8/15/2012
Social Support and Health:
Benefits with Friends?
Matthew Pantell, MS4
UC Berkeley – UCSF Joint Medical Program
Santa Rosa Family Medicine Residency Talk, 8/13/12
UC BERKELEY
UC SAN FRANCISCO
JOINT MEDICAL PROGRAM
Case
Two patients:
Both 60 year-old men with history of obesity,
hypertension, and CHF. Come in for check-ups. Both
take their medication “90% of the time.” Both exercise
three times a week. No hx of depression.
Pt. A
Pt. B
-Lives with partner
-Group activities once a month
-Sees friends once a week
-Feels supported
-Lives alone
-Belongs to no group
-Sees kids/friends once a month
-“I could use more emotional support”
Does this change your level of concern?
Outline
Brief History of the Social Determinants of
Health
Background on Social Support
Social Support and Mortality
Social Support and Morbidity
Social Support vs. Traditional Risk Factors
Potential Mechanisms
Implications
John Cassel
Epidemiologist, UNC
Wade Hampton Frost Lecture, 1976
Social environment susceptibility to illness
Improving social relationships as intervention
History of Social
Determinants of Health
George Engel
Psychiatrist, University of Rochester
Engel G. A need for a new medical
model: A challenge for biomedicine.
Nature. 1977;196(4286):129-136.
Biopsychosocial model of medicine
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Michael Marmot
Epidemiologist, University College London
(trained at UC Berkeley)
Social Gradients in Health
Social gradients are well-established
Social factors: Education, income, neighborhood
Outcomes: Mortality, morbidity, biomarkers
Whitehall Study, 1978
Social gradient in health
Social Support Definitions
Social Support and
Social Isolation
Social Support
Resources provided by other people
Information leading a person to believe she/he is cared for
Feeling of belonging or value
Social Networks/Integration
Frequency of contacts
Number of contacts
Density of network
Social Isolation
Lack of aforementioned factors
Emile Durkheim
Theories of Social Support
French sociologist
“Le Suicide” - 1897
Direct Effects
Support
Isolated individuals
suicide risk
Health
Stress-Buffering
Stress
Health
_
Support
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Isolation and Mortality Risk
Berkman & Syme (1979) social isolation & mortality
Social Support and
Mortality
Social Isolation is Associated with
Increased Risk of All-Cause Mortality
Social Isolation is Associated with
Increased Risk of All-Cause Mortality
Women
Men
Mortality Percentage
0.85
0.95
Survival Percentage
0.75
0.75
Survival Percentage
Mortality Percentage
0.85
0.95
Women
0
50
100
Months Since Interview
1 (Most Isolated)
3 (Somewhat Isolated)
Log-rank P <0.01
150
2 (Very Isolated)
4 (Not Isolated)
0
Log-rank P <0.01
Risk Remain After Adjustment for
Covariates, Although Attenuated
3.5
3.0
*
2.5
Hazard Ratio
Hazard Ratio
2.5
*
2.0
1.5
1.0
*
*
*
2.0
1.5
1.0
0.5
0.5
0.0
0.0
Most
* p <0.05
Women
3.5
*
*
150
2 (Very Isolated)
4 (Not Isolated)
Risk Remain After Adjustment for
Covariates, Although Attenuated
Men
*
3.0
50
100
Months Since Interview
1 (Most Isolated)
3 (Somewhat Isolated)
Least
Most
Most
Isolated
Least
Least
Isolated
Most
Most
Least
* p <0.05
Least
Most
Most
Isolated
Least
Most
Least
Least
Isolated
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Post MI Survival
CVD Events/Deaths
Cardiovascular
*
Men
*
Hazard Ratio
Hazard Ratio
Women
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
*
Most
Least
Most
Least
Most
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Least
*
*
*
CHF Events/Deaths
Post Stroke Survival
High Support + Adherent
Most
Least
Most
Least
Most
Low Support + Adherent
Least
High Support + Non-Adherent
Low Support + Non-Adherent
Level of Social Isolation
* p <.05
Most
Least
Respiratory
Cancer
Women
Men
12
10
10
8
6
4
2
*
*
*
8
6
4
Least
Most
Least
Most
Least
3.0
3.0
2.5
2.0
1.5
1.0
Most
Least
Most
Least
Most
Level of Social Isolation
* p <.05
Most
2.5
2.0
1.5
1.0
0.0
Most
Least
*
0.5
0.0
0
Most
3.5
0.5
2
0
Men
3.5
Hazard Ratio
12
Hazard Ratio
14
Hazard Ratio
Hazard Ratio
Women
14
Least
Most
Least
Most
Least
Most
Least
Most
Least
Most
Least
Level of Social Isolation
* p <.05
Least
Most
Least
Infectious Disease
Women
*
25
*
Men
*
25
*
Social Support and
Morbidity
*
20
Hazard Ratio
Hazard Ratio
20
*
15
10
5
15
10
5
0
0
Most
Least
Most
Least
Most
Least
Most
Least
Most
Least
Most
Least
Level of Social Isolation
* p <.05
Most
Least
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Kaplan-Meier survival estimates
0.00
Mortality Percentage
0.25
0.50
0.75
%
WithoutPercentage
Limitation
Limitation
1.00
Functional Decline
Incident Lower
Extremity Limitation
0
20
40
Months Since Interview
Low Support
High Support
60
80
Middle Support
Log rank test p < 0.001
Persistent Lower
Extremity Limitation
Pain Intensity
0.00
Mortality Percentage
0.25
0.50
0.75
%Limitation
WithoutPercentage
Limitation
1.00
Kaplan-Meier survival estimates
0
20
40
Months Since Interview
Low Support
High Support
60
80
Middle Support
Log rank test p < 0.001
Osteoarthritis and
Quality of Life
Risk of Falls
Age-adjusted annual fall rates by quartiles of social integration scores. ***p(trend)
=.001; **p(trend) =.01; *p (trend) ≤.05.
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Isolation vs. Traditional
Risk Factors
Women
2.5
2.0
1.5
1.0
*
Men
3.0
*
Hazard Ratio
3.0
Hazard Ratio
Social Isolation vs.
Traditional Clinical Risks
2.5
2.0
*
*
1.5
1.0
0.5
0.5
0.0
0.0
* p <0.05
Odds of Decreased
Mortality by Risk Factor
Potential Mechanisms
Potential Mechanisms
Less access to tangible resources (Cohen)
Less promotion of healthy behaviors (Berkman & Glass)
Less promotion of self-efficacy
Potential Mechanisms
Altered levels of CRP
(Ford et al., 2006)
(Berkman & Glass)
Upregulation of neuroendocrine activity (Seeman & McEwen)
Increased allostatic load (Berkman & Glass)
Increased CRP (Ford et al.)
Increased inflammatory gene expression (Cole et al.)
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Potential Mechanisms
Altered genome transcriptional activity
(Cole et al., 2007)
Implications
In Practice
Risk
monitoring
Do
you live with a partner? With anybody?
Do
you participate in a group activity?
How
Summary
often are you in contact with family/friends?
In
the past year, could you have used more
emotional support?
How much?
A little / some / a lot
Thanks for the
Social Support!
Social isolation is risk factor for many conditions
Mortality
All-cause
Cardiovascular
Respiratory
Infectious Disease
Morbidity
Functional decline
Pain
Poor quality of life
Fall risk
Social support is worth assessing
Don’t forget to take a social history!
References
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1976;104(2):107-123.
Engel G. A need for a new medical model: A challenge for biomedicine. Nature. 1977;196(4286):129-136.
Marmot M, Rose G, Shipley M, Hamilton P. Employment grade and coronary heart disease in British civil servants. Journal of Epidemiology
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Pantell M, Rehkopf D, Jutte D, Syme SL, Balmes J, Adler N. Social integration and mortality: An analysis of a national sample using the
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