Advancing social connection as a public health priority in the United States.

Most major U.S. government health agencies, healthcare providers and associations, and public/private healthcare funders do not recognize social relationships as a health determinant or risk marker comparable to other public health priorities.

“Despite these laudable efforts, social relationships remain notably missing from the lists of currently accepted determinants of health for most major U.S. government agencies, healthcare providers and associations, and public/private healthcare funders 1 (e.g., Centers for Disease Control [CDC], Healthy People 2020, American Heart Association), and largely unrecognized or underappreciated by the”

• cites Centers for Disease Control [CDC]Not checked yet

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• cites Healthy People 2020Not checked yet

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• cites American Heart AssociationNot checked yet

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The strength of the association between social connection and health outcomes is comparable to that of many leading health determinants that receive substantial public health resources.

“Despite mounting evidence that the magnitude of these associations is comparable to many leading health determinants (that receive significant public health resources), government agencies, healthcare providers and associations, and public/private healthcare funders are slow to recognize human social relationships as either a health determinant or health risk marker in a manner that is comparable”

• Also stated in: § The Seriousness of the Problem · boosted

  “As shown in Figure 1a, the magnitude of effect of social connection on mortality risk is comparable, and in many cases exceeds, that of other well-accepted risk factors.”

• cites Holt-Lunstad, Smith & Layton, 2010Not checked yet

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The World Health Organization lists social support networks as a determinant of health.

“Most notably, the World Health Organization (WHO) now lists “Social Support Networks” as a determinant of health (WHO, n.d.)”

• cites WHO, n.d.Not checked yet

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Being embedded in high-quality close relationships and feeling socially connected is associated with lower risk of all-cause mortality and multiple disease morbidities.

“A robust body of scientific evidence indicates that being embedded in high-quality close relationships and feeling socially connected to the people in your life is associated with decreased risk for all-cause mortality as well as a range of disease morbidities.”

• Also stated in: § Abstract · boosted

  “Broad-based epidemiological studies provide clear and compelling evidence that social relationship status and functioning predict an array of important health outcomes and risk for premature mortality (House, Landis, & Umberson, 1988; Holt-Lunstad, Smith & Layton, 2010; Sbarra, Law, & Portley, 2011; Robles, Slatcher, Trombello, & McGinn, 2014; Shor & Roelfs, 2015).”

• cites House, Landis, & Umberson, 1988Not checked yet

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• cites Holt-Lunstad, Smith & Layton, 2010Not checked yet

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• cites Sbarra, Law, & Portley, 2011Not checked yet

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Across measurement approaches, being socially connected is associated with a 50% reduced risk of early death.

“Across measurement approaches (structural, functional, multi-dimensional), being socially connected is associated with a 50% reduced risk of early death (Holt-Lunstad, Smith & Layton, 2010), demonstrating that social disconnection is indeed a severe problem.”

• cites Holt-Lunstad, Smith & Layton, 2010Not checked yet

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A public health focus on social relationships has the potential to make the CDC's Winnable Battles more winnable.

“In this way, a public health focus on social relationships has the potential to make the CDC’s winnable battles more winnable.”

Prevalence rates of social connection risk factors are comparable with well-established risk factors.

“Prevalence rates or the proportion of the population affected, are also comparable with well-established risk factors (Figure 1b).”

More than a quarter of the U.S. population, 27%, lives alone.

“For example, more than a quarter of the US population (27%) lives alone”

• cites US Census Bureau, 2012Not checked yet

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Social rejection has damaging effects for psychological and physical well-being through biologically plausible pathways.

“A parallel line of work indicates social rejection has damaging effects for psychological and physical well-being through biologically plausible pathways (Slavich & Irwin, 2014).”

• cites Slavich & Irwin, 2014Not checked yet

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The magnitude of effect of social connection on mortality risk is comparable to, and in many cases exceeds, that of other well-accepted risk factors.

“As shown in Figure 1a, the magnitude of effect of social connection on mortality risk is comparable, and in many cases exceeds, that of other well-accepted risk factors.”

Structural and functional measures of social connection are weakly correlated, sharing 20-30% variance.

“In evaluating these statistics, it is important to note that structural and functional measures are weakly correlated (20–30% shared variance)”

Social connections influence health-relevant behaviors that are already widely recognized for their economic costs to individuals, families, and the broader health care system.

“Importantly, social connections influence a number of health-relevant behaviors that are already widely recognized for their economic costs to the individual, family, and the broader health care system.”

The heritability of loneliness is roughly 40%.

“For example, the heritability of loneliness is roughly 40% (Goossens, van Roekel, Verhagan, et al., 2015)”

• cites Goossens, van Roekel, Verhagan, et al., 2015Not checked yet

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Being more socially connected, as indicated by higher family cohesion, marital status, and living with someone else, is associated with greater adherence to medical recommendations.

“Considering informal social support, being more socially connected (higher family cohesion, martial status, and living with someone else) is associated with greater adherence to medical recommendations (DiMatteo, 2004), which result in better treatment outcomes and lowered medical costs.”

• cites DiMatteo, 2004Not checked yet

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There are multiple psychological pathways toward chronic loneliness, including intimate, relational, and collective loneliness.

“Psychologically, there appear multiple pathways toward chronic loneliness, including intimate, relational, and collective loneliness, each of which attends to a different dimension of one’s social standing (Cacioppo, Grippo, London, et al., 2015).”

• cites Cacioppo, Grippo, London, et al., 2015Not checked yet

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Social connection, including low social integration, loneliness, and relational distress, is multiply determined.

“Social connection (low social integration, loneliness, and relational distress) is multiply determined as well.”

Between 20% and 43% of U.S. adults over age 60 experience frequent or intense loneliness.

“Between 20% and 43% of U.S. adults over age 60 experience frequent or intense loneliness—higher than the prevalence of merely living alone (Perissinotto, Stijacic Cenzer, & Covinsky, 2012).”

• cites Perissinotto, Stijacic Cenzer, & Covinsky, 2012Not checked yet

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Most epidemiological evidence controls for other health determinants, suggesting that social connection contributes to risk independently of those determinants.

“Importantly, although social relationships are closely related to existing health priorities (i.e., close relationships shape important health behaviors), most epidemiological evidence controls for these effects— suggesting that being socially connected contributes to risk independent of these other health determinants.”

Identifying intervention targets to improve health by promoting and improving relationships has proven difficult.

“Identifying intervention targets to improve health via promoting and improving relationships has proven difficult (Cohen & Janicki-Deverts, 2009).”

• cites Cohen & Janicki-Deverts, 2009Not checked yet

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Measures in each domain of social connection independently predict morbidity and mortality.

“Importantly, measures in each of these domains independently predict morbidity and mortality; and, given weak correlations among them, each may influence health through different pathways (Cohen, Underwood, & Gottlieb, 2000).”

• cites Cohen, Underwood, & Gottlieb, 2000Not checked yet

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The presence of a supportive person, or even thinking about supportive others, can attenuate cardiovascular and neuroendocrine responses to stress.

“The general finding is that the presence of a supportive person or even thinking about supportive others can attenuate cardiovascular and neuroendocrine responses to stress.”

• cites Hostinar, Sullivan, & Gunnar, 2014Not checked yet

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Current estimates of the severity of social disconnection are conservative.

“Thus, current estimates of severity are conservative”

According to the Basic Priority Rating System criteria, there is sufficient evidence to prioritize social relationships in public health.

“According to these criteria, there is sufficient evidence to prioritize social relationships in public health.”

• Also stated in: § Prioritization Summary · plain

  “Thus, based on these commonly accepted BPRS core criteria, there is sufficient evidence to support prioritizing social connection in public health.”

An aging population, smaller families, and greater mobility reduce the ability to draw on familial informal support in old age.

“Taken together with an aging population, smaller families and greater mobility reduces the ability to draw upon familial sources of informal support in old age (Lafreniere et al, 2003; Rook, 2009).”

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• cites Rook, 2009Not checked yet

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The data are clear that social relationships have a large-scale impact on health.

“As reviewed above, the data are quite clear that social relationships have a “large-scale impact on health.””

Taken together, demographic trends suggest that Americans are becoming less socially connected.

“Taken together, these trends suggest that Americans are becoming less socially connected.”

Extant data indicate that social disconnection is highly prevalent.

“At this juncture, the extant data indicates that social disconnection is highly prevalent”

When considering whether social connections have known effective strategies to address them, the data are mixed and less compelling, largely because attention remains relatively limited.

“However, when considering whether social connections have “known effective strategies to address them” the data is mixed and less compelling, largely because attention remains relatively limited.”

Among married couples, three in ten relationships are severely discordant.

“Among married couples, 3 in 10 relationships are severely discordant (Whisman, Beach, & Snyder, 2008).”

• cites Whisman, Beach, & Snyder, 2008Not checked yet

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A growing literature indicates that a portion of the risk factors for social disconnection are modifiable and can be targeted for effective intervention.

“a growing literature indicates that this is indeed the case.”

Across measurement approaches, gender, age, and country of origin, less socially connected people are at greater risk for earlier mortality.

“Consistent across measurement approaches, gender, age, country of origin, those who are less socially connected are at greater risk for earlier mortality.”

Social disconnection is a severe problem.

“demonstrating that social disconnection is indeed a severe problem”

Total health care costs were significantly lower among breast cancer patients randomized to psychosocial support plus standard care compared with those who received standard care alone.

“For example, in addition to improving quality of life, total health care costs were significantly lower among breast cancer patients randomized to psychosocial support in addition to standard care compared to those who only received standard care (Arving, Brandberg, Feldman, Johansson, & Glimelius, 2014; Gillespie, O’Shea, Paul, O’Dowd, & Smith, 2012).”

• cites Arving, Brandberg, Feldman, Johansson, & Glimelius, 2014Not checked yet

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• cites Gillespie, O’Shea, Paul, O’Dowd, & Smith, 2012Not checked yet

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Clear experimental evidence, particularly in animal models, shows that social connections are causally associated with health-relevant biological pathways from gene expression to neural functioning.

“Clear experimental evidence, particularly in animal models, shows that social connections are causally associated with health-relevant biological pathways at multiple levels from gene expression to neural functioning (Cacioppo et al., 2015).”

• cites Cacioppo et al., 2015Not checked yet

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The magnitude of risk from social disconnection is comparable to currently recognized leading health determinants.

“and the magnitude of this risk is comparable currently recognized leading health determinants.”

A more recent meta-analysis involving over 8,000 patients with chronic illness reported moderate effect sizes for patients' physical and mental health.

“A similar, yet more recent meta-analysis involving over 8,000 patients with chronic illness reported moderate effect sizes for both patients’ physical and mental health (Hartmann, Bäzner, Wild, Eisler, & Herzog, 2010).”

• cites Hartmann, Bäzner, Wild, Eisler, & Herzog, 2010Not checked yet

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Measurement approaches that consider multiple aspects of relationships are the strongest predictors of mortality risk.

“Of note, measurement approaches that consider multiple aspects of relationships are the strongest predictors of mortality risk.”

Most causal chains in public health, especially around social determinants of health, are complex.

“Most causal chains in public health— especially around social determinants of health—are complex (Victoria, Habicht, & Bryce, 2004).”

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Recent efforts to identify psychosocial vital signs for inclusion in electronic health records provide a template for selecting social connection measures.

“Recent efforts to identify psychosocial “vital signs” for inclusion in electronic health records (EHRs; Institute of Medicine, 2014; Matthews, Adler, Forrest, & Stead, 2016) provide a template for selecting social connection measures.”

• cites Institute of Medicine, 2014Not checked yet

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• cites Matthews, Adler, Forrest, & Stead, 2016Not checked yet

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The U.S. health system relies largely on tertiary prevention.

“The US health system relies largely on tertiary prevention—i.e., interventions that reduce the worsening of existing morbidities, such as the ENRICHD trial.”

Large-scale intervention efforts that focus on a single level of analysis are likely to be hampered from the start.

“From this perspective, large-scale intervention efforts that focus on a single level of analysis are likely to be hampered from the start.”

Theoretically-informed prevention programs that target social relationships directly can have considerable promise for promoting public health.

“a key lesson of the NFP is that theoretically-informed prevention programs that target social relationships directly can have considerable promise for promoting public health.”

Research on prevention of childhood obesity via school-based interventions suggests that multi-faceted interventions lasting 1-4 years and involving parents can yield meaningful differences in children's body mass.

“Research on the prevention of childhood obesity via school-based interventions (promoting physical activity and improved diet) suggests that multi-faceted interventions lasting 1–4 years and involve parents can yield meaningful differences in children’s body mass (Sobol-Goldberg, Rabinowitz, & Gross, 2013).”

• cites Sobol-Goldberg, Rabinowitz, & Gross, 2013Not checked yet

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Disappointing results from large intervention trials, including ENRICHD and the federal Healthy Marriages Initiative, are a hurdle for funding relationship science.

“Another hurdle is disappointing results from large intervention trials, including ENRICHD and the federal Healthy Marriages Initiative (large effectiveness trials of relationship education, reviewed in Johnson, 2012).”

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Efforts to formulate physical activity recommendations, primarily informed by prospective observational studies, faced and overcame challenges similar to those that social connection recommendations would face.

“Efforts to formulate recommendations for physical activity, which were primarily informed by prospective observational studies (whereas controlled intervention studies informed activity types and dose), faced and overcame similar challenges.”

• cites Blair et al., 2004Not checked yet

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• cites Haskell et al., 2007Not checked yet

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The Nurse-Family Partnership program is widely recognized to influence several important maternal and child outcomes, including reductions in child abuse and neglect.

“is widely recognized to influence several important maternal and child outcomes, including reductions in child abuse and neglect (Coalition for Evidence-Based Policy, 2014).”

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In early intervention and prevention, who is targeted may be as important as what is targeted, as suggested by the NFP and Abecedarian Project targeting at-risk groups.

“the NFP and Abecedarian Project targeted at-risk groups suggesting that who is targeted may be as important as what is targeted.”

Translating observational findings into interventions that reliably prevent or lessen risk is notoriously challenging in public health.

“Translating observational findings into interventions that can reliably prevent or lessen the risk is notoriously challenging in public health.”

Effect sizes for school-based childhood obesity interventions are generally small, with a standardized mean difference in BMI of −.076 across more than 50,000 children.

“Although effect sizes are generally small (e.g., a standardized mean difference in BMI = −.076 for intervention relative to control group across > 50,000 children)”

• cites Sobol-Goldberg, Rabinowitz, & Gross, 2013Not checked yet

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Major public health campaigns are designed around increasing physical activity in schools.

“major public health campaigns are designed around increasing physical activity in schools (see: www.letsmove.gov/schools).”

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Current evidence on relationship interventions is primarily restricted to individual, dyadic, and group levels, with societal-level interventions almost non-existent.

“however, current evidence is primarily restricted to individual, dyadic and group levels, with societal level interventions almost non-existent.”

The evidence supporting the contention that social connection is crucial to human development, health, and survival is unequivocal.

“The evidence (summarized in Figure 1 and 2A) supporting this contention is unequivocal.”

Targeting early social relationships while bolstering the social support mothers receive from family and friends can have durable effects on both maternal and child health outcomes.

“the NFP suggests that targeting early social relationships (e.g., promoting parent-child bonding consistent with Attachment Theory) while bolstering the social support mothers receive from family and friends can have durable effects on both maternal and child health outcomes.”

Implementing successful physical activity interventions, especially with children and adolescents, has proven exceptionally difficult.

“yet, implementing successful physical activity interventions, especially with children and adolescents, has proven exceptionally difficult (Metcalf, Henley, & Wilkin, 2012).”

• cites Metcalf, Henley, & Wilkin, 2012Not checked yet

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Interventions that target one component of social connection may not be effective in reducing risk across other components.

“Further, interventions that target one component of social connection (e.g., social isolation) may not be effective in reducing risk across components (e.g., perceived loneliness or relationship quality).”

The ENRICHD trial was based largely on a top-down logic of building an intervention around correlational findings without first demonstrating that strengthening social network ties was causally tied to clinical markers in experimental studies.

“In retrospect, the ENRICHD trial was based largely on a top-down logic of building an intervention around correlational findings without first demonstrating that strengthening social network ties was causally tied to the clinical markers of interest in experimental studies.”

The pooled effect for family member interventions relative to treatment as usual reflects a 72-84% chance of improved mental or physical health.

“The pooled effect for family member interventions relative to treatment as usual reflect a 72–84% chance of improved mental or physical health compared to treatment as usual.”

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Efforts aimed at smoking and obesity treatment and prevention have been far more successful at a societal level than at an individual level.

“This is important to note, given that efforts aimed at smoking and obesity treatment and prevention have been far more successful at a societal level than individual level approaches (e.g., Lemmens, Oenema, Knut, & Brug, 2008).”

• cites Lemmens, Oenema, Knut, & Brug, 2008Not checked yet

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A European Society of Cardiology task force reviewed evidence for all purported CVD risk factors and recommended that psychosocial risk factors, including social isolation, should be assessed as a risk factor for future CVD.

“a European Society of Cardiology task force reviewed the evidence for all purported CVD risk factors and recommended that psychosocial risk factors, including social isolation, should be assessed as a risk factor for future CVD (Authors/Task Force Members, Piepoli, Hoes, et al., 2016).”

• cites Authors/Task Force Members, Piepoli, Hoes, et al., 2016Not checked yet

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The Carolina Abecedarian Project indicates that improving cognitive and social stimulation in early life and early school intervention reduces the likelihood of cardiovascular and metabolic diseases in the mid-30s.

“For example, the Carolina Abecedarian Project indicates that improving cognitive and social stimulation in early life (birth to age 5), and early intervention in school, reduces the likelihood of cardiovascular and metabolic diseases in the mid-30s (Campbell, Conti, Heckman, et al., 2014).”

• cites Campbell, Conti, Heckman, et al., 2014Not checked yet

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Experimental research from animal studies to human RCTs demonstrates that several dimensions of social relationships can be targeted and altered.

“Overall, the experimental research—from animal studies to human RCTs—is clear in demonstrating that several dimensions of social relationships can be targeted and altered”

Brief scales assessing social connection-related constructs suitable for epidemiological studies are now available.

“brief scales assessing social connection-related constructs that are suitable for epidemiological studies are now available (Cyranowski et al., 2013; Hahn et al., 2010).”

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• cites Hahn et al., 2010Not checked yet

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The Berkman-Syme Social Network Index received the same highest ratings on readiness and priority for EHR inclusion and usefulness for clinical, research, and population monitoring purposes as race/ethnicity, education, physical activity, tobacco use, and neighborhood characteristic measures.

“The measure received the same highest ratings on readiness and priority for inclusion in EHRs and usefulness for clinical, research, and population monitoring purposes as race/ethnicity, education, physical activity, tobacco use, and neighborhood characteristic measures.”

• cites Pantell et al., 2013Not checked yet

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