Loneliness is a public health issue: Let’s tackle it together

0:00:46.8 Lindsay Kobayashi: If you're listening to this podcast and you're experiencing loneliness or you think you might be experiencing loneliness but you're not sure, I would say that loneliness is really common and it can be hard to admit to yourself and even harder to admit to other people around you. Humans are social creatures and when you're feeling like you're not being social, it can make you feel bad. I would say that just recognizing that feeling and then starting to probe why it's there, why you're feeling that way, and what you can do to help change that in your life is important. I would encourage everyone to address it if and when you do feel lonely, because if you let it go for a long period of time, there can be long-term negative effects in health.

0:01:36.3 Host: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important health topics, stuff that affects the health of all of us at a population level, from the microscopic to the macroeconomic, the social to the environmental, from cities to neighborhoods, states to countries, and around the world.

0:02:08.3 Host: In 2023, US Surgeon General Vivek Murthy issued a national health advisory on a loneliness epidemic happening in the US. According to the advisory, loneliness is far more than just a bad feeling. It harms both individual and societal health. To learn more about how loneliness affects beyond a personal level and into the population level, we sat down with Lindsay Kobayashi, an Associate Professor of Epidemiology at the University of Michigan School of Public Health. She's a Social Epidemiologist and studies aging and the social determinants of health that impact our well-being as we grow older.

0:02:43.2 LK: One of the reasons why I'm so interested in the social determinants of health is because the social world is so important for shaping health and health disparities in populations. And focusing on loneliness and social connections is one aspect of those social determinants of health. And a reason that I focus on aging is because that is often when we see the strongest health disparities and variations in health status within populations start to emerge. And I really think of aging and the later period of life as the accumulation of experiences, of exposures, of both risk factors and protective factors for health starting to accumulate and then express themselves in physical, mental, and cognitive health later in life.

0:03:30.2 LK: Loneliness has really important physical health implications. Over the last couple of decades, there's been a robust body of evidence coming out that links loneliness with a range of different health conditions. These range from both physical function, cognitive function during aging, cardiovascular health, and even risk of all-cause mortality.

0:04:02.3 LK: Loneliness in the context of public health is typically defined as the psychological experience or perception of a lack of social connections. It's the way that you feel when the social relationships and connections that you experience don't match what you would ideally want them to be. And that's different from social isolation. And that's a really important point to make because a lot of the time we talk about loneliness, social relationships, social connections, social engagement in a very interchangeable way. We talk about loneliness as this psychological or perceived experience of social isolation, but in public health research and practice, we talk about loneliness a little bit different than a person's sort of measured level of social connections or relationships. If you were actually to count up the different types of social relationships that they have in their life. What is the measured strength of those relationships and what types of social activities are they taking part in. It can be hard to recognize and acknowledge, whether that's to yourself even or to people around you, that you are in fact feeling lonely.

0:05:12.6 LK: And it might express itself as feeling unhappy or feeling a little bit off. But when we kind of recognize and acknowledge that that feeling is there and say it out loud, it's really just as simple as saying, I feel lonely, or I don't feel connected to people around me, or I feel isolated, or I feel alone. And actually, in research studies in public health, when we measure loneliness, whether that's face-to-face or telephone interviews with researchers or pen and paper or online questionnaires, that's exactly how we measure loneliness. There are a number of research scales that are used to measure loneliness. A common one is called the UCLA Loneliness Scale. It gives simple statements, such as, "I felt lonely much of the time," and then the respondent who's taking the survey will respond on a scale that ranges from strongly agree to strongly disagree. So it's a very kind of straightforward and simple concept to acknowledge and talk about once you acknowledge and recognize that you have that feeling.

0:06:15.0 LK: Anyone can be vulnerable to loneliness. I wouldn't say there's necessarily one population group who is most vulnerable to loneliness. I think at some level, loneliness is a common aspect of the human experience. And again, it changes over time. It's something we all experience at different points in time. One thing that I thought was really interesting that came out during the COVID-19 pandemic was that younger population groups, so teenagers and young adults, were the most vulnerable to experience loneliness during the pandemic. And I think that's still true today. But when it comes to the health effects of loneliness, evidence indicates that it's older adults who are experiencing the strongest health consequences of being lonely. And that might be just because older adults overall are at risk for a greater number of chronic health conditions and mortality relative to younger adults.

0:07:05.3 Host: Kobayashi and her students have been studying this health consequences in older adults. She describes one such study led by her former PHD student.

0:07:12.3 LK: Who's actually graduated now Doctor Xu Xinyu.

0:07:15.6 Host: That documented the relationship between loneliness and cognitive function.

0:07:19.0 LK: A study led by my Ph.D. Student, Xu Xinyu, looked at the association of cumulative loneliness over an eight-year period in relation to subsequent memory aging among older adults in the US. And this was using data from the Health and Retirement Study, which is a nationally representative sample of adults aged 50 and over in the US. And in this study, we saw that people who experienced loneliness over a longer duration of time, over the eight-year exposure period, had a dose-response relationship with the rate of their memory decline as they aged, which we refer to as memory aging. So what this means is that people who experienced longer durations of loneliness over an eight-year period experienced faster memory aging as they aged. The results of the study indicate that experiencing loneliness is bad for our cognitive health as we get older.

0:08:22.9 LK: The reasons why loneliness impacts memory function during aging are still unknown and under investigation. I think there might be two reasons. One, there might be a direct physiological impact of loneliness on brain function, and that could be through pathways such as inflammation or stress biomarkers. But the evidence linking loneliness with memory or brain function as mediated by some of these physiological indicators is still unclear. The other potential pathway could be through behavioral coping mechanisms that people use to help them deal with loneliness that might have adverse effects on the brain. So these could be things like drinking alcohol, like further withdrawing into social isolation. That could be a maladaptive coping mechanism to deal with, an initial experience of loneliness. And so I think we need a little bit more evidence on the mechanisms that link loneliness with memory aging.

0:09:27.1 LK: But regardless, I think that when thinking from a public health perspective, intervening on loneliness itself should help to reduce some of these adverse population health effects that we see associated with loneliness that are not limited to memory aging, so things like mortality risk. So I think loneliness is a good intervention point, even if we don't yet fully understand all of the mechanisms that link it with adverse health outcomes.

0:10:00.7 LK: Loneliness is not a static experience. It is dynamic. And what I mean by that is that feelings of loneliness change over time as we live our lives. And I think that around the world, everyone experienced periods of loneliness during the COVID-19 pandemic. And I think that's a really great example where external circumstances changed in such a way that with COVID-19 restrictions, a lot of us weren't able to go out and take part in our usual social activities and to see people as often. And there's been solid survey evidence, both from researchers at universities as well as public health agencies such as the CDC, showing that there was a rise in self-reported loneliness in the US population. I know this is true in other countries as well during the COVID-19 pandemic. So I think it's something that most people can probably relate to, if not only during the COVID-19 pandemic but also during other times in our lives. It's really natural for feelings of loneliness to go up and down during different life stages.

0:11:07.6 LK: There might be times in your life where you don't feel lonely and you feel like you've got family around you, that you've got friends around you, that you've got hobbies and social activities or clubs that you enjoy, but there might be other times where you don't feel like you have those things as much and you do feel lonely. Or even if you do have people around you, there might be circumstances that are preventing you from really connecting with them and preventing you from engaging in different social groups and activities. And that's what I mean when I say that loneliness is dynamic over time and not static.

0:11:41.4 Host: While experiencing an ebb and flow of feelings of loneliness is normal, long periods of loneliness can have the greatest effects on your health later in life. Once more, Kobayashi and Xu collaborated to explore loneliness, this time looking at the cumulative effects of loneliness among older adults.

0:11:58.9 LK: What Xu Xin and I found in this study was that there was a dose-response relationship between the duration of time that someone experienced loneliness and their risk of mortality. So essentially, the longer that someone felt lonely, the higher their risk for subsequent all-cause mortality. And we measured this for a very long time. We measured loneliness over an eight-year period. We observed that as people experienced longer durations of feeling lonely as they aged, there was a higher risk of experiencing mortality. And these translated into a greater number of deaths that were attributable to loneliness over increasingly long time periods that someone felt lonely. So for example, amongst people that were consistently lonely over the full eight-year period that we studied, we observed 288 excess deaths per 10,000 person-years of follow-up.

0:13:01.9 LK: How you can interpret those numbers is that if you were to take 10,000 people in the population who all felt lonely consistently over an eight-year period and followed them for one year, there would be an excess of 288 deaths within that population of 10,000 people that would not have occurred had those people not felt lonely over an eight-year period. And because loneliness is something that is modifiable, it's not inevitable, it's something that can be changed through intervention. Anytime we have excess deaths, that's too many deaths.

0:13:41.1 Dr. Vivek Murthy: I wanted to reconnect with these friends, but I was also ashamed to ask for support when I hadn't exactly been there for them for several years. Feeling distant from friends and family led to a deep sense of loneliness within me. That loneliness paved the way for self-doubt and shame as I came to question my own self-worth. The truth is, it took more than a year of struggling with the pain and shame of loneliness.

0:14:09.0 Host: That was Dr. Vivek Murthy, the US Surgeon General, addressing the University of Michigan School of Public Health graduating class of 2023 and speaking about his own experience with long-term loneliness. It was around that same time he released the National Advisory on what was dubbed our Epidemic of Loneliness and Isolation, detailing the public health significance of social disconnection and proposed population-level interventions to combat the loneliness epidemic in the US. Kobayashi is hopeful about the administration's acknowledgment of loneliness as a public health issue.

0:14:43.2 LK: I think it's incredibly important and exciting to see that the Surgeon General has released this advisory on loneliness as an epidemic. I think that the loneliness epidemic is turning into quite a nice catchphrase that is getting people's attention. And if you actually read the advisory, you see that a lot of the interventions are multilevel across different aspects of society and societal organization and are structural in nature. And that is really exciting from a public health perspective.

0:15:19.6 LK: What really struck me about this Surgeon General's advisory was that they had considered a social factor as a really major influence on population health, which I think is really innovative. Even though loneliness is an experience that is incredibly personal, it can be hard to talk about sometimes, and it's something that we go through as individuals, it's important to talk about it at a population level rather than an individual level because loneliness is often produced by the external circumstances that we live in. And I think that, like with many public health interventions, the most effective interventions to address loneliness that's experienced by individual people will be to address factors at the societal level and amongst communities.

0:16:13.9 LK: The factors leading to loneliness as an epidemic are really complex and have evolved over time. I don't think it's possible to put our finger on one thing and say, that's it. I certainly think the COVID-19 pandemic has been negative with... Well, with respect to a lot of things, but also with respect to our social fabric in society. I think that a lot of people are still feeling some after effects of social isolation and loneliness as a result of the pandemic. The internet, digital technologies, and social media, I don't think they are inherently bad or inherently good, but I do think that the way in which they have been used has led to more social isolation. When we use social media and the internet as a substitute for building meaningful in-person relationships, that really can lead to isolation and loneliness.

0:17:14.7 LK: One thing that I think is particularly important, and I know this is a trendy catchphrase, but I think the built environment is actually really important. What do our cities, our towns, and our communities look like when we go out into the world and encounter other people? Whether that's in day-to-day life, doing things like grocery shopping or going to the doctor, or getting involved in different types of clubs and societies and organizations that exist within our community. We don't have walkable cities, and there's not a lot of funding support for public spaces that people can spend time in, in cities, towns, and communities. And I think the more that we have public resources available for spaces to spend time in with other people, to spend leisure time in, and public support for different organizations and groups without financial barriers, for example, the more we can be social and live our lives in public spaces and interact more with other people in meaningful ways.

0:18:14.5 LK: And I think that comes down to urban planning, to funding for municipal services and resources, and the way in which we design our cities and live in our cities. And that's one thing amongst many that I think is actually incredibly important for addressing loneliness at the population level. Something that stood out to me about the Surgeon General's advisory about the loneliness epidemic was that the national strategy put forward does address remedying loneliness and social isolation at multiple levels. If you look at the advisory, there are recommendations that go all the way from the individual to national, territory, local, and tribal governments. So it really does have multi-level recommendations and across sectors as well, and I think that's really important.

0:19:05.0 LK: I think that the more that we feel like we are a community, both within our immediate local communities, but also at the state level, at the national level, for us to feel like a cohesive society as a country, I think that is something that actually is also important for addressing loneliness. And while there were aspects of the Surgeon General's report that talked about cultivating a culture of connection, for example, I think it could have been more explicit. But I will acknowledge I think this is an incredibly difficult intervention and an incredibly difficult issue that our society is facing right now, not only with respect to addressing loneliness, but many other issues going on. My hope now is that governments at different levels will pay attention to this advisory and enact its recommendations.

0:19:54.5 Host: As Kobayashi said, the Surgeon General's Loneliness Advisory offers numerous recommendations for individuals, all levels of government, and to various sectors, including a specific section outlining what public health professionals and public health departments can do. It encourages the field of public health to take action to promote greater connection and prevent social disconnection via the development of public programs, professional training, innovative interventions, and more. For her part, Kobayashi plans to continue gathering data to support the recommendations and future interventions for loneliness in a variety of populations.

0:20:30.0 LK: Right now, I'm planning a new series of studies that are focused on how we maintain cognitive resilience as we age. One aspect of that is social isolation and loneliness, or addressing social isolation and loneliness. I'm interested in health disparities during aging and addressing how we can promote cognitive health and resilience across people from a wide range of population groups and make sure that this is done in an equitable way. I have a new study that I'm planning that uses data from the Longitudinal Study of Aging in India, where there is a large older population that largely has not had access to formal education. Education is thought to be the strongest protective factor for dementia and cognitive health as we age. And I'm planning a series of studies aiming to look at whether social engagement, social relationships, and a lack of loneliness can act as substitutes for formal education and helping to build and boost cognitive resilience for the current generation of older adults who have not had the access to go to school earlier in their lives.

0:21:46.1 LK: So the idea is maybe social engagement and loneliness can be an effective intervention to promote cognitive health during aging for older adults who have not had the opportunity to go to school.

0:22:03.2 LK: Even though the Surgeon General issued an advisory with a lot of recommendations across different sectors, I think that implementing them in practice is going to be incredibly challenging. The language used in the advisory was quite broad, and I think that's likely because what an intervention might look like, whether that is at the policy level or at the individual level, is probably going to look different in different contexts and for different population groups. And from a research perspective in the field of public health, there is evidence for individual-based interventions such as different types of support groups, cognitive behavioral therapy, pet therapy even, but we don't have evidence on structural or community-based interventions to address loneliness.

0:22:56.6 LK: There is no evidence out there to help support interventions at the structural level, and that is something that we can change in the field of public health by designing studies to test structural interventions where possible. And having an evidence base with which to develop and implement interventions by governments I think is an important piece that we have agency to contribute to in the field of public health.

0:23:33.0 Host: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health. Visit our website, Population-Healthy.com, for more resources on the topics discussed in this episode and to find more episodes. If you enjoyed the show, remember to subscribe, rate, and review wherever you listen to podcasts. Be sure to follow us on social media and consider sharing this episode with friends. Population Healthy is produced by Andrea LaFerle, Brian Lillie, and Crissy Zamarron and hosted by Michael Kaziborski. Hope you can join us for our next episode where we'll dig in further to public health topics that affect all of us at a population level.