Abstract
Social isolation and loneliness have become pervasive in industrialized countries, including the United States.1,2 Reports indicate over 50% of Americans in 2024 felt lonely and that an estimated 25% of older adults are socially isolated.1,3 The former US Surgeon General, Dr Vivek Murth, has repeatedly stressed the dangers of loneliness and social isolation on health and productivity. 2 The World Health Organization considers social disconnection and loneliness to be primary drivers for depression, anxiety, and chronic disease. 1
Unfortunately, social isolation and loneliness affect persons with diabetes (PWDs) to a higher degree than their peers. 4 These negatively impact diabetes complications and self-care behaviors critical to diabetes management.1,2,4,5 In addition, social disconnection and loneliness are risk factors for the development of type 2 diabetes (T2D) itself. 5 The goal of this article is to help define social isolation and loneliness, explore their impact on health and self-care behaviors, and discuss potential interventions to support those living with diabetes.
Defining Social Isolation and Loneliness
Although social isolation and loneliness are often studied in tandem, they are not the same. One is more objectively measured, and the other relies on one’s perception. For definitions of these terms, see Figure 1. It is important to note that although studies separate social isolation from loneliness, they do not always use a standardized way of measuring these factors. Thus, measurement of social isolation and/or loneliness can vary study to study.
Negative Influences of Social Isolation and Loneliness on Health
Although the COVID-19 pandemic may have triggered more discussion about social isolation, we have decades of research to show just how damaging it can be to health.2,5,6 Poorer health habits, higher rates of chronic metabolic diseases (eg, cardiovascular disease and diabetes), and increased anxiety, depression, and dementia all have links to social isolation and/or loneliness.2,5,6
The 2023 Surgeon General’s report, “Our Epidemic of Loneliness and Isolation,” acknowledges social isolation and loneliness as drivers of stress and chronic inflammation. 2 It is noted that these influences have similar health outcomes to excessive smoking, alcohol use, or physical inactivity. Dr Vivek Muth, author of the report, refers to social connection as being “as essential to our long-term survival as food [and] water.” 2
ADCES7 Diabetes Self-Care Behaviors Through the Social Connectedness Lens
Positive social connections can help PWDs increase their self-care behaviors (eg, smoking cessation or increased physical activity), whereas the lack of support can create negative impacts on diabetes outcomes and health behaviors.2,5 It is critical that certified diabetes care and education specialists (CDCESs) understand the influence of social isolation and/or loneliness on a PWD’s ability to manage their condition. In the following, the ADCES7 is used as a guide to explore these influences.
Healthy Eating and Being Active
Food has cultural and social constructs that should not be discounted. Living and eating with others increases the quality and variety of food one consumes while also influencing food preparation and access. Loneliness can impact bingeing or restriction, either increasing the desire for higher caloric, tastier foods or creating a more rigid dietary pattern.7,8 Overall, both social isolation and loneliness have been linked to poorer dietary intake.2,5,7,8
Social connection is a fundamental human need, as essential to survival as food, water, and shelter.
Physical activity offers a vital role in health—influencing things such as metabolic function, muscle mass, bone density, balance, and more. Many studies point to reduced physical activity in those who are lonelier and more isolated.2,5
Taking Medication
Cardiometabolic medications are critical for managing T2D, lipids, and blood pressure, which, in turn, reduces the risk of diabetes complications. Similar to healthy eating patterns, social connectedness can assist in one’s ability to understand medication instructions and obtain, organize, and use medications as prescribed.2,9,10 Medication use inconsistencies are more likely for those who are socially isolated.2,9,10
Monitoring and Reducing Risks
Social isolation and loneliness, independent of diabetes, can increase cardiovascular disease risks. Heart disease and stroke are nearly 30% higher, and mortality risk almost double in those who are more isolated.2,6 Similarly, people who are social isolated and living with chronic kidney disease (CKD) see accelerations in the development of both cardiovascular disease or mortality. 11 CKD and microvascular complications are associated with social isolation or loneliness to similar degrees as smoking, hypertension, and physical inactivity. 12
Actions to monitor and/or reduce diabetes complications can be negatively impacted by these social factors. In larger, more longitudinal studies, smoking was more likely and cessation more difficult for lonely individuals.2,5,13 Poorer self-care routines and lower prioritization of diabetes care were evident in other studies looking at social connectedness and health behaviors.2,5,9,13
CKD and microvascular complications are associated with social isolation/loneliness to similar degrees as smoking, hypertension, and physical inactivity
Interestingly, social isolation and loneliness have mixed results on health care utilization. Social isolation may increase hospitalizations and hospital stays and reduce attendance at posthospitalization follow-up, whereas loneliness increases primary care visits.14,15
Problem Solving and Healthy Coping
PWDs make significantly more daily health decisions than those without diabetes. The ability to navigate these and everyday life stressors depends on a number of factors: sleep habits, eating and exercise routines, glucose trends, psychological health, and social connectedness and/or loneliness.3,14,16-18
Studies show interruptions to relationships and support systems due to trauma, chronic stressors, or mental health struggles increase the risk of T2D.2,16,17 As mentioned previously, impacts on metabolic and psychological health and one’s ability to engage in necessary health behaviors are evident in other studies.2,5,9,12,18
The CDCES’s Role in Addressing Social Isolation and Loneliness
There are many ways CDCESs can expand care recommendations through the lens of social connectedness. A great place to start is by simply asking oneself, “How are my current recommendations going to impact this person socially?” and “How can I modify my recommendations to be more socially inclusive?” A few other ideas are listed in the following.
Social connectedness is an essential and undeniable part of health. For PWDs, social isolation and loneliness are drivers for both the development of the disease and long-term health outcomes. The United States is struggling with increased rates of social isolation. However, the diabetes population is harder hit, with higher rates of isolation and loneliness reported. Diabetes health, self-care behaviors, and complications are all impacted. Thus, it is imperative CDCESs incorporate both assessments and interventions for social connectedness into routine care. ■