Cited by 424Health disparities and outcomesDeath Anxiety and Social ExclusionCardiac Health and Mental Health

The DOI matches its Crossref record; 25 of the 26 references it cites were found in a registry or an index; 1 of the 6 sources its claims cite were checked for support.

Contribution of risk factors to excess mortality in isolated and lonely individuals: an analysis of data from the UK Biobank cohort study

Open access
Elovainio, Marko, Hakulinen, Christian, Pulkki-Råback, Laura, Virtanen, Marianna, Josefsson, Kim, Jokela, Markus, Vahtera, Jussi, Kivimäki, Mika·2017·The Lancet Public Health

Abstract

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.

Overview

AI snapshot

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.

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Integrity signals

Registry

Crossref · 10.1016/s2468-2667(17)30075-0

Cites

25 of 25 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Figures

Figure 1 Proportions of the social isolation–mortality association attributable to biological, behavioural, and psychological factors HR=hazard ratio. PERM=percentage of excess risk mediated. SHR=sub-hazard ratio. *Adjusted for age, sex, ethnic origin, and chronic disease.
Figure 1 Proportions of the social isolation–mortality association attributable to biological, behavioural, and psychological factors HR=hazard ratio. PERM=percentage of excess risk mediated. SHR=sub-hazard ratio. *Adjusted for age, sex, ethnic origin, and chronic disease.CC BY · PubMed Central
Figure 2 Proportions of the loneliness–mortality association attributable to biological, behavioural, and psychological factors HR=hazard ratio. PERM=percentage of excess risk mediated. SHR=sub-hazard ratio. *Adjusted for age, sex, ethnic origin, and chronic disease.
Figure 2 Proportions of the loneliness–mortality association attributable to biological, behavioural, and psychological factors HR=hazard ratio. PERM=percentage of excess risk mediated. SHR=sub-hazard ratio. *Adjusted for age, sex, ethnic origin, and chronic disease.CC BY · PubMed Central

Verification

Claims the paper makes

31 Own result · 8 Own method · 5 Not checked yet · 5 Own interpretation · 1 Supported

Verify all 5 references — free account

Show all 35 claims

  • It may state two separate claims as one. 8
  • Probably not a substantial claim. 9
15 of 15
  • 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.”
4 of 4

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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.

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Metadata

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
Venue
The Lancet Public Health
Publisher
Elsevier BV
Published
2017-06
Volume
2
Issue
6
Pages
e260-e266
ISSN
2468-2667 (ISSN-L)
OpenAlex
W2611831262
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
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

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