Association of Loneliness and Risk Factor Control and CVD in Diabetes
- Among the social determinants of loneliness and social isolation, which have been implicated in risk of CVD, in diabetes, only loneliness was associated with a higher risk.
- Loneliness ranked lower in relative strength for predicting CVD than LDL-C, BMI, and urinary albumin/creatinine ratio, similar to eGFR, HbA1c, and systolic BP levels, but higher than depression score and lifestyle risk factors such as smoking, physical activity, and diet.
- The risk attributable to loneliness was found in CHD but not strokes.
What is the relative degree of association of loneliness and social isolation scales with cardiovascular disease (CVD) risk in diabetes and the relative importance of loneliness and social isolation with traditional risk factors?
The authors used the UK Biobank Study with >500,000 participants and limited the study to 18,509 diabetics at baseline after excluding 6,219 with prevalent coronary heart disease (CHD), stroke, or heart failure and 2,135 participants with missing data on loneliness or isolation. Analyses of covariance (generalized linear models) and chi-square were used for comparison of continuous and categorical variables, respectively, between diabetes patients by loneliness and isolation status. Cox proportional hazards models were used to evaluate the association between the loneliness or isolation scale and the risk of CVD separately, and follow-up years were used as the underlying time metric. To estimate how important loneliness or isolation is in predicting CVD, they analyzed the relative importance of loneliness or isolation and other traditional risk factors by calculating the R2 values of the Cox models.
During a mean follow-up of 10.7 years, 3,247 total CVD incidents were documented, including 2,771 CHD and 701 strokes. About 40% had a degree of loneliness and 55% social isolation. In the fully adjusted model, compared with participants with the lowest loneliness score (zero), hazard ratios (95% confidence interval) for CVD were 1.11 (1.02 and 1.20) and 1.26 (1.11 and 1.42) for participants with a loneliness scale of 1 and 2, respectively (p-trend < 0.001). No significant associations were observed for social isolation. Patients with a higher loneliness or isolation scale tended to have higher body mass index (BMI), glycated hemoglobin (HbA1c), depression score, and a lower degree of risk factor control and were more likely to use insulin and to have diabetes complications. Loneliness ranked higher in relative strength for predicting CVD than the lifestyle risk factors (diet, physical activity, alcohol, and smoking) in diabetics. A significant additive interaction between loneliness and the degree of risk factor control on the risk of CVD was observed (p for additive interaction = 0.005).
Among diabetes patients, loneliness, but not social isolation scale, is associated with a higher risk of CVD and shows an additive interaction with the degree of risk factor control.
The American Heart Association recently recommended attention to the social determinants of health (SDOH) in addition to traditional risk factors in assessing risk of CVD in diabetes. Loneliness and social isolation are two important components of SDOH that reflect different aspects of social contact. Loneliness usually refers to the emotional feelings related to the quality of social relations, while isolation refers to the quantity of social relations by contact, each of which has been significantly related to higher risk of CVD. This study was able to clarify that there is a clear difference between the two components of social relations when assessing implications for CVD risk in diabetes, and that loneliness adds to rather than simply being the explanation for poor control of traditional risk factors.
Keywords: Body Mass Index, Cardiovascular Diseases, Coronary Disease, Depression, Diabetes Mellitus, Heart Failure, Glycated Hemoglobin A, Insulin, Life Style, Loneliness, Primary Prevention, Risk Factors, Social Isolation, Stroke
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