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Loneliness is an unpleasant emotional state induced by perceived isolation. Until about 200 years ago, the English word for being on one’s own was ‘oneliness’, a term that connoted solitude, and was generally considered an essential and positive experience in life. However, solitude and loneliness are not synonymous. Loneliness is also described as ‘social pain’ from an unwanted lack of connection and intimacy. Artists have likened loneliness to hunger, not only because we can feel it physically, sometimes described as an ache, a hollowness or a sense of coldness, but also because these physical sensations might be the body’s way of telling us that we are missing something that is important to our survival and flourishing.
In this issue of Heart, Bu and colleagues,1 in a prospective observational study that comprised approximately 5000 adults followed for about 10 years, found that individuals reporting high levels of loneliness had 30%–48% increased risks of developing cardiovascular disease (CVD) and CVD-related hospital admission, respectively, even after adjusting for the usual cardiovascular risk factors.1 This major study has three implications: (1) loneliness should be considered among the most dangerous CVD risk factors; (2) feeling lonely is a highly modifiable state that would seemingly respond to lifestyle adjustments as compared with the other foremost psychosocial CVD risk factors—depression and stress/anxiety—which typically require prescription medication or exercise2; and (3) social isolation without the anguish of loneliness does not appear to increase CVD risk.
The current study confirms prior data showing that self-reported loneliness is significantly correlated with increased healthcare utilisation and heightened morbidity and mortality risks.3 4 Advanced age, poor health, fewer years of formal education, functional limitations, cognitive decline and sensory loss are factors associated with loneliness, and all of these issues are also linked to CVD and increased morbidity/mortality rates.3 Thus, akin to the other major psychosocial stressors, the association between loneliness and CVD may be a bidirectional function with arrows of causation both ways; loneliness causes CVD and vice versa.3 Or perhaps, several pernicious risk factors, such as social isolation, physical inactivity and substance abuse, predispose to both loneliness and CVD.
Feeling lonely sometimes is unavoidable, owing to geographical factors, or physical and/or mental limitations, especially now with the COVID-19 pandemic. However, some loneliness is self-inflicted simply due to lack of time spent connecting with others. Companionship and relationships require nourishment and effort and therefore often take a back seat to solitary screen time—whether it be for work or entertainment. When we consider the breadth of evidence supporting how fundamental our relationships are to mental and physical health, interpersonal interactions should become a top priority.3 Arguably, establishing and maintaining relationships should be among our most vitally important day-to-day missions in life. This can be accomplished simply by spending more time interacting with family, friends and neighbours, or perhaps consider volunteering, or joining a club or group, whether the meetings are in person or virtual.2–4
Exercise is arguably medicine’s most formidable ally in the battle against CVD for both prevention and mitigation. Physically interactive play, such as tennis, badminton, golf and dancing, has been shown to be the best type of exercise for conferring longevity.2 Thus, the most effective remedy would be one that addresses both arms of a bidirectional feedback loop, and exercise done among peers is likely to ease loneliness while simultaneously lowering CVD risk. Physical play promotes both emotional bonding and moderate levels of physical activity, and is a powerful and natural therapy for relieving psychosocial stress and enhancing overall well-being.
Loneliness epidemic?
The increasingly large proportion of people living alone, the reduced rates of civic engagement and religious affiliation, and the rising rates of individualism have prompted mass media portrayals of a ‘loneliness epidemic’.3 5 While robust risk-adjusted data show that loneliness is still prevalent, it has not increased in recent decades, and baby boomers are not more lonely than prior generations.5 Nevertheless, loneliness does increase after age 75, and is associated with poor health, having fewer close family and friends, and living without a spouse/partner.3 5 Thus, as the life expectancy increases, we are all at risk of becoming lonelier.
Single-person households were uncommon in centuries past and today are at historically unprecedented levels. The prevalence of single-person households began a steady rise in the middle of the 20th century, and today account for approximately 50%, 30% and 25% of all households in Sweden, the UK and the USA, respectively.6 A recent study found that living alone, regardless of the reason, was correlated with a higher risk of CVD.4 A logical explanation for this might be that living alone increases feelings of loneliness.
Yet living alone turns out to be a surprisingly poor predictor of loneliness. Paradoxically, the countries with the highest proportion of single-person households (Sweden, Japan, Denmark, Switzerland, USA and UK) are also among the nations with the lowest proportion of people reporting that they feel lonely (figure 1).6 Similarly, Bu and colleagues1 found that while loneliness was cardiotoxic, social isolation did not independently increase CVD risk. Clearly, loneliness is a subjective perception that does not strongly correlate with objective social settings, and cohabitation is not necessary to prevent loneliness.
Self-reported loenliness among older adults. Share of survey respondents who report feeling lonely at least some of the time. For all countries estimates correspond to population ages 65+, except in the following cases: US (ages 72+), UK (ages 65-74), anf Finland (ages 75+). Estimates correspondend to people who report feeling lonely "some of the time", "most of the time", or "almost all the time". This is in contrast to those that report feeling lonely "rarely", "almost none of the time", or "never".
Battling loneliness during social distancing
The coronavirus/COVID-19 lockdown caused a sudden mandatory disruption in our face-to-face connections with other people. Physical distancing decrees have exacerbated the sense of loneliness for many people. Tragically, this COVID-19 pandemic has forced many people to live and sometimes even die alone. Even so, these stressful times can be instructive in helping us realise how essential human relationships are to our overall well-being.
Plants and pets are potent allies in the struggle against loneliness, especially for people living in single-person households during the pandemic quarantine. People living alone with a dog have a 33% lower risk of all-cause mortality and a 36% lower risk of CVD mortality compared with people living alone without a dog.7 These longevity benefits conferred by dog ownership were twofold to threefold higher for people living in single-person households compared with those in multiple-person households.
Gardening has been shown to reduce stress and lessen feelings of loneliness by fostering connection to the natural world and by nurturing plants.8 Gardening involves physical activity, mindfulness and exposure to sunlight, fresh air and soil microbes, and also promotes social interaction with other gardeners and neighbours.9 Thus, tending a garden and/or adopting a dog appear to be effective strategies for reducing loneliness and mitigating CVD risk.
Some studies report that social media can heighten feelings of loneliness, but this may only be the case when the online activity is not supplemented by real life activities. It is important to remember this technology is merely a tool rather than the solution itself. Yet, during this time of mandated social distancing, social media, phone calls and video chats with our family, friends and coworkers help us feel more connected, which is profoundly reassuring for many.
We thank Bu and colleagues1 for their important contribution to the increasingly nuanced body of knowledge regarding psychosocial stress, highlighting the cardiovascular dangers of loneliness, and for helping stimulate potential interventions for reducing and relieving the suffering of the lonely heart.
Footnotes
Contributors All authors worked on the content and revisions and approved the final paper.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.
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