2025 Volume 32 Issue 8 Pages 897-910
Aim: Although social participation, defined as involvement in social activities, may be beneficial for cardiovascular health, evidence about the association remains limited. This systematic review summarized the relationship between social participation and cardiovascular risk factors.
Methods: Original articles of longitudinal observational studies published in English before January 1, 2024, were searched via PubMed, Scopus, and Cochrane Library. Two investigators selected eligible literature for four health outcomes: hypertension, diabetes, dyslipidemia, and obesity.
Results: Eight articles (including duplicates) covering cohort studies were included. The results indicated that social participation is associated with lower hypertension risk, but gender differences may exist in the association between social participation and hypertension. Two articles from a Japanese cohort study were found on diabetes, both of which reported significant preventive association with social participation. The only study on dyslipidemia showed a higher hyperlipidemia risk among women, but not men, with social participation. Two studies on the risk of obesity showed inconsistent results, with one reporting the association between social participation and maintenance of smaller waist circumference only among men, while the other found no association with body mass index.
Conclusions: There is some evidence of the association between social participation and better cardiovascular health outcomes. However, evidence on gender differences and validation of the methodology for measuring social participation was still lacking.
Cardiovascular diseases are the leading cause of death worldwide, accounting for 20.5 million deaths in 2021 alone1). Lifestyle-related diseases, such as hypertension, type 2 diabetes mellitus, dyslipidemia, and obesity, are major risk factors for life-threatening cardiovascular diseases, including coronary heart disease2) and stroke3, 4). Strategies that address the underlying psychological and social factors to promote lifestyle modifications would be effective in reducing these modifiable risk factors.
Recently, social participation has attracted the attention of public health researchers and practitioners in relation to promoting healthy aging and creating age-friendly cities5). Social participation refers to engagement in activities within formal and informal social groups6). Participation in social networks through cultural, social, and civic activities has been suggested to encourage health-promoting behaviors such as increased physical activity or smoking cessation7). However, comprehensive evidence of the benefits of social participation is still lacking.
The present study aims to examine whether social participation contributes to preventing cardiovascular diseases. To understand the evidence from preceding studies, we conducted a systematic literature review that examined the association of social participation with four cardiovascular risk factors: hypertension, diabetes, dyslipidemia, and obesity.
We systematically searched PubMed, Scopus, and the Cochrane Library for longitudinal observational studies published in English before January 1, 2024. There were no restrictions on target countries. Articles such as reviews, letters, or protocols were excluded. Searches were conducted separately for the four outcomes of hypertension, diabetes, dyslipidemia, and obesity. The following search terms and synonyms were used for each outcome: “hypertension” or “blood pressure” for hypertension; “diabetes mellitus” or “glucose intolerance” or “blood glucose” or “HbA1c” or “diabetes” for diabetes; “dyslipidemias,” or “triglycerides,” or “cholesterol, LDL,” or “cholesterol, HDL,” or “hyperlipidemia” for dyslipidemia; and “overweight,” or “obesity,” or “waist circumference,” or “body weight,” or “body mass index” for obesity. Social participation in this review was defined as membership or active engagement in social groups or activities, regardless of whether their primary purpose was health promotion. The outcome terms were combined with (1) “observational study” or “cohort study” or “retrospective study” (terms for study design), and (2) “social participation,” “social activity,” “social networking,” “social communication,” “volunteers,” “recreation,” “community event,” “senior citizens’ club,” “social club,” “health education,” “laughter,” “health class,” “music,” “singing,” or “hobbies,” and “participation” (exposure terms). Furthermore, the following terms were used for the exclusion of literature: “systematic review,” “meta-analysis,” “review,” “cross-sectional study,” “pregnancy,” “pediatrics,” “protocol,” “hospitalization,” or “surgery.” Examples of the literature search strategy are presented in Supplementary Table 1.
| Hypertension | |
| #9 | (#5) AND (#8) |
| #8 | (#6) OR (#7) |
| #7 | (((((((((((((“Volunteers”[MeSH Terms] OR “Volunteers” OR “Volunteer” OR “Voluntary Workers” OR “Voluntary Worker” OR “Worker, Voluntary” OR “Volunteer Workers” OR “Volunteer Worker” OR “Worker, Volunteer” OR “Volunteer Personnel” OR “Personnel, Volunteer” OR “Volunteerism” OR “Untrained Personnel” OR “Personnel, Untrained”) OR (“Volunteerism” OR “Voluntary” OR “Volunteer activity”)) OR (“Recreation”[MeSH Terms] OR “Recreation” OR “Recreations”)) OR (“Community Events” OR “Community Event”)) OR (“Senior citizens’ club” OR “Seniors’ club” OR “Seniors club”)) OR (“Social clubs” OR “Social club”)) OR (“Health education”[MeSH Terms] OR “Health education” OR “Education, Health” OR “Community Health Education” OR “Education, Community Health” OR “Health Education, Community” OR “Health program” OR “Health programs” OR “Health course”)) OR (“Laughter”[MeSH Terms] OR “Laughter”)) OR (“Health class”)) OR (“Music”[MeSH Terms] OR “Music” OR “Songs” OR “Song” OR “Vocal”)) OR (“Singing”[MeSH Terms] OR “Singing” OR “Whistling” OR “Whistlings” OR “Vocalization, Rhythmic” OR “Rhythmic Vocalization” OR “Rhythmic Vocalizations” OR “Vocalizations, Rhythmic” OR “Chant” OR “Chants” OR “Singer” OR “Singers”)) OR (“Hobbies”[MeSH Terms] OR “Hobbies” OR “Hobby”))) AND ((“Participation”)) |
| #6 | (((“Social participation”[MeSH Terms] OR “Social participation” OR “Participation, Social” OR “Social Engagement” OR “Engagement, Social” OR “Social Citizenship” OR “Citizenship, Social”) OR (“Social activity”)) OR (“Social Networking”[MeSH Terms] OR “Social Networking” OR “Networking, Social” OR “Social Networks” OR “Network, Social” OR “Social Network”)) OR (“Social communication”) |
| #5 | (#3) NOT (#4) |
| #4 | ((((((((((“Systematic review”[Publication Type] OR “Systematic review”) OR (“Meta-analysis”[Publication Type] OR “Meta-analysis”)) OR (“Review”)) OR (“Cross-sectional studies”[MeSH Terms] OR “Cross- sectional studies”)) OR (“Pregnancy”[MeSH Terms] OR “Pregnancy” OR “Pregnancies” OR “Gestation”)) OR (“Pregnant”)) OR (“Pediatrics”[MeSH Terms] OR “Pediatrics”)) OR (“Pediatric” OR “Children” OR “Childhood” OR “Infant” OR “Boys” OR “Girls”)) OR (“Protocol”[title])) OR (“Hospitalization”[MeSH Terms] OR “Hospitalization” OR “Hospitalizations”)) OR (“Surgery”) |
| #3 | (#1) AND (#2) |
| #2 | ((“Observational Study”[Publication Type] OR “Observational Study” OR “Observational studies”) OR (“Cohort Studies”[MeSH Terms] OR “Cohort Studies” OR “Cohort Study” OR “Cohort”)) OR (“Retrospective Studies”[MeSH Terms] OR “Retrospective Studies” OR “Retrospective Study” OR “Studies, Retrospective” OR “Study, Retrospective” OR “Retrospective Study”) |
| #1 | (“Hypertension”[MeSH Terms] OR “Hypertension” OR “Blood Pressure, High” OR “Blood Pressures, High” OR “High Blood Pressure” OR “High Blood Pressures”) OR (“Blood Pressure”[MeSH Terms] OR “Blood Pressure” OR “Pressure, Blood” OR “Diastolic Pressure” OR “Pressure, Diastolic” OR “Pulse Pressure” OR “Pressure, Pulse” OR “Systolic Pressure” OR “Pressure, Systolic” OR “Pressures, Systolic”) |
| Diabetes Mellitus | |
| #9 | (#5) AND (#8) |
| #8 | (#6) OR (#7) |
| #7 | (((((((((((((“Volunteers”[MeSH Terms] OR “Volunteers” OR “Volunteer” OR “Voluntary Workers” OR “Voluntary Worker” OR “Worker, Voluntary” OR “Volunteer Workers” OR “Volunteer Worker” OR “Worker, Volunteer” OR “Volunteer Personnel” OR “Personnel, Volunteer” OR “Volunteerism” OR “Untrained Personnel” OR “Personnel, Untrained”) OR (“Volunteerism” OR “Voluntary” OR “Volunteer activity”)) OR (“Recreation”[MeSH Terms] OR “Recreation” OR “Recreations”)) OR (“Community Events” OR “Community Event”)) OR (“Senior citizens’ club” OR “Seniors’ club” OR “Seniors club”)) OR (“Social clubs” OR “Social club”)) OR (“Health education”[MeSH Terms] OR “Health education” OR “Education, Health” OR “Community Health Education” OR “Education, Community Health” OR “Health Education, Community” OR “Health program” OR “Health programs” OR “Health course”)) OR (“Laughter”[MeSH Terms] OR “Laughter”)) OR (“Health class”)) OR (“Music”[MeSH Terms] OR “Music” OR “Songs” OR “Song” OR “Vocal”)) OR (“Singing”[MeSH Terms] OR “Singing” OR “Whistling” OR “Whistlings” OR “Vocalization, Rhythmic” OR “Rhythmic Vocalization” OR “Rhythmic Vocalizations” OR “Vocalizations, Rhythmic” OR “Chant” OR “Chants” OR “Singer” OR “Singers”)) OR (“Hobbies”[MeSH Terms] OR “Hobbies” OR “Hobby”))) AND ((“Participation”)) |
| #6 | (((“Social participation”[MeSH Terms] OR “Social participation” OR “Participation, Social” OR “Social Engagement” OR “Engagement, Social” OR “Social Citizenship” OR “Citizenship, Social”) OR (“Social activity”)) OR (“Social Networking”[MeSH Terms] OR “Social Networking” OR “Networking, Social” OR “Social Networks” OR “Network, Social” OR “Social Network”)) OR (“Social communication”) |
| #5 | (#3) NOT (#4) |
| #4 | ((((((((((“Systematic review”[Publication Type] OR “Systematic review”) OR (“Meta-analysis”[Publication Type] OR “Meta-analysis”)) OR (“Review”)) OR (“Cross-sectional studies”[MeSH Terms] OR “Cross- sectional studies”)) OR (“Pregnancy”[MeSH Terms] OR “Pregnancy” OR “Pregnancies” OR “Gestation”)) OR (“Pregnant”)) OR (“Pediatrics”[MeSH Terms] OR “Pediatrics”)) OR (“Pediatric” OR “Children” OR “Childhood” OR “Infant” OR “Boys” OR “Girls”)) OR (“Protocol”[title])) OR (“Hospitalization”[MeSH Terms] OR “Hospitalization” OR “Hospitalizations”)) OR (“Surgery”) |
| #3 | (#1) AND (#2) |
| #2 | ((“Observational Study”[Publication Type] OR “Observational Study” OR “Observational studies”) OR (“Cohort Studies”[MeSH Terms] OR “Cohort Studies” OR “Cohort Study” OR “Cohort”)) OR (“Retrospective Studies”[MeSH Terms] OR “Retrospective Studies” OR “Retrospective Study” OR “Studies, Retrospective” OR “Study, Retrospective” OR “Retrospective Study”) |
| #1 | ((((“Diabetes Mellitus”[MeSH Terms] OR “Diabetes Mellitus”) OR (“Glucose Intolerance”[MeSH Terms] OR “Glucose Intolerance” OR “Glucose Intolerances” OR “Intolerance, Glucose” OR “Intolerances, Glucose” OR “Impaired Glucose Tolerance” OR “Glucose Tolerance, Impaired” OR “Glucose Tolerances, Impaired” OR “Impaired Glucose Tolerances” OR “Tolerance, Impaired Glucose” OR “Tolerances, Impaired Glucose”)) OR (“Blood glucose”[MeSH Terms] OR “Blood glucose” OR “Blood Sugar” OR “Sugar, Blood” OR “Glucose, Blood”)) OR (“HbA1c” OR “Hemoglobin A1c”)) OR (diabetes) |
| Dyslipidemia | |
| #9 | (#5) AND (#8) |
| #8 | (#6) OR (#7) |
| #7 | (((((((((((((“Volunteers”[MeSH Terms] OR “Volunteers” OR “Volunteer” OR “Voluntary Workers” OR “Voluntary Worker” OR “Worker, Voluntary” OR “Volunteer Workers” OR “Volunteer Worker” OR “Worker, Volunteer” OR “Volunteer Personnel” OR “Personnel, Volunteer” OR “Volunteerism” OR “Untrained Personnel” OR “Personnel, Untrained”) OR (“Volunteerism” OR “Voluntary” OR “Volunteer activity”)) OR (“Recreation”[MeSH Terms] OR “Recreation” OR “Recreations”)) OR (“Community Events” OR “Community Event”)) OR (“Senior citizens’ club” OR “Seniors’ club” OR “Seniors club”)) OR (“Social clubs” OR “Social club”)) OR (“Health education”[MeSH Terms] OR “Health education” OR “Education, Health” OR “Community Health Education” OR “Education, Community Health” OR “Health Education, Community” OR “Health program” OR “Health programs” OR “Health course”)) OR (“Laughter”[MeSH Terms] OR “Laughter”)) OR (“Health class”)) OR (“Music”[MeSH Terms] OR “Music” OR “Songs” OR “Song” OR “Vocal”)) OR (“Singing”[MeSH Terms] OR “Singing” OR “Whistling” OR “Whistlings” OR “Vocalization, Rhythmic” OR “Rhythmic Vocalization” OR “Rhythmic Vocalizations” OR “Vocalizations, Rhythmic” OR “Chant” OR “Chants” OR “Singer” OR “Singers”)) OR (“Hobbies”[MeSH Terms] OR “Hobbies” OR “Hobby”))) AND ((“Participation”)) |
| #6 | (((“Social participation”[MeSH Terms] OR “Social participation” OR “Participation, Social” OR “Social Engagement” OR “Engagement, Social” OR “Social Citizenship” OR “Citizenship, Social”) OR (“Social activity”)) OR (“Social Networking”[MeSH Terms] OR “Social Networking” OR “Networking, Social” OR “Social Networks” OR “Network, Social” OR “Social Network”)) OR (“Social communication”) |
| #5 | (#3) NOT (#4) |
| #4 | ((((((((((“Systematic review”[Publication Type] OR “Systematic review”) OR (“Meta-analysis”[Publication Type] OR “Meta-analysis”)) OR (“Review”)) OR (“Cross-sectional studies”[MeSH Terms] OR “Cross- sectional studies”)) OR (“Pregnancy”[MeSH Terms] OR “Pregnancy” OR “Pregnancies” OR “Gestation”)) OR (“Pregnant”)) OR (“Pediatrics”[MeSH Terms] OR “Pediatrics”)) OR (“Pediatric” OR “Children” OR “Childhood” OR “Infant” OR “Boys” OR “Girls”)) OR (“Protocol”[title])) OR (“Hospitalization”[MeSH Terms] OR “Hospitalization” OR “Hospitalizations”)) OR (“Surgery”) |
| #3 | (#1) AND (#2) |
| #2 | ((“Observational Study”[Publication Type] OR “Observational Study” OR “Observational studies”) OR (“Cohort Studies”[MeSH Terms] OR “Cohort Studies” OR “Cohort Study” OR “Cohort”)) OR (“Retrospective Studies”[MeSH Terms] OR “Retrospective Studies” OR “Retrospective Study” OR “Studies, Retrospective” OR “Study, Retrospective” OR “Retrospective Study”) |
| #1 | ((((“Dyslipidemias”[MeSH Terms] OR “Dyslipidemias” OR “Dyslipidemia” OR “Dyslipoproteinemias” OR “Dyslipoproteinemia”OR “Hyperlipidemia”) OR (“Triglycerides”[MeSH Terms] OR “Triglycerides” OR “Triacylglycerols” OR “Triacylglycerol” OR “Triglyceride”)) OR (“Cholesterol, LDL”[MeSH Terms] OR “Cholesterol, LDL” OR “Low Density Lipoprotein Cholesterol” OR “beta-Lipoprotein Cholesterol” OR “Cholesterol, beta-Lipoprotein” OR “beta Lipoprotein Cholesterol” OR “LDL Cholesterol” OR “Cholesteryl Linoleate, LDL” OR “LDL Cholesteryl Linoleate”)) OR (“Cholesterol, HDL”[MeSH Terms] OR “Cholesterol, HDL” OR “alpha-Lipoprotein Cholesterol” OR “Cholesterol, alpha-Lipoprotein” OR “alpha Lipoprotein Cholesterol” OR “HDL Cholesterol” OR “High Density Lipoprotein Cholesterol” OR “Cholesterol, HDL2” OR “HDL2 Cholesterol” OR “HDL(2) Cholesterol” OR “Cholesterol, HDL3” OR “HDL3 Cholesterol” OR “HDL(3) Cholesterol”)) OR (“Hyperlipidemias”[MeSH Terms] OR “Hyperlipidemias” OR “Hyperlipidemia” OR “Hyperlipemia” OR “Hyperlipemias” OR “Lipidemia” OR “Lipidemias” OR “Lipemia” OR “Lipemias”) |
| Obesity | |
| #9 | (#5) AND (#8) |
| #8 | (#6) OR (#7) |
| #7 | (((((((((((((“Volunteers”[MeSH Terms] OR “Volunteers” OR “Volunteer” OR “Voluntary Workers” OR “Voluntary Worker” OR “Worker, Voluntary” OR “Volunteer Workers” OR “Volunteer Worker” OR “Worker, Volunteer” OR “Volunteer Personnel” OR “Personnel, Volunteer” OR “Volunteerism” OR “Untrained Personnel” OR “Personnel, Untrained”) OR (“Volunteerism” OR “Voluntary” OR “Volunteer activity”)) OR (“Recreation”[MeSH Terms] OR “Recreation” OR “Recreations”)) OR (“Community Events” OR “Community Event”)) OR (“Senior citizens’ club” OR “Seniors’ club” OR “Seniors club”)) OR (“Social clubs” OR “Social club”)) OR (“Health education”[MeSH Terms] OR “Health education” OR “Education, Health” OR “Community Health Education” OR “Education, Community Health” OR “Health Education, Community” OR “Health program” OR “Health programs” OR “Health course”)) OR (“Laughter”[MeSH Terms] OR “Laughter”)) OR (“Health class”)) OR (“Music”[MeSH Terms] OR “Music” OR “Songs” OR “Song” OR “Vocal”)) OR (“Singing”[MeSH Terms] OR “Singing” OR “Whistling” OR “Whistlings” OR “Vocalization, Rhythmic” OR “Rhythmic Vocalization” OR “Rhythmic Vocalizations” OR “Vocalizations, Rhythmic” OR “Chant” OR “Chants” OR “Singer” OR “Singers”)) OR (“Hobbies”[MeSH Terms] OR “Hobbies” OR “Hobby”))) AND ((“Participation”)) |
| #6 | (((“Social participation”[MeSH Terms] OR “Social participation” OR “Participation, Social” OR “Social Engagement” OR “Engagement, Social” OR “Social Citizenship” OR “Citizenship, Social”) OR (“Social activity”)) OR (“Social Networking”[MeSH Terms] OR “Social Networking” OR “Networking, Social” OR “Social Networks” OR “Network, Social” OR “Social Network”)) OR (“Social communication”) |
| #5 | (#3) NOT (#4) |
| #4 | ((((((((((“Systematic review”[Publication Type] OR “Systematic review”) OR (“Meta-analysis”[Publication Type] OR “Meta-analysis”)) OR (“Review”)) OR (“Cross-sectional studies”[MeSH Terms] OR “Cross- sectional studies”)) OR (“Pregnancy”[MeSH Terms] OR “Pregnancy” OR “Pregnancies” OR “Gestation”)) OR (“Pregnant”)) OR (“Pediatrics”[MeSH Terms] OR “Pediatrics”)) OR (“Pediatric” OR “Children” OR “Childhood” OR “Infant” OR “Boys” OR “Girls”)) OR (“Protocol”[title])) OR (“Hospitalization”[MeSH Terms] OR “Hospitalization” OR “Hospitalizations”)) OR (“Surgery”) |
| #3 | (#1) AND (#2) |
| #2 | ((“Observational Study”[Publication Type] OR “Observational Study” OR “Observational studies”) OR (“Cohort Studies”[MeSH Terms] OR “Cohort Studies” OR “Cohort Study” OR “Cohort”)) OR (“Retrospective Studies”[MeSH Terms] OR “Retrospective Studies” OR “Retrospective Study” OR “Studies, Retrospective” OR “Study, Retrospective” OR “Retrospective Study”) |
| #1 | ((((((“Overweight”[MeSH Terms] OR “Overweight”) OR (“Obesity”[MeSH Terms] OR “Obesity”))) OR ((“Waist circumference”[MeSH Terms] OR “Waist circumference” OR “Circumference, Waist” OR “Circumferences, Waist” OR “Waist Circumferences”)) OR (“Body weight”[MeSH Terms] OR “Body weight” OR “Body Weights” OR “Weight, Body” OR “Weights, Body”)) OR (“Body Mass Index”[MeSH Terms] OR “Body Mass Index” OR “Index, Body Mass” OR “Quetelet Index” OR “Index, Quetelet” OR “Quetelet’s Index” OR “Quetelets Index”)) OR (“BMI”)) |
Two investigators independently reviewed the abstracts of the retrieved articles and excluded those that did not examine social participation as an exposure or did not assess one of the targeted outcomes. Since this review focuses on primary prevention, studies that included patients were excluded. The full text was then reviewed, and those items in which exposure was not clearly defined as social participation or the primary outcomes were not adequately measured were excluded. Screenings were performed independently by the two investigators. In cases of disagreement, a third investigator made the final decision.
This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. The protocol of this study is registered in PROSPERO (registration ID: CRD42023397194).
The flow of study selection for each cardiovascular health outcome is presented in Fig.1, 2, 3, 4. Ultimately, a total of eight articles were included in the present review (three for hypertension, two for diabetes, one for dyslipidemia, and two for obesity). All articles were cohort studies, and covered the countries of China, Japan, England, Canada, and the United States. It should be noted that one of the articles from Japan assessed the relationship between social participation and multiple non-communicable diseases (NCDs), including hypertension, diabetes, and hyperlipidemia. As a result, this article was included in each corresponding section of the review. A summary of the articles is provided in Table 1.
＊Other publication types included reviews, letters, editorials, protocols, trial registry entries, book chapters, and conference proceedings.
＊Other publication types included protocols and trial registry entries.
＊Other publication types included protocols.
＊Other publication types included protocols.
| Reviewed outcome | Author (published year) | Study/cohort name | Sample size; population | Country | Age at entry | Follow-up years | Social participation measures | Outcome measures | Adjusted variables | Relative risk |
|---|---|---|---|---|---|---|---|---|---|---|
| Hypertension |
Sneed et al. (2013)8) |
The Health and Retirement Study |
1,654 (666 men and 988 women); nationally representative sample of community- dwelling adults excluding those who were hypertensive at baseline |
United States | 51–91 |
4 years (2006–2010) |
Volunteerism: Time spent in the past 12 months doing volunteer work for religious, educational, health-related, or other charitable organizations. |
Hypertension: self-reported use of antihypertensive medications, or average resting systolic blood pressure ≥ 140 mmHg, or average resting diastolic blood pressure ≥ 90 mmHg |
Age, race/ ethnicity, sex, employment status, marital status, education, baseline systolic blood pressure, baseline diastolic blood pressure, self- reported history of diabetes, cancer, heart problems, lung problems, or stroke |
Individuals who had volunteered at least 200 hours (vs. nonvonlunteers): OR = 0.60 (95% CI: 0.40–0.90) 100–199 hours (vs. nonvonlunteers): OR = 0.78 (95% CI: 0.48–1.27) 50–99 hours (vs. nonvonlunteers): OR = 0.96 (95% CI 0.65–1.41) 1–49 hours (vs. nonvonlunteers): OR = 0.95(95% CI: 0.68–1.33) |
| Hypertension |
Tu et al. (2018)9) |
The China Health and Retirement Longitudinal Study |
5,483 (2,591 men and 2,892 women); nationally representative sample excluding those who were hypertensive at baseline ＊Sampling weights were applied to produce nationally representative estimates of variables. |
China | ≥ 45 |
2 years (2011–2013) |
Social participation: attended any of the following activities once a week or more frequently in the previous 1 month at baseline:
|
Hypertension: systolic blood pressure was ≥140 mmHg, diastolic blood pressure was ≥90 mmHg or they self-reported taking antihypertensive medication |
Age, marital status, educational attainment, body mass index categories, location of residence, smoking status, alcohol consumption, self-reported poor health, depressive symptoms |
Men: IRR = 1.10 (95% CI: 0.93–1.31) Women: IRR = 0.80 (95% CI: 0.67–0.95) |
| Hypertension | Oshio et al. (2019)10) |
The Longitudinal Survey of Middle-aged and Elderly Persons |
16,290 men and 17,248 women; nationwide sample excluding respondents who reported diagnosis of hypertension at baseline ＊A total of 25,823 to 30,774, depending on outcomes |
Japan | 50–59 |
9 years (2005–2014) |
|
Hypertension: diagnosed with hypertension by a medical doctor at the survey time |
Educational attainment, age, household spending, marital status, current smoking, heavy alcohol consumption, self-rated health |
Men: SP: HR = 0.95 (95% CI: 0.88–1.02) SP with others: HR = 0.96 (95% CI: 0.84– 1.04) SP alone: HR = 0.93 (95% CI: 0.85–1.04) Women: SP: HR = 0.91 (95% CI: 0.84–0.99) SP with others: HR = 0.91 (95% CI: 0.83– 0.99) SP alone: HR = 0.94 (95% CI: 0.83–1.06) |
| Diabetes mellitus | Oshio et al. (2019)10) |
The Longitudinal Survey of Middle-aged and Elderly Persons |
16,290 men and 17,248 women; nationwide sample excluding respondents who reported diagnosis of diabetes at baseline ＊A total of 25,823 to 30,774, depending on outcomes |
Japan | 50–59 |
9 years (2005–2014) |
|
Diabetes: diagnosed with diabetes by a medical doctor at the survey time | Educational attainment, age, household spending, marital status, current smoking, heavy alcohol consumption, self-rated health |
Men: SP: HR = 0.86 (95% CI: 0.77–0.95) SP with others: HR = 0.87 (95% CI: 0.78– 0.97) SP alone: HR = 0.81 (95% CI: 0.70–0.94) Women: SP: HR = 0.75 (95% CI: 0.66–0.85) SP with others: HR = 0.73 (95% CI: 0.64– 0.83) SP alone: HR = 0.85 (95% CI: 0.71–1.03) |
| Diabetes mellitus | Shibayama et al. (2018)11) |
The Longitudinal Survey of Middle-aged and Elderly Persons |
31,615; nationally representative sample excluding respondents who reported diagnosis of diabetes at baseline |
Japan | 50–59 |
8 years (2005–2013) |
Participation in social activities such as community events, volunteerism or providing support to older people. |
Diabetes incidence: self- administered questionnaire (diagnosed by a physician as having diabetes in the previous year) |
Sex, age, self- rated health, current hypertension and dyslipidemia status, actively smoke, habitually consume alcohol, aware of appropriate portion sizes, take care to eat a balanced diet, maintain a healthy bodyweight, brush teeth after every meal, attend a medical checkup each year, exercise status |
HR = 0.89 (95% CI: 0.87–0.92) |
| Dyslipidemia | Oshio et al. (2019)10) |
The Longitudinal Survey of Middle-aged and Elderly Persons |
16,290 men and 17,248 women; nationwide sample excluding respondents who reported diagnosis of hyperlipidemia at baseline ＊A total of 25,823 to 30,774, depending on outcomes |
Japan | 50–59 |
9 years (2005–2014) |
Social participation (SP): participated in at least one of six types (“hobbies or cultural activities,” “exercise or sports,” “community events,” “support for children,”“support for the elderly,” and “other activities”). |
Hyperlipidemia: diagnosed with hyperlipidemia by a medical doctor at the survey time |
Educational attainment, age, household spending, marital status, current smoking, heavy alcohol consumption, self-rated health |
Men: HR = 1.07 (95% CI: 0.98–1.16) Women: HR = 1.27 (95% CI: 1.17–1.38) |
| Obesity | Kouvonen et al. (2012)12) |
The English Longitudinal Study of Ageing |
4,280 (1,907 men and 2,373 women); people living in England, drawn from households who participated in annual nationally representative cross-sectional household surveys |
England | ≥ 52 |
4 years (2004/2005– 2008/2009) |
Social participation: members of any type of organizations, clubs, or societies including (a) political party, trade union, or environmental group; (b) tenants’ or residents’ group or Neighborhood Watch; (c) church or other religious group; (d) charitable association; (e) education, arts or music group, or evening class; (f) social club |
Maintaining or achieving waist circumference (WC) in the recommended range: ≤ 97 cm for men and ≤ 88 cm for women |
Age, ethnicity, marital status, baseline waist circumference, total household wealth, long- term limiting illness, depression, smoking, and physical activity |
Men with WC ≤ 97cm at baseline: Political party, trade union or environmental group: OR = 1.20 (95% CI: 0.79–1.96) Tenants’ or residents’ group or Neighbourhood Watch: OR = 1.41 (95% CI: 0.90–2.21) Church or other religious group: OR = 1.59 (95% CI: 0.94–2.67) Charitable associations: OR = 1.95 (95% CI: 1.19–3.21) Education, arts or music groups or evening class: OR = 2.48 (95% CI: 1:35–4.57) Social club: OR = 0.93 (95% CI: 0.60–1.47) Men with WC > 97cm at baseline: Political party, trade union or environmental group: OR = 0.56 (95% CI: 0.29–1.09) Tenants’ or residents’ group or Neighbourhood Watch: OR = 0.87 (95% CI: 0.49–1.44) Church or other religious group: OR = 1.17 (95% CI: 0.68–2.01) Charitable associations: OR = 0.68 (95% CI: 0.36–1.26) Education, arts or music groups or evening class: OR = 0.91 (95% CI: 0.45–1.85) Social club: OR = 1.03 (95% CI: 0.60–1.75) Women with WC ≤ 88cm at baseline: Political party, trade union or environmental group: OR = 1.23 (95% CI: 0.75–2.03) Tenants’ or residents’ group or Neighbourhood Watch: OR = 1.00 (95% CI: 0.98–1.02) Church or other religious group: OR = 1.01 (95% CI: 0.69–1.46) Charitable associations: OR = 0.71 (95% CI: 0.48–1.04) Education, arts or music groups or evening class: OR = 0.90 (95% CI: 0.60–1.36) Social club: OR = 1.00 (95% CI: 0.66–1.53) Women with WC > 88cm at baseline: Political party, trade union or environmental group: OR = 0.54 (95% CI: 0.26–1.12) Tenants’ or residents’ group or Neighbourhood Watch: OR = 1.08 (95% CI: 0.67–1.76) Church or other religious group: OR = 1.35 (95% CI: 0.87–2.11) Charitable associations: OR = 1.02 (95% CI: 0.62–1.69) Education, arts or music groups or evening class: OR = 0.99 (95% CI: 0.52–1.57) Social club: OR = 0.95 (95% CI: 0.57–1.57) |
| Obesity | Wu et al. (2018)13) |
The Montreal Neighborhood Networks and Healthy Aging Study |
2,606; people who were non- institutionalized, have resided at their current address for at least one year, and able to complete the questionnaire in French or English, selected based on the census tracts and age groups |
Canada | ≥ 25 |
5 years (2008– 2013/2014) |
Social participation: active in any civic groups or associations as a volunteer or an officer over the past five years |
Obesity status: adjusted body mass index > 30 kg/m2 (self- reported BMI was adjusted using a Statistics Canada correction factor) |
Year of data collection, gender, age, socioeconomic status, marital status, household language, isolation |
OR = 1.36 (95% CI: 0.85–2.16) |
OR, odds ratio; CI, confidence interval; IRR, incidence rate ratio; HR, hazard ratio.
It has been shown that social participation is inversely associated with the risk of developing hypertension but that this association is subject to gender differences.
The selected studies presented data from the US, China, and Japan. The Health and Retirement Study conducted in the US followed 1,654 men and women aged 51–91 over four years8). The study found that participants who spent 200 hours or more in volunteer work for religious, educational, health-related, or other charitable organizations in the 12 months prior to baseline were 40% less likely to develop hypertension compared to non-volunteers (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40–0.90). Based on the finding that no interaction was observed between volunteerism and demographic factors (sex, age, marital status, employment status, education, race/ethnicity) or baseline systolic/diastolic blood pressure, the authors suggested that the association was similar across various background of the participants.
Notably, studies from Asian countries showed an association between social participation and hypertension only among women. In the China Health and Retirement Longitudinal Study, which followed 2,591 men and 2,892 women aged 45 years or older for two years, a negative association between social participation and the development of hypertension was found in women, but no significant association was observed in men9). Similarly, Oshio et al. analyzed the data of middle-aged Japanese participated in the Longitudinal Survey of Middle-aged and Elderly Persons (LSMEP) to determine whether social participation experience would prevent the onset of NCDs (i.e. diabetes, heart disease, stroke, hypertension, hyperlipidemia, and cancer) and to examine whether social participation involving interactions with others differs from the one engaged in alone, in relation to health outcomes10). They followed 16,290 men and 17,248 women who were 50–59 years old at baseline for 9 years, and the results indicated that women who participated in at least one social activity (“hobbies or cultural activities,” “exercise or sports,” “community events,” “support for children,” “support for the elderly,” and “other activities”) had a lower risk of developing hypertension compared to those who did not (hazard ratio [HR] 0.91, 95% CI 0.84–0.99). However, the difference was no longer significant in a sensitivity analysis, which excluded participants who developed hypertension or dropped out in the first 1–2 years of the follow-up. This result suggested that individuals with preclinical diseases, which could lead to less social participation, might have caused an overestimation of the preventive benefit of social participation. In men, no significant difference was observed in the multivariable adjusted model (HR 0.95, 95% CI 0.88–1.02). Furthermore, the analysis of women by type of social participation (alone or with others) revealed that social participation with others had a lower risk of hypertension (HR 0.91, 95% CI 0.83–0.99), whereas no such association was observed for social participation alone (HR 0.94, 95% CI 0.83–1.06).
Diabetes MellitusTwo reports from Japan, using data from the LSMEP, examined the association between social participation and the incidence of diabetes. Both reported a significant inverse association of social participation with diabetes onset.
In the aforementioned study by Oshio et al., social participation had a lower risk of the diabetes incidence in both men and women10). The association remained statistically significant in the sensitivity analysis, which excluded participants who developed diabetes or dropped out early in the follow-up period (HR 0.84, 95% CI 0.74–0.96 in men, and HR 0.74, 95% CI 0.64–0.86 in women). These findings suggest a robust inverse association between social participation and diabetes incidence.
The other article, by Shibayama et al., investigated the relationship between the onset of diabetes and social engagement, which was assessed as participation in social activities (such as community events, volunteerism, or providing support to older people), living with someone, having the companionship of friends, and employment status11). The results of an eight-year follow-up of 31,615 individuals aged 50–59 years showed a significantly lower risk of diabetes onset among those who participated in social activities (HR 0.89, 95% CI 0.87–0.92).
DyslipidemiaOnly a single study reported the association between social participation and lipid outcomes. The aforementioned study by Oshio et al. showed that women with social participation had a higher risk of self-reported diagnosis of hyperlipidemia (HR 1.27, 95% CI 1.17–1.38), while no such association was observed in men (HR 1.07, 95% CI 0.98–1.16)10).
ObesityStudies examining the association between social participation and obesity have shown inconsistent results. Kouvonen et al. analyzed data from the English Longitudinal Study of Ageing, which followed 4,280 men and women aged 52 years or older over four years12). They found that participation in education, arts or music groups, or evening classes, and participation in charitable associations were associated with maintaining a recommended waist circumference (≤ 97 cm) in men who had a recommended waist circumference at baseline (participation in education, arts or music groups, or evening classes: OR 2.48, 95% CI 1.35–4.57; participation in charitable associations: OR 1.95, 95% CI 1.19–3.21). However, social participation was not associated with achieving recommended waist circumferences for men with larger baseline waist circumferences. Moreover, no association between social participation and maintaining or achieving a recommended waist circumference (≤ 88 cm) was found in women. In contrast, a study from Canada which included 5-year follow-up of 2,606 men and women aged 25 or older who participated in the Montreal Neighborhood Networks and Healthy Aging Study, reported that no association was found between social participation and obesity defined as a body mass index ＞30 kg/m2 13).
This systematic review investigated the association of social participation with major cardiovascular risk factors. Few longitudinal observational studies evaluated the association between social participation and hypertension, diabetes, dyslipidemia, or obesity. Although there was not necessarily a sufficient number of studies on these topics, the studies generally consistently showed that social participation was inversely associated with the risk of hypertension and diabetes. Evidence on dyslipidemia was insufficient. Furthermore, the results of the studies about the risk of obesity differed depending on the population and outcome measures used (i.e., waist circumference and body mass index).
Several mechanisms may explain the relationship between social participation and cardiovascular risk factors. One of these is the change in health behaviors through social activity participation. Social participation often involves physical activities, and previous studies have reported successful health promotion interventions that increase physical activity levels among older adults by utilizing volunteer activities14, 15). Social participation is also associated with health-promoting behaviors such as increased intake of vegetables and fruits16) and abstinence from smoking17). Moreover, health behavior can also be changed through social networks developed by participation in social activities. Low social participation may lead to social isolation and loneliness, which could be associated with adverse health behaviors such as decreased physical activity18, 19). In fact, favorable health outcomes (i.e., lower mortality risks among the elderly population) related to social ties have been reported20). Sneed et al.8) highlighted that since older adults are vulnerable to reduced social connectedness due to social transitions such as retirement, divorce, bereavement, or children’s independence, maintaining a social network may be beneficial for engaging in favorable health behaviors.
Another explanation of the relationship between social participation and cardiovascular health outcomes is that social participation may reduce stress or strengthen stress-coping ability. It has been reported that social stress, including that arising from inadequate support or social isolation, has a negative impact on cardiovascular health21). By participating in social activities, social integration may develop a sense of purpose, belonging, and security, which can help participants better cope with stress7). Furthermore, helping others may release stress-buffering and restorative hormones that decrease activity in the hypothalamic-pituitary-adrenal (HPA) axis by regulating the stress response. Prosocial behavior, such as volunteering, activates the reward-related areas of the brain that regulate oxytocin and vasopressin22), hormones that regulate HPA activity, and cortisol stress response23). Moreover, in social activities involving cultural experience, cultural stimulation may play a specific role in physical and mental health, possibly through psychoneuroimmunological mechanisms24). There is a report of lower mortality for individuals who frequently participate in cultural events such as visits to cinemas, concerts, museums, or art exhibitions25).
Focusing on the resources exchanged among participants of social activities, social participation may affect cardiovascular health outcomes in both positive and negative ways. Social participation may promote the dissemination of health information, access to informal healthcare, and maintenance of healthy behavioral norms7), such as norms regarding diet and physical activities. Furthermore, in a homophilous community, network members tend to share common perceptions and behavioral patterns regarding health26). Engagement in such a homophilous community may help individuals foster favorable health norms and behaviors shared among its members, but may also adversely reinforce unhealthy norms and behaviors within its members27).
It should also be noted that gender differences may exist in the relationship between social participation and cardiovascular health outcomes. Only two studies among those included in the present review (Tu et al.9) and Oshio et al.10)) performed gender-specific analyses. Interestingly, both of them reported that social participation was associated with lower hypertension risk only in women. In addition, according to Oshio et al.10), women were at higher risk of developing hyperlipidemia when participating in social activities, whereas men were not. Men may spend less time in communities, where social participation usually takes place, and therefore may be less influenced by the neighborhood environment28, 29). Although the reviewed studies defined social participation as individual-level variables, Tu et al. noted that social or physical environments that engender more social participation also affect health, particularly in individuals who stay in the environment longer (i.e., women)9). Because many social activities included in the assessment of social participation in the reviewed articles involved community-level activities, the statistically significant association may have been observed only in women, who are more likely to be influenced by the community. Furthermore, Ikeda et al. pointed out the association between social support and higher drinking frequency at social events or increased fat intake in Japanese men. They suggested that “enkai” (drinking meetings, which are often workplace-based socializing events in Japanese culture) may be related to the increased risk of metabolic syndrome30). Workplaces and work-related interactions, which are the main places for social interaction for men, were not included in our review’s evaluation of social participation. This matter may have resulted in the lack of significant association observed in the reviewed studies. Ikeda et al. also pointed out that social support was associated with a higher intake of Western desserts in women30), which may lead to a higher risk of dyslipidemia.
Another explanation for gender differences may be the difference in roles men and women assume in social activities. Specifically, in Asian culture, men are more likely to be in key positions. This matter may have an adverse effect, as it can be a psychological stressor offsetting the health benefit of social participation, as suggested by Tu et al.9). However, it has also been reported in a Japanese study that occupying key positions within an organization has a protective role, promoting the mental health of older Japanese men in rural areas, with the interpretation that men might feel rewarded by seeking authoritative positions in their culture31). Further research is needed on the relationship between cardiovascular health outcomes and social roles in social activities.
It should be noted that the measures used to assess social participation or its degree varied across studies. For instance, while Tu et al.9) defined social participation as attendance in social activities, Kouvonen et al.12) defined it as memberships of social groups. The effect of social participation is exhibited differently depending on the number, type, and frequency of the activities32-36). Further, Oshio et al. found that the role of interaction with others in social activities is another key dominant10). A standardized definition of social participation has not yet been developed37). Douglas and colleagues defined three concepts of social participation (social connections, informal social participation, and volunteering) based on a literature review38), whereas Zhang and colleagues proposed a four-level classification schema based on the depth and breadth of social interactions39). Additionally, the findings of Sneed et al. highlighted that a certain level of participation is needed for the successful prevention of hypertension8). A consensus on the definition of social participation and validated measurement approaches remains to be established.
This study had several limitations. Most of the studies in our literature review targeted middle-aged or older adults (aged 50 years or older). Also, countries included in the reviewed articles were limited to the US, China, Japan, England, and Canada. Since the motivators and effects of social participation may vary by age group and cultural or environmental background, the implications from our review may thus not apply directly to other populations. However, Sneed et al.8) reported that the elderly population is less socially connected than the younger population. Since a large part of the evidence in our review was from Japan, the most rapidly aging society in the world, their research focus on the seniors has important public health implications.
In addition, the possibility of reverse causality cannot be discounted, as people with extant diseases may be prevented from engaging in social activities because of physical capability and, in the case of obesity, stigma and negative self-concepts related to physical appearance12). While Sneed et al.8) attempted to decrease this possibility by utilizing the prospective study design and control for chronic diseases, the results of the sensitivity analysis by Oshio et al. suggested the possibility of overestimation due to preclinical diseases10). Intervention studies are needed to link social participation and cardiovascular health outcomes causally.
Although we summarized the current evidence, studies examining the relationship between social participation and cardiovascular health outcomes were limited, precluding meta-analysis. Japanese guidelines on cardiovascular health40-43) address the association of cardiovascular health outcomes with factors such as psychological stress, lifestyle changes (physical activity and diet), and residential environment and refer to community-based approaches and group intervention strategies. However, they do not directly mention social participation in the context of preventing cardiovascular diseases. Therefore, further research to accumulate more robust evidence is warranted.
Although research about the association of social participation with cardiovascular risk factors has been limited, some studies demonstrate the preventive role of social participation against cardiovascular health outcomes. Since several studies have shown gender differences in the association, future studies should address the role of biological and psychosocial gender differences. Moreover, a consensus on the definition of social participation and standardized measurement methodologies needs to be established.
The authors would like to thank Natsumi Ishii and Tsubasa Sakurai of Fukushima Medical University School of Medicine and Juntendo University Graduate School of Medicine staff for their assistance in conducting the systematic review. This study was supported by Japan Agency for Medical Research and Development (AMED) under Grant Number JP22rea522104.
All authors report no conflict of interest.
