ADCES7 SELF-CARE BEHAVIOR: Healthy Coping
Social isolation and loneliness have become pervasive in industrialized countries, including the United States.1,2 Reports indicate over 50% of Americans in 2024 felt lonely and that an estimated 25% of older adults are socially isolated.1,3 The former US Surgeon General, Dr. Vivek Murth, has repeatedly stressed the dangers of loneliness and social isolation on health and productivity.2 The World Health Organization considers social disconnection and loneliness to be primary drivers for depression, anxiety, and chronic disease.1
Unfortunately, social isolation and loneliness affect persons with diabetes (PWDs) to a higher degree than their peers.4 These negatively impact diabetes complications and self-care behaviors critical to diabetes management.1,2,4,5 In addition, social disconnection and loneliness are risk factors for the development of type 2 diabetes (T2D) itself.5 The goal of this article is to help define social isolation and loneliness, explore their impact on health and self-care behaviors, and discuss potential interventions to support those living with diabetes.
Although social isolation and loneliness are often studied in tandem, they are not the same. One is more objectively measured, and the other relies on one’s perception. For definitions of these terms, see Figure 1. It is important to note that although studies separate social isolation from loneliness, they do not always use a standardized way of measuring these factors. Thus, measurement of social isolation and/or loneliness can vary study to study.
Although the COVID-19 pandemic may have triggered more discussion about social isolation, we have decades of research to show just how damaging it can be to health.2,5,6 Poorer health habits, higher rates of chronic metabolic diseases (eg, cardiovascular disease and diabetes), and increased anxiety, depression, and dementia all have links to social isolation and/or loneliness.2,5,6
The 2023 Surgeon General’s report, “Our Epidemic of Loneliness and Isolation,” acknowledges social isolation and loneliness as drivers of stress and chronic inflammation.2 It is noted that these influences have similar health outcomes to excessive smoking, alcohol use, or physical inactivity. Dr Vivek Muth, author of the report, refers to social connection as being “as essential to our long-term survival as food [and] water.”2
Positive social connections can help PWDs increase their self-care behaviors (eg, smoking cessation or increased physical activity), whereas the lack of support can create negative impacts on diabetes outcomes and health behaviors.2,5 It is critical that certified diabetes care and education specialists (CDCESs) understand the influence of social isolation and/or loneliness on a PWD’s ability to manage their condition. In the following, the ADCES7 is used as a guide to explore these influences.
Food has cultural and social constructs that should not be discounted. Living and eating with others increases the quality and variety of food one consumes while also influencing food preparation and access. Loneliness can impact bingeing or restriction, either increasing the desire for higher caloric, tastier foods or creating a more rigid dietary pattern.7,8 Overall, both social isolation and loneliness have been linked to poorer dietary intake.2,5,7,8
Social connection is a fundamental human need, as essential to survival as food, water, and shelter.
–Dr. Vivek Murth, former US Surgeon General
Physical activity offers a vital role in health—influencing things such as metabolic function, muscle mass, bone density, balance, and more. Many studies point to reduced physical activity in those who are lonelier and more isolated.2,5
Cardiometabolic medications are critical for managing T2D, lipids, and blood pressure, which, in turn, reduces the risk of diabetes complications. Similar to healthy eating patterns, social connectedness can assist in one’s ability to understand medication instructions and obtain, organize, and use medications as prescribed.2,9,10 Medication use inconsistencies are more likely for those who are socially isolated.2,9,10
Social isolation and loneliness, independent of diabetes, can increase cardiovascular disease risks. Heart disease and stroke are nearly 30% higher, and mortality risk almost double in those who are more isolated.2,6 Similarly, people who are social isolated and living with chronic kidney disease (CKD) see accelerations in the development of both cardiovascular disease or mortality.11 CKD and microvascular complications are associated with social isolation or loneliness to similar degrees as smoking, hypertension, and physical inactivity.12
Actions to monitor and/or reduce diabetes complications can be negatively impacted by these social factors. In larger, more longitudinal studies, smoking was more likely and cessation more difficult for lonely individuals.2,5,13 Poorer selfcare routines and lower prioritization of diabetes care were evident in other studies looking at social connectedness and health behaviors.2,5,9,13
Interestingly, social isolation and loneliness have mixed results on health care utilization. Social isolation may increase hospitalizations and hospital stays and reduce attendance at posthospitalization follow-up, whereas loneliness increases primary care visits.14,15
PWDs make significantly more daily health decisions than those without diabetes. The ability to navigate these and everyday life stressors depends on a number of factors: sleep habits, eating and exercise routines, glucose trends, psychological health, and social connectedness and/or loneliness.3,14,16-18
Studies show interruptions to relationships and support systems due to trauma, chronic stressors, or mental health struggles increase the risk of T2D.2,16,17 As mentioned previously, impacts on metabolic and psychological health and one’s ability to engage in necessary health behaviors are evident in other studies.2,5,9,12,18
There are many ways CDCESs can expand care recommendations through the lens of social connectedness. A great place to start is by simply asking oneself, “How are my current recommendations going to impact this person socially?” and “How can I modify my recommendations to be more socially inclusive?” A few other ideas are listed in the following.
Use screenings to assess for gaps in social support. The Diabetes Distress Assessment System is a great place to start when assessing social connectedness.19 Higher scores on interpersonal areas can signify the PWD is struggling with social connectedness. There are also tools like the UCLA LonelinessScale or the LubbenSocial NetworkScale.
Encourage and include support systems (family, friends, etc) to join in diabetes training. For adults with diabetes, support increases self-care actions and self-efficacy.20 Ensure consult rooms and classrooms are large enough to accommodate support persons. Help the PWD and their support systems navigate common points of relational friction. If your program provides group classes, create avenues for participants to stay connected afterward. This could be through a drop-in program, a private group social media page, or an exchange of numbers and emails. Encourage the PWD to utilize diabetes support groups or join the diabetes online community (DOC).
Help people embrace their communities and find purpose. Social connectedness often gives people a sense of meaning in the world. A sense of purpose increases positive health behaviors.21 Most people have a special interest or skill set that can be of service to others. Encourage PWDs to join clubs, councils, churches, or city programs. Communities often need help with things such as litter clean up, meal or prescription delivery, or reading program support for young kids. If someone is homebound, they may be able to foster a shelter animal, help with social media sites, or manage paperwork for volunteer organizations.
Focus self-care recommendations on connectedness. Find ways diabetes selfcare behaviors can be tailored through social connection. For example, modify physical activity recommendations to include walking with a coworker, biking with one’s child, or joining group exercise classes. Consider nutrition recommendations that reduce stress in social settings, such as the diabetes plate method or intuitive eating. Think outside the box: Consider hosting a community meal from a community garden.
Embrace the nuanced. Managing diabetes is not all or nothing; there is a social cost to rigid expectations of those living with diabetes. The middle ground, in which someone with diabetes can manage it well and have a high level of pleasure, is important to explore. Avoid either/or language, which may increase isolation through shame, guilt, and stigma.22 Help people break away from black and white thinking—such as “good and bad” food or “good and bad” glucose levels.22
Social connectedness is an essential and undeniable part of health. For PWDs, social isolation and loneliness are drivers for both the development of the disease and long-term health outcomes. The United States is struggling with increased rates of social isolation. However, the diabetes population is harder hit, with higher rates of isolation and loneliness reported. Diabetes health, self-care behaviors, and complications are all impacted. Thus, it is imperative CDCESs incorporate both assessments and interventions for social connectedness into routine care.
World Health Organization. From loneliness to social connection: charting a path to healthier societies: report of the WHO Commission on Social Connection. June 30, 2025. Accessed July 1, 2025. https://www.who.int/groups/commission-on-social-connection
Office of the Surgeon General, U.S. Department of Health and Human Services. Our epidemic of loneliness and isolation: the U.S. Surgeon General’s advisory on the healing effects of social connection and community. 2023. Accessed July 1, 2025. https://www.hhs.gov/sites/default/files/surgeongeneral-social-connection-advisory.pdf
The Cigna Group. Loneliness in America 2025. Accessed July 6, 2025. https://newsroom.thecignagroup.com/loneliness-in-america
Liang YY, Chen Y, Feng H, et al. Social isolation, loneliness and subsequent risk of major adverse cardiovascular events among individuals with type 2 diabetes mellitus. Gen Psychiatr. 2023;36:e101153. doi:10.1136/gpsych-2023-101153
Song Y, Zhang L, Liu Y, et al. Social isolation, loneliness, and incident type 2 diabetes mellitus: results from two large prospective cohorts in Europe and East Asia and mendelian randomization. eClinicalMedicine. 2023;64:102236. doi:10.1016/j.eclinm.2023.102236
Valtorta NK, Kanaan M, Gilbody S, Ronzi S, Hanratty B. Loneliness and social isolation as risk factors for coronary heart disease and stroke: systematic review and meta-analysis of longitudinal observational studies. Heart. 2016;102(13):10091016. doi:10.1136/heartjnl-2015-308790
Zhang X, Ravichandran S, Gee GC, et al. Social isolation, brain food cue processing, eating behaviors, and mental health symptoms. JAMA Netw Open. 2024;7(4):e244855. doi:10.1001/jamanetworkopen.2024.4855
Hanna K, Cross J, Nicholls A, Gallegos D. The association between loneliness or social isolation and food and eating behaviours: a scoping review. Appetite. 2023;191:107051. doi:10.1016/j.appet.2023.107051
Strom JL, Egede LE. The impact of social support on outcomes in adult patients with type 2 diabetes: a systematic review. Curr Diab Rep. 2012;12(6):769-781. doi:10.1007/s11892-012-0317-0
Lu J, Zhang N, Mao D, Wang Y, Wang X. How social isolation and loneliness effect medication adherence among elderly with chronic diseases: an integrated theory and validated cross-sectional study. Arch Gerontol Geriatr. 2020;90:104154. doi:10.1016/j.archger.2020.104154
Zeng X, Jiang Y, Liu Z, et al. Social isolation is associated with the acceleration of death and incident cardiovascular disease in adults with chronic kidney disease. J Am Heart Assoc. 2025;14(11):e038951. doi:10.1161/JAHA.124.038951
Liang YY, Chen Y, Feng H, et al. Social isolation, loneliness, and risk of microvascular complications among individuals with type 2 diabetes mellitus. Am J Kidney Dis. 2024;84(5):557566.e1. doi:10.1016/j.ajkd.2024.08.039
Dyal SR, Valente TW. A systematic review of loneliness and smoking: small effects, big implications. Subst Use Misuse. 2015;50(13):1697-1716. doi:10.3109/10826084.2015.1027933
Cayenne NA, Jacobsohn GC, Jones CMC, et al. Association between social isolation and outpatient follow-up in older adults following emergency department discharge. Arch Gerontol Geriatr. 2021;93:104298. doi:10.1016/j.archger.2020.104298
Christiansen J, Pedersen SS, Andersen CM, Qualter P, Lund R, Lasgaard M. Loneliness, social isolation, and healthcare utilization in the general population. Health Psychol. 2023;42(2):63-72. doi:10.1037/hea0001247
Nelson CA, Scott RD, Bhutta ZA, Harris NB, Danese A, Samara M. Adversity in childhood is linked to mental and physical health throughout life. BMJ. 2020;371:m3048. doi:10.1136/bmj.m3048
Kelly SJ, Ismail M. Stress and type 2 diabetes: a review of how stress contributes to the development of type 2 diabetes. Annu Rev Public Health. 2015;36:441-462. doi:10.1146/annurev-publhealth-031914-122921
Zhou J, Tang R, Wang X, Li X, Heianza Y, Qi L. Improvement of social isolation and loneliness and excess mortality risk in people with obesity. JAMA Netw Open. 2024;7(1):e2352824. doi:10.1001/jamanetworkopen.2023.52824
Diabetes Distress Assessment & Resource Center. For providers. Behavioral Diabetes Institute. Accessed August 10, 2025. https://diabetesdistress.org/for-providers/
Baig AA, Benitez A, Quinn MT, Burnet DL. Family interventions to improve diabetes outcomes for adults. Ann N Y Acad Sci. 2015;1353(1):89-112. doi:10.1111/nyas.12844
Kim ES, Shiba K, Boehm JK, Kubzansky LD. Sense of purpose in life and five health behaviors in older adults. Prev Med. 2020;139:106172. doi:10.1016/j.ypmed.2020.106172
Dickinson JK, Guzman SJ, Maryniuk MD, et al. The use of language in diabetes care and education. Diabetes Care. 2017;40(12):1790-1799. doi:10.2337/dci17-0041
