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Social support. Kristina Orth-Gomér. Internal medicine Social medicine/Public health Karolinska institutet, Sthlm + Psykosomatisk medicin Charit é Universit ä tsmedizin Berlin. A lonely man is a strong man. Social support - definition.

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Social support

Kristina Orth-Gomér

Internal medicineSocial medicine/Public healthKarolinska institutet, Sthlm+Psykosomatisk medicinCharité 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)2.44*2.81*

Techumseh (MI)3.87*1.97

Evans county (GEO)



North Karelia (SF)2.63*1.92

Gothenburg (S)4.00*-

Swedish survey of 1.50*1.50*

living coditionsHouse 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


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


Life style

Controlling for life style

Protective effects on CVD incidence

social integration = .45


attachment = . 58


Rosengren A Wilhelmsen L

Orth-Gomer K, 2003


  • 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


Attachment did not significantly affect prognosis in women.Are close emotional ties stressful rather than protective in women?

Negative effects of social ties?


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?

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








Progression of atherosclerosis by level of marital stress mean segment diameter change (mm)

Mediating Mechanisms



Autonomic imbalance


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

Adjusted for age, menopausal status, educational level, smoking,

exercise and alcohol consumption



  • All female patients, aged 65 or under who wereadmitted 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 Sleep quality

  • Premature awaking index

  • Heavy snoring

  • Not feeling refreshed

Recurrent cardiac events and subjective sleep quality

Sleep qualitynScoresHR (95% CI)* p


average1414-61.97 (1.01-3.85).047

poor687-92.55 (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


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?


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


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 MeanSEMP




Sedentary lifestyle



Obesity (kg/m2)


BMI>28.637.61.43 .001

Systolic blood pressure (mmHg)


>14036.11.75 .001


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


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”


  • 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

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