Why Loneliness Shortens Lives

Dr. Alan Rozanski: [00:00:00] On a scale of 0 to 10, how energetic and alive do you feel now compared to a time in your life where you felt energetic? And if your number is six, seven or below, why is that the case? Is it something in terms of your sense of purpose? You feel lonely. Do you you know, you’re maybe you’re not exercising, your diet poor?

Peter Bowes: [00:00:24] Hello and welcome to the Live long podcast. I’m Peter Bowes. This is where we explore the art and science behind living long and well. Now, loneliness isn’t just a social issue, it is a serious threat to our health. The World Health Organization estimates it contributes to hundreds of thousands of deaths each year, on a par with some of the major chronic diseases. We understand now that it isn’t about how many people we know, but whether we feel seen, valued and connected. Doctor Alan Rozanski has spent decades exploring how our relationships shape our biology behavior and ultimately, our lifespan. As a cardiologist and pioneer in behavioral medicine, he places social connection at the heart of what it means to live long. So how strong is the evidence and what does meaningful connection actually mean in modern life? Doctor Rozanski, it’s great to talk to you.

Dr. Alan Rozanski: [00:01:24] It’s a pleasure to be here. And thank you for having me here today.

Peter Bowes: [00:01:26] And I think it is probably fair to say, Alan, that looking back historically, that we haven’t always taken as seriously as diet and exercise our social connections in terms of our overall health. Would you say that’s fair to say? And when did you realize that this issue leads to loneliness is crucially important to us?

Dr. Alan Rozanski: [00:01:50] Well, it was a progression. I mean, my work, you know, as a conventional cardiologist, had no behavioral part in it at all whatsoever. It’s the evidence that, you know, drew me into it. Basically, I started off looking at the effects of acute stress on heart disease, and the relationship was pretty powerful. And I decided to study the mind body relationship stronger. And this was back in the 1980s when the field of biobehavioral medicine was in its true infancy. I mean, there was, of course, always a knowledge and some, level that the the psychological and social factors were important, but the ability to study them. we didn’t have the tools till the 80s. We didn’t have strong epidemiological studies. We didn’t have the physiology tools to measure it well. And pretty soon,social relationships turned out to be a very important part of the equation. Of course not the only one. I mean, basically, there’s a whole set of psychological factors that govern our health and well-being, including our sense of purpose and, and, the emotions we have, optimism, gratitude versus, you know, being depressed and things like that, how we handle stress. But among all of those, our social relationships are also extremely important.

Peter Bowes: [00:03:06] You’ve just given me a little flavor of it, but maybe, your bio is in the show notes for this episode, but just give me a little snapshot of your career and how it has progressed in relation to this issue.

Dr. Alan Rozanski: [00:03:17] Sure. So I started off just wanting to be a private practicing doctor. And at the end of my training, just before that, there was this new field that opened up called nuclear cardiology, where we could put patients on treadmills and put a camera in front of them with an isotope that we injected the patient look at the blood flow or the wall motion of the heart. And I just thought this was the neatest thing. So I went out to get specialty training in it, and then took a job at Cedars-Sinai Medical Center. And about 2 to 3 years into that work, there was data coming out that showed that while people were engaging in their daily life activities, and you would put an ambulatory ECG monitor on them. We didn’t have that technology before. We were finding that people were developing evidence of lack of blood supply. These were people with heart disease, not normal people without heart disease, but they were developing these abnormalities while driving a car and things like that, and we didn’t understand it. So the thought came to me, gee, we could study this in a laboratory. Why don’t we take some of our patients who are, coming in for stress testing? And before we put them on a bicycle to look at the wall motion of the heart, let’s have them do a series of mental tasks. what I should say is that when we put them on a bicycle and they’re exercising, the wall should go in more vigorously. But if there’s a blockage, one of the coronary arteries, then as they’re exercising, a wall will start to slow down or even stop moving temporarily. And that’s how we diagnose heart disease non-invasively. Well, we started doing, doing this, doing mental tasks. We had three tasks, had them subtract serial sevens and had another thing called the word stroop task. But the third task was just half the patients speak about the stress in their lives. And lo and behold, a number of the patients with heart disease developed these wall motion abnormalities just by speaking about the stress that they were having. So that was just my aha moment. I just just was stunned by that. I mean, that was the evidence of the mind body relationship. So after that, I got a sabbatical from the MacArthur Foundation to be on different campuses studying the determinants of health, promoting health, damaging behaviors. I met many leading people in the field, and was just really so impressed by the, the elegance of the, of the, studies. I mean, I was by that time a hardcore, researcher and looked, you know, for real evidence in terms of how things work in terms of biology. And it just couldn’t be denied. We were seeing here that there was a pathway where, you know, whether it’s depression or whether it’s, social isolation or, loneliness or anxiety, even to some extent were causing these abnormalities in physiological function and in epidemiological studies were coming out, for example, showing that people who were depressed in stepwise fashion are more depressed they were the greater the risk for developing heart disease and actually having premature death. So that was that was how I got going.

Peter Bowes: [00:06:18] Yeah. It’s interesting you explain it like that because I wanted to ask you, and I think a lot of people wonder about this in terms of physically what’s happening in our body that is detrimental to our health when we are suffering from the effects of social isolation, because it’s a it’s a joining of the dots that it’s difficult for some people to, to make. I think if you think about being overweight and your diet, it’s easy to correlate the two. But matters of social isolation and ultimately loneliness are not so easy to to understand, are they.

Dr. Alan Rozanski: [00:06:49] From the biology point of view, not so easy but I think we have a lot of clues to be fairly clear on what’s going on, even if we can’t be precise. Basically, to understand this, all we have to understand that we have this basic psychological need to be connected to other people, just like we have a physical needs to eat, to drink, to sleep. We have basic psychological needs. One of them is our need to be connected to others, and others are need to have a sense of meaning and purpose in our life. There’s a certain sense of need for autonomy. There’s other basic psychological needs, but our need to be connected to others and our need for purpose are really very primal, basic needs. Now with social needs, first of all, that that need is can be highly expressed. Some people are introverts and very happy. Other people need to be express their extroverted ness, right? some people can be lonely in a crowd. Some people it’s one friends all you need and another aspect of that is that in the work years when you’re in a job that you’re not only meeting your need for purpose, but you have a structure there in terms of your network and, you know, you have social connectedness with your peers. So the need for to be socially connected to people may be masked somewhat, can be masked for decades even. And then people retire and all of a sudden they don’t have that structure, the meaning and the job and the connectedness to their colleagues, and then their social needs become more acute. But if you haven’t, you know, prepared for that, that’s where a lot of the loneliness of old aging becomes a problem.

Peter Bowes: [00:08:30] Interesting. You should say that for some people, just one connection, just one friend might be enough?

Dr. Alan Rozanski: [00:08:38] That is true. It’s very variable. Very variable. You know, it’s, That’s what that’s what it seems like. Yeah.

Peter Bowes: [00:08:46] And there is a distinction, isn’t there, between being alone and being lonely because being alone for some people for a period of time during their day or their week can actually be beneficial.

Dr. Alan Rozanski: [00:08:59] Yes. So let me go back to the other point. There is data. The first study that came out ever, that was a large epidemiological study, was published in 1979. It was called the Alameda County Study, and it was headed by Lisa Berkman, a famous epidemiologist who at the time, what they did is they looked at the size of people’s social network. It was just as simple as that. You know, how many people, you know, did you interact with in your community, whether you belong to a religious group, etc.? And they found this proportional relationship. The stronger, the larger your network, the longer the longevity was. So it was all about the size of your social network. The data seems to indicate that there’s both that kind of even synergistic. So that even though you may be satisfied with a single relationship being connected to others seems to have a synergistic effect. Maybe I would phrase it that way.

Peter Bowes: [00:09:59] And as we publish this episode, it is Mental Health Awareness Month. And I mentioned in the introduction that the World Health Organization has estimated that hundreds of thousands of people are dying each year as a result of a lack of social connections, and that could be on a par with chronic diseases. I’m just wondering how robust the evidence is for that kind of figure.

Dr. Alan Rozanski: [00:10:25] Yeah. so it elevates risk, just like hypertension and smoking and other things. Elevate your risk. This will elevate your risk as well. You know, maybe you’re talking about a 30 to 40% increase in risk. It’s not as striking as factors like, you know, heavy smoking, or diabetes, but it’s a significant risk factor, you know, and it the thing is that we tend in research to isolate these factors. Like we’ll say, okay, look at social isolation and you’ll, you’ll correct for other factors, like other psychological factors even. And so you’re, you’re coning down that risk because you’re correcting for factors when actually social isolation may be causing people to have poorer health behaviors and so forth. So actually, its effect may be even greater than we measure in the literature. That’s one thing. The second thing is longevity isn’t the only measure. For example, when people are lonely and we’re talking about chronic loneliness, it increases your risk for depression very substantially. So it’s it’s a big quality of life issue.

Peter Bowes: [00:11:33] And we’ve used this phrase social connections a lot already during this conversation. And I think it’s probably fair to say that in the modern world, social connections is sometimes used to mean how many people, you know online, how many social media connections do you have? Is there any way that these kinds of connections can replace traditional social connections, in-person connections?

Dr. Alan Rozanski: [00:11:58] Well, I think the answer is twofold. It’s like, anything that we’re using in life, any power, any technology, any, any convenience can have positive effects or negative effects. So the, the, to be able to be connected to people, particularly to loved ones to, to older, you know, parents, things like that. I mean, this is a very powerful thing. But on the other hand, it can also become the equivalent of social junk food, right? Because you may, if you’re, if you’re just using that as a substitute to really, you know, make time to see a friend and so forth, there’s a certain element of the depth of relationship that comes from the time you spend with somebody where you’ve been able to, you know, broach your confidence and know that someone’s there for you and you’ve seen them in action. Be there for you and you’ve experienced things together. So they’ve shared experiences. Well, the superficial stuff, it’s it’s not sufficient. So it’s really, it’s really both ways, right? It depends how you utilizing the, the convenient relationships versus the in depth relationships.

Peter Bowes: [00:13:08] We’re seeing around certainly the United States, we’re seeing lawsuits at the moment directed at social media, especially as it applies to, to young people and to children. The use of this kind of connection, to what extent are you concerned that maybe the younger generations are getting used to this kind of social connection that isn’t face to face and perhaps suffering because they’re not with people as much as they could be?

Dr. Alan Rozanski: [00:13:35] Yeah, I think that there’s a concern about that, right? I mean, people are working more remotely, and I think you can see there there’s been a movement of a part on a part of certain companies and not just a few, that we need to get people back in the office because they see that the nature of the relationships, the mentoring, the, the camaraderie, the peer support and creativity sometimes gets affected when people are in isolation. But they’ve also noticed that sometimes people aren’t as, as, maybe even a little bit more awkward sometimes in starting jobs because they don’t have the gift of  you know, you develop a talent in anything you do, including your social relationships. I mean, when you’re 30, you think back how you were in your 20s. I wish I’d known this earlier. That comes from the experience of doing things. So when we’re in isolation, like anything else that atrophies, if you’re not using it, your social relationships can too, if you’re in isolation. No question.

Peter Bowes: [00:14:35] Do you think clinicians should take a greater responsibility for identifying this kind of problem? Should it be part of our annual health assessment, for example. And if it is, how would it happen?

Dr. Alan Rozanski: [00:14:48] I don’t know if it should be routine across the board in terms of an annual assessment. I’m trying just to be practical speaking and just knowing how much I’m fighting against a tide to get exercise questions on questionnaires so that we’re asking everybody how much you’re moving and things like that, which is so critically important. But, so I’m not sure we would get there with that. But I do think what we’ve seen is the rise of an interest in longevity and in terms of new specialties such as the, the American College of Lifestyle Medicine, which I guess began around 15, 20 years ago with physicians and physiatrists are the people who are interested in, in promulgating healthy lifestyles as a way of combating chronic disease. And I think that those types of practitioners will be very keen to look at people’s social relationships, help manage them. And so that if you’re a patient interested in that sort of thing, it should be on your radar to do that. I do think doctors are keen to sense if there’s a sense of like depression or of a loss of vitality in a patient. and then if there is, you know, have some open ended questions about that. But again,that comes from more it’s, it’s, it’s not the routine. I’m not having that expectation of someone’s going in to get the cholesterol checked, for example. That’s, I just want to say that.

Peter Bowes: [00:16:16] Now you have written about what you describe as the six domains of health, of which this is part. But it is much more than that, isn’t it? We are a whole being. There is a holistic element to this in terms of taking care of our. Yes, our social connections. But our diet and exercise and sleep and all of those other key pillars of good health.

Dr. Alan Rozanski: [00:16:37] Yeah. No, that’s that’s a very important point here. So basically, I think the issue is that we have. And you see that all of this is centering around, you know, like, what should doctors do and what should be measured and things like that. I think that the basic misunderstanding we have is what is health itself. and what happened was in the early years of my career, I was studying all of these factors which were contributing to disease risk. And, and it broadened not just from, you know, diet and exercise and lack of sleep to looking at these other domains. And ultimately, I just looked at the, at the data and I asked a simple question, you know, I said, look, the body is a Geiger counter. Essentially, anything that promotes longevity protects your physiology, decreases the risk of chronic diseases, healthy. Anything that does the opposite shortens lifespan or damages your physiology is is unhealthy. So we know smoking is unhealthy, for example. But I said, wow. And I developed this understanding, mind you, over decades. But I said there are these other domains. The physical domain is one domain. The quality of your thinking is the second domain. The data is clear. Optimists live longer. For example, pessimists. The opposite. People with a sense of gratitude also live longer. So there’s a an effect of of quality, of thinking on our health in the emotional domain. It’s it’s also true with depression, for example, where people, you know, have a much higher risk for, for illness if it’s not successfully treated. And this is a social domain. And then there’s the, the sense of purpose, very, very potent domain of health. People thrive better when they have a sense of, of life purpose on that day. It is clear. And the. Six domain is in terms of, of how we manage stress. And there’s a lot to say about that. But the point about all of those is that when you look at them, even though they’re all different areas, they they have one thing in common. They all produce a sense of vitality when you are having a sense of purpose, when you’re feeling socially connected. When you are, you know, on your game in terms of productivity and, and things like that. And when you’re exercising, you have a stronger sense of vitality. And that, I think is a real understanding of health. you know, to use an analogy, just like we wouldn’t say that not being depressed means you’re happy. I wouldn’t say not being diseased means you’re healthy. And we’ve lacked a definition of health. And that’s what I came to realize about 15 years ago that that when I look at a patient or an individual and I see that there are the vitality is down when their sense of feeling energetic is down, then it’s usually just a matter of time to figure out which of these domains is lacking in one way or another. So I realized that that’s really a North star, you know, that you can use to, you know, foster your own health.

Peter Bowes: [00:19:36] And you’re a cardiologist. There is a strong or at least there is a correlation with an individual’s heart health. When you consider all of these other factors, we normally think about our heart. We think about our cholesterol, we think of our blood pressure, and maybe how much activity we get involved in. But the range of factors affecting your heart health are enormous, aren’t they?

Dr. Alan Rozanski: [00:19:57] Yes. All these factors affect your heart. Look, when you when you’re not exercising, when you’re having a poor diet, when you’re not getting enough sleep, we know for sure those affect your heart in multiple ways. Interestingly, when you look at the other domains here, one of the ways they affect your heart is because they drag down your, your, your physical health habits that, that those are just, empiric observations when people are depressed, when they’re, you know, brooding, ruminating, pessimistic, when they’re lonely, they tend to have decidedly worse health behaviors. and then that becomes an important mechanism by which those factors, you know, can cause more disease.

Peter Bowes: [00:20:40] You mentioned managing stress a moment ago. Where does someone start in managing their stress? Because it’s easier said than done, isn’t it?

Dr. Alan Rozanski: [00:20:50]  yeah. And like, I’m not sure where to begin with it. So,

Peter Bowes: [00:20:57] Well, that’s why I raised the point really, because it’s such an overwhelming issue for some people.

Dr. Alan Rozanski: [00:21:02] Know it can be, but all these things can be broken down. The, the what if I say to you, you know, well, you know what? If you would wake up in the morning and you wouldn’t feel a sense of purpose and challenge in your life, you know, in other words, we need stress. We, because we are built as a human being. That is a basic psychological need to pursue meaning. And meaning is pursued through a sense of purpose and struggle. And we all understand that that’s just intrinsically how we’re built as human beings. So actually, stress also builds us. In other words, it can sense, you know, when you’re handling things and you’re managing stress and when you’ve overcome challenges that you didn’t even want, but you look back upon it, you realize you grew from it. You have a sense of self-confidence. You have a sense of self-esteem. So the first place to start with stress is to realize, wait, there’s a very strong upside of stress. There’s an upside and there’s a downside, you know? So what’s the difference between the two? So the negative stress or the toxic stress, if you will, is things that have the following features. It’s something that is feels overwhelming to you. It’s something that you feel you can’t control. If it’s causing a lot of negativity, emotional negativity, or if it’s some sort of meaningless stress. In other words, the worst example of that is like trauma and child abuse. I mean, you know where these kids are imposed upon this awful stress and it has no sense of meaningfulness. So any of those elements, creates a sense of toxicity. And if it’s prolonged periods of time, it can have an overwhelmingly negative effect on bodily function.

Peter Bowes: [00:22:46] Interesting. It’s fascinating subject. I often when I talk about stress, and I sometimes use the example that if we weren’t stressed or at least tense before, let’s say a job interview, that you might actually perform less well if you’ve gone into it totally relaxed and blasé, almost, that that is the kind of stress that I see as as positive before, before a big moment in your life, it might be getting married, it might be some other important meeting, but that’s what you’re talking about, right? That’s the kind of beneficial stress.

Dr. Alan Rozanski: [00:23:15] Yeah. it’s the rites of. Passage in life, you know, that, we, we may feel all of that, you know, sometimes that works in our favor. Sometimes it doesn’t. Right? Some athletes just thrive under stress and some, you know, that’s the change of the momentum in a football game. Right. You know. Yeah. It’s it’s always an exciting thing. You know, what’s how people are affected emotionally by by the challenge and whether they think they can succeed or not. So if it’s challenging but you feel you can succeed, it’s yeah, you feel good about that. Otherwise you might not. So again, it’s one of those double edged swords.

Peter Bowes: [00:23:55] Exactly. I get it that everything is is ultimately connected in terms of our health. But I’m just curious, is there one change population wise that you would encourage for people to improve our health as a population?

Dr. Alan Rozanski: [00:24:12] I don’t know if we work it on a population level. We work on a personal level. We spent a lot of time with your audience here. Talking about this can affect your health. This can affect your health. We really want to emphasize the very positive side of this, which is that there’s so many positive things that you can do to promote your health, and it’s never too late. And when you you’re either in life, you know, moving up the ladder or down a ladder, you know, you can get into a vicious cycle of negativity. And then you might not, you know, may have the same energy. You may not eat as well, but you can go on to a virtuous cycle. So sometimes you find,and we find this often that we were able to take an individual and, you know, take them to a cardiac rehab program after a heart attack. And they began to get, you know, into a regular routine with exercise. And all of a sudden they’re feeling more hopeful about some job stuff they’re doing and they’re sleeping better. So, you know, the goal is to, look at the positive side of all these things and realize, indeed, there are many positive things we could do to promote our health, but it’s highly individual for any given person, on a population level. Now there’s been a big move with, to understand, for example, to give you an example, and it’s not all things, resistance training. There’s more and more data coming out in terms of the absolute importance of muscle care. And so the American College of Sports Medicine, which have had guidelines for many years just in a landmark guidance, changed their recommendations to emphasize any amount of resistance training you do will promote your health. And this also echoes, by the way, new guidelines in terms of the physical activity guidelines for Americans, which were published in 2018, were revolutionary, which came to realize for the first time, every time you do something for, you know, in terms of physical movement, it actually benefits your health. And that’s not a euphemism. In other words, there’s data, for example, from a large study called the UK Biobank, where they put wrist accelerometers on people and studied them over 70,000 people. They studied, they followed them for years, and they found that even small amounts of physical activity, less than two minutes in duration were associated with better physical health. The more of those little spurts of physical activity you did. The lower your risk of mortality during a follow up study that they performed. Which means every time you go to the store and you park farther away, and every time you take an up the stairs instead of the escalator, you’re promoting your health. So these, these are things we’re trying to get into the mainstream. And I think it’s gaining traction. So I do think we’re succeeding in doing things for public health. And we see there’s many things to be very positive about.

Peter Bowes: [00:27:02] I think it’s interesting that you phrased it like that, because I think it is getting the point across that that, as I said before, everything is connected. So on resistance training, you do your resistance training, you can improve your muscle strength. And if you improve your muscle strength, especially over 60, 70, there’s perhaps less chance of you becoming frail. But if you do suffer from frailty, then the chances of you being socially disconnected because you’re staying at home, because you feel as if physically you, you can’t do anything else that can lead ultimately to the topic that we started with that is loneliness, right?

Dr. Alan Rozanski: [00:27:35] Yes, exactly. Yes, yes.

Peter Bowes: [00:27:37] Let me ask you, this is a bit more of a personal question. As you’ve delved into this issue throughout your career, how do you see your future longevity, and what do you do on a daily basis to try to maintain your health and your social outlook at an optimum level?

Dr. Alan Rozanski: [00:27:56] Me, myself.

Peter Bowes: [00:27:58] Yeah.

Dr. Alan Rozanski: [00:27:58] Yeah. Well, I think I, you know, I just, you know, try to follow what I’m preaching here. I think it’s important to be physically active to, you know, I try to go to the gym or to do something physically or take in the summertime. I love taking walks. So I’ll, you know, try to take a 45 minute walk, try to be more brisk about it, do some resistance training. I’ve been trying to pay more attention to sleep recently, you know, and, try to follow a good diet.I have a lot of things that provide me with a sense of purpose. and, I just feel, you know, blessed with what I’m doing.

Peter Bowes: [00:28:36] And from reading some of your work, would you agree with me that healthspan is the most important attribute to aim for as opposed to a lifespan healthspan where we enjoy the fullness of health for as long as possible?

Dr. Alan Rozanski: [00:28:52] I don’t know if I’m such a big fan of the healthspan lifespan sort of thing, you know, because actually, in part when we talk about Healthspan and some like to describe it as years lived without disease, you’re actually, you know, formulating a definition of health based on disease. nevertheless, I prefer this concept of vitality. You know, I, you know, you can pose a question to yourself. I have a vitality question. You know, you can scale it on a scale of 0 to 10. How energetic and alive do you feel now compared to a time in your life where you felt energetic? And I’m not talking about foot day. We’re over a period of time you felt energetic and if your number is six, seven or below, why is that the case? Do you have a is it something in terms of your sense of purpose? You feel lonely? Do you you know, you’re maybe not exercising your diet poor. Maybe it’s anxiety, maybe it’s stress. So I think that if the if you again, these things are interconnected and they move forward. If you’re on the right path, your life is always. Life is always movement. Life is always a ladder. Life is always a new place to get to. So as long as you are, you know, on the right path, then you’re promoting your health, you know, so I’m not sure that I, you know, I think there is I don’t want to downplay the importance of healthspan. I think it’s a very important concept, especially compared to when you’re just looking at longevity, which in itself is, is not the way to look at it. But I think the vitality paradigm is better.

Peter Bowes: [00:30:23] Doctor Rozanski It’s it’s a fascinating area. I’m going to put a link in the show notes to this episode where people can go and read more about your work, but it is certainly something I would put very high in terms of the list of things that we should be considering about ourselves, and perhaps higher now than we than we used to. And that is social connection. So I appreciate your insight.

Dr. Alan Rozanski: [00:30:43] Thank you.

Peter Bowes: [00:30:44] Thank you very much indeed.

Dr. Alan Rozanski: [00:30:44] Thank you for having me. It’s been a pleasure.

Peter Bowes: [00:30:47] The Life Long podcast is a Healthspan Media production. I’m Peter Bowes. You can contact me through our website, livelongpodcast.com, where you’ll also find show notes for this episode.