Download Social support and health

Social support
Kristina Orth-Gomér
Internal medicine
Social medicine/Public health
Karolinska institutet, Sthlm
+
Psykosomatisk medicin
Charité Universitätsmedizin
Berlin
A lonely man is a strong man
Social support - definition
• Social support is the resource provided by
other people (S Cohen, L Syme 1985)
• Social networks - structure
• Social supports - function
• Social relations may have negative and
positive effects on health
Social networks and health
”the patterns of prospective association between
social integration (that is the number and
frequency of social relationships and contacts) and
mortality are remarkably similar, with some
variations by race, sex and geographic locale.”
House et al., Science, 1988
Age adjusted relative mortality risk
(RR)
low vs high social network index
Alameda county (CA)
Techumseh (MI)
Evans county (GEO)
whites
blacks
North Karelia (SF)
Gothenburg (S)
Swedish survey of
living coditions
men
2.44*
3.87*
women
2.81*
1.97
1.83*
1.08
2.63*
4.00*
1.50*
1.07
1.59
1.92
1.50*
House et al., Science, 1988
Swedish Survey of Living
Conditions
•
•
•
•
17 400 men and women, age 15 to 65
Representative of the Swedish population
Followed for 6 years
Low Social network interaction predicted
mortality in men of all ages
• Excess risk 50%, controlling for other risk
factors
Men, aged 50, born in Göteborg
• 741 men, born in 1933
• Followed for 6 years and 15 years
• Attachment - close emotional ties
• Social integration - help with appraisal and
coping, tangible support, belonging
Social inegration (AVSI)
• How many people do you know?
• How many people do you have regular contact with?
• How many friends do you have who can come to visit any
time?
• How many people can you trust?
• How many people can you ask for small favors?
• How many people can you turn to in difficulties and expect
real help?
6 and 15 year incidence by social
integration
%
14
14
12
10
9
8
6
6
5.7
4.5
4
1.59
2
0
low
middel
high
6 year incidence
15 year incidence
Attachment (AVAT)
• Is there anyone you can lean on?
• Is there anyone who feels very close to you?
• Is there anyone you can share happiness with, who would
also feel happy ?
• Is there anyone you can share most private feelings with ?
• Is there anyone to hold and comfort you?
• Do people really appreciate what you do for them?
6 and 15 year incidence by
attachment
%
14
13
12
10
8
8
6
6 year incidence
15 year incidence
5.8
3.5
4
2
0
low
high
Life style
Controlling for life style
Protective effects on CVD
incidence
social integration = .45
P=.014
attachment = . 58
P=.019
Rosengren A Wilhelmsen L
Orth-Gomer K, 2003
Conclusions
• Socially integrated men have half the risk of
getting a myocardial infarction over 15 yrs
• Attachment is also protective
• Both effects are independent of other risk
factors
SUPERWOMAN
The Stockholm Female Coronary Risk Study
•Community based case-control study
•All women aged 65 years or younger and
hospitalized for acute AMI or unstable AP
in Stockholm 1991-1994 (n=292)
•Aged matched healthy control women,
obtained from the census register of
Stockholm (n=292)
Orth-Gomér et al Circulation 1997
The Stockholm Female Coronary Risk Study
The patients (n=292) were followed for a
median of 5 years (3 to 6 years)
Recurrent events included (n=81):
cardiac death
recurrent AMI
revascularization procedures
Attachment did not significantly
affect prognosis in women.
Are close emotional ties
stressful rather than protective in
women?
Negative effects of social ties?
Aim
To evaluate the impact of stress from
social relations on prognosis in
women CHD patients - controlling
for both disease severity, standard
risk factors and work stress as
measured at baseline.
The Stockholm Marital Stress Scale
Is the relationship with your spouse loving?
Is the relationship with your spouse friendly?
Is the relationship with your spouse routine-like ?
Is the relationship with your spouse problematic?
Do you engage in leisure activities together with your spouse?
Do you have your own private life outside the relationship with your spouse?
Is your spouse your closest confidant?
Are there things you can’t talk openly about with each other?
Have you had serious problems in the relationship with your spouse previously?
Have you had serious problems in the relationship with your spouse currently?
Have you had serious crises in your relationhip?
Have you solved problems actively together?
Do you have a sexual relationship with your spouse?
Do you find the sexual relationship with your spouse satisfactory?
Has your sexual relationship been affected by your heart disease?
Has your sexual relationship ceased due to your heart disease?
Marital & work stress and CHD
Odds ratio: OR (95 % C.l.)
Multivariate adjusted for: age, education, smoking, BMI, SBP, cholesterol, triglycerides, HDL (in
5-year follow-up even for diabetes and left ventricular dysfunction)
case-control study
5-year follow-up
10.2
(2.4; 23.6)
12
12
10
10
8
8
4.5
4.0
(2.5; 8.4)
(1.8; 8.9)
6
4
2
5.7
(1.3; 24.3)
6
4
1
2
0
1
1.6
(0.8; 3.3)
2.9
(1.3; 6.5)
0
no stress
marital
stress
work
stress
both
no stress
work
stress
marital
stress
both
OR
Depressive symptoms
•
•
•
•
•
•
•
•
•
Lack enthusiasm
Poor appetite
Feel lonely
Feel bored
Troubled sleep
Cry easily
Feel downhearted
Low in energy
Feel hopeless
Pearlin, J Health Soc Behav 22:337-356 1981
Pathways for men
Pathways for women
Low SES
Lack of social resources
Emotional stress at work
Inadequate reward/lack of control
Emotional stress in family life
anger
hostility
social isolation
lack of attachment
Depressed feelings
hopelessness
fatigue
smoking habits
excess alcohol consumption
lack of physical exercise
abdominal fat
poor nutrition
overweight/obesity
lack of physical exercise
cardiac arrythmia
ventricular extrasystole
ventricular fib
elevated systolic blood pressure
hypertension
autonomic dysfunction
poor vagal break
autonomic dysfuntion
HRV / SDNN
hypercoagulability
poor fibrinolysis
disturbed metabolism
low HDL/Apolipoprtein A
BUFFER EFFECT
STRESSOR
DISEASE
SOCIAL SUPPORT
MAIN EFFECT
SOCIAL ISOLATION
DISEASE
Progression of atherosclerosis by
level of marital stress
mean segment diameter change (mm)
0,14
0,12
0,1
0,08
0,06
0,04
0,02
0
-0,02
-0,04
level of marital stress
mild or
absent
moderate
high
Mediating Mechanisms
Atherogenic
Thrombotic
Autonomic imbalance
IS THE MEATABOLIC
SYNDROME A MEDIATING
MECHANISM?
The metabolic syndrome
• Defined according to WHO
• Fasting plasma glucose > 7.0 mmol/l
• Blood pressure > 160/90 mmHg
• Central obesity ( w/h >.85 or BMI>30
kg/m2)
• Fasting TG >1.7mmol/l or HDL<1.0 mmol/l
Social support and the Metabolic
Syndrome in middle-aged Swedish women
3,5
3
2,5
2
social support
1,5
1
0,5
0
low
intermediate
high
Adjusted for age, menopausal status, educational level, smoking,
exercise and alcohol consumption
IS POOR SLEEP A
MEDIATING MECHANISM?
Methods
• All female patients, aged 65 or under who were admitted with an
acute coronary syndrome between 1991 and 1994 in Stockholm
(n=292)
• Diagnosis at baseline: Acute Myocardial Infarction (n=110) or
unstable Angina Pectoris (n=182)
• followed for five years for recurrent event
• sleep complaints were measured at baseline using a standardized
questionnaire
• 283 women answered the sleep questionnaire
The Sleep Questionnaire
Have you perceived any of the following
complaints during the last time?
•Difficulties falling asleep
•Disturbed/restless sleep
•Premature awaking
•Heavy snoring
•Not feeling refreshed
Sleep quality
index
Recurrent cardiac events and
subjective sleep quality
Sleep quality n
Scores HR (95% CI)*
p
good
74
0-3
1
average
141
4-6
1.97 (1.01-3.85)
.047
poor
68
7-9
2.55 (1.24-5.24)
.011
*Hazards ratio, adjusted for age, BMI, symptoms of heart failure, hypertension,
diagnosis at index event, diabetes, HDL-cholesterol, triglyderides, smoking, and
education
Controlling for work stress did
not change the results!
Depressive symptoms
•
•
•
•
•
•
•
•
•
Lack enthusiasm
Poor appetite
Feel lonely
Feel bored
Troubled sleep
Cry easily
Feel downhearted
Low in energy
Feel hopeless
Pearlin, J Health Soc Behav 22:337-356 1981
Proportion of women surviving free of cardiac
events according to sleep quality and depression
1,0
,9
,8
Poor/mod. sleep & two or
more depressive sumptoms
poor/mod. Sleep quality & no
ore one depressive symptom
good sleep quality & two or
more depressive symptoms
good sleep quality & no or
one depressive symptom
,7
,6
0
T im e (m o n th )
20
40
60
80
Leineweber et al., 2002
Results
Poor sleep quality and not
feeling well-rested are
associated with poorer
prognosis in women with
a prior cardiac event.
Are variations in heart rate
and rhythm - autonomic
imbalance a mediating
mechanism?
HEART RATE VARIABILITY
Derived from 24-hour Holter recordings:
SDNN index Total power
Low Frequency power (LF)
High Frequency power (HF)
Very Low Frequency power (VLF)
SDNN index:
average of the standard deviations of all normal to normal
intervals for each 5-minute interval of the entire recording
(ms)
HRV - high (healthy)
low (unhealthy)
Heart rate variability =
ability ofthe heart to react to
stressors
Differences in SDNN index (msec) between
standard risk factor groups, adjusted for age
(controls, N=249).
Standard risk factors
Smoking
No
Yes
.05
Sedentary lifestyle
No
Yes
.05
Obesity (kg/m2)
BMI28.6
BMI>28.6
Systolic blood pressure (mmHg)
140
>140
Mean
SEM
P
42.9
40.0
.83
1.21
42.7
39.4
.77
1.48
43.2
37.6
.76
1.43
.001
43.0
36.1
.72
1.75
.001
Conclusions
Social supports affect men and
women differently
Men benefit from both social
integration and attachment
Women´s close emotional ties sometimes stressful
Cognitive group based one year
educational program
”Friskare Kvinnohjärtan”
Increased social support
Increased self esteem
Improved communication skills
Topics discussed in the groups
• Atherosclerosis and its risk factors
• Psychological consequences of clinical
CHD
• Stress physiology. Recognizing multiple
sources of stress - at work at home,
elsewhere
• Indivdual standard risk factor profile
topics continued
Positive/negative emotions
Exercise book with daily concrete reports
Maintained throughout the course
exercises
Daily practice of altered behavior:
”Choosing the longest line”
”Driving in the right lane”
”Avoid getting angry”
”Every patient needs to talk at least once
every session”
continued
• Roles/”strong and weak legs to stand on”
”parent ” child” ”professional pride”…
• ”avoid standing on just one leg”
• adaptation to specific social conditions
(work, professional,family life)
• general life situation- how is life? How
wouls I like it?What is important in life?
The end