Social Connection And Physical Health Statistics

Social Connection And Physical Health Statistics 2027

Social connection is associated with several physical-health outcomes, including survival, cardiovascular events, diabetes, frailty and kidney disease. The strength and interpretation vary with the measure, population, outcome and adjustment model.

What are the key social connection and physical-health estimates?

How should readers interpret these statistics?

TermInterpretation
LonelinessSubjective feeling of insufficient or unsatisfying connection.
Social isolationLimited contact, participation or network connection, measured differently across studies.
Living aloneA household arrangement; it does not establish loneliness or poor support.
Odds ratio (OR)A ratio of odds, not probabilities. Favorable survival coding is stated where used.
Hazard ratio (HR)A ratio of modeled event hazards over follow-up, not an absolute event chance.
Relative risk (RR)A ratio of risks over a source-defined period.
Pooled effect size (ES)Source label retained for the 2023 review; no specific ratio class imputed here.
95% confidence intervalUncertainty around an estimate under the source model;1 is the no-association ratio.
Absolute riskAn event probability over a specified period, requiring baseline-risk information not supplied by a ratio alone.

How are social relationships associated with survival?

The 2010 review coded stronger social relationships in the direction of higher survival odds. An odds ratio above 1 in this section therefore has a different interpretation from an adverse-outcome ratio above 1 elsewhere. Structural, functional and subtype analyses share underlying evidence.

How were stronger relationships associated with survival?

Observational synthesis with heterogeneous measures/adjustment. These are survival odds, not 50% longer life or absolute survival probabilities.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F01 All social-relationship measures
Meta-analysis
OR 1.5 (95% CI 1.42–1.59)
CI excludes 1
Stronger versus weaker social relationships
Higher ratio means greater survival odds with stronger relationships; Random-effects overall and main measurement categories
Literature search January 1900–January 2007; underlying cohort dates vary
Participants represented by the specified source analysis; Published analysis/model n=308,849; Published overall meta-analysis participant count; contributing studies=148
S01
Results: Omnibus analysis; structural, functional and combined sections
F02 Structural measures only
Meta-analysis
OR 1.57 (95% CI 1.46–1.7)
CI excludes 1
Greater structural connection
Higher ratio means greater survival odds with stronger relationships; Random-effects overall and main measurement categories
Literature search January 1900–January 2007; underlying cohort dates vary
Participants represented by the specified source analysis; Selected model/pooled n not established; contributing studies=63
S01
Results: Omnibus analysis; structural, functional and combined sections
F03 Functional measures only
Meta-analysis
OR 1.46 (95% CI 1.28–1.66)
CI excludes 1
Greater functional support
Higher ratio means greater survival odds with stronger relationships; Random-effects overall and main measurement categories
Literature search January 1900–January 2007; underlying cohort dates vary
Participants represented by the specified source analysis; Selected model/pooled n not established; contributing studies=24
S01
Results: Omnibus analysis; structural, functional and combined sections
F04 Combined structural/functional measures
Meta-analysis
OR 1.44 (95% CI 1.32–1.58)
CI excludes 1
Stronger combined relationship measures
Higher ratio means greater survival odds with stronger relationships; Random-effects overall and main measurement categories
Literature search January 1900–January 2007; underlying cohort dates vary
Participants represented by the specified source analysis; Selected model/pooled n not established; contributing studies=61
S01
Results: Omnibus analysis; structural, functional and combined sections

How did selected relationship measures differ?

Studies can contribute to several categories. Measurement differences do not show which type of relationship intervention works best. Received support and living-alone CIs include 1.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F05 Received social support
Meta-analysis
OR 1.22 (95% CI 0.91–1.63)
CI includes 1
More received support
Higher ratio means greater survival odds with stronger relationships; Table 4 measurement-specific synthesis
Literature search January 1900–January 2007; underlying cohort dates vary
Participants represented by the specified source analysis; Selected model/pooled n not established; contributing studies=9
S01
Table 4; source footnote on shifted units of analysis
F06 Perceived availability of support
Meta-analysis
OR 1.35 (95% CI 1.22–1.49)
CI excludes 1
More perceived support
Higher ratio means greater survival odds with stronger relationships; Table 4 measurement-specific synthesis
Literature search January 1900–January 2007; underlying cohort dates vary
Participants represented by the specified source analysis; Selected model/pooled n not established; contributing studies=73
S01
Table 4; source footnote on shifted units of analysis
F07 Complex social integration measures
Meta-analysis
OR 1.91 (95% CI 1.63–2.23)
CI excludes 1
Greater integration
Higher ratio means greater survival odds with stronger relationships; Table 4 measurement-specific synthesis
Literature search January 1900–January 2007; underlying cohort dates vary
Participants represented by the specified source analysis; Selected model/pooled n not established; contributing studies=30
S01
Table 4; source footnote on shifted units of analysis
F08 Living arrangement, inverse coded
Meta-analysis
OR 1.19 (95% CI 0.99–1.44)
CI includes 1
Not living alone versus living alone, source inverse coding
Higher ratio means greater survival odds with stronger relationships; Table 4 measurement-specific synthesis
Literature search January 1900–January 2007; underlying cohort dates vary
Participants represented by the specified source analysis; Selected model/pooled n not established; contributing studies=17
S01
Table 4; source footnote on shifted units of analysis

What do mortality reviews show about disconnection?

Loneliness, social isolation and living alone are related but distinct exposures. Reviews differ in ages, health conditions, measures and included cohorts. Cause-specific mortality is not disease incidence. The 2023 review retains its ES label; the 2025 older-adult review reports HRs, including uncertain cancer estimates.

What did the 90-cohort mortality review report?

ES is the source label; no specific HR/RR/OR class or risk-percentage conversion is imposed. Selected GRADE certainty low/very low. Analysis n values overlap across outcomes.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F09 Isolation: all-cause mortality
Meta-analysis
ES 1.32 (95% CI 1.26–1.39)
CI excludes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Source pooled effect size; cancer-isolation value is trim-and-fill adjusted
2023 review; underlying cohort dates vary; exact search cutoff not established from inspected public materials
Participants represented by the specified source analysis; Published analysis/model n=1,485,469; Published Supplementary Table 11 analysis participant count; overlapping outcomes are not additive; contributing studies=38
S02
Original abstract; Supplementary Table 11, printed pp.64–65
F10 Loneliness: all-cause mortality
Meta-analysis
ES 1.14 (95% CI 1.08–1.2)
CI excludes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Source pooled effect size; cancer-isolation value is trim-and-fill adjusted
2023 review; underlying cohort dates vary; exact search cutoff not established from inspected public materials
Participants represented by the specified source analysis; Published analysis/model n=1,209,407; Published Supplementary Table 11 analysis participant count; overlapping outcomes are not additive; contributing studies=45
S02
Original abstract; Supplementary Table 11, printed pp.64–65
F11 Isolation: cancer mortality, bias-adjusted
Meta-analysis
ES 1.24 (95% CI 1.19–1.28)
CI excludes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Supplementary Table 11 trim-and-fill-adjusted ES; raw pooled ES 1.22
2023 review; underlying cohort dates vary; exact search cutoff not established from inspected public materials
Participants represented by the specified source analysis; Published analysis/model n=1,171,644; Published Supplementary Table 11 analysis participant count; overlapping outcomes are not additive; contributing studies=11
S02
Original abstract; Supplementary Table 11, printed pp.64–65
F12 Loneliness: cancer mortality
Meta-analysis
ES 1.09 (95% CI 1.01–1.17)
CI excludes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Source pooled effect size; cancer-isolation value is trim-and-fill adjusted
2023 review; underlying cohort dates vary; exact search cutoff not established from inspected public materials
Participants represented by the specified source analysis; Published analysis/model n=476,404; Published Supplementary Table 11 analysis participant count; overlapping outcomes are not additive; contributing studies=3
S02
Original abstract; Supplementary Table 11, printed pp.64–65
F13 Isolation: cardiovascular mortality
Meta-analysis
ES 1.34 (95% CI 1.25–1.44)
CI excludes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Source pooled effect size; cancer-isolation value is trim-and-fill adjusted
2023 review; underlying cohort dates vary; exact search cutoff not established from inspected public materials
Participants represented by the specified source analysis; Published analysis/model n=1,265,108; Published Supplementary Table 11 analysis participant count; overlapping outcomes are not additive; contributing studies=12
S02
Original abstract; Supplementary Table 11, printed pp.64–65

What did that review report in clinical populations?

Disease-specific populations, not general-population incidence. Related cohort contributions are not independent replications or treatment trials.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F14 Prior CVD: isolation and all-cause death
Meta-analysis
ES 1.28 (95% CI 1.1–1.48)
CI excludes 1
Social isolation in people with CVD
Higher ratio means more adverse outcome in the exposed group; Source pooled effect size, clinical-population strata
2023 review; underlying cohort dates vary; exact search cutoff not established from inspected public materials
Participants with cardiovascular disease; Published analysis/model n=487,722; Published Supplementary Table 11 analysis participant count; overlapping outcomes are not additive; contributing studies=8
S02
Original abstract; Supplementary Table 11, printed pp.64–65
F15 Breast cancer: isolation and all-cause death
Meta-analysis
ES 1.51 (95% CI 1.34–1.7)
CI excludes 1
Social isolation in breast cancer
Higher ratio means more adverse outcome in the exposed group; Source pooled effect size, clinical-population strata
2023 review; underlying cohort dates vary; exact search cutoff not established from inspected public materials
Participants with breast cancer; Published analysis/model n=18,955; Published Supplementary Table 11 analysis participant count; overlapping outcomes are not additive; contributing studies=4
S02
Original abstract; Supplementary Table 11, printed pp.64–65
F16 Breast cancer: isolation and cancer death
Meta-analysis
ES 1.33 (95% CI 1.02–1.75)
CI excludes 1
Social isolation in breast cancer
Higher ratio means more adverse outcome in the exposed group; Source pooled effect size, clinical-population strata
2023 review; underlying cohort dates vary; exact search cutoff not established from inspected public materials
Participants with breast cancer; Published analysis/model n=18,955; Published Supplementary Table 11 analysis participant count; overlapping outcomes are not additive; contributing studies=4
S02
Original abstract; Supplementary Table 11, printed pp.64–65

How was loneliness associated with mortality in older adults?

Older-adult/clinical populations; heterogeneous measurement and adjustments. Outcomes and samples overlap. Single-study outcomes are explicitly marked; cancer CIs crossing 1 are not conclusive increases.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F17 All-cause mortality
Meta-analysis
HR 1.14 (95% CI 1.1–1.18)
CI excludes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=308,948; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=52
S03
Results: Loneliness primary/secondary mortality outcomes
F18 CVD mortality
Meta-analysis
HR 1.3 (95% CI 1.09–1.54)
CI excludes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=37,104; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=6
S03
Results: Loneliness primary/secondary mortality outcomes
F19 Cancer mortality: one study
Meta-analysis
HR 1.02 (95% CI 0.68–1.53)
CI includes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=6,915; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=1
S03
Results: Loneliness primary/secondary mortality outcomes

How was social isolation associated with mortality in older adults?

Older-adult/clinical populations; heterogeneous measurement and adjustments. Outcomes and samples overlap. Single-study outcomes are explicitly marked; cancer CIs crossing 1 are not conclusive increases.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F20 All-cause mortality
Meta-analysis
HR 1.35 (95% CI 1.27–1.43)
CI excludes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=233,279; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=37
S03
Results: Social isolation primary/secondary mortality outcomes
F21 CVD mortality
Meta-analysis
HR 1.37 (95% CI 1.19–1.56)
CI excludes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=63,434; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=4
S03
Results: Social isolation primary/secondary mortality outcomes
F22 Cancer mortality
Meta-analysis
HR 1.13 (95% CI 0.98–1.29)
CI includes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=54,759; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=5
S03
Results: Social isolation primary/secondary mortality outcomes
F23 Other mortality: one study
Meta-analysis
HR 1.24 (95% CI 1.03–1.49)
CI excludes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=30,430; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=1
S03
Results: Social isolation primary/secondary mortality outcomes

How was living alone associated with mortality in older adults?

Older-adult/clinical populations; heterogeneous measurement and adjustments. Outcomes and samples overlap. Single-study outcomes are explicitly marked; cancer CIs crossing 1 are not conclusive increases.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F24 All-cause mortality
Meta-analysis
HR 1.21 (95% CI 1.13–1.3)
CI excludes 1
Living alone
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=86,553; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=17
S03
Results: Living alone primary/secondary mortality outcomes
F25 CVD mortality
Meta-analysis
HR 1.37 (95% CI 1.17–1.61)
CI excludes 1
Living alone
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=4,868; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=2
S03
Results: Living alone primary/secondary mortality outcomes
F26 Cancer mortality: one study
Meta-analysis
HR 1.36 (95% CI 0.98–1.89)
CI includes 1
Living alone
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=1,522; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=1
S03
Results: Living alone primary/secondary mortality outcomes
F27 Other mortality: one study
Meta-analysis
HR 1.76 (95% CI 1.29–2.4)
CI excludes 1
Living alone
Higher ratio means more adverse outcome in the exposed group; Random-effects outcome synthesis; one-study rows retain that single estimate
Literature search through December 31, 2023; cohort dates and follow-up vary
Older adults represented in the review, including selected clinical populations; Published analysis/model n=1,522; Published outcome-specific meta-analysis participant count; not additive across outcomes; contributing studies=1
S03
Results: Living alone primary/secondary mortality outcomes
Chart 1. Dots are pooled HRs; lines are 95% CIs. Measures/populations overlap and differ; this is not a causal ranking. No-association value is 1. Original source [S03].

What do studies find for heart disease and stroke?

The 2016 pooled relative risks and the 2018 UK Biobank models answer different questions. In the UK cohort, broader adjustment substantially attenuated the incident-event associations. Keeping the fully adjusted confidence intervals visible prevents a point estimate from being mistaken for a conclusive increase.

What were the pooled CHD and stroke associations?

Poor social relationships combines loneliness/isolation measures. RR is relative risk, not absolute probability. These observational findings do not establish prevention by intervention.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F28 Coronary heart disease incidence
Meta-analysis
RR 1.29 (95% CI 1.04–1.59)
CI excludes 1
Poorer social relationships
Higher ratio means more adverse outcome in the exposed group; Most adjusted estimates; random-effects pooling
Studies published through May 2015; follow-up 3–21 years
Participants represented by the specified source analysis; Selected model/pooled n not established; contributing studies=11
S04
Abstract; pooled results and source forest plots
F29 Stroke incidence
Meta-analysis
RR 1.32 (95% CI 1.04–1.68)
CI excludes 1
Poorer social relationships
Higher ratio means more adverse outcome in the exposed group; Most adjusted estimates; random-effects pooling
Studies published through May 2015; follow-up 3–21 years
Participants represented by the specified source analysis; Selected model/pooled n not established; contributing studies=8
S04
Abstract; pooled results and source forest plots

What did demographic-only cardiovascular models show?

These estimates precede broader risk-factor adjustment and are related to the later models below. The isolation–AMI demographic estimate is omitted because of a CI typographical issue in the inspected abstract.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F30 Isolation and first stroke: demographic model
Cohort study
HR 1.39 (95% CI 1.25–1.54)
CI excludes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Demographic adjustment
UK Biobank baseline 2006–2010; reported follow-up 7.1 years; exact administrative cutoff not established from abstract
Participants represented by the specified source analysis; Selected model/pooled n not established
S05
Original author abstract, demographic-adjusted results
F31 Loneliness and first heart attack: demographic model
Cohort study
HR 1.49 (95% CI 1.36–1.64)
CI excludes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Demographic adjustment
UK Biobank baseline 2006–2010; reported follow-up 7.1 years; exact administrative cutoff not established from abstract
Participants represented by the specified source analysis; Selected model/pooled n not established
S05
Original author abstract, demographic-adjusted results
F32 Loneliness and first stroke: demographic model
Cohort study
HR 1.36 (95% CI 1.2–1.55)
CI excludes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Demographic adjustment
UK Biobank baseline 2006–2010; reported follow-up 7.1 years; exact administrative cutoff not established from abstract
Participants represented by the specified source analysis; Selected model/pooled n not established
S05
Original author abstract, demographic-adjusted results

What happened after broader cardiovascular adjustment?

All four 95% CIs include 1. This is important uncertainty, not proof that connection has no health relevance. Model attenuation does not establish what an intervention would do.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F33 Isolation and first heart attack: fully adjusted
Cohort study
HR 1.07 (95% CI 0.99–1.16)
CI includes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Fully adjusted as described by authors
UK Biobank baseline 2006–2010; reported follow-up 7.1 years; exact administrative cutoff not established from abstract
Participants represented by the specified source analysis; Selected model/pooled n not established
S05
Original author abstract, fully adjusted results
F34 Isolation and first stroke: fully adjusted
Cohort study
HR 1.06 (95% CI 0.96–1.19)
CI includes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Fully adjusted as described by authors
UK Biobank baseline 2006–2010; reported follow-up 7.1 years; exact administrative cutoff not established from abstract
Participants represented by the specified source analysis; Selected model/pooled n not established
S05
Original author abstract, fully adjusted results
F35 Loneliness and first heart attack: fully adjusted
Cohort study
HR 1.06 (95% CI 0.96–1.17)
CI includes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Fully adjusted as described by authors
UK Biobank baseline 2006–2010; reported follow-up 7.1 years; exact administrative cutoff not established from abstract
Participants represented by the specified source analysis; Selected model/pooled n not established
S05
Original author abstract, fully adjusted results
F36 Loneliness and first stroke: fully adjusted
Cohort study
HR 1.04 (95% CI 0.91–1.19)
CI includes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Fully adjusted as described by authors
UK Biobank baseline 2006–2010; reported follow-up 7.1 years; exact administrative cutoff not established from abstract
Participants represented by the specified source analysis; Selected model/pooled n not established
S05
Original author abstract, fully adjusted results
Chart 2. All four 95% CIs include 1. Fully adjusted observational models; exact selected outcome bases unavailable. Do not present the point estimates alone as conclusive risk increases. Original source [S05].

Was isolation associated with death after prior cardiovascular disease?

Mortality among participants with a prior event, not the chance of developing that event. Exact selected subgroup/model n unavailable.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F37 Isolation after prior heart attack
Cohort study
HR 1.25 (95% CI 1.03–1.51)
CI excludes 1
Social isolation with prior AMI
Higher ratio means more adverse outcome in the exposed group; Fully adjusted; prior-disease subgroup
UK Biobank baseline 2006–2010; reported follow-up 7.1 years; exact administrative cutoff not established from abstract
UK Biobank participants with prior AMI; Selected model/pooled n not established
S05
Original author abstract, prior AMI/stroke mortality
F38 Isolation after prior stroke
Cohort study
HR 1.32 (95% CI 1.08–1.61)
CI excludes 1
Social isolation with prior stroke
Higher ratio means more adverse outcome in the exposed group; Fully adjusted; prior-disease subgroup
UK Biobank baseline 2006–2010; reported follow-up 7.1 years; exact administrative cutoff not established from abstract
UK Biobank participants with prior stroke; Selected model/pooled n not established
S05
Original author abstract, prior AMI/stroke mortality

What do prospective diabetes studies show?

The 2023 paper studied UK Biobank and CHARLS separately. Their isolation definitions and health-data systems differ. The selected rows use each cohort’s Model 3, including clinical and lifestyle covariates. They are related contrasts, not five separate studies or evidence that any one person will develop diabetes.

What did the UK diabetes cohort show?

Different isolation contrasts. Published UK model cohort includes all levels, not only the exposed group. HRs are not absolute diabetes probabilities; adjustment cannot eliminate all confounding.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F39 UK: most versus least isolated
Cohort study
HR 1.17 (95% CI 1.11–1.23)
CI excludes 1
Most versus least isolated
Higher ratio means more adverse outcome in the exposed group; Fully adjusted Model 3
UK baseline 2006–2010, mean follow-up 13.5 years, records with varying cutoffs through 2022; CHARLS 2011–2018, mean follow-up 5.8 years
UK Biobank analytic cohort without baseline diabetes; Published analysis/model n=423,503; Published UK cohort model base across exposure categories; covariate missingness handled per methods
S06
Table 2, separate effects, Model 3
F40 UK: lonely versus not lonely
Cohort study
HR 1.21 (95% CI 1.13–1.3)
CI excludes 1
Lonely versus not lonely
Higher ratio means more adverse outcome in the exposed group; Fully adjusted Model 3
UK baseline 2006–2010, mean follow-up 13.5 years, records with varying cutoffs through 2022; CHARLS 2011–2018, mean follow-up 5.8 years
UK Biobank analytic cohort without baseline diabetes; Published analysis/model n=423,503; Published UK cohort model base across exposure categories; covariate missingness handled per methods
S06
Table 2, separate effects, Model 3
F41 UK: moderately versus least isolated
Cohort study
HR 1.06 (95% CI 1.02–1.11)
CI excludes 1
Moderately versus least isolated
Higher ratio means more adverse outcome in the exposed group; Fully adjusted Model 3
UK baseline 2006–2010, mean follow-up 13.5 years, records with varying cutoffs through 2022; CHARLS 2011–2018, mean follow-up 5.8 years
UK Biobank analytic cohort without baseline diabetes; Published analysis/model n=423,503; Published UK cohort model base across exposure categories; covariate missingness handled per methods
S06
Table 2, separate effects, Model 3

What did the Chinese diabetes cohort show?

CHARLS exposure instruments differ from UK Biobank. Similar point estimates do not prove identical effects or independent evidence from other CHARLS publications.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F42 CHARLS: isolated versus not isolated
Cohort study
HR 1.22 (95% CI 1.06–1.4)
CI excludes 1
Isolated versus not isolated
Higher ratio means more adverse outcome in the exposed group; Fully adjusted Model 3
UK baseline 2006–2010, mean follow-up 13.5 years, records with varying cutoffs through 2022; CHARLS 2011–2018, mean follow-up 5.8 years
Chinese CHARLS analytic cohort, adults 45+, without baseline diabetes; Published analysis/model n=13,800; Published CHARLS cohort model base across exposure categories; covariate missingness handled per methods
S06
Table 3, separate effects, Model 3
F43 CHARLS: lonely versus not lonely
Cohort study
HR 1.21 (95% CI 1.07–1.36)
CI excludes 1
Lonely versus not lonely
Higher ratio means more adverse outcome in the exposed group; Fully adjusted Model 3
UK baseline 2006–2010, mean follow-up 13.5 years, records with varying cutoffs through 2022; CHARLS 2011–2018, mean follow-up 5.8 years
Chinese CHARLS analytic cohort, adults 45+, without baseline diabetes; Published analysis/model n=13,800; Published CHARLS cohort model base across exposure categories; covariate missingness handled per methods
S06
Table 3, separate effects, Model 3
Chart 3. Different instruments and contrasts across cohorts; related models share samples. Lines are 95% CIs; no absolute diabetes probability or intervention effect is estimated. Original source [S06].

How is social connection associated with frailty?

Frailty studies consider weakness, weight loss, exhaustion, activity and walking speed. The meta-analysis and cohort estimates are odds ratios. Cross-sectional associations at baseline differ from prospective estimates at repeat assessment. New publication dates can describe much older collection periods.

What did the 2026 frailty meta-analysis report?

Odds ratios, not relative risks. High heterogeneity, especially isolation I²95.1%; exposure-specific pooled counts unavailable in abstract. Estimates do not establish screening or treatment benefit.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F44 Isolation and frailty: pooled cohorts
Meta-analysis
OR 1.31 (95% CI 1.16–1.48)
CI excludes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Random-effects odds ratios
Included cohort publications 2018–2025; exact search date/underlying collection periods not established in abstract
Participants represented by the specified source analysis; Selected model/pooled n not established
S07
Original author abstract, Results
F45 Loneliness and frailty: pooled cohorts
Meta-analysis
OR 1.83 (95% CI 1.76–1.89)
CI excludes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Random-effects odds ratios
Included cohort publications 2018–2025; exact search date/underlying collection periods not established in abstract
Participants represented by the specified source analysis; Selected model/pooled n not established
S07
Original author abstract, Results

What were the baseline frailty associations?

Baseline associations cannot establish temporal direction. The reported baseline cohort 447322 is not automatically the exact selected model n.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F46 Loneliness and frailty: cross-sectional
Cohort study
OR 2.344 (95% CI 2.211–2.484)
CI excludes 1
Loneliness
Higher ratio means more adverse outcome in the exposed group; Cross-sectional baseline analysis; adjustment details not fully established from abstract
Baseline 2006–2010; repeat assessment 2012–2013
Participants represented by the specified source analysis; Selected model/pooled n not established
S08
Original author abstract, baseline results
F47 Isolation and frailty: cross-sectional
Cohort study
OR 2.02 (95% CI 1.926–2.117)
CI excludes 1
Social isolation
Higher ratio means more adverse outcome in the exposed group; Cross-sectional baseline analysis; adjustment details not fully established from abstract
Baseline 2006–2010; repeat assessment 2012–2013
Participants represented by the specified source analysis; Selected model/pooled n not established
S08
Original author abstract, baseline results

What were the prospective frailty associations?

Same underlying UK cohort as baseline and overlapping other UK Biobank papers. Data collected 2006–2013, although paper published 2026. Follow-up sample is not the full baseline sample.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F48 Loneliness and frailty: prospective
Cohort study
OR 2.484 (95% CI 1.773–3.48)
CI excludes 1
Baseline loneliness
Higher ratio means more adverse outcome in the exposed group; Prospective repeat-assessment analysis; exact eligible model n unavailable
Baseline 2006–2010; repeat assessment 2012–2013
Participants represented by the specified source analysis; Selected model/pooled n not established
S08
Original author abstract, prospective results
F49 Isolation and frailty: prospective
Cohort study
OR 1.488 (95% CI 1.115–1.987)
CI excludes 1
Baseline isolation
Higher ratio means more adverse outcome in the exposed group; Prospective repeat-assessment analysis; exact eligible model n unavailable
Baseline 2006–2010; repeat assessment 2012–2013
Participants represented by the specified source analysis; Selected model/pooled n not established
S08
Original author abstract, prospective results
Chart 4. Repeat-assessment ORs with 95% CIs, not risk ratios. Exact prospective model n unavailable; publication year differs from collection years. No-association value is 1. Original source [S08].

What do the kidney-disease models show?

The kidney paper provides a useful example of why model choice matters. Its abstract incidence estimates correspond to Model 1. The fully adjusted Model 3 values are smaller. Mortality among participants with existing CKD is a separate outcome and population from new CKD among initially unaffected participants.

Which kidney-incidence estimates appear in the abstract?

These abstract figures are Model 1, not the fully adjusted estimates. They concern new CKD among those without baseline CKD. Table cohort n 406332; exact complete-case model count not separately established.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F50 Isolation and incident CKD: Model 1
Cohort study
HR 1.21 (95% CI 1.17–1.26)
CI excludes 1
Most versus least isolated
Higher ratio means more adverse outcome in the exposed group; Model 1: demographic/socioeconomic adjustment
UK Biobank baseline 2006–2010; median follow-up 13.5 years; exact cutoff not established in this compilation
Participants represented by the specified source analysis; Selected model/pooled n not established
S09
Abstract; Table 2, Model 1
F51 Loneliness and incident CKD: Model 1
Cohort study
HR 1.26 (95% CI 1.21–1.33)
CI excludes 1
Lonely versus not lonely
Higher ratio means more adverse outcome in the exposed group; Model 1: demographic/socioeconomic adjustment
UK Biobank baseline 2006–2010; median follow-up 13.5 years; exact cutoff not established in this compilation
Participants represented by the specified source analysis; Selected model/pooled n not established
S09
Abstract; Table 2, Model 1

What were the fully adjusted kidney-incidence estimates?

Same source cohort/model sequence, not an independent replication or intervention. Estimates attenuate after adjustment. Table cohort n 406332; complete-case model count not separately established.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F52 Isolation and incident CKD: Model 3
Cohort study
HR 1.09 (95% CI 1.04–1.13)
CI excludes 1
Most versus least isolated
Higher ratio means more adverse outcome in the exposed group; Model 3: broader lifestyle, clinical and genetic adjustment
UK Biobank baseline 2006–2010; median follow-up 13.5 years; exact cutoff not established in this compilation
Participants represented by the specified source analysis; Selected model/pooled n not established
S09
Table 2, Model 3 and covariate footnotes
F53 Loneliness and incident CKD: Model 3
Cohort study
HR 1.12 (95% CI 1.08–1.19)
CI excludes 1
Lonely versus not lonely
Higher ratio means more adverse outcome in the exposed group; Model 3: broader lifestyle, clinical and genetic adjustment
UK Biobank baseline 2006–2010; median follow-up 13.5 years; exact cutoff not established in this compilation
Participants represented by the specified source analysis; Selected model/pooled n not established
S09
Table 2, Model 3 and covariate footnotes

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What were the mortality associations among people with CKD?

Different population/outcome from CKD incidence. Table cohort n 60331; exact complete-case model counts not separately established. Mortality associations are not individual life-expectancy predictions.

Finding / designEstimate and 95% CIExposure, direction and modelPeriod, population and baseOriginal source
F54 Isolation and mortality with baseline CKD
Cohort study
HR 1.33 (95% CI 1.26–1.4)
CI excludes 1
Most versus least isolated
Higher ratio means more adverse outcome in the exposed group; Model 3 in participants with baseline CKD
UK Biobank baseline 2006–2010; median follow-up 13.5 years; exact cutoff not established in this compilation
UK Biobank participants with CKD at baseline; table cohort 60331; Selected model/pooled n not established
S09
Table 3, Model 3 and covariate footnotes
F55 Loneliness and mortality with baseline CKD
Cohort study
HR 1.1 (95% CI 1.03–1.17)
CI excludes 1
Lonely versus not lonely
Higher ratio means more adverse outcome in the exposed group; Model 3 in participants with baseline CKD
UK Biobank baseline 2006–2010; median follow-up 13.5 years; exact cutoff not established in this compilation
UK Biobank participants with CKD at baseline; table cohort 60331; Selected model/pooled n not established
S09
Table 3, Model 3 and covariate footnotes

What does a ratio-minus-one calculation mean?

The workbook converts ten selected ratios and their interval bounds into relative contrasts using point estimate minus 1. For example, HR 1.17 corresponds to 17% higher modeled hazard, while OR 1.50 corresponds to 50% higher odds in its stated direction. These are neither percentage-point differences nor absolute probabilities.

FindingMetric-specific interpretationPoint contrastInterval contrast
F01relative odds of survival50.0%42.0% to 59.0%
F17relative hazard14.0%10.0% to 18.0%
F20relative hazard35.0%27.0% to 43.0%
F28relative risk29.0%4.0% to 59.0%
F29relative risk32.0%4.0% to 68.0%
F33relative hazard7.0%-1.0% to 16.0%
F39relative hazard17.0%11.0% to 23.0%
F48relative odds of the adverse outcome148.4%77.3% to 248.0%
F52relative hazard9.0%4.0% to 13.0%
F53relative hazard12.0%8.0% to 19.0%

Methodology and limitations

This resource selects 55 point estimates, each with a 95% confidence interval, in 19 related groups from nine peer-reviewed papers. Five reviews contribute 31 estimates; four cohort papers contribute 24. There are 14 ORs,31 HRs, two RRs and eight pooled ES values retaining their source label. Repeated models, categories, outcomes and reviews are not independent studies.

2027 is the editorial edition, reviewed November 6, 2026. Publication years range from 2010 to 2026, while collection and review-search periods are stated separately. The 2026 frailty cohort paper uses baseline 2006–2010 and repeat 2012–2013 data. This is a selected research reference, not a prospectively registered exhaustive review or a pooled analysis conducted by MyLittleDesire.

Loneliness is a subjective feeling; isolation describes limited social connection/contact; living alone is a household arrangement. Stronger support, larger networks and household composition are not interchangeable. Exposures and reference groups retain their study definitions. Mortality, new disease and baseline frailty are separate endpoints.

OR, HR and RR are not interchangeable. An OR compares odds; an HR compares event hazards over follow-up under the model; an RR compares risks over a defined period. ES is retained for Wang et al. because its public tables use that pooled label across studies reporting different ratio measures. No specific class is imputed and those ES values are excluded from metric-specific percentage calculations. An association ratio cannot supply an individual absolute probability without the relevant baseline risk and time horizon.

Holt-Lunstad et al. coded values above 1 toward greater survival with stronger relationships. The OR 1.50 is therefore 50% higher survival odds, not 50 percentage points,50% longer life or a 50% reduction in death risk. Its Table 4 subtypes reuse studies and differ from the main measurement categories. Some study estimates used relatively limited adjustment. A received-support CI crossing 1 is retained.

Wang et al.’s public abstract and Supplementary Table 11 were inspected. The isolation–cancer estimate 1.24 is a trim-and-fill adjustment for possible publication bias; the raw pooled value is 1.22. These are not independent results. Other selected estimates retain their specified population/model. The source’s selected certainty ratings are low or very low, and publication-bias sensitivity changes some estimates. Its full overall 2,205,199 is not assigned to each row; table-specific analysis counts are retained and must not be summed.

Nakou et al. searched through December 2023 and included 86 studies. Some secondary outcomes use one study. Heterogeneity is substantial and all-cause prediction intervals include 1, so pooled confidence intervals do not describe the range of effects expected in every future setting. Outcome-specific participant counts overlap. Cancer estimates whose confidence intervals include 1 are not described as established associations. No unique worldwide sample size is created by adding reviews.

Hakulinen et al.’s demographic and fully adjusted UK models differ. All four selected fully adjusted incident-event intervals include 1. Broader adjustment may involve confounding and mediating factors; attenuation is not an experimentally measured treatment effect. The exact selected event/subgroup model sizes are unavailable in the inspected abstract. A demographic isolation–AMI CI contains an extraneous typographical dash, so that model is omitted instead of repaired without verification.

Song et al.’s full text and Tables 2–3 establish UK and CHARLS Model 3 estimates. Published cohort-model bases are 423,503 and 13,800, with covariate missingness handled through imputation or unknown categories. Model bases include reference and other exposure levels. MR estimates and population-attributable fractions are not counted here. Other papers using UK Biobank can overlap these participants.

Zhao et al.’s frailty review and Zhou et al.’s cohort estimates were checked in their original author abstracts; complete statistical details and selected model bases were not established from full reports. High isolation heterogeneity and the unknown smaller prospective UK sample remain visible. Cross-sectional associations do not establish temporal order, and frailty odds ratios should not be called equal-sized risk increases.

Guo et al.’s full Tables 2–3 distinguish Model 1 from Model 3. Abstract incidence values 1.21/1.26 are Model 1; Model 3 is 1.09/1.12. Mortality Model 3 among CKD patients is 1.33/1.10. Table cohorts are 406,332 without and 60,331 with CKD; exact complete-case model counts are not separately established here. All models share the source cohort and cannot be counted as replication.

Nine selected confidence intervals include 1. This is uncertainty compatible with the no-association value at the stated confidence level, not proof that the true effect is exactly zero. Confidence intervals and study covariate adjustment do not rule out residual confounding, reverse causation, measurement error or selection bias. These estimates do not establish how much a social intervention would change disease incidence or mortality, and they do not support treating social isolation as literally equivalent to smoking a fixed number of cigarettes.

Questions readers ask

Does a 50% survival-odds association mean living 50% longer?

No. The 2010 estimate is an odds ratio under the study’s survival coding. It does not measure lifespan extension, absolute survival improvement or a randomized treatment effect.

Does loneliness cause heart disease or diabetes?

These selected observational estimates do not establish a treatment effect or rule out confounding and reverse causation. Model definitions and adjustment choices matter.

Why include estimates whose intervals cross 1?

Omitting them would hide uncertainty. They are compatible with the no-association value under the source model and should not be presented as conclusive increases.

Can these papers tell me my personal disease risk?

A ratio alone cannot supply an individual probability. Baseline risk, follow-up time, clinical factors and the source population would be needed.

Are living alone, isolation and loneliness the same?

No. Someone can live alone with a strong network, or feel lonely despite frequent contact. The exposures should retain their original definitions.

Related social-connection research

Explore our loneliness statistics, friendship statistics, and social support during life changes statistics.

Original papers and methods

  1. Holt-Lunstad, Smith & Layton / PLOS Medicine [S01] — Social Relationships and Mortality Risk: A Meta-analytic Review
    Published: July 27, 2010. Period: Literature search January 1900–January 2007; underlying cohort dates vary. Full source/starting analytic n=308,849, not automatically every model’s base. 148 contributing study/cohort collections in source. Random-effects synthesis of prospective observational studies; transformed odds ratios coded so higher values favor survival with stronger relationships. The overall OR 1.50 concerns survival odds, not 50% longer life,50 percentage points or an intervention effect. Main structural/functional/combined categories differ from Table 4 subtype analyses that reuse studies. Some source models used minimal adjustment. Table 4 selected participant counts not supplied; k is contributing studies, not people. Original companion/full-text source.
  2. Wang et al. / Nature Human Behaviour [S02] — A systematic review and meta-analysis of 90 cohort studies of social isolation, loneliness and mortality
    Published: June 19, 2023. Period: 2023 review; underlying cohort dates vary; exact search cutoff not established from inspected public materials. Full source/starting analytic n=2,205,199, not automatically every model’s base. 90 contributing study/cohort collections in source. Prospective-cohort meta-analysis; original abstract and public Supplementary Table 11 inspected; estimates retain the source label ES. Source tables combine literature reporting HR/RR and label pooled values ES; this compilation does not impute a specific HR/RR/OR class or convert ES to risk percentages. Isolation–cancer 1.24 is the trim-and-fill-adjusted estimate; raw pooled value 1.22 is not substituted. Source GRADE ratings are low/very low for selected outcomes. Cohorts and outcomes overlap; analysis participant counts are not additive. Original companion/full-text source.
  3. Nakou et al. / Aging Clinical and Experimental Research [S03] — Loneliness, social isolation, and living alone: a comprehensive systematic review, meta-analysis, and meta-regression of mortality risks in older adults
    Published: January 21, 2025. Period: Literature search through December 31, 2023; cohort dates and follow-up vary. No unique/full participant count assigned here; see source-specific bases. 86 contributing study/cohort collections in source. Random-effects HR synthesis of prospective/longitudinal older-adult studies, including some clinical populations. No unique overall participant count is assigned across overlapping exposures/outcomes. Outcome-specific published analysis counts retained. Some secondary outcomes rely on one study. Heterogeneity/publication bias affect interpretation; all-cause prediction intervals include 1. Cancer CIs crossing 1 are retained, not described as established increases. Original companion/full-text source.
  4. Valtorta et al. / Heart [S04] — Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies
    Published: Online April 18, 2016; journal issue July 2016. Period: Studies published through May 2015; follow-up 3–21 years. Full source/starting analytic n=181,006, not automatically every model’s base. 16 contributing study/cohort collections in source. Longitudinal observational review,23 papers from 16 studies; pooled relative risks from 11 CHD and 8 stroke studies using most adjusted models. Poor social relationships combines loneliness/isolation measures; it is not a single loneliness item. Outcome-specific participant totals not separately established here. Relative risk does not provide absolute event probability or prove that a connection intervention prevents disease. Original companion/full-text source.
  5. Hakulinen et al. / Heart [S05] — Social isolation and loneliness as risk factors for myocardial infarction, stroke and mortality: UK Biobank cohort study of 479054 men and women
    Published: 2018; Heart 104:1536–1542. Period: UK Biobank baseline 2006–2010; reported follow-up 7.1 years; exact administrative cutoff not established from abstract. Full source/starting analytic n=479,054, not automatically every model’s base. 1 contributing study/cohort collections in source. Prospective observational cohort; demographic and more extensively adjusted Cox models; selected estimates from original author abstract/cohort publication record. Full cohort count is not assigned to each incident-outcome or prior-disease model. Incident fully adjusted estimates all have CIs including 1. Changes between models are not effects of treatment or proof a mechanism is fully explained. The demographic isolation–AMI abstract CI contains a typographical dash; that model estimate is omitted rather than silently repaired. Original companion/full-text source.
  6. Song et al. / eClinicalMedicine [S06] — Social isolation, loneliness, and incident type 2 diabetes mellitus: results from two large prospective cohorts in Europe and East Asia and Mendelian randomization
    Published: September 21, 2023; October 2023 collection. Period: UK baseline 2006–2010, mean follow-up 13.5 years, records with varying cutoffs through 2022; CHARLS 2011–2018, mean follow-up 5.8 years. No unique/full participant count assigned here; see source-specific bases. 2 contributing study/cohort collections in source. Prospective UK Biobank and CHARLS Cox analyses; fully adjusted Model 3 estimates selected from Tables 2–3. UK cohort 423503, CHARLS 13800; missing covariates imputed or treated as unknown categories per methods. Published model cohort bases retained, not only the exposed subgroup. Exposure definitions differ between cohorts. MR and population-attributable fractions are not included in this dataset; observational HRs are not treatment effects. Original companion/full-text source.
  7. Zhao et al. / Archives of Gerontology and Geriatrics [S07] — Social isolation, loneliness and the risk of Frailty status: a meta-analysis of observational studies
    Published: Online March 17, 2026; July 2026 issue. Period: Included cohort publications 2018–2025; exact search date/underlying collection periods not established in abstract. Full source/starting analytic n=78,769, not automatically every model’s base. 8 contributing study/cohort collections in source. Random-effects odds-ratio synthesis of cohort studies; selected estimates and CIs verified in original author abstract. Exact exposure-specific pooled bases not supplied in inspected abstract. Isolation heterogeneity I²95.1%; loneliness I²43.4%. A larger odds ratio does not establish a stronger causal effect or that screening prevents frailty. Full report methods not inspected. Original companion/full-text source.
  8. Zhou et al. / Aging & Mental Health [S08] — Loneliness, social isolation, and frailty: results from a prospective analysis of UK biobank participants
    Published: Online June 7, 2026; cohort website posting August 30 is not the journal publication date. Period: Baseline 2006–2010; repeat assessment 2012–2013. Full source/starting analytic n=447,322, not automatically every model’s base. 1 contributing study/cohort collections in source. UK Biobank baseline and repeat-assessment analyses using mixed-effects models; original author abstract inspected. 447322 is the reported baseline analytic sample; the selected cross-sectional/prospective model bases are not separately confirmed. Prospective repeat-assessment sample is smaller/unknown here, not 502269 or 447322 by default. Cross-sectional and prospective ORs are related analyses of the same cohort. Publication 2026 does not mean recent collection. Original companion/full-text source.
  9. Guo et al. / International Journal of Surgery [S09] — Association of social isolation and loneliness with the incidence and life expectancy of chronic kidney disease: a population-based cohort study
    Published: Online September 23, 2025; January 2026 issue. Period: UK Biobank baseline 2006–2010; median follow-up 13.5 years; exact cutoff not established in this compilation. Full source/starting analytic n=466,663, not automatically every model’s base. 1 contributing study/cohort collections in source. Cox models in separate cohorts without CKD 406332 and with CKD 60331; Model 1 and Model 3 explicitly distinguished. Abstract incidence estimates 1.21/1.26 are Model 1, not fully adjusted. Table 2 Model 3 gives 1.09/1.12. Table 3 Model 3 gives 1.33/1.10 for mortality among CKD patients. Table cohort sizes are supplied in population notes; exact complete-case model counts are not separately established. Life-expectancy models not converted into individual predictions. Original companion/full-text source.

How to cite this resource

MyLittleDesire. Social Connection & Physical Health Statistics 2027. Proposed URL: https://mylittledesire.com/social-connection-physical-health-statistics/. Use after publication and add access date.