Associations between social isolation, loneliness, and objective physical activity among the aged.
Abstract
The health risk impacts of social isolation and loneliness can be mediated through lifestyle and biological processes. This study seeks to test the hypothesis that loneliness and social isolation are associated with more sedentary behaviors and reduced objective physical activity. The study will comprise of 300 participants including 150 community based men(n=150) and 150 women(n=150) aged between 50-70 years (mean 65).To obtain the best results, the study participants will be expected to wear wrist-mounted accelerometers for more than 7days throughout the study period, and their sleep logs will be monitored. The final results of the study will be presented as standardized regression coefficients (β) with standard errors (SE) for loneliness and social isolation. Variance inflation factor values will also be determined for all regression models to determine the multicollinearity within an acceptable range. The relationship between loneliness or social isolation and physical activity will be analyzed through linear regressions. The outcome variables will include: the time spent on sedentary behaviors, total activities count, and moderate/vigorous and light activities. Loneliness and social isolation will be assessed using standard questionnaires and depressive symptoms, mobility, and poor health limitations will be the study covariates.
Introduction
The degree in which people are embedded and interconnected has a significant impact on longevity and health. Social isolation refers to a lack of consistent contact with friends and family and a lack of engagement in social organizations. Loneliness, on the other hand, refers to the subjective perception or experience of being isolated. These aspects play a major contribution to the welfare and health implications of older people. In most occurrences, socially isolated individuals tend to feel more lonely even though loneliness and social isolation are weakly correlated. Having fewer social contacts may be satisfying for some individuals, while others may feel lonely despite having numerous social contacts. Therefore, loneliness and social isolation are considered to be distinct constructs with probable different disease pathways.
Past research studies have presented the relationship between loneliness and social isolation, mortality risks, and chronic illnesses development independently amid other pre-existing healthy illnesses and socio-demographic factors. Different meta-analytic reviews have supported these relationships. The search mechanisms behind these implications have focused on two major pathways. One of these annotates that direct psychobiological processes are in charge of loneliness and social isolation, thus stimulating neuroendocrine dysregulation, controlling blood pressure and autonomic function disturbances, chronic allostatic load, and inflammatory responses. The second one argues that health behaviors are the key contributors to major health risks with the lonely and socially isolated individuals having the least preferred lifestyles. Social relationships have been linked to having healthy diets, moderate drinking, and non-smoking behaviors (Lara et al. 2019).). According to an analysis of the UK Biobank, it was pointed out that health behaviors accounted for over 30% of the mortality risks associated with loneliness and social isolation over a six and a half years follow up period(Elovainio et al. 2017).
Links between physical activity and social relationships are very crucial since continued physical activity is linked to various positive impacts including reduced frailty and disability, reduced cardiovascular risks, greater independence, reduced suicidal thoughts beneficial metabolic profiles as well as improved quality of life(Bornheimer et al. 2019)..Social relationships have proved to be very useful in promoting physical activity with friends. Families can encourage one another to take part in physical activity or just by influencing others through personal behaviors (social control). Individuals are more likely to be engaged in social organizations that are active in nature, including visiting relatives and friends, attending cultural events like concerts and theater, or participating in other outdoor activities. The latter may be very crucial among older people since most of their physical activity emanates from short outdoor trips.
Past scholarly works show that early life isolation is associated with future physical inactivity though studies on the older populace and those analyzing loneliness and social isolation remain scarce. A study conducted by Whait et al. 2018, indicated that social isolation is both linearly and strongly associated with the use of social media(a proxy for sedentary living). This resulted in limited participation in physical activities, higher levels of loneliness, and limited contact with neighbors, continuing in old age. Matthews et al. 2015, shows that childhood social isolation is strongly associated with increased risks of cardiovascular diseases, physical inactivity high levels of inflammation, depression, and other negative outcomes in adulthood. Additionally, repeated episodes of isolation during childhood and adulthood forecast poor health outcomes, including physical inactivity in old age(Cornwell, & Waite, 2009). The English Longitudinal Study of Ageing finding also reported that loneliness and social isolation were cross-sectionally associated with low levels of vigorous and or moderate physical activity. However, after a ten-year longitudinal analysis, loneliness was not related to physical inactivity, but social isolation had a positive correlation. ( Marshall, et al. 2015).
According to a study conducted in 2019 on the impact of social support and loneliness among college students, isolation was identified with lower scores in the composite subjective score, physical activity prompt and deferred review, verbal familiarity, and in reverse digit range and with a progressively quick decay from benchmark to follow‐up in the composite intellectual score and reverse digit length. Moreover, higher social isolation was related to lower scores in the composite psychological score, verbal familiarity, and forward digit length, yet not with a quicker pace of decay (Hefner, and Eisenberg, 2009).
Cross-sectional relationships between loneliness and isolation and physical activity are also outlined in the UK Biobank (Elovainio, et al. 2017), contrarily, there were no cross-sectional or cross-sectional relationships between physical activity and social networks observed from a community-based study conducted in Chicago with loneliness being linked to poor physical activity(Visser, & Koster, 2013).
All these research findings were grounded on self-reports on physical activity. Although these kinds of measures are crucial, physical activity seems to be over-reported systematically, with most of the activities being recalled compared to studies employing objective measures. However, the inaccuracy of these self-reports could have been exaggerated among the elderly resulting from recall errors. Most of the activities emanated from daily routine chores as opposed to distinct periods of formal exercise.
In view of that, the current study will investigate the relationship between social relationships in the form of loneliness and isolation using accelerometer-based measures of physical activities in a community-based sample comprising of 300men and women aged 50-70 years. The study will hypothesize that loneliness and social isolation will have an inverse relationship with the physical activity counts, with high sedentary behaviors and limited light or vigorous/moderate physical activity during wake times. Factors that may confound the relationship between loneliness/social isolation and physical activity will be considered. One of these factors will include physical health as poor health is directly related to loneliness and social isolation and have a higher probability of limiting physical activity. The other factors that will be considered include daily living mobility and impairment problems and depression. Past research also shows that socioeconomic status partially explains the association between loneliness/social isolation and physical activity may be secondary to one of these factors, thus supporting their inclusion in the study.
METHODOLOGY
Study population
To test the hypothesis of the study that loneliness and social isolation are associated with more sedentary behaviors and reduced objective physical activity, 300 participants will be included. The participants will comprise o 150 community based men(n=150) and 150 women(n=150) aged between 60-70 years (mean 65).To obtain the best results, the study participants will be expected to wear wrist-mounted accelerometers for eight days. The data will be collected once every two weeks using self-completion questionnaires and computer-assisted personal interviews with frequent home visits from a psychotherapist who will be collecting the biomarkers. Prior to the study, informed consent will be sought from the participants.
Similarly, the study protocols approval will be sought from the National Research Ethics Service. To test the study’s reliability and the study materials, a pretest study will be done, including a random subsample, which will be required to complete the daily sleep logs and wear the accelerometers for five days. One of the major purposes of the pretest study will be to assess whether the study materials could have any technical problems.
Measures
Social isolation
The social isolation measure will be created through assigning one point in case the participants have less than one month contact)telephone, face-face, email/written) with their family members or friends and if the did not take part in social organizations such as religious groups, committees, and social clubs. Marital status will not be included in the study since unmarried isn’t a reflection of social isolation, especially among older adults who may have been in marriage and raised children together but lost their spouses later on. The scores for measuring social isolation will range from 0-4 with the highest scores indicating higher social isolation levels. The participants will be classified as those with no social isolation(0 scores) and those with some levels of isolation(having one or more scores in the initial analysis).
Loneliness
Loneliness will be assessed using the 3-item short form of the Revised UCLA (University of California, Los Angeles) Loneliness. A good example of the questionnaire items is ‘How often do you feel like you don’t have enough companionship?’ The items will be scored on a three-point scale (1 = hardly ever, 3 = often) and eventually be summed up to create the overall score with higher scores signifying higher levels of loneliness.
Objective physical activity
The study participants will wear triaxial accelerometers (Gene Activ; Activinsights Ltd., Cambs, UK) on non-dominant wrists for eight successive 24-h days. The accelerometers will be fitted in the homes of the study participants at the end of the psychotherapist’s visit. The participants will also be required to complete daily sleep and wake times and activities reporting diaries like bicycle riding and any no-ware events.
Physical activity will be sampled and stored at 50 Hz in gravity units (1 unit = 9.81 m/sec2). The first-day results will be discarded, and data will be obtained from the second day towards the 8th day summing up to a maximum 7days of 24-h measurements. Non-wear periods will be determined using GeneActiv software algorithms for participants’ who will have a wear time of at least 95% per day. Those who will have worn the devices weekday and weekend will also be included in the analysis.
The results will be converted into 1 min epochs and analyzed, and the total activity counts will be summed up for more than 24hours for weekdays and weekends and their combinations. Additionally, the number of min/hr between 7:00 and 23:00h spent on light/moderate/vigorous and sedentary activities will be calculated through validated cut-points. Finally, values for weekdays, weekends, and the entire week will be calculated separately.
Heath and mobility impairment
Self-rated health will be measured using disease outcomes and mortality prediction for single items. The respondents will be required to rate their health status perceptions into five categories: excellent, good, fair, and poor. To determine the chronic illnesses presence, the respondents will be probed on past presence long-standing illnesses. If so, they will indicate whether the illnesses impaired their abilities to take care of themselves or take part in social other activities. The participant’s mobility will be determined by asking them questions on physical activities, including arm function and leg mobility(extending arms beyond the shoulder level and walking for at least 100 yards). This will be modeled as a continuous variable.
Depressive symptoms
The 8-item Centre for Epidemiologic Studies Depression Scale (CES-D) will be used to measure depressive symptoms with a score of ≥3 indicating significant symptomatology.
Socioeconomic factors
Total wealth will be calculated net of debt. This will include property-owned property, business assets, financial wealth, and physical wealth, including artwork and jewelry.The analysis will use Age-related wealth quintiles while educational achievements will be classified as formal, intermediate, and higher education.
Other variables
Marital status will be classified into married/cohabiting and others. Age will be categorized into 50-60 and 60-70, smoking status: current smoker, ex-smoker, and non-smoker. At the same time, alcohol consumption will be assessed based on being consumed more than five times a week, or daily consumption as a measure of activity levels.
Statistical analysis
The characteristics of the isolated and non- isolated participants will be compared using the T-test for the constantly distribute variables, while Χ2 will be used to compare categorical variables. The results will be presented as means ± standard deviation and N (percentage). Further, Pearson’s correlations and T-tests will be used to examine the relationship between loneliness and other characteristics. The variance between weekend and weekdays activity counts will be analyzing through variance repeated measures analysis with the day(weekend, weekday) as factors within the person and social isolation as factors between the person. Similarly, the relationship between loneliness or social isolation and physical activity will be analyzed using combined weekend and weekday data. Separate regressions will also be conducted on total activity counts and the mean mins/hr used on sedentary behaviors and light and moderate/vigorous activities. The vigorous /moderate physical activities will be skewed using a transformation log.
Conversely, four models will be evaluated in the analysis presenting the unadjusted relationship between loneliness/social isolation and activity in the first model. The second model will be adjusted for age, gender, marital status, education achievement, non-pensionable wealth, alcohol consumption, smoking, number of mobility impairments, and depressive symptoms; depressive symptoms will be included in the third model. In contrast, loneliness/social isolation will be included in the fourth model. Total activity counts, accelerometer wear time, will also be included as a covariate. The final results of the study will be presented as standardized regression coefficients (β) with standard errors (SE) for loneliness and social isolation. Variance inflation factor values will also be determined for all regression models to assess the multicollinearity within an acceptable range.
DISCUSSION
This study will seek to investigate the relationship between social relationships in the form of loneliness social isolation and objectively measured physical activity among older men and women in the 50-70 years age group. The major research prediction is that social isolation will present a positive relationship with lower total activity counts, less time spent on moderate /vigorous and light activities, and more time spent in sedentary behaviors. The relationships are anticipated to be independent of age, gender, marital status, socioeconomic status, loneliness, and depressive symptoms. It is also expected that loneliness will not have a positive relationship with sedentary behaviors and physical activities considering the age and gender covariates,
INTERPRETATIONS
Research on the impacts of loneliness and social isolation on health is a very crucial research undertaking. In the United States, the size of the social network has presented some decline in recent years following the reductions in non-kin and kin confidants as well as less neighborhood and community connections. In the United Kingdom, approximately 1/3 of people aged 65 years and above live alone, and approximately 20% of them go for more than a month without family and friends. The prevalence of loneliness is quite stable among the elderly over the past years despite the reported cases of loneliness accounting for 1/3.
The study will measure physical activity using an accelerometer-based measure instead of self-reporting to offer more objective evidence on the association with social relationships. Primarily, self-report measures are the key foundations for the majority of observational epidemiology relating activities with health impacts. Nonetheless, alterations in norms with disability and age, which comprise of recall problems, vigorous activity, and inaccurate measures completion where high intensity or moderate predominate, may restrain the accuracy of the older adults’ self-reports. The study’s’ accelerometers will be trapped on the wrist instead of fitting them on the waist to help in providing both daytime and night data.
Past research findings on the relationship between self-reported physical activity and loneliness are quite mixed, with several studies presenting a negative correlation. In a large-scale study comprised of over 3,000 older men and women, unlike loneliness, social isolation showed a more substantial relationship of inactivity for more than ten decades. It is anticipated that the current research study will support the notion that social isolation is strongly related to individuals’ health behaviors more than loneliness. The justification behind this could be because people who are socially isolated may not have positive social influences from friends and family members and therefore, they are more susceptible to descriptive(other individuals behaviors) and injunctive ( what other individuals expect from them)norms
cross-sectional relationship between physical activity and social isolation does not merely imply a direct association since the link may be secondary to many other factors associated with physical activity and social behavior. Mobility limitations, poor self-rated health, and long-standing restraining illness will imply greater sedentary behavior and reduced activity in bivariate analysis. Nevertheless, the multivariable regressions propose that the factors play a very significant role in amplifying the relationship.
The cross-sectional nature of this study will also help in preventing causal conclusions from being derived. It is feasible that high levels of social isolation result in low activity levels, but it is also conceivable that less active individuals tend to isolate themselves from social connections. Nonetheless, the social isolation measures will include face-to-face meetings, and electronic, and telephone communication implies that low physical activity may not interdict social contacts. It is also evident that most older people activity piles up through outdoor trips, which may have social and practical functions.
The significance of the social isolation measure is well-grounded as it has proved to be very effective in forecasting mortality and other health implications. However, the present study will compare the isolated and non-isolated peoples, and the impacts might be stronger with a sample having higher levels of social integration. The social isolation measure will be comprehensive in that it will consider contacts with family and friends together with civic participation despite not considering the size of the networks. Some of the facets of social contact may be strongly related to physical activity, unlike others, thus creating the need for future research. The other issue that may require further studies is the examination of probable interactive influences of loneliness, and social isolation on physical activity. This may necessitate a bigger sample size, unlike the one included in the study. However, one of the major strengths of this study is that it will be conducted within a well-featured longitudinal cohort study.
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