling lonely in a crowd, or simply not feeling like they belong, and are accepted by the people that are around them. So they may feel profoundly lonely, despite the fact that they’re not isolated.
Dr. Julianne Ho…: Conversely, people can be isolated but not feel lonely. They may take pleasure in being alone. So they’re definitely isolated and perhaps withdrawn from social circles, but yet don’t feel lonely.
Dr. Julianne Ho…: And then also there’s living alone, which we think is kind of a crude indicator. Because you can live alone and still have a wide social network, and not be isolated. And not necessarily feel lonely. But nonetheless, all three of them are independent risk factors for premature mortality. And equivalently so.
Bill Frist: That brings us sort of to the natural wood thought of the role of social media. In the rural areas where I spend a lot of time in Appalachia and in Southwest Virginia, it’s really interesting to me to see the number of people who live alone and who work the land, and are farmers. And a few go into a nearby community to work. And their use of Facebook is really high. Really high. And every time I see that, I see the pleasure they receive. Sort of like the old knitting clubs of country living in the old days where people would get together and exchange stories. Do you see social media playing a positive role or a negative role, or a few examples in how the use of social media affects all three of the categories we just discussed.
Dr. Julianne Ho…: Yes.
Bill Frist: Open the door.
Dr. Julianne Ho…: So the role of social media on all of this is actually I think one of the biggest areas where we need more data on. So there’s no question that the way in which we are interacting socially has changed. So one of the big questions is, is this for the better or for the worst? So one of the things we have to keep in mind is we have decades of research. So for instance, all of the information I just shared with you about these really robust impacts that they have on health. They followed people over often decades.
Dr. Julianne Ho…: So if we think about the role of social media, it’s relatively recent. And in fact, even if we think about smartphones. It’s often cited that 2012 is the point in which the majority of Americans owned smartphones. That’s 2012, that’s seven years ago. And yet, these studies started before the widespread use of that.
Dr. Julianne Ho…: So one of the things we have to really be aware of is that we don’t have good longterm on the effects of this. So what we have are a lot of correlational studies. And what these correlational studies often find … well first of all, it’s complex. And it can depend on how it’s used and who’s using it. And, but one of the things I should just mention about the correlational studies is because they’re correlational, we don’t know the direction of the effect.
Dr. Julianne Ho…: So let’s say, because there have been studies that have shown that there’s been a correlation between social media use and loneliness. But what we don’t know is, is it that social media is causing people to become more lonely? Or is it that people who are lonely are using social media more? So a correlational study really can’t get at the direction of the effect. Even the studies that have followed people over time, they’re often very short term followups.
Dr. Julianne Ho…: So one of the things that we just have to keep in mind with, with these is that they are tools, right? And they can have incredible advantages and conveniences. But there can also be downsides to them. Any tool can be used for good or bad. And I think the key is recognizing and utilizing the strengths, but being very cautious about the potential downside and potential detrimental effects of-
Bill Frist: There’s no real message to share with the leadership of the Twitter, or Facebook, or LinkedIn. If you sit down with them and they say, “What advice would you give me?” Recognizing that in the business of communication and you’re in the business of loneliness and defining it as a risk factor. Is there any advice that you could give them, or sensitivities, or things they should be aware of? I’m putting myself sort of in the CEO position. Is there anything they should listen to?
Dr. Julianne Ho…: Yeah. So one of the things that I know I’m certainly interested in is to what extent are users using these is in essence of substitution, or this is the destination versus as a tool to connect in real life.
Dr. Julianne Ho…: And there may be ways in which they can actually identify, because I’m sure it’s a mix of both, right? But how can their tools be used then perhaps for those where it’s the destination, it’s the only place that they are connecting? How can they potentially use those tools to move those users into connecting in real life?
Bill Frist: Real connection, yeah.
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Bill Frist: And now back to the episode.
Bill Frist: Sort of like the use of technology on telehealth and telemedicine. There’s a real role for it as a tool, but it doesn’t mean you can disconnect it from the sort of empathetic touch and relationship. And it’s the same challenge.
Dr. Julianne Ho…: We also need to really be careful because of course, not all connection is positive. And of course these tools can be used to bully, to harass, and can create conflict. So just like relationships in real life, not all relationships are positive. So of course the caveat of connecting in real life is connecting in positive ways. Because it’s really the positive relationships that have these health benefits, and in fact the data shows that negativity in relationships actually increases risk.
Bill Frist: Yeah, it makes sense. In our podcast, one of the reasons people are attracted to our podcast is that we march from this region of health and health care, which we’ve talked about, with isolation and loneliness being a predictor. And then we moved to the social media, which is sort of the more technology innovation sort of end of things. And the last area is the policy world. How does your research, your fantastic research which is really pioneering research and opened up this whole movement and attention to the loneliness. How does it affect policy or how can policy affect it?
Dr. Julianne Ho…: Yeah. I think that policy has a place and a role in addressing this issue. It’s not the only solution, but there’s absolutely implications for policy. And in essence, I’ve thought a lot about this because when we look at some of the kinds of programs that are aimed at trying to help reduce loneliness or reduce isolation. That there’s limited success.
Dr. Julianne Ho…: So I started looking to other kinds of public health issues. And what I found was that similar to other public health issues, that efforts that are aimed at the individual often are aiming at those who are at the highest risk, are the most resource intensive, most time intensive, and the least successful. And that really what we need to do is start looking at people earlier in the risk trajectory, so more prevention efforts. And more population-based efforts. And that we’re going to have a much wider impact in reducing overall population risk if we can focus on these.
Dr. Julianne Ho…: And if we think about the framework that the World Health Organization has for health and all policy, I’d like to argue we need to have social and all policy. And we need to think about our existing policies, and do these existing policies promote social connections, or do they hinder social connections?
Dr. Julianne Ho…: And we can start by whether it’s housing or transportation, how we design our cities. We can think of lots of education, workplace policies. How can we create policies that can facilitate social connection rather than hinder them?
Dr. Julianne Ho…: And I think there’s enormous room of potential for that. And I know some people think, when they think policy. And I’m not kidding, I’ve had someone actually say, “So what are you going to do? Legislate good relationships for all? It’s not like you can put hugs in the water.” But we certainly can think about for instance, including this in health education in K-12. Including it in training of our medical doctors, in medical training, and other health professions. We can think about transportation policy. We can think about how we design our cities. Our roadways. Are our cities walkable, are our communities walkable? Cities, to suburbs, to rural areas. How we design them to help people be engaged with their communities. This has far reaching implications.
Bill Frist: I love it. Almost as a checklist or a filter on every policy that’s out there. At least address or at least have the conversation about connectedness and the issues surrounding isolation. Is there a science to all this? Not a medical science to it is are there chemicals in our brains, are the neural networks that are being informed? Again, we don’t to spend a lot of time with that, but where does all this come from within our bodies?
Dr. Julianne Ho…: Yeah. So it’s widely recognized that we are social beings. So much like other social species, that it is adaptive for us to be with others. Right? So if you think about other animals, that they’re better able to evade predators, they can rely on being part of a group. Resources, sources of warmth, protection from the elements. All sorts of protective effects or adaptive. And humans are social species. And in fact, we are one of the most vulnerable species at birth. If we are left alone, we will literally die. But importantly, the evidence shows that beyond this critical early period, we still need others to survive. So what’s going on?
Dr. Julianne Ho…: So neuroscientists have been looking at various areas of the brain and how this impacts our periphery. That can in turn, of course influence health relevant processes.
Dr. Julianne Ho…: So if we can think about this in kind of a very basic way throughout human history. When we’re alone, we have to be much more vigilant to our environment. We have to be much more vigilant to threats. We have to be much more on guard. This can activate the fight or flight response and other kinds of physiological responses. But being around others also provides resources to help us manage our environment better.
Dr. Julianne Ho…: So for instance, there is neuroscience research that has shown that when facing a threat by yourself versus with others and particularly close others, that we use less metabolic resources when we’re with others relative to being alone.
Dr. Julianne Ho…: So in essence, our bodies, we have these responses that we are much more activated when we’re isolated. So this physiological. So for instance, social isolation or lacking social connections has been linked to cardiovascular responses. So higher blood pressure, greater cardiovascular reactivity. It has been linked to stress related hormones. Research has shown that it is linked to immune functioning.
Dr. Julianne Ho…: So one of the interesting areas of research is on inflammation. So as we know, inflammation is implicated in a variety of chronic illnesses. And being isolated or lonely. So for instance, chronic loneliness has been associated with chronic elevations in inflammation. And conversely, being more socially connected, whether it’s social support or social integration, is associated with lower inflammation. So that may be one of the biological pathways that explains why the relationships are associated with a diverse set of illnesses.
Bill Frist: That really explains why it’s a risk factor. Because if you’re really knocking down the entire body’s defense mechanisms and you’re introducing a stressor which drives up the stress aspect of the body. It hits every single organ throughout the body. And that science is there. And the reason why I think this conversation is so important is that people tend to dismiss loneliness or a lot of the social factors surrounding prevention and health, and disease. And what your great contribution is to quantify it and to do it through not just your own individual study, but bringing together all the studies that have been performed. And it’s a real contribution because it debunks any sort of dismissal of it being such soft science, it’s not going to have an impact on me. Because you’ve been able to elevate it, it’s probably one of the most important risk factors for premature death that is out there today. And let’s say it just one more time again, in terms of the impact. The quantified impact on the smoking is what again?
Dr. Julianne Ho…: So lacking social connections carries a similar risk to smoking up to 15 cigarettes per day. But I think it’s important to recognize that this is just as, if not more impactful than these other factors that we take quite seriously for our health. And devote considerable attention and resources towards. And it’s time that we take our relationships just as seriously for our health.
Bill Frist: Yeah, no, that’s exactly right. That’s exactly right. Let’s just close from all your research and your speaking around the country and interacting with people both in the field and in academia as well. Is there one element that makes you more optimistic about either the reception you’re receiving or that your data is receiving when you look to the future? I kind of want to project out two or three years from now. You and I have known each other for about a year or so, and I’ve watched things change radically with this understanding and this life that you’ve been shining. But let’s say if you’re optimistic about one thing in a direction with your research and with the impact that I think you’re having, what would it be?
Dr. Julianne Ho…: I think that we’re gaining more awareness. So with efforts such as your own and others, we’re starting to get the word out. We’ve had data on this for some time. It has been under recognized. So one of the key things or steps in terms of actually doing something to mitigate this risk is first recognizing that it’s a real concern. And I think that people are starting to come around and recognize the importance of loneliness. But it’s more than just loneliness, and it’s more than just an effect on our wellbeing or our mental health. That this has an impact on our physical health, and ultimately how long we live. And I think the optimistic part of this is that being socially connected is a powerful protective factor. And that that’s something that every single one of us can improve on. We’re all somewhere on that spectrum, and every one of us can benefit from that.
Dr. Julianne Ho…: So I would like to also see the national discussion really focus on social connection as part of a healthy lifestyle, rather than simply kind of let’s just deal with the really lonely people. And the rest of us, it doesn’t apply to. This applies to everybody. Everyone.
Bill Frist: Everybody. Thank you for your tremendous contribution. You’ve inspired me. And as I speak to others, I’m going to kind of keep amplifying that message. And you provided the fundamental understanding. And once people understand they can do some great things in terms of remedying the challenges that we have out there surrounding loneliness. Thank you very much for being with us today.
Dr. Julianne Ho…: Thank you for having me, yeah.
Bill Frist: This episode of A Second Opinion was produced by Todd Schlosser, the Modus Creative group, and Snapshot Interactive. You can subscribe to A Second Opinion on Apple Podcasts or wherever you’re listening right now. And be sure to rate and review A Second Opinion so we can continue to bring you great content. You can get more information about the show and our guests and sponsors at asecondopinionpodcast.com. A Second Opinion broadcast from Nashville, Tennessee, the nation’s Silicon Valley of health services. Where we engage at the intersection of policy, medicine, and innovation.