Health Implications of Loneliness and Obesity
Published in the Encyclopedia of Obesity
by Dr. J. Ryan Fuller
Frequent, intense, and enduring loneliness can have far reaching health implications. Many of its sequelae may complicate health conditions of obese patients through physiological, emotional, social, and behavioral means. Unlike related states of anxiety and depression, typically viewed as pathological, loneliness occurs within the normal and even healthy range of functioning, across the lifespan. Loneliness has been identified in children, adolescents, and adults. Males and females across every race and culture experience loneliness at similar rates, although some interesting variations have been identified, e.g., coping strategies may vary.
Approximately 80% of survey respondents indicated being lonely occasionally, 15% much of the time, and 5% reported never feeling lonely. These rates corroborate the ubiquitous nature of loneliness and support the notion that it can be typical of the human condition. However, individuals who report being lonely much of the time may represent an unhealthy subgroup. A general definition is necessary, before further discussing pathological loneliness.
A definition of loneliness includes affective and cognitive aspects of the experience; feelings (e.g., emptiness, sadness), situations (e.g., being alone), and cognitions (e.g., I’m all alone). Within this entry loneliness will be defined as a negative subjective state associated with the perception that one’s interpersonal relationships are inferior in number and/or quality desired for adequate social connection or belonging. This definition highlights the interplay of emotional and cognitive aspects of loneliness.
Cognitions for Lonely and Loneliness
The cognitive aspect (i.e., discrepancy between desired and perceived relationships) helps distinguish it from other negative emotional states, such as depression. It is also important to note that the objective (or actual) number or quality of social relationships is not included in its definition. This emphasizes the phenomenological aspects of loneliness and differentiates it from solitude or simply being alone, in fact, time alone is not correlated with loneliness. It is the acceptability of the social network rather than the objective quality/quantity that determines the affective state.
Although present throughout the lifespan, loneliness may be more prevalent at different developmental stages. Some studies indicate adolescents report the highest rates, while others indicate young adults with commensurate rates. Increased focus on peer relationships and social status may raise both the expectations and value of social belongingness, creating higher rates of loneliness when these needs are not met. Cross-sectional studies found elderly community members report less loneliness, even though social network size may decrease in aging populations. A cognitive explanation for this resilience may be changes in expectations, cultivating some evolution of preparedness or acceptability. Another hypothesis proposes that the quality of relationships at this age is most critical, buffering against decreased quantity.
There may be a tendency to underestimate loneliness in males when using measures with high face validity (i.e., instruments including the word “lonely”), as males may be less likely to endorse such items. Overall consistent gender differences have not been found, males and females are similar in terms of perceived social connectedness. However, mixed results have been at times discovered indicating small variations may be present at different ages. Few gender differences have been observed in children and adults, but some studies indicate adolescent males may report more loneliness than females. Other studies indicate no differences; therefore future studies are necessary before concluding adolescent males are the loneliest demographic.
The 20-item UCLA Loneliness Scale is the most common loneliness measure. A self-report questionnaire is well suited for measuring this construct. Some analyses support multiple dimensions of loneliness, but this scale is generally used to represent a single factor, trait loneliness, which is the frequent experience of loneliness. Trait measurement enables scientists to attribute characteristic thoughts, behaviors, and emotions to lonely “types,” those experiencing loneliness across time and situation.
Lonely individuals’ (i.e., those high in trait loneliness) number of friends and the amount of time spent in social situations may not distinguish them from their non-lonely counterparts. But they may differ in other important ways. As already noted, lonely individuals are more likely to experience depressive symptoms. There is abundant data indicating that depression results in work absenteeism, decreased productivity, increased health care costs, is related to poorer prognoses of many conditions, and possibly plays a causal role in the development of certain diseases, such as coronary heart disease. Data indicate that loneliness is not only predictive of depressive symptoms, but also of many of the same deleterious health effects even when holding depressive symptoms constant. Impaired cardiovascular and immune function, higher rates of substance use (mixed results with alcohol), sleep inefficiency, anxiety, suicide, overutilzation of health care services, and fewer self-care behaviors may result from chronic loneliness. Even though loneliness does not predict blood pressure differences, the mechanisms by which lonely and non-lonely achieve blood pressure may differ in crucial ways. Evidence suggests that high trait loneliness is indicative of higher total peripheral resistance and lower cardiac output. This finding may elucidate mechanisms of cardiovascular strain, which result in long-term health problems. There is further evidence that loneliness is predictive of blood pressure increases, as individuals age. Therefore, high trait loneliness may warrant further study and clinical consideration.
The number of mechanisms responsible for the effects of loneliness is unknown. Unfortunately, regardless of whether the mechanisms are biological, social, behavioral, psychological, or a combination, there is a clear circularity of loneliness and its maladaptive sequelae. Loneliness may precede depressive symptoms, depressive social- withdrawal behaviors lead to more social isolation and fewer opportunities to develop social skills, which in turn hinders social networking. This pattern of withdrawal increases isolation, which may lead to negative cognitive cycles.
Loneliness is also associated with negative thoughts about the self and others. The circularity of cognitions may maintain or exacerbate loneliness. As the lonely person cycles through the behavioral loop of withdrawal and isolation, it is reasonable to assume negative evaluations of the self and the future become more common as social failures accumulate. In fact, these evaluations, along with greater distrust and suspicion have been frequently observed in lonely individuals. This decreases the sense of group belonging, and social opportunities are more likely to be viewed as threatening and are therefore avoided. Lonely individuals become more distrustful and feel more threatened by socialization. Distrust and perception of threat further inhibits initiation of social activities, preventing opportunities for social skill development. Unfortunately this cycle may result in more threatened, anxious, isolated, and skill deficient lonely persons.
Loneliness has been associated with obesity. Recent research indicates that overweight children are more likely to become both the victims and perpetrators of “bullying” behavior. Unfortunately, both victims and perpetrators are likely to struggle with social rejection, which studies indicate lead to decreased will-power. Successful diabetes management and caloric restriction, skills needed by many obese patients, may thereby become less likely.
Unlike obese females, obese men may experience loneliness at the same rates as normal-weight males; however loneliness will still impact obese men’s health differently. Studies indicate that when a non-restricting person becomes lonely, he/she may eat less, while a restricting person (e.g., person on weight-loss plan) will overeat. Therefore obese men’s weight loss may be impeded by loneliness even if it occurs at “normal” frequencies. In addition, it is clear that obese males and females as children and adults face negative bias and discrimination, providing social, vocational, educational and economic challenges.
Although both loneliness and obesity are predictive of a number of future negative outcomes, research has not determined the precise relationship obesity and loneliness in combination produce. One finding does suggest that depression is more likely when loneliness is attributed to physical appearance. In general it can be said loneliness and obesity increase the chance of negative medical outcomes, but to what extent there is overlap, additive, or synergistic effects remains unclear.
Loneliness poses a significant barrier to the treatment of obesity. It is one of the most common overeating triggers (antecedents), is associated with overeating for those attempting to restrict calories, and produces passive coping strategies. Most weight loss treatments include both caloric restriction and active coping strategies. Therefore, loneliness may interfere with successful weight loss and maintenance. Given the paucity of research on loneliness and specifically its role in the development, maintenance, and treatment of obesity, further finding and research is clearly warranted.
Self-esteem and obese women, Shame and guilt
J Ryan Fuller, Ph.D.
Director of Behavior
Columbia Department of Medicine
New York Obesity Research Center
J. Ryan Fuller, Ph.D.
New York Behavioral Health