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The association of loneliness with bone mineral density, osteoporosis, osteopenia, fall, and sarcopenia among older adults: results from Mr. and Ms. Os (Hong Kong) study
To assess the association between loneliness and musculoskeletal conditions, including bone mineral density (BMD), osteoporosis, osteopenia, falls, and sarcopenia among older adults.
Methods
This longitudinal study utilized data from two follow-up assessments conducted four years apart among community-dwelling older Chinese adults in the Mr. OS and Ms. OS Hong Kong cohorts. Loneliness was assessed using the De Jong Gierveld Loneliness Scale. BMD was measured by dual-energy X-ray absorptiometry at baseline. Fall and fracture history was self-reported, and the SARC-F questionnaire was measured at baseline and follow-up. Sarcopenia was diagnosed according to the Asian Working Group for Sarcopenia 2019 at baseline. Regression models were used to examine the associations between baseline loneliness and musculoskeletal outcomes, adjusted for demographic and health-related covariates.
Results
In total, 1053 and 466 participants were included in the cross-sectional and longitudinal analyses. At baseline, after adjustment, compared to the absence of loneliness, severe loneliness was significantly associated with the lower hip (β = -0.031, 95% CI [-0.053, -0.008]) and femoral neck BMD (β = -0.027, 95% CI [-0.047, -0.006]), and increased odds of osteoporosis (OR = 3.278, 95% CI [1.187, 9.051]) and osteopenia (OR = 2.471, 95% CI [1.303, 4.684]) in reference to those without either condition. Each unit increase in emotional loneliness scores was associated with lower BMD in the hip and femoral neck, and increased odds of osteoporosis and osteopenia after adjustment (p < 0.05). After adjustment, loneliness was not cross-sectionally associated with falls or sarcopenia (p > 0.05). Longitudinally, severe loneliness (OR = 2.302, 95% CI [1.024, 5.177]) and higher social loneliness scores (OR = 1.340, 95% CI [1.076, 1.667]) at baseline predicted positive SARC-F (≥ 4) at follow-up after adjusting for baseline level and covariates. Loneliness did not significantly predict falls at follow-up after full adjustment (p < 0.05).
Conclusion
Healthcare professionals should consider psychological factors, such as loneliness, when working with older adults who have these musculoskeletal conditions.
This study found that loneliness is associated with musculoskeletal conditions such as low BMD, osteoporosis, osteopenia and possible sarcopenia after accounting for sociodemographic and health characteristics. Healthcare professionals should consider psychological factors, such as loneliness, when working with older adults who have these musculoskeletal conditions.
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Introduction
Musculoskeletal conditions become increasingly common with age, including sarcopenia, osteoporosis, osteopenia, falls, and associated fractures. Globally, it is estimated that 10% to 27% of older adults are affected by sarcopenia [1], while 19.7% suffer from osteoporosis and 40.4% from osteopenia [2]. Approximately 30% of older adults have experienced a fall in the past year [3]. The lifetime risk of osteoporotic fractures is estimated to be 40–50% for women and 13–22% for men [4]. These musculoskeletal conditions significantly impact the overall wellbeing and quality of life of older adults. In Hong Kong, the aging population, which has the highest life expectancy, poses a significant burden on both the healthcare system and society, making the prevention of these conditions increasingly important.
Loneliness is a condition that reflects a sense of disconnection, often characterized by the feeling that the desired quantity or quality of emotional and social connections is unmet [5]. It is common among older adults and can be attributed to factors such as being unmarried, living alone, having a limited social network, low levels of social activity, poor self-reported health, and poor functional status [6, 7]. The mean prevalence of loneliness among older adults aged 60 and older was 25.6% before COVID-19, rising to 39.4% during the pandemic [8]. In Hong Kong, approximately 35% of older adults aged 60 and above experienced moderate to severe loneliness, while up to 46% reported feeling lonely sometimes or always [9, 10]. Numerous studies indicate that loneliness is a risk factor for various chronic conditions, including hypertension, cardiovascular disease, stroke, atherosclerosis, lung disease, obesity, and metabolic disorders [11]. Additionally, it is significantly associated with mortality in older adults [11].
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Loneliness is often associated with psychological factors such as depression and anxiety [11], which have been shown to correlate with the development of the aforementioned musculoskeletal conditions [12, 13]. For instance, studies indicated that depressive states are significant risk factors for osteoporosis in postmenopausal women [14]. Additionally, loneliness may lead to reduced physical activity, which can accelerate bone loss and muscle mass decline [15]. Therefore, loneliness may be associated with an increased risk of musculoskeletal conditions.
However, there are currently few studies examining the association between loneliness and these musculoskeletal conditions. Only one study has identified a significant longitudinal association between loneliness and sarcopenia in older adults aged 60 and above [16]. A recent systematic review and meta-analysis of 15 studies found that living alone and social isolation were associated with a 1.5 and 1.7 times higher risk of sarcopenia, respectively [17]. This significant association was further supported by subsequent studies [16, 18]. Another study found that socially isolated older adults were more likely to experience fractures during a three-year follow-up [19].
Given the lack of research on this topic, this study was conducted to assess the association between loneliness and musculoskeletal conditions, including bone mineral density (BMD), osteoporosis, osteopenia, falls, fractures, and sarcopenia among older adults. By analyzing the associations among these factors, new insights and intervention strategies can be provided to improve musculoskeletal health in the aging population.
Methods
Study setting and design
This longitudinal study utilized data from the year-14 and year-18 follow-up assessments of the Osteoporotic Fractures in Men (Mr. Os) and Women (Ms. Os) Hong Kong cohorts [20‐22]. Mr. Os and Ms. Os Hong Kong represent the first large-scale prospective cohort study on bone health in East Asians. The primary objective of these cohorts was to determine the relationship between a range of anthropometric, lifestyle, medical, and other factors with BMD at the hip and spine. The cohort study was conducted in accordance with the Declaration of Helsinki. The study protocol received ethical approval from the Ethics Committees of the Chinese University of Hong Kong (CREC Ref. No.: 2003.102). Written informed consents were obtained from all participants.
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Participants
The Mr. OS and Ms. OS Hong Kong cohorts initially recruited 2000 Chinese men and 2000 Chinese women aged 65 years or above from local communities between August 2001 and March 2003. Recruitment was primarily conducted through advertisements posted in housing estates and local community centres. The sample of each gender was stratified by age, with approximately one-third of participants in each of the following age groups: 65–69, 70–74, and 75 years or older in 2001 – 2003. To date, five follow-up assessments have been conducted for the Mr. OS and Ms. OS cohorts, specifically after 2 years, 4 years, 7 years, 14 years, and 18 years. For the present study, we included all participants who completed the year-14 assessment and had available data for loneliness at that time. Furthermore, all participants who completed the year-18 assessment were included in the longitudinal analysis.
Measurements
Table 1 summarizes the exposure, outcomes, and covariates measured at baseline and follow-up in the study.
Table 1
The exposure, outcomes, and covariates measured at baseline and follow-up in the study
Category
Measurement
Baseline
Follow-up
Exposure
Loneliness (De Jong Gierveld Loneliness Scale)
√
Outcomes
Bone mineral density
√
Osteoporosis and osteopenia
√
Sarcopenia
√
SARC-F scale (strength, assistance with walking, rising from a chair, climbing stairs, and falls)
√
Fall and fracture history
√
√
Covariates
Age, sex, number of chronic conditions, obesity, alcohol consumption, score on the Geriatric Depression Scale, and physical activity level
√
Loneliness
The six-item version of the De Jong Gierveld Loneliness Scale (DJGLS-6) was used to measure loneliness [23]. The scale comprises 6 items, 3 are indicators of emotional loneliness and 3 are indicators of social loneliness. Answer categories are ‘yes’, ‘more or less’ and ‘no’. The total scores on the loneliness scale ranged from 0 to 6, with higher scores indicating greater loneliness. To define the loneliness categories, a score of 0–1 indicates ‘not lonely’, 2–4 indicates ‘moderate lonely’ and 5–6 indicates ‘severe lonely’. This scale has been reported to be a reliable and valid measure of loneliness among Hong Kong older adults [24].
Bone mineral density (BMD) and osteoporosis
Bone mineral density, assessed only at the year-14 follow-up (baseline of our study), was measured using a dual-energy X-ray absorptiometry (DXA) device (QDR Model 4500W, Hologic, Inc., Waltham, MA, USA). The regions of interest included the spine (at L1-L4 levels), the femoral neck, and the hip were measured. The coefficient of variation of the DXA equipment ranged from 1.5% to 3.8% for the spine, femoral neck, and hip. T-score was calculated in the spine, femoral neck, and hip for all participants [25]. Diagnostic criteria for the classification of osteoporosis were established based on T-scores derived from DXA bone mineral density measurements. BMD values (g/cm2) were expressed as T-scores for men above 50 years old and postmenopausal women (number of SD above/below the mean for healthy 30-year-old adults of the same sex). The sex-specific mean BMD and standard deviation were calculated. The maximum sex-specific mean BMD was identified as the peak BMD. Osteoporosis and osteopenia were defined according to the World Health Organization guidelines [26], using the lowest T-score from the three measured sites: a T-score of -2.5 or lower indicates osteoporosis, and a T-score between -1 and -2.5 indicates osteopenia.
Sarcopenia
Sarcopenia was defined according to the Asian Working Group for Sarcopenia (AWGS) 2019 consensus [27], as age-related loss of muscle mass in conjunction with low muscle strength and/or low physical performance. Appendicular skeletal muscle mass (ASM) was measured using DXA, with low muscle mass defined as height-adjusted ASM < 7.0 kg/m2 for men and < 5.4 kg/m2 for women. Low muscle strength was indicated by a handgrip strength of < 28 kg for men and < 18 kg for women. Low physical performance was indicated by a 6-m walk speed of < 1.0 m/s or a 5-time chair stand test time of ≥ 12 s. At baseline, participants meeting the criteria for low muscle mass and either low muscle strength or low physical performance were classified as having sarcopenia.
SARC-F
The SARC-F (strength, assistance with walking, rising from a chair, climbing stairs, and falls) questionnaire was used to measure the level of sarcopenia. It has 5 items on strength, assistance in walking, rising from a chair, climbing stairs, and falls [28]. The SARC-F score ranges from 0 to 10, with a score of 4 or more indicating potential sarcopenia [28].
Fall and fracture history
Fall and fracture history were assessed using self-reported questionnaires, with participants reporting whether they had experienced any falls or fractures in the past year. Both were defined as binary variables (yes/no), indicating the presence of at least one fall or fracture or the absence of any falls or fractures in the preceding 12 months.
Covariates
Age, sex, number of chronic conditions, obesity, alcohol consumption, score on the Geriatric Depression Scale (GDS), and physical activity level were collected as covariates. Chronic conditions include diabetes, Graves’ disease, hypothyroidism, stroke, Parkinson’s disease, hypertension, heart attack, congestive heart failure, chronic obstructive pulmonary disease (COPD), glaucoma, cataract, arthritis or gout, cancer, and dizziness. Body mass index (BMI) was used to identify obesity, with a BMI ≥ 25 classified as obese. Alcohol consumption was defined as having consumed 12 glasses of alcohol in the past 12 months. The Chinese-validated GDS was used to measure depressive symptoms [29]. The total GDS score ranges from 0 to 15, with higher scores indicating a greater level of depression. Physical activity level was measured with the Chinese Version of the Physical Activity Scale for the Elderly (PASE-C) to quantify the self-reported occupational, household, and leisure activities over the past seven days [30]. The total score of PASE-C is calculated by multiplying the time spent on each activity by the weight of the item. The PASE-C has been shown with satisfactory reliability and validity in Chinese populations aged 60 years and older [31, 32].
Data analysis
To summarize the sample characteristics, means and standard deviations were calculated for continuous variables, while frequencies and percentages were calculated for categorical variables. The relationships between loneliness (overall category, emotional, and social) at baseline and musculoskeletal outcomes were examined using regression analyses. Outcomes included baseline BMD at the hip, femoral neck, and spine; baseline osteoporosis, osteopenia, fall history, and sarcopenia; and follow-up falls and SARC-F. Due to the limited number of fracture history cases, it was not included as an outcome in the regression model. Linear regression was used for BMD, multinomial logistic regression for osteoporosis and osteopenia with normal as the reference, and binomial logistic regression for all other outcomes. Each model included only one loneliness measure at a time and was run both unadjusted and adjusted for age, sex, number of chronic conditions, obesity, alcohol consumption, and physical activity. Longitudinal models were additionally adjusted for the baseline level of the outcome. An alpha level of 0.05 was used to determine statistical significance. All statistical analyses were performed using Stata, version 16.0 (Stata Corp LLC, College Station, TX, USA).
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Declaration of generative AI and AI-assisted technologies in the writing process
During the preparation of this work the authors used AI (Perplexity) in order to improve language and readability. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.
Results
Baseline characteristics
Data from the year-14 assessment (collected between November 16, 2015 and September 29, 2017) were used as the baseline of this study, and data from the year-18 assessment (collected between December 16, 2019 and April 26, 2022) served as the follow-up, representing an average interval of 4.4 ± 0.7 years. The baseline sample comprised 1053 participants with ages ranging from 77 to 100 years (M = 83.3, SD = 3.9). A total of 466 participants returned for the follow-up assessment, 333 were lost to follow-up, and 254 passed away. Table 2 presents the demographic characteristics and summary statistics for all variables included in the analyses, for both the full baseline sample and the participants included in the longitudinal analysis. At baseline, 301 participants (28.6%) were classified as not lonely, 547 participants (51.9%) as moderately lonely, and 205 participants (19.5%) as severely lonely. The mean score for emotional loneliness was 1.4 (SD = 0.9), and the mean score for social loneliness was 1.4 (SD = 1.3). 173 participants (16.4%) had normal BMD status, while 527 participants (50%) had osteopenia and 349 (33.1%) had osteoporosis. Furthermore, 520 participants (49.3%) were diagnosed as having sarcopenia, 58 (12.4%) had positive SARC-F score of 4 or more, and 202 (19.2%) and 15 (1.4%) participants had experienced at least one fall or one fracture in the past year, respectively.
Table 2
Baseline characteristics of included participants
Characteristics
All participants (n = 1053)
Participants included in the longitudinal analysis (n = 466)
Mean ± SD or n (%)
Mean ± SD or n (%)
Age
83.3 ± 3.9
82.4 ± 3.5
Sex
Male
507 (48.1)
233 (50.0)
Female
546 (51.9)
233 (50.0)
Number of chronic diseases
0–1
182 (17.3)
86 (18.5)
2–3
554 (52.6)
257 (55.2)
≥ 4
213 (20.2)
123 (26.4)
Alcohol consumption
97 (9.2)
46 (9.9)
Obesity
332 (30.7)
153 (32.8)
PASE
72.7 ± 40.8
79.1 ± 41.9
GDS
3.9 ± 3.2
3.6 ± 3.1
Loneliness
Not lonely (0–1)
301 (28.6)
124 (26.6)
Moderate lonely (2–4)
547 (51.9)
253 (54.3)
Severe lonely (5–6)
205 (19.5)
89 (19.1)
Emotional loneliness score
1.4 ± 0.9
1.3 ± 0.9
Social loneliness score
1.4 ± 1.3
1.5 ± 1.2
Positive SARC-F (≥ 4)
174 (16.5)
58 (12.4)
Sarcopenia
520 (49.3)
221 (47.4)
Fall
202 (19.2)
77 (16.5)
Fracture
14 (1.3)
4 (0.9)
BMD status
Normal
173 (16.4)
88 (18.9)
Osteopenia
527 (50.0)
253 (54.3)
Osteoporosis
349 (33.1)
124 (26.6)
Hip BMD
0.76 ± 0.15
0.78 ± 0.14
Hip T-score
-1.80 ± 1.10
-1.64 ± 1.06
Femoral neck BMD
0.62 ± 0.13
0.64 ± 0.13
Femoral neck T-score
-1.59 ± 0.85
-1.49 ± 0.86
Spine BMD
0.91 ± 0.21
0.93 ± 0.21
Spine T-score
-0.84 ± 1.98
-0.61 ± 1.92
BMD: Bone Mineral Density; BMI: body mass index; GDS: Geriatric Depression Scale; PASE: Physical Activity Scale for the Elderly; SARC-F: strength, assistance with walking, rising from a chair, climbing stairs, and falls; SD: standard deviation.
Comparison between participants who completed the follow-up assessment and those who did not
Compared to participants who completed the follow-up assessment (Table 3), those who did not were significantly older and had lower levels of physical activity, higher levels of depression, lower BMD, more positive SARC-F scores, and more diagnosed osteoporosis (p < 0.05).
Table 3
Comparison between participants who completed the follow-up assessment and those who did not
Characteristics
Participants who completed the follow-up assessment (n = 466)
Participants who did not complete the follow-up assessment (n = 587)
p
Mean ± SD or n (%)
Mean ± SD or n (%)
Age
82.4 ± 3.5
84.0 ± 4.0
< 0.001*
Sex (Female)
233 (50.0)
313 (53.3)
0.284
Number of chronic diseases
0.532
0–1
86 (18.5)
101 (17.2)
2–3
257 (55.2)
313 (53.3)
≥ 4
123 (26.4)
173 (29.5)
Alcohol consumption
46 (9.9)
51 (8.7)
0.510
Obesity
153 (32.8)
169 (28.8)
0.180
PASE
79.1 ± 41.9
67.4 ± 39.1
< 0.001*
GDS
3.6 ± 3.1
4.1 ± 3.3
0.011*
Loneliness
Not lonely (0–1)
124 (26.6)
177 (30.2)
0.353
Moderate lonely (2–4)
253 (54.3)
294 (50.1)
Severe lonely (5–6)
89 (19.1)
116 (19.8)
Emotional loneliness score
1.3 ± 0.9
1.4 ± 0.9
0.093
Social loneliness score
1.5 ± 1.2
1.4 ± 1.3
0.270
Positive SARC-F (≥ 4)
58 (12.4)
116 (19.8)
0.002*
Sarcopenia
221 (47.4)
299 (50.9)
0.235
Fall
77 (16.5)
125 (21.3)
0.051
Fracture
4 (0.9)
10 (1.7)
0.236
BMD status
< 0.001*
Normal
88 (18.9)
85 (14.5)
Osteopenia
253 (54.3)
274 (46.7)
Osteoporosis
124 (26.6)
225 (38.3)
Hip BMD
0.78 ± 0.14
0.74 ± 0.15
< 0.001*
Hip T-score
-1.64 ± 1.06
-1.92 ± 1.13
< 0.001*
Femoral neck BMD
0.64 ± 0.13
0.61 ± 0.12
< 0.001*
Femoral neck T-score
-1.49 ± 0.86
-1.67 ± 0.84
< 0.001*
Spine BMD
0.93 ± 0.21
0.89 ± 0.21
< 0.001*
Spine T-score
-0.61 ± 1.92
-1.02 ± 2.00
< 0.001*
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* p < 0.05. BMD: Bone Mineral Density; BMI: body mass index; GDS: Geriatric Depression Scale; PASE: Physical Activity Scale for the Elderly; SARC-F: strength, assistance with walking, rising from a chair, climbing stairs, and falls; SD: standard deviation.
Cross-sectional association between loneliness and musculoskeletal outcomes
At baseline, compared to the absence of loneliness, severe loneliness was negatively associated with hip BMD (β = -0.039, 95% CI [-0.066, -0.012]) and femoral neck BMD (β = -0.029, 95% CI [-0.051, -0.006]) (Fig. 1), as well as with increased odds of osteoporosis (OR = 2.477, 95% CI [1.411, 4.348]), osteopenia (OR = 1.919, 95% CI [1.118, 3.294]), and fall history (OR = 1.649, 95% CI [1.049, 2.592]) before adjustment (Fig. 2). After adjustment (Fig. 1 and 2), the associations with hip BMD (β = -0.031, 95% CI [-0.053, -0.008]), femoral neck BMD (β = -0.027, 95% CI [-0.047, -0.006]), osteoporosis (OR = 3.278, 95% CI [1.187, 9.051]), and osteopenia (OR = 2.471, 95% CI [1.303, 4.684]) remained significant, while the association with fall history became non-significant (p > 0.05). Compared to no loneliness, moderate loneliness was significantly associated with osteopenia after covariate adjustment (OR = 1.586, 95% CI [1.030, 2.441]) (Fig. 2).
Fig. 1
The cross-sectional association between loneliness and BMD (n = 1053)
The model was adjusted for age, sex, number of chronic diseases, obesity, alcohol consumption, the Physical Activity Scale for the Elderly, and the Geriatric Depression Scale. BMD: Bone Mineral Density; CI: confidence interval.
† Normal BMD (DXA > -1.0) was served as the reference group. The model was adjusted for age, sex, number of chronic diseases, obesity, alcohol consumption, the Physical Activity Scale for the Elderly, and the Geriatric Depression Scale. CI: confidence interval; DXA: dual-energy X-ray absorptiometry; OR: odds ratio.
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Before adjustment, each point increase in the emotional loneliness score were significantly associated with lower BMD at the hip (β = -0.015, 95% CI [-0.026, -0.005]), femoral neck (β = -0.013, 95% CI [-0.021, -0.004]), and spine (β = -0.015, 95% CI [-0.029, -0.003]) (Fig. 1), as well as with increased odds of osteoporosis (OR = 1.370, 95% CI [1.116, 1.682])(Fig. 2). After adjustment (Fig. 1 and 2), the associations remained significant in hip BMD (β = -0.013, 95% CI [-0.021, -0.004]), femoral neck BMD (β = -0.013, 95% CI [-0.021, -0.005]), osteoporosis (OR = 2.801, 95% CI [1.406, 3.079]). The association between emotional loneliness and osteopenia became significant (OR = 1.306, 95% CI [1.018, 1.676]). In contrast, social loneliness scores were not significantly associated with any musculoskeletal outcomes in the unadjusted models. However, after adjustment, higher social loneliness scores were significantly associated with increased odds of osteopenia (OR = 1.184, 95% CI [1.010, 1.388])(Fig. 2).
Longitudinal association between baseline loneliness and follow-up fall and SARC-F
In the longitudinal analysis (Fig. 3), severe loneliness at baseline was significantly associated with positive SARC-F at follow-up (OR = 3.032, 95% CI [1.607, 5.721]). This association remained significant after adjusting for baseline SARC-F level alone (OR = 2.156, 95% CI [1.067, 4.358]), and when adjusting for baseline level and other covariates (OR = 2.302, 95% CI [1.024, 5.177]). Higher emotional loneliness scores at baseline were significantly associated with increased odds of falls (OR = 1.393, 95% CI [1.073, 1.809]) and positive SARC-F (OR = 1.292, 95% CI [1.006, 1.659]) at follow-up. However, after adjusting for baseline fall history and other covariates, the association with incident falls became non-significant (OR = 1.237, 95% CI [0.930, 1.645]). Similarly, the association between emotional loneliness and positive SARC-F became non-significant after adjusting for baseline SARC-F level alone (OR = 1.093, 95% CI [0.827, 1.446]); therefore, further adjustment for other covariates did not alter this result. Higher social loneliness scores at baseline were significantly associated with positive SARC-F at follow-up (OR = 1.388, 95% CI [1.152, 1.672]). This association remained significant even after adjusting for baseline SARC-F level alone (OR = 1.316, 95% CI [1.074, 1.612]), as well as after adjusting for baseline level and other covariates (OR = 1.340, 95% CI [1.076, 1.667]).
Fig. 3
The longitudinal association between baseline loneliness and follow-up fall and SARC-F (n = 466)
Model 1 was not adjusted for covariates. Model 2 was adjusted for the baseline level of fall/SARC-F. Model 3 was adjusted for baseline level of fall/SARC-F, age, sex, number of chronic diseases, obesity, alcohol consumption, the Physical Activity Scale for the Elderly, and the Geriatric Depression Scale. CI: confidence interval; OR: odds ratio; SARC-F: strength, assistance with walking, rising from a chair, climbing stairs, and falls.
Discussion
This is the first study to assess the association between loneliness and multiple musculoskeletal conditions, including BMD, osteoporosis, osteopenia, falls, and sarcopenia among community-dwelling older adults. Severe loneliness, especially the emotional dimension, was found to have a cross-sectional association with lower BMD osteopenia, and osteoporosis, even after adjusting for demographic and health-related covariates. Moderate loneliness was independently associated with osteopenia. Significant cross-sectional associations of severe loneliness with falls were only observed before adjustment. Emotional loneliness score was associated with lower BMD, osteoporosis, osteopenia after adjustment. In the longitudinal analysis, severe loneliness at baseline, particularly its social dimension, was associated with positive SARC-F score at follow-up. Participants who did not complete the follow-up assessment were older and had poorer health outcomes.
Loneliness demonstrated a cross-sectional association with lower BMD, osteoporosis, osteopenia, and fall; however, significant associations were maintained only for lower BMD, osteopenia and osteoporosis after adjustment. This aligns with findings from the English Longitudinal Study of Ageing, which showed an initial association between loneliness and self-reported falls that became insignificant after adjusting for health and lifestyle factors[33]. Of the two dimensions of loneliness, emotional loneliness showed significant cross-sectional associations with musculoskeletal outcomes. It is characterized by the feeling of emptiness and anxiety resulting from a lack of a meaningful relationship with a significant other or a close friend[34]. This suggests a potential emotional impact of loneliness on the musculoskeletal system, which may be mediated by depressed mood, as adjusted for in the analysis. A meta-analysis of 23 studies in older adults showed that loneliness had a significantly moderate effect on depression[35]. Other systematic reviews with meta-analyses supported that depression is associated with increased risks of osteoporosis, falls, and sarcopenia[36‐38]. Furthermore, lack of physical activity, also adjusted for in the analysis, can also be a potential mediator. Negative emotions caused by loneliness may reduce an individual's willingness to exercise. Research has shown significant associations between loneliness and physical inactivity, which can further affect musculoskeletal health[15, 39]. It is also worth noting that, after adjustment, moderate loneliness was significantly associated with osteopenia. This suggests that loneliness may impact bone health at an early stage, highlighting the need for early intervention strategies.
In the longitudinal analysis after adjusting for baseline level and covariates, only the social loneliness dimension at baseline was significantly associated with a positive SARC-F score at follow-up out of the two dimensions of loneliness. Different from emotional loneliness, social loneliness is the experience of lacking a broad social network of friends or neighbors who share common activities and interests [34]. Lacking enough social support, social loneliness may lead to poorer health behaviors, such as reduced physical activity and social engagement, which are essential for maintaining muscle mass [39‐41]. Furthermore, research has found that people living alone tend to have less dietary diversity and significantly insufficient intake of core foods such as fruits, vegetables, and fish [42]. Social loneliness may contribute to poor dietary habits and insufficient nutrient intake such as protein, which can increase the risk of muscle loss [43, 44].
In this study, emotional and social loneliness had different effects on the musculoskeletal outcomes in the cross-sectional and longitudinal analysis. Emotional loneliness may reflect short-term psychological states, whereas social loneliness might have a sustained impact on muscle health through long-term behavioral mechanisms, potentially predicting possible sarcopenia during follow-up. These findings emphasize the importance of assessing loneliness multidimensionally, as different dimensions may impact musculoskeletal outcomes through unique mechanisms.
Healthcare providers should consider screening older adults for loneliness, especially those at risk for or diagnosed with osteoporosis or sarcopenia, and provide early intervention. Future research should prioritize longitudinal studies with larger samples to examine the long-term effects of loneliness on musculoskeletal conditions. Mediation analyses should explore potential mediating factors such as depression, physical inactivity, and poor diet. Intervention studies should assess whether reducing loneliness can improve musculoskeletal health. Future studies could also examine the potential interplay between loneliness, mental health (e.g., depression) and health behaviors (e.g., physical activity and dietary habits) in the context of musculoskeletal health.
The strengths of this study included its assessment of the association between loneliness and musculoskeletal conditions, which is an under-researched area. Furthermore, by examining both the emotional and social dimensions of loneliness, the study provides a more comprehensive understanding of its relationship with musculoskeletal health outcomes. This study also had several limitations that should be acknowledged. First, DXA was not repeated at follow-up, therefore BMD and sarcopenia were not measured at the follow-up assessment. Consequently, we were unable to measure the longitudinal associations and causal relationship of loneliness with BMD, osteoporosis, and sarcopenia. The cross-sectional design for most analyses restricts causal inferences. However, SARC-F were measured at both baseline and follow-up, allowing us to examine the longitudinal association between loneliness and possible sarcopenia. Second, there were limited cases of fractures reported at baseline and follow-up, making it difficult to assess the association between loneliness and fracture. Third, the study participants were advanced in age at baseline, with an average age of 83 years, which likely contributed to the significant loss to follow-up during the assessment. Importantly, follow-up assessments were mostly conducted during the COVID-19 pandemic, during which Hong Kong enforced public health restrictions and social distancing, potentially affecting participant retention and accessibility. Due to the fact that participants lost to follow-up were older and had poorer health conditions, the longitudinal results may only represent a healthier or more active subgroup. Caution is needed when generalizing these findings to the broader older adult population or to younger groups. Imputation may not be suitable for imputing missing data when a large proportion is missing. Fourth, loneliness, SARC-F, falls, and fractures were self-reported by the participants, which raises the possibility of recall bias and social desirability bias. Fifth, some potential confounders, such as osteoporosis medications, were not measured in this study. Last, the study sample was older, had a higher education level, and was more likely to be married compared to the general older population in Hong Kong; therefore, the results should be generalized with caution [45].
Conclusion
In conclusion, loneliness is associated with musculoskeletal conditions such as low BMD, osteoporosis, osteopenia and possible sarcopenia after accounting for sociodemographic and health characteristics among older adults in this study. These findings highlight the importance of healthcare professionals considering psychological factors, such as loneliness, when working with older adults who have these musculoskeletal conditions. However, due to the specific demographic characteristics of the study population, caution is necessary when generalizing these results to younger or more diverse older adult populations.
Ethical approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent
Informed consent was obtained from all individual participants included in the study.
Conflict of interest
Zijun Xu, Yiqi Li, Huiqi Song, Regina Wing Shan Sit, Jason C.S. Leung, Dicken Cheong Chun Chan, Timothy C.Y. Kwok, and Samuel Yeung Shan Wong declare that they have no conflict of interest.
Acknowledgements
We thank the generous donation of Ms. Therese Pei Fong Chow.
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The association of loneliness with bone mineral density, osteoporosis, osteopenia, fall, and sarcopenia among older adults: results from Mr. and Ms. Os (Hong Kong) study
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Yiqi Li
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