Contribution of risk factors to excess mortality in isolated and lonely individuals: an analysis of data from the UK Biobank cohort study
Open accessAbstract
BACKGROUND: The associations of social isolation and loneliness with premature mortality are well known, but the risk factors linking them remain unclear. We sought to identify risk factors that might explain the increased mortality in socially isolated and lonely individuals. METHODS: We used prospective follow-up data from the UK Biobank cohort study to assess self-reported isolation (a three-item scale) and loneliness (two questions). The main outcomes were all-cause and cause-specific mortality. We calculated the percentage of excess risk mediated by risk factors to assess the extent to which the associations of social isolation and loneliness with mortality were attributable to differences between isolated and lonely individuals and others in biological (body-mass index, systolic and diastolic blood pressure, and handgrip strength), behavioural (smoking, alcohol consumption, and physical activity), socioeconomic (education, neighbourhood deprivation, and household income), and psychological (depressive symptoms and cognitive capacity) risk factors. FINDINGS: 466 901 men and women (mean age at baseline 56·5 years [SD 8·1]) were included in the analyses, with a mean follow-up of 6·5 years (SD 0·8). The hazard ratio for all-cause mortality for social isolation compared with no social isolation was 1·73 (95% CI 1·65-1·82) after adjustment for age, sex, ethnic origin, and chronic disease (ie, minimally adjusted), and was 1·26 (95% CI 1·20-1·33) after further adjustment for socioeconomic factors, health-related behaviours, depressive symptoms, biological factors, cognitive performance, and self-rated health (ie, fully adjusted). The minimally adjusted hazard ratio for mortality risk related to loneliness was 1·38 (95% CI 1·30-1·47), which reduced to 0·99 (95% CI 0·93-1·06) after full adjustment for baseline risks. INTERPRETATION: Isolated and lonely people are at increased risk of death. Health policies addressing risk factors such as adverse socioeconomic conditions, unhealthy lifestyle, and lower mental wellbeing might reduce excess mortality among the isolated and the lonely. FUNDING: Academy of Finland, NordForsk, and the UK Medical Research Council.
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Written from the paper’s full text.
TL;DR
In UK Biobank, socially isolated and lonely adults had higher mortality, but the excess risk was largely explained by socioeconomic, behavioural, psychological, and health-related factors. Social isolation retained a 26% higher fully adjusted mortality risk, whereas loneliness’s association was fully attenuated after adjustment.
Key findings
- Among 466,901 participants (mean age 56.5 years, SD 8.1; 55% women; 95% white), 9% were socially isolated and 6% lonely; during mean follow-up of 6.5 years (SD 0.8), 11,593 died.
- Social isolation was associated with all-cause mortality: minimally adjusted HR 1.73 (95% CI 1.65–1.82), fully adjusted HR 1.26 (95% CI 1.20–1.33), with 64% overall attenuation after adjustment for biological, behavioural, socioeconomic, psychological, and self-rated health factors.
- Loneliness was associated with all-cause mortality: minimally adjusted HR 1.38 (95% CI 1.30–1.47), fully adjusted HR 0.99 (95% CI 0.93–1.06). Depressive symptoms (PERM 60–77%) and self-rated health (61–84%) were the strongest mediators for loneliness.
- For social isolation, the largest single explanatory groups were socioeconomic factors (35%), behavioural factors (34%), and self-rated health (32%); biological factors explained 10% and cognitive performance 4%.
Methods
- Prospective cohort analysis using UK Biobank baseline data and mortality follow-up from 2007–10 to Aug 14, 2015; 466,901 of 502,656 recruited participants had complete data on social isolation, loneliness, and mortality.
- Social isolation was measured with a three-item scale (living alone, infrequent friend/family visits, no weekly social activities), defined as score 2–3; loneliness was measured with two questions, defined as score 2.
- Cox proportional hazards models with age as timescale estimated all-cause mortality; competing-risks regression estimated cause-specific mortality; percentage of excess risk mediated (PERM) quantified contributions of biological, behavioural, socioeconomic, psychological, and self-rated health factors, with multiple imputation for missing data.
Limitations
- The paper states the response rate was low, so selection bias should be considered for population prevalence estimates; social network and interaction measures were simple; missing covariate data reduced sample size at successive adjustment stages; residual confounding and reverse causality cannot be ruled out; findings cannot be extrapolated beyond ages 40–69 years.
- The text also makes evident that the sample was predominantly white (95%) and from UK Biobank volunteers, which may limit generalizability to other populations.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
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Cites
Statistics
Claims the paper makes
0 of 6 cited sources checked · 0 supported · 0 flagged
- Findingown data
In sensitivity analysis excluding those with chronic disease at baseline, social isolation remained associated with all-cause mortality (hazard ratio 1.22, 95% CI 1.08-1.38).
“In the sensitivity analysis testing for reverse-causation bias, the association between social isolation and all-cause mortality was still apparent (hazard ratio 1·22, 95% CI 1·08–1·38).”
Quote in the paperSubstantial claim - Findingown data
Biological factors explained 10% of the association between social isolation and mortality.
“decreased by 10% after adjustment for biological risk factors, 34% after adjustment for behavioural risk factors, 35% after adjustment for socioeconomic factors, 18% after adjustment for depressive symptoms, 4% after adjustment for cognitive performance, and 32% after adjustment for self-rated health”
Quote in the paperSubstantial claim - Findingown data
The association between social isolation and mortality was weaker in women than in men.
“although it was weaker in women than in men (appendix p 6).”
Quote in the paperNot a substantial claim - Findingown data
For loneliness, behavioural factors explained 32-53% of the excess mortality.
“Depressive symptoms (PERM 60–77%) and self-rated health (61–84%) seemed to be the strongest mediators, in addition to socioeconomic (41–50%) and behavioural factors (32–53%; figure 2).”
Quote in the paperSubstantial claim - Findingown data
The association between loneliness and all-cause mortality was consistent across sex, age, ethnic, and chronic disease subgroups.
“This association was consistent across sex and age groups, ethnic groups, and participants with and without chronic disorders at baseline (appendix p 7).”
Quote in the paperNot a substantial claim
- Findingown data
Loneliness is associated with increased mortality from other causes, with a minimally adjusted sub-hazard ratio of 1.24 (95% CI 1.15-1.34).
“and other causes (1·24, 1·15–1·34; figure 2).”
Quote in the paperSubstantial claim - Findingown data
Loneliness is associated with increased mortality from neoplasms, with a minimally adjusted sub-hazard ratio of 1.75 (95% CI 1.61-1.91).
“Lonely individuals had an increased risk of death from neoplasms (minimally adjusted sub-hazard ratio 1·75, 95% CI 1·61–1·91)”
Quote in the paperSubstantial claim - Findingown data
When both isolation and loneliness were included in the same model, only social isolation predicted all-cause mortality (hazard ratio 1.27, 95% CI 1.20-1.33).
“When both isolation and loneliness were tested in the same model, only social isolation predicted all-cause mortality (hazard ratio 1·27, 95% CI 1·20–1·33).”
Quote in the paperSubstantial claim - Findingown data
Self-rated health explained 32% of the association between social isolation and mortality.
“decreased by 10% after adjustment for biological risk factors, 34% after adjustment for behavioural risk factors, 35% after adjustment for socioeconomic factors, 18% after adjustment for depressive symptoms, 4% after adjustment for cognitive performance, and 32% after adjustment for self-rated health”
Quote in the paperSubstantial claim - Findingown data
Loneliness is associated with increased mortality from diseases of the circulatory system, with a minimally adjusted sub-hazard ratio of 1.30 (95% CI 1.23-1.39).
“diseases of the circulatory system (1·30, 1·23–1·39)”
Quote in the paperSubstantial claim - Findingown data
For loneliness, self-rated health explained 61-84% of the excess mortality.
“Depressive symptoms (PERM 60–77%) and self-rated health (61–84%) seemed to be the strongest mediators, in addition to socioeconomic (41–50%) and behavioural factors (32–53%; figure 2).”
Quote in the paperSubstantial claim - Findingown data
Social isolation is associated with increased mortality from other causes, with a minimally adjusted sub-hazard ratio of 1.57 (95% CI 1.48-1.66).
“and other causes (1·57, 1·48–1·66; figure 1).”
Quote in the paperSubstantial claim - Findingown data
After full adjustment, the association between loneliness and all-cause mortality attenuates to a hazard ratio of 0.99 (95% CI 0.93-1.06), indicating full attenuation.
“which reduced to 0·99 (95% CI 0·93–1·06) after full adjustment for baseline risks.”
- Also stated in: § Results · plain
“Serial adjustments led to complete attenuation of the association (fully adjusted hazard ratio 0·99, 95% CI 0·93–1·06; figure 2).”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
Social isolation is associated with increased mortality from diseases of the circulatory system, with a minimally adjusted sub-hazard ratio of 1.68 (95% CI 1.59-1.77).
“diseases of the circulatory system (1·68, 1·59–1·77)”
Quote in the paperSubstantial claim - Findingown data
Behavioural factors explained 34% of the association between social isolation and mortality.
“decreased by 10% after adjustment for biological risk factors, 34% after adjustment for behavioural risk factors, 35% after adjustment for socioeconomic factors, 18% after adjustment for depressive symptoms, 4% after adjustment for cognitive performance, and 32% after adjustment for self-rated health”
Quote in the paperSubstantial claim - Findingown data
For loneliness, socioeconomic factors explained 41-50% of the excess mortality.
“Depressive symptoms (PERM 60–77%) and self-rated health (61–84%) seemed to be the strongest mediators, in addition to socioeconomic (41–50%) and behavioural factors (32–53%; figure 2).”
Quote in the paperSubstantial claim - Findingown data
Socioeconomic factors explained 35% of the association between social isolation and mortality.
“decreased by 10% after adjustment for biological risk factors, 34% after adjustment for behavioural risk factors, 35% after adjustment for socioeconomic factors, 18% after adjustment for depressive symptoms, 4% after adjustment for cognitive performance, and 32% after adjustment for self-rated health”
- Also stated in: § Discussion · boosted
“we show that 35% of the relation between mortality and social isolation was attributable to education, neighbourhood deprivation, and household income (ie, socioeconomic factors).”
Quote in the paperSubstantial claim - Also stated in: § Discussion · boosted
- Findingown data
For loneliness, depressive symptoms explained 60-77% of the excess mortality.
“Depressive symptoms (PERM 60–77%) and self-rated health (61–84%) seemed to be the strongest mediators, in addition to socioeconomic (41–50%) and behavioural factors (32–53%; figure 2).”
Quote in the paperSubstantial claim - Findingown data
Cognitive performance explained 4% of the association between social isolation and mortality.
“decreased by 10% after adjustment for biological risk factors, 34% after adjustment for behavioural risk factors, 35% after adjustment for socioeconomic factors, 18% after adjustment for depressive symptoms, 4% after adjustment for cognitive performance, and 32% after adjustment for self-rated health”
Quote in the paperNot a substantial claim - Findingown data
The present results do not imply that biological factors are major contributing factors to the social isolation-mortality association.
“Contrary to previous findings,6 the present results do not imply that biological factors (eg, obesity, high diastolic and systolic blood pressure, and low handgrip strength) are major contributing factors.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [6] Cacioppo, 2002, Loneliness and health: potential mechanisms, Psychosom Med source
Not checked in the free run.
- Findingown data
After full adjustment for socioeconomic, behavioural, psychological, biological, cognitive, and self-rated health factors, the association between social isolation and all-cause mortality attenuates to a hazard ratio of 1.26 (95% CI 1.20-1.33).
“was 1·26 (95% CI 1·20–1·33) after further adjustment for socioeconomic factors, health-related behaviours, depressive symptoms, biological factors, cognitive performance, and self-rated health (ie, fully adjusted).”
- Also stated in: § Results · plain
“The overall attenuation after adjustment for all these factors (ie, fully adjusted) was 64% (hazard ratio 1·26, 95% CI 1·20–1·33).”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
The association between social isolation and mortality was still apparent among those with no prevalent chronic disease at baseline and after adjustment for a range of health-related covariates.
“However, we noted an association between social isolation and mortality even among those with no prevalent chronic disease at baseline and after adjustment for a range of health-related covariates.”
Quote in the paperSubstantial claim - Findingown data
Social isolation is associated with increased mortality from neoplasms, with a minimally adjusted sub-hazard ratio of 2.06 (95% CI 1.92-2.20).
“Socially isolated individuals had an increased risk of death from neoplasms (minimally adjusted sub-hazard ratio 2·06, 95% CI 1·92–2·20)”
Quote in the paperSubstantial claim - Findingown data
Depressive symptoms explained 18% of the association between social isolation and mortality.
“decreased by 10% after adjustment for biological risk factors, 34% after adjustment for behavioural risk factors, 35% after adjustment for socioeconomic factors, 18% after adjustment for depressive symptoms, 4% after adjustment for cognitive performance, and 32% after adjustment for self-rated health”
Quote in the paperSubstantial claim - Findingown data
Social isolation is associated with increased all-cause mortality in UK Biobank participants, with a minimally adjusted hazard ratio of 1.73 (95% CI 1.65-1.82).
“The hazard ratio for all-cause mortality for social isolation compared with no social isolation was 1·73 (95% CI 1·65–1·82) after adjustment for age, sex, ethnic origin, and chronic disease (ie, minimally adjusted)”
- Also stated in: § Results · plain
“In the multivariable analyses, the hazard ratio for social isolation compared with no social isolation was 1·73 (95% CI 1·65–1·82) after adjustment for age, sex, ethnic origin, and chronic disease (ie, minimally adjusted)”
Quote in the paperSubstantial claim - Also stated in: § Results · plain
- Findingown data
There was a dose-response pattern in the associations of social isolation and loneliness with all-cause mortality.
“The dose–response analyses revealed a dose–response pattern in the associations of social isolation and loneliness with all-cause mortality (appendix p 5).”
Quote in the paperNot a substantial claim - Findingown data
Risk factors explained 64% of the association between social isolation and all-cause mortality.
“The overall attenuation after adjustment for all these factors (ie, fully adjusted) was 64% (hazard ratio 1·26, 95% CI 1·20–1·33).”
- Also stated in: § Discussion · plain
“Risk factors explained 64% of the association between social isolation and mortality, leaving over a third independent of socioeconomic factors, health-related behaviours, depressive symptoms, biological factors, and cognitive capacity.”
Quote in the paperSubstantial claim - Also stated in: § Discussion · plain
- Interpretationown data
The association between loneliness and mortality is fully attributable to worse risk-factor levels in the exposed group.
“our findings suggest that the association between loneliness and mortality is fully attributable to the worse risk-factor levels in the exposed group.”
Quote in the paperSubstantial claim- Rests on an assumption: The associations between social isolation/loneliness and mortality are causal and the measured risk factors lie on the causal pathway, so that the percentage of excess risk mediated can be interpreted as mediation.
- Rests on an assumption: There is no unmeasured confounding of the associations between social isolation/loneliness and mortality beyond the covariates adjusted for.
- Rests on an assumption: The baseline risk factors adequately capture the mediating pathways over the follow-up period.
- Interpretationown data
Most of the excess mortality among socially isolated and lonely people could be attributed to adverse socioeconomic conditions, an unhealthy lifestyle, and lower mental wellbeing.
“Most of the excess mortality among socially isolated and lonely people could be attributed to adverse socioeconomic conditions, an unhealthy lifestyle, and lower mental wellbeing.”
Quote in the paperSubstantial claim- Rests on an assumption: The associations between social isolation/loneliness and mortality are causal and the measured risk factors lie on the causal pathway, so that the percentage of excess risk mediated can be interpreted as mediation.
- Rests on an assumption: There is no unmeasured confounding of the associations between social isolation/loneliness and mortality beyond the covariates adjusted for.
- Rests on an assumption: The baseline risk factors adequately capture the mediating pathways over the follow-up period.
- Study design and conductown data
The study measured only simple forms of the complex phenomenon of social networks and interaction.
“We measured only simple forms of the complex phenomenon of social networks and interaction, although similar results have been reported in studies using more advanced network analysis.27”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [27] Kroenke, 2013, Social networks, social support, and burden in relationships, and mortality after breast cancer diagnosis in the Life After Breast Cancer Epidemiology (LACE) study, Breast Cancer Res Treat source
Not checked in the free run.
- Study design and conductreasoning
Because analyses were adjusted for prevalent chronic diseases at baseline, the estimated contribution of biological risk factors did not include variation in these diseases.
“However, because our analyses were adjusted for prevalent chronic diseases at baseline, the estimated contribution of biological risk factors did not include variation in these diseases.”
Quote in the paperSubstantial claim - Study design and conductreasoning
The UK Biobank provided a large sample, substantially reducing the risk of random error.
“The UK Biobank provided an opportunity to investigate the associations of social isolation and loneliness with mortality and their links to risk factors in a large sample, substantially reducing the risk of random error.”
Quote in the paperSubstantial claim - Interpretationown data
The association between mortality and social isolation seemed stronger than the association between mortality and loneliness.
“The association between mortality and social isolation seemed stronger than the association between mortality and loneliness.”
Quote in the paperSubstantial claim - Study design and conductcitation
Social isolation was assessed with a multi-item scale that previous studies refer to as having the best predictive validity for mortality.
“We used a multi-item assessment of social isolation, which is referred to in previous studies as the best predictive validity for such a measurement strategy in relation to mortality.4”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [4] Holt-Lunstad, 2015, Loneliness and social isolation as risk factors for mortality: a meta-analytic review, Perspect Psychol Sci source
Not checked in the free run.
- Interpretationown data
Isolated and lonely people are at increased risk of death.
“Isolated and lonely people are at increased risk of death.”
Quote in the paperSubstantial claim
- May combine two claims. 8
- Classified as probably not a substantial claim. 9
May combine two claims.
Findingown dataThe association between social isolation and all-cause mortality was consistent across sex, age, ethnic, and chronic disease subgroups, although it was weaker in women than in men.
“This association was consistent across sex and age groups, ethnic groups, and participants with and without chronic diseases at baseline, although it was weaker in women than in men (appendix p 6).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataThe multivariable, minimally adjusted complete-case analysis showed similar associations between all-cause mortality and social isolation (hazard ratio 1.29, 95% CI 1.14-1.47) and loneliness (0.93, 0.77-1.11).
“The multivariable, minimally adjusted complete-case analysis showed similar associations between all-cause mortality and social isolation (hazard ratio 1·29, 95% CI 1·14–1·47) and loneliness (0·93, 0·77–1·11).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataThe fully adjusted sub-hazard ratios for social isolation cause-specific mortality remained statistically significant and ranged from 1.32 to 1.22.
“but the fully adjusted sub-hazard ratios remained statistically significant and ranged from 1·32 to 1·22 (figure 1).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataLoneliness is associated with increased all-cause mortality, with a minimally adjusted hazard ratio of 1.38 (95% CI 1.30-1.47) in the main analysis and 1.37 (95% CI 1.28-1.46) in the complete-case analysis.
“The minimally adjusted hazard ratio for mortality risk related to loneliness was 1·38 (95% CI 1·30–1·47)”
- Also stated in: § Results · plain
“In the complete case analysis, the minimally adjusted hazard ratio for the risk of death from any cause in lonely individuals compared with those who were not lonely was 1·37 (95% CI 1·28–1·46).”
Quote in the paperSubstantial claim- Also stated in: § Results · plain
May combine two claims.
Findingown dataSocial isolation and loneliness were associated with higher levels of depressive symptoms, smoking, and high alcohol intake frequency.
“Social isolation and loneliness were associated with higher levels of depressive symptoms, smoking, and high alcohol intake frequency, all of which are well established correlates of social isolation and loneliness (appendix p 3).”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataThe study did a sensitivity analysis to test whether reverse-causation bias affected the results.
“To test whether reverse-causation bias (ie, the effect of chronic disease on social isolation) affected our results, we did a sensitivity analysis examining the association between social isolation and all-cause mortality (imputed data, but chronic disease missingness not imputed) after adjustment for all covariates in those without chronic disease at baseline.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductreasoningThe possibility of residual confounding cannot be completely ruled out.
“The possibility of residual confounding cannot be completely ruled out in observational studies such as ours, although the association between social isolation and mortality remained even after adjustment for a wide range of potential confounders.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductcitationLoneliness was assessed with two questions similar to those in the revised UCLA Loneliness Scale.
“Similar questions are included in scales such as the revised UCLA Loneliness Scale.13”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [13] Hughes, 2004, A short scale for measuring loneliness in large surveys: results from two population-based studies, Res Aging source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataMissing data on covariates reduced the sample size at each successive stage of regression adjustment.
“Missing data on the covariates reduced the sample size at each successive stage of the regression model adjustment, although the results were similar when the analyses were repeated with only participants who provided complete data on all the variables.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductnone givenThe response rate was low, and selection bias should be taken into account when making inferences about population prevalence figures.
“However, the response rate was low, and selection bias should be taken into account especially when making inferences about population prevalence figures.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationSimilar results have been reported in studies using more advanced network analysis.
“although similar results have been reported in studies using more advanced network analysis.27”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [27] Kroenke, 2013, Social networks, social support, and burden in relationships, and mortality after breast cancer diagnosis in the Life After Breast Cancer Epidemiology (LACE) study, Breast Cancer Res Treat source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductreasoningReverse causality can affect the results of observational research; in this study, chronic disease might have affected both social isolation and mortality.
“Similarly, reverse causality can affect the results of observational research. For example, in our study, chronic disease might have affected the risk of both social isolation and mortality.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataThe results were similar when analyses were repeated with only participants who provided complete data on all variables.
“although the results were similar when the analyses were repeated with only participants who provided complete data on all the variables.”
Quote in the paperNot a substantial claimMay combine two claims.
Interpretationown dataThe sample comprised participants aged 40-69 years; hence the findings cannot be extrapolated beyond this age range.
“Finally, the sample comprised participants aged between 40 years and 69 years; hence, the findings cannot be extrapolated beyond this age range.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing).
Study design and conductown dataThe study used multiple imputation by chained equations to account for missing data.
“We accounted for missing data by multiple imputation by chained equations, which generated five imputed datasets.22”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [22] White, 2011, Multiple imputation using chained equations: issues and guidance for practice, Stat Med source
Not checked in the free run.
The paper relies on this without support.
The associations between social isolation/loneliness and mortality are causal and the measured risk factors lie on the causal pathway, so that the percentage of excess risk mediated can be interpreted as mediation.
“We calculated the percentage of excess risk mediated by risk factors to assess the extent to which the associations of social isolation and loneliness with mortality were attributable to differences between isolated and lonely individuals and others in biological (body-mass index, systolic and diastolic blood pressure, and handgrip strength), behavioural (smoking, alcohol consumption, and physical”
The paper relies on this without support.
There is no unmeasured confounding of the associations between social isolation/loneliness and mortality beyond the covariates adjusted for.
“The possibility of residual confounding cannot be completely ruled out in observational studies such as ours, although the association between social isolation and mortality remained even after adjustment for a wide range of potential confounders.”
The paper relies on this without support.
The baseline risk factors adequately capture the mediating pathways over the follow-up period.
“We calculated the percentage of excess risk mediated by risk factors to assess the extent to which the associations of social isolation and loneliness with mortality were attributable to differences between isolated and lonely individuals and others in biological (body-mass index, systolic and diastolic blood pressure, and handgrip strength), behavioural (smoking, alcohol consumption, and physical”
The paper relies on this without support.
The UK Biobank cohort's selection bias does not materially affect the associations between social isolation/loneliness and mortality.
“However, the response rate was low, and selection bias should be taken into account especially when making inferences about population prevalence figures. However, prevalence and incidence were not the focus of the present study.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Social isolation and loneliness are strongly linked to anxiety, depression, self-harm, and suicide attempts across life.
“A major adverse consequence of the COVID-19 pandemic is likely to be increased social isolation and loneliness (as reflected in our surveys),4 which are strongly associated with anxiety, depression, self-harm, and suicide attempts across the lifespan.24, 25”
From Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science (2020) · cites this paper as [24]
In non-pandemic contexts, the prevalence of loneliness ranges from 6-76%, with variations across demographic groups and countries.
“in non-pandemic contexts, evidence suggests that the prevalence of loneliness ranges from 6–76%; with variations across demographic groups [5,13–17] and countries [18,19].”
From Loneliness in the UK during the COVID-19 pandemic: Cross-sectional results from the COVID-19 Psychological Wellbeing Study (2020) · cites this paper as [17]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Conflicting minimally adjusted complete-case estimate for loneliness
MajorThe paper gives a minimally adjusted complete-case hazard ratio for loneliness of 1·37, but later describes a minimally adjusted complete-case estimate of 0·93. The two estimates imply different conclusions about whether loneliness is associated with higher mortality.
“The multivariable, minimally adjusted complete-case analysis showed similar associations between all-cause mortality and social isolation (hazard ratio 1·29, 95% CI 1·14–1·47) and loneliness (0·93, 0·77–1·11).”
“In the complete case analysis, the minimally adjusted hazard ratio for the risk of death from any cause in lonely individuals compared with those who were not lonely was 1·37 (95% CI 1·28–1·46).”
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Kanbay, M., Tanrıöver, C., Çöpür, S., Peltek, İ. B., Mutlu, A., Mallamaci, F., & Zoccali, C. (2023) · European Journal of Clinical Investigation · doi:10.1111/eci.14032 · Cited by 42 · see citing works
Ethnocentrism Effects on Consumers’ Behavior during COVID-19 Pandemic
Migliore, G., Rizzo, G., Schifani, G., Quatrosi, G., Vetri, L., & Testa, R. (2021) · Economies · doi:10.3390/economies9040160 · Cited by 39 · see citing works
Salman, D., Beaney, T. E., Robb, C. E., Loots, C. A. D. J., Giannakopoulou, P., Udeh‐Momoh, C. T., Ahmadi‐Abhari, S., Majeed, A., Middleton, L. T., & McGregor, A. H. (2021) · BMJ Open · doi:10.1136/bmjopen-2021-050680 · Cited by 37 · see citing works
Lara, E., Moreno‐Agostino, D., Martín‐María, N., Miret, M., Rico‐Uribe, L. A., Olaya, B., Cabello, M., Haro, J. M., & Ayuso‐Mateos, J. L. (2020) · Social Science & Medicine · doi:10.1016/j.socscimed.2020.113087 · Cited by 33 · see citing works
The impact of sitting time and physical activity on mental health during COVID-19 lockdown
Pears, M., Kola, S., & Azevedo, L. B. (2021) · Sport Sciences for Health · doi:10.1007/s11332-021-00791-2 · Cited by 38 · see citing works
Characteristics of Social Networks and Mortality Risk: Evidence From 2 Prospective Cohort Studies
Kauppi, M., Kawachi, I. I., Batty, G. D., Oksanen, T., Elovainio, M. J., Pentti, J., Aalto, V., Virtanen, M., Koskenvuo, M. J., Vahtera, J., et al. (2017) · American Journal of Epidemiology · doi:10.1093/aje/kwx301 · Cited by 35 · see citing works
Self-citationVariability in Brain Structure and Function Reflects Lack of Peer Support
Schurz, M., Uddin, L. Q., Kanske, P., Lamm, C., Sallet, J., Bernhardt, B. C., Mars, R. B., & Bzdok, D. (2021) · Cerebral Cortex · doi:10.1093/cercor/bhab109 · Cited by 26 · see citing works
de Lange, A. G., Kaufmann, T., Quintana, D. S., Winterton, A., Andreassen, O. A., Westlye, L. T., & Ebmeier, K. P. (2021) · Behavioural Brain Research · doi:10.1016/j.bbr.2021.113510 · Cited by 36 · see citing works
- Authors
- Elovainio, M., Hakulinen, C., Pulkki-Råback, L., Virtanen, M., Josefsson, K., Jokela, M., Vahtera, J., & Kivimäki, M.
- Affiliations
- University of Helsinki (FI)
- Finnish Institute of Occupational Health (FI)
- Finnish Institute for Health and Welfare (FI)
- University of Turku (FI)
- Corresponding author
- Elovainio, Marko
- ORCID
- Venue
- The Lancet Public Health
- Publisher
- Elsevier BV
- Published
- 2017-06
- Volume
- 2
- Issue
- 6
- Pages
- e260-e266
- ISSN
- 2468-2667 (ISSN-L)
- PMC
- PMC5463031
- OpenAlex
- W2611831262
- Semantic Scholar
- 94f75fba3a76a3153f8bfe3202352047d45762a0
- Cited by
- 411
- References
- 26
- Citations by year
- 2026: 39 · 2025: 52 · 2024: 64 · 2023: 52 · 2022: 42 · 2021: 59 · 2020: 60 · 2019: 18 · 2018: 20 · 2017: 4
- FWCI
- 31.02
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- The Lancet Public Health (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- UTUPub (University of Turku) (submittedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- UCL Discovery (University College London) (submittedVersion)
- Työväentutkimus Vuosikirja (submittedVersion)
- STM:n Hallinnonalan avoin julkaisuarkisto (Julkari) (submittedVersion)
- Funders
- Academy of Finland (265977)
- UK Medical Research Council (K013351)
- Topics
- Social Sciences › Health › Health disparities and outcomes
- Social Sciences › Psychology › Social Psychology › Death Anxiety and Social Exclusion
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Keywords
- social isolation, loneliness, excess mortality, all-cause mortality, risk factors, mediation analysis, socioeconomic deprivation, health behavior, depressive symptoms, body mass index, blood pressure, grip strength, physical activity, alcohol consumption, smoking, cognitive ability, UK Biobank
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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