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Only the lonely

MagazineJanuary 2011 (Vol. 21 Issue 10)Only the lonely

It all started with a chance remark over a couple of beers

It all started with a chance remark over a couple of beers. A local physician was drinking with the head of medicine at the University of Oklahoma, and he happened to mention that heart disease seemed to be much less frequent in Roseto, a small town in Pennsylvania close to his surgery, than in neighbouring Bangor.

Roseto's community of 1600 people was almost entirely made up of transplanted Italians-they even named their small town after the town they left behind in Italy-while the 5000 people in Bangor were an ethnic mix.

The two doctors were sure that nationality and ethnic origins had little to do with heart disease, but they were otherwise unable to explain the extraordinary longevity and health rates being noted by the local doctor in Roseto.

The name of the physician has since been lost, but the head of medicine was Stewart Wolf, whose name became synonymous with the 'Roseto effect', as it would come to be known.

Wolf started his research in 1966, when deaths from heart attack and heart disease in Roseto were close to zero among men aged between 55 and 64 years-a 10-year period during which cardiac mortality was high among the rest of the nation's population. Older men in Roseto also fared better than their national counterparts, with a death rate of just half that of the rest of the country.

There were two other statistics peculiar to Roseto that caught Wolf's eye: the crime rate was non-existent; and applications for public assistance were also zero.
So, Italians, a lack of crime and no one living off benefits-what did all this have to do with heart disease and longevity?

Wolf decided to team up with sociologist John Bruhn at Northern Arizona University, who helped him to dig a little deeper. Their initial discoveries appeared only to add to the mystery, and flew in the face of government guidelines concerning heart health.

Virtually all the men in the town faced daily hazards as workers in slate quarries that were 200 feet deep, and their diets were appalling. Far from eating the so-called Mediterranean diet, like their friends back in Italy, these transplanted Italians were eating sausage and meatballs cooked in lard-in other words, heart-attack food. Not surprisingly, their cholesterol scores were on the high side, with many of the older men recording levels up to 200 mg/dL, and most of them were smokers.

The way they lived was also un-American. Three generations of a family lived under the one roof, with the elderly being the most venerated members of the family. Rosetons also appeared to do everything together-evening walks, social clubs and church festivals. In fact, their level of conformity was extraordinary. All displays of wealth-whether through clothing, housing or cars-were strictly taboo, although this was probably little to do with choice, as most everyone in the town was as poor as all the others.

The end of the Roseto effect

And this, Wolf and Bruhn realized, wasn't a problem; in fact, it was the reason the Rosetons enjoyed such good health and longevity. This theory was confirmed when they looked at the health data. Their research covered a wide sweep of years-they analyzed death certificates in both Roseto and Bangor from 1935 to 1985-and they discovered that rates of heart attack and longevity began to 'normalize' in Roseto from 1965 onwards, when the town started to become more prosperous, and its citizens moved from the town centre out into the newly built suburbs. By 1985, there were no differences in longevity and heart attack rates between the two towns (Am J Public Health, 1992; 82: 1089-92).

In a book that Wolf and Bruhn subsequently co-authored, they wrote: "People are nourished by other people." In essence, Roseto was a demonstration of the old homily that a problem shared is a problem halved. People supported each other, and there was always someone to turn to. As a con-sequence, no one felt completely isolated, despairing or stressed. A sense of community and sharing was even more important in determining health than were lifestyle choices, and could even counteract the effects of cigarette-smoking, high cholesterol levels and an unhealthy diet-all factors that would normally contribute to heart disease (Wolf S, Bruhn J.G. The Power of Clan. The Influence of Human Relationships on Heart Disease. New Brunswick, NJ: Transaction Publishers, 1993).

Roseto isn't unique. Many other studies have noted the importance of community in helping people to live a long and healthy life, and the phenomenon has been witnessed in groups as diverse as the Amish and social clubs. One study of 230 church-goers noted that they were almost never depressed, even when their income was low or when they faced difficult life challenges (Health Soc Work, 2008; 33: 9-21).

It appears that collective or communal cultures and societies give their members a tacit or explicit expectation of social support. "Such support seems to buffer vulnerable individuals from the environmental risks or stress-ors that serve as triggers to dep-ressive episodes," said researchers from Northwestern University in Evanston, IL (Proc R Soc B, 2010; 277: 529-37).

Being lonely, being ill

If community and a sense of belonging is a safeguard against mental and physical disease, then premature death, its opposite-the feeling of social isolation-must be damaging to our health. Indeed, countless studies have demon-strated that this is so.

Two studies, which were being prepared at around the same time as the Roseto research, have demonstrated what happens to people who feel isolated. These studies-carried out in San Francisco, CA, and in Eastern Finland, and involving some 20,000 people-revealed that those who felt lonely, and were lacking in social relationships and support, were up to three times more likely to die of heart disease and other causes than those who felt connected to others.

As the Roseto researchers discovered, having a social connection, or not, was a more powerful agent of wellness and disease than the usual risk factors of high cholesterol, hypertension, smoking or a family history of heart disease (Am J Epidemiol, 1979; 109: 186-204; Am J Epidemiol, 1988; 128: 370-80).
In fact, living alone or feeling isolated is equivalent to smoking 15 cigarettes a day or being an alcoholic, and it's twice as harmful as being obese. Researchers at Brigham Young University in Utah arrived at these conclusions after analyzing 148 studies that measured the relationship between frequency of human interaction and overall health over a seven-year period.

Conversely, having social connections and ties with friends, family, neighbours and the wider community had a protective effect, and improved the chances of survival by 50 per cent.

What's more, the researchers believe that the protective effect could well be even greater, but they had taken a conservative view of the data. By the same token, the harmful effects of isolation could also be more dramatic.

"Physicians, health professionals, educators and the media take risk factors such as smoking, diet and exercise seriously. The data presented here make a compelling case for social relationship factors to be added to that list," said lead researcher Timothy Smith (PLoS Med, 2010; 7: e1000316).
Other studies have revealed a number of other findings.

o Isolation contributed to more illnesses and early death among people who lived alone in Munich suburbs, according to an analysis of 100 case studies (Gesundheitswesen, 2010; February 19, e-published ahead of publication).

o Social isolation is "clinically relevant" and a significant, albeit often overlooked, cause of disease, say researchers from the University of Exeter, who studied the health profiles of 393 older people who were living alone on their own (Qual Life Res, 2010; July 25, DOI: 10.1007/s11136-010-9717-2).

o Cancer is more likely to progress if you live alone. Breast cancer growth appears to accelerate more quickly among those who are socially isolated, say researchers at the University of Chicago. (However, these were animal studies, so they may not necessarily apply to humans.) They also warn that isolation doesn't have a negative effect only on breast cancer-it could also have profound effects on a range of chronic diseases, such as obesity, type 2 diabetes and hypertension, or raised blood pressure (Cancer Prev Res, 2009; 2: 850-61).

o People with three or fewer people in their social-support network are nearly three times more likely to die of heart disease compared with those who have larger social networks. They are also twice as likely to die of any other disease. As the Roseto studies found, isolation had a greater impact on health than the usual hazards, such as smoking, say researchers at the Duke University Medical Center in North Carolina, after analyz-ing the social profiles of 430 patients with coronary artery disease (CAD) (Psychosom Med, 2001; 63: 267-72).

o Loneliness has a cumulative effect over time, and the blood pressure of isolated individuals increased over a four-year period, researchers at the University of Chicago found. They also discovered a direct correlation between blood pressure and periods of loneli-ness and, in particular, a sense of being alone (Psychol Aging, 2010; 25: 132-41).

o In a study of 13,812 older retired adults, 16.9 per cent reported that they were lonely-and they were also the ones more likely to suffer from chronic diseases and depression, according to a West Virginia University School of Nursing study (Res Gerontol Nurs, 2010; 3: 113-25).

o Being socially isolated-and feeling alone-doubles the risk of death from circulatory disease, such as ischaemic heart disease, say researchers from the University of British Colum-bia in Vancouver. Also, the risk disappeared in those who never felt alone, irrespective of whether they actually lived in isolation or not (Soc Sci Med, 2010; 71: 181-6).

o A perceived lack of social support, a subjective factor reported by patients, appears to make ovarian cancer worse by escalating the growth and progression of the disease. In a study of 68 ovarian-cancer patients, those who reported feeling alone had "significantly higher" rates of tumour growth (Brain Behav Immun, 2010; doi:10.1016/ j.bbi.2010.10.012).

o Social isolation appears to have a greater impact on men than on women, according to a study that measured levels of leptin in the blood, a predictor of cardiovascular disease. In the 643 men and 586 women being studied, social isolation apparently raised leptin levels in men, but not in women, said researchers from Munich University in Germany (Psychoneuroendocrinology, 2010 August 5; e-pub ahead of print).

The mind-body connection

It is indisputable that social isolation is a major cause of chronic disease and, especially, heart problems and cancer. What is less clear is how it happens-through what biological mechanism does loneliness trigger disease.
For cognitive disorders such as Alzheimer's disease, the association may be easier to grasp. One study, for example, observed that older people who feel isolated and lonely are twice as likely to develop the disorder as those who maintain a social network.

As the researchers concluded, "It may be that loneliness may affect systems in the brain dealing with cognition and memory, making lonely people more vulnerable to the effects of age-related decline in neural pathways" (Arch Gen Psychiatry, 2007; 64: 234-40).

Researchers at the Harvard School of Public Health have also researched the phenomenon and believe that isolation causes inflammatory problems, possibly due to a poorly functioning immune system. Virtually all of the lonely men they tested had raised levels of C-reactive protein (CRP), inter-leukin-6 and fibrinogen, all of which are markers of inflammation.

But when they looked closer at the lifestyles of these lonely men, it was revealed that they were either smokers, drank too much alcohol, took little or no exercise, or were simply obese. In other words, being alone appeared to be influencing their behaviour which, in turn, was having an impact on their health (American Heart Association Scientific Sessions, 2003; abstr 378).

However, it isn't always that simple, say researchers at the University of Chicago.
People who feel lonely don't always adopt poor lifestyles and, yet, they still become sick. It may be that lonely people are simply generating more stress hormones, say researchers, which encourage tumour growth especially in cases of breast cancer. As Dr Caryn Lerman, a deputy editor of the journal Cancer Prevention Research, in which the study was published, commented: "This study uses an elegant preclinical model and shows that social isolation alters expression of genes important in mammary gland tumour growth" (Cancer Prev Res [Phila], 2009; 2: 850-61).
Professor Thea Tisty, of the University of California at San Francisco, says that the study also adds to the growing evidence that there's a causal association between isolation and chemicals in the blood, such as stress hormones, that could be turning genes on and off within cells. As a result, the cells may then become cancerous (BBC News, 29 September 2009;http://news.bbc.co.uk/2/hi/health/8279425.stm).

How lonely is lonely?

Feeling lonely is an entirely subjective experience. Individuals can have a wide circle of friends and still feel lonely, or have just one or two friends and feel part
of a community. Marriage is the single most important relationship most of us have, and the sense of closeness we feel with our partner can determine our sense of isolation or connection.

Two studies make the point. The first study, of 255 people with rheumatoid arthritis, discovered that those who were happily married felt less pain from their condition. Those who had an "unstressed" marriage reported lower pain levels than did those who were either unmarried or "distressed married" participants, researchers at Johns Hopkins School of Medicine in Baltimore, MD, found (J Pain, 2010; 11: 958-64).

On the other hand, we may feel so isolated when our partner dies that it kills us, a phenomenon known as the 'widowhood effect'. Researchers at St Andrew's University in Scotland tracked 58,685 men and 58,415 women who were married in 1991. Over the following 15 years, 5013 men and 9646 women became widowed and, of these, 40 per cent of widowers and 26 per cent of widows died within three years of losing their partner.

Although the deaths were put down to various causes, the researchers found that the widow-hood effect-and the sudden realization of being alone-was the common factor in those who had died (Epidemiology, 3 November 2010; doi: 10.1097/EDE.0b013e3181fdcc0b). Although the surviving partner may have had a wide and supportive network, the loss of 'the significant other' was paramount.
Indeed, another study suggests that the significant factor isn't the social network per se, but the support it offers. Even a supportive network of just one or two people could be sufficient to make someone feel connected and part of a community, say researchers at the University of Michigan in Ann Arbor (Psychosom Med, 2001; 63: 273-4).

One study of Pakistani women living in East Lancashire in the UK emphasizes the point. Isolation for them was a feeling of being "stuck" and feeling a "loss of a sense of control in depression". Their isolation, as they told researchers from the University of Manchester, was partly due to social and cultural factors, but it was also, in some cases, self-imposed (J Affect Disord, 2011; 128: 49-55).
Although the depth of connection is also vital, the extent of the social network appears to be enough to ward off the more common ailments. One study found that those who had the widest social networks also had the greatest resistance to the common cold. In a study of 276 volunteers aged 18-55 years, those who had the fewest social contacts were four times more likely to develop a cold than those with the widest spread of social ties. However, having social ties may also be an indication of a more positive and optimistic outlook, which would also determine how likely we are to suffer from the usual aches and pains (JAMA, 1997; 277: 1940-4).

Being lonely is often associated with being old, especially after a partner dies and the survivor is incapacitated. However, a feeling of isolation cuts across all population groups and ages. The Brigham Young University researchers, who concluded that social isolation was equivalent to smoking 15 cigarettes a day, also discovered that the phenomenon could be seen across all age groups. "This effect is not isolated to older adults. Relationships provide a level of protection across all ages," said lead researcher Timothy Smith (PLoS Med, 2010; 7: e1000316).

Even children aren't immune. Children as young as five who feel isolated and alone are far more likely to suffer from heart disease as an adult. When researchers at the University of Wisconsin studied 1037 children and followed their progress into adulthood, they found that, by the age of 26, those who had been socially isolated as children were far more likely to have cardiovascular disease, or to be candidates for it, with raised blood pressure, higher cholesterol and/or obesity (Arch Pediatr Adolesc Med, 2006; 160: 805-11).

In this Age of the Internet, the web can both isolate people and bring them together. In one study of 1319 respondents, 18 (1.2 per cent) were described as "Internet addicts"-and all of these 'addicts' were moderately or severely depressed, said researchers from Leeds University. Most were young men who also visited porn, gaming or community sites (Psychopathology, 2010; 43: 334).

However, the Internet doesn't always keep us isolated. It can also bring people together, as happened with a group of women who suffered peripartum cardiomyo-pathy, a rare and devastating heart condition that can arise towards the end of pregnancy or soon after giving birth. In a small study of 12 women diagnosed with the condition, an online support group was a vital resource for the sharing of information and the telling of the stories of other fellow suffer-ers, thereby providing hope. As one woman said to the investigators from Research for Health in Ohio, "I am not alone" (Comput Inform Nurs, 2010; 28: 215-21).

Human being belonging

We need contact with others if we are to stay well, and live a long and healthy life. A sense of community is one of the most important factors in determining wellbeing, and a lack of it has as big an impact on our health as cigarette-smoking, alcoholism and obesity, as studies have proven.

Yet, having a community isn't just a casual thing. We need to feel that we have someone to turn to in times of trouble, or that we are all working towards the same goal, as the residents of Roseto used to feel. This feeling is what provides the sense of connectedness and belonging that promotes health and longevity.
Sadly, the research is way ahead of medical practice and social care, and no one 'on the ground' is currently taking into account the importance of feelings of isolation and loneliness as a major cause of chronic disorders.
Until they do, many of us will continue to die of a lonely heart.

Bryan Hubbard

Believe in something

Many things can bring about feelings of isolation and loneliness. It may be the result of the death of a partner or loved one, or chronic depression, or just because of a generally pessimistic view of the world and of mankind. Ultimately, it adds up to a profound feeling of discon-nectedness and hopelessness-the sense that we are utterly alone.

Not surprisingly, having a religious or philosophical belief that we are all connected can have a beneficial effect on our health and wellbeing, whether or not we have a strong social network.

Indeed, those who have strong religious beliefs are better able to cope following a stroke, as one study of 132 stroke patients discovered. Patients who had religious or spiritual beliefs had less anxiety and depression than those who were agnostic or atheist (Stroke, 2007; 38: 993-7).

Religious beliefs helped to prevent Croatian war veterans from committing suicide. Those who had strong religious convictions also had less chronic post-traumatic stress than those who had no faith (J Nerv Ment Dis, 2008; 196: 79-83).
In addition, it may be enough just to have these beliefs privately, without belonging to a wider community of fellow believers, such as a church congregation. One study discovered that people with religious or spiritual beliefs who did not belong to any organized religion enjoyed better mental equilibrium than people who had no such beliefs at all (Altern Ther Health Med, 2006; 12: 26-35).

Furthermore, non-religious, spiritual beliefs that made people feel connected to something greater also included forgiveness and empathy. In a study of 99 volunteers, those who had learned how to forgive and empathize with others demonstrated dramatically lower levels of depression and stress after a year compared with a control group (Explore, 2006; 2: 498-508).

Getting connected

There are many techniques and lifestyle choices that can help us to overcome a sense of loneliness and its worst effects. Here are just a few.

o Meditation. This practice can help us to feel connected and reduce levels of stress. Several techniques have been tested, all with highly positive results. Mindfulness meditation helped with life depression in a group of 91 women suffering from fibromyalgia (Arthritis Rheum, 2007; 57: 77-85), while Transcendental Meditation (TM) could even save your life. According to a study of 202 participants, TM reduced the early-stage symptoms of hypertension (raised blood pressure), reduced the risk of a fatal heart problem by 30 per cent and lowered the risk of cancer by 49 per cent (Am J Cardiol, 2005; 95: 1060-4). Kundalini yoga meditation can help to improve mood, lower stress levels and reduce the worst symptoms of obsessive- compulsive disorder, according to a small study of 12 meditators (CNS Spectr, 1999; 4: 34-47). Guided imagery is another meditative technique that can reduce stress, although researchers believe that it's more effective in people who regularly practise the technique (BMC Complement Altern Med, 2005; 5: 21).

o Touch therapy. Touch is an obvious, and palpable, way to feel connected. It's been found that adults who were hugged a great deal by their parents when they were children are better able to cope (Science, 1997; 277: 1859-61). Touch appears to have the same beneficial effects as having a positive outlook, and a general sense of warmth and empathy. In each case, the body releases oxytocins-nonapeptides that reduce stress levels and lower blood pressure (Z Psychosom Med Psychother, 2005; 51: 57-80). Of the touch therapies, massage therapy was more effective than relaxation therapy, and helped to reduce anxiety and depression, while increasing vitality and general health (Complement Ther Med, 2007; 15: 157-63).

o Exercise. Various sorts of exercise regimes can help you to feel more connected, and reduce levels of depression and anxiety. Strenuous exercise on a gym bike helps people feel more relaxed afterwards (Clin J Sport Med, 2006; 16: 341-7), while Tai Chi, a form of controlled-movement exercise, improves general health and psychological wellbeing (Med Sci Monit, 2007; 13: CR488-97). However, the 'king' of exercises is yoga, which has also been studied more than any other type of physical activity. It
can lift depression (J Altern Complement Med, 2007; 13: 419-26), reduce anxiety (Indian J Physiol Pharmacol, 2006; 50: 41-7) and even help cancer patients who are depressed after having to endure bouts of chemotherapy (Integr Cancer Ther, 2007; 6: 242-50).

The glass half full

It's a moot point: Does loneliness make us pessimistic and 'down', or is a pessimistic outlook the cause of our loneliness?

An optimist-someone who generally thinks the best of other people and situations-is more outward-going, and will tend to seek out others for help, social contact and friendship. This, in turn, has a direct impact on his health and longevity. One study of 800 people discovered that having a positive outlook added 15 years to longevity, whereas a negative outlook-where people blame themselves for bad outcomes, believe that such events will continue indefinitely and allow these events to affect many aspects of their lives-increased the risk of death by 19 per cent (Mayo Clin Proc, 2000; 75: 140-3).

It's been found that pessimists suffer from more illnesses than do optimists, and have generally poorer health (Cognit Ther Res, 1988; 12: 119-32), whereas optimists enjoy better health both mentally and physically (Mayo Clin Proc, 2002; 77: 748-53).

And having optimism is something we can work on, says psychologist Martin Seligman. Our negative thoughts are often knee-jerk, unconscious, responses to problems or setbacks. Nevertheless, we can work on them by keeping a journal of any negative thoughts we have, and by giving ourselves credit when something good happens to us and not beating ourselves up when bad things happen (Dossey L. The Extraordinary Healing Powers of Ordinary Things. New York: Harmony Books, 2006).

VOL. 21 NO. 10


Beating the change

In vino veritas

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