Social isolation, loneliness and subsequent risk of major adverse cardiovascular events among individuals with type 2 diabetes mellitus

Abstract

Background: Individuals with type 2 diabetes mellitus (T2DM) are more vulnerable to social disconnection compared with the general population; however, there are few relevant studies investigating this issue.

Aims: To investigate whether social isolation or loneliness may be associated with subsequent risk of developing major adverse cardiovascular events, whether these associations vary according to fatal and non-fatal outcomes and how behavioural, psychological and physiological factors mediate these associations.

Methods: This longitudinal analysis included data from 19 360 individuals with T2DM at baseline (2006-2010) from the UK Biobank. Social isolation and loneliness were measured using self-report questionnaires. The study outcomes included the first events of myocardial infarction (MI) or stroke (n=2273) and all-cause (n=2820) or cardiovascular disease-related mortality through linked hospital data or death registries.

Results: Over a median follow-up of 12.4 years (interquartile range (IQR): 11.6-13.3 years), participants who were more socially isolated (most social isolation vs least social isolation) experienced increased risks for all-cause (hazard ratio (HR) : 1.33, 95% confidence interval (CI): 1.19 to 1.47) and cardiovascular disease (HR: 1.36, 95% CI: 1.17 to 1.59) mortality but not first MI or stroke. Loneliness (yes vs no) was associated with a greater risk for a composite of incident MI or stroke (HR: 1.37, 95% CI: 1.19 to 1.57) but not mortality. Social isolation was associated with fatal MI and stroke, whereas loneliness was associated with non-fatal MI and stroke. The significant associations of social isolation and loneliness with outcomes were mainly mediated by behavioural factors (mediating proportion: 17.8%-28.2% and 17.6%-17.8%, respectively).

Conclusions: Among individuals with T2DM, social isolation and loneliness are associated with a greater risk of developing major adverse cardiovascular events, with differences in both risks stratified according to fatal and non-fatal events and underlying mediating factors.

Keywords: Epidemiologic Studies; Mental Health; Mortality; Risk Factors; Social Isolation.

Figure 1

Flowchart of participant selection.

Figure 2

Association of social isolation (A) and its items (B) with subsequent risk for major adverse cardiovascular events, including mortality, MI or stroke following type 2 diabetes mellitus. HRs were adjusted for demographic behavioural, psychological, physiological and diabetes-related factors, and comorbidities. CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio; MI, myocardial infarction.

Figure 3

Associations of loneliness (A) and its items (B) with subsequent risk for major adverse cardiovascular events, including mortality, MI or stroke following type 2 diabetes mellitus. HRs were adjusted for demographic behavioural, psychological, physiological and diabetes-related factors, and comorbidities. CI, confidence interval; CVD, cardiovascular disease; HR, hazard ratio; MI, myocardial infarction.

Figure 4

Social isolation, loneliness and subsequent risk for major adverse cardiovascular events, including mortality, myocardial infarction or stroke following type 2 diabetes mellitus. Social isolation was associated with a higher risk of fatal events, including mortality and fatal MI or stroke. Conversely, the association of loneliness with the risk of first MI or stroke was mainly driven by non-fatal events. CI, confidence interval; CVD, cardiovascular disease; MACE, major adverse cardiovascular events; MI, myocardial infarction.