Loneliness as a Public Health Imperative: Reframing Social Disconnection in Aging North Carolina

Introduction

Loneliness and social isolation are becoming recognized as material determinants of population health, rather than unfortunate, private aspects of the aging process. This shift reflects increasing evidence associating social disconnection with elevated risk of premature mortality, cardiovascular disease, stroke, depression, anxiety, and dementia, rivaling other established risk factors, such as obesity or physical inactivity.¹ By 2030, all 73 million American Baby Boomers will be 65 or older, signaling a demographic tipping point where older adults will outnumber children. As the aging cohort faces retirement, bereavement, and chronic illness or mobility limitations, more individuals will become vulnerable to social isolation and loneliness.

In North Carolina, these issues deserve particular scrutiny. The state is aging rapidly, with older adults outnumbering children in 88 of the state’s 100 counties and a growing “snowbird,” or seasonal, population, in which older adults migrate to escape cold Northern and Midwestern winters.² Geographic dispersion, rural infrastructure constraints, and uneven access to transportation, broadband, and community-based services may intensify social disconnection, particularly for older adults living alone, managing disability, or navigating caregiving roles.³ Social isolation and loneliness in North Carolina’s diverse communities are further shaped by cultural norms and contexts, like multigenerational household structures or racial and ethnic disparities.

This commentary frames loneliness and social isolation among North Carolina’s older adults as structurally and clinically embedded within the aging process, which necessitates integrated, measurable, and resourced healthy aging strategies.

North Carolina’s Unique Demographic Landscape

As the state with the 9th largest population of adults aged 65 and older, North Carolina’s unique demographic profile heightens urgency for targeted aging and behavioral health policy considerations.² More than one-quarter of North Carolina’s older adult population lives alone, one-third live either below or just above the poverty line, and one-third live with at least one disability.⁴ These factors do not automatically cause loneliness and social isolation; rather, they represent well-established risk markers for diminished social support and behavioral health.⁵

Living alone is neither synonymous with isolation nor a guarantee of loneliness but can signal gaps in day-to-day support. For widowed or divorced older adults, social networks may shrink; for those whose adult children have migrated for work, geographic distance converts family availability into episodic support.^6,7 Living alone may increase reliance on inconsistent social connection opportunities and expensive formal care resources.³

Nearly half of older adults must also juggle caregiving responsibilities for their grandchildren, spouses, or other loved ones, further straining social and financial safety nets for self-care.⁴ While often rewarding, caregiving can be isolating. Many caregivers face undue burdens that force them to neglect their social networks, finances, and health, increasing their risk for anxiety and depression.⁸

Loneliness and social isolation are not only individual-level conditions. North Carolina’s uneven structural and community landscape compounds these demographic vulnerabilities. North Carolina faces a statewide long-term care and behavioral workforce shortage; the state needs approximately 200,000 direct care workers by 2032, and 94 out of 100 counties are designated professional mental health shortage areas, indicating that behavioral health coverage is both an intragenerational access issue and a geographically slanted burden.^9,10 These shortages create geographic and age-spanning access constraints, limiting high-quality, timely behavioral health interventions across the lifespan. Accessible and affordable mental health touchpoints are critical for early identification and management of depression, anxiety, and related conditions that shape long-term socioemotional and physical health trajectories.¹¹

Workforce shortages pose intragenerational risks: delayed or foregone treatment earlier in life may compound with aging-related risk factors, increasing susceptibility to unaddressed social withdrawal and loneliness in later life. Geographic inequities further complicate this landscape. Rural North Carolina communities face disproportionate burdens when accessing behavioral health services and social connections, even when interest exists. The migration of younger residents and the rising proportion of older adults can strain the tax base needed for financing community-based infrastructures, community-building “third places” (e.g., community centers, churches, hobby clubs), and health workforce development.¹² Compounded with few incentives to recruit and retain a rural health workforce, younger adult departures also suppress opportunities for formal and community-based behavioral health services. Unique telehealth challenges and public transportation constraints require older adults to travel even longer distances for health services and social engagement or forego their behavioral health needs.¹³

North Carolina’s Behavioral Risk Factor Surveillance System (BRFSS) data underscore state-specific social disconnection among older adults. Utilizing BRFSS data, approximately 439,000, or 24% of older adults, report feeling lonely, and 268,000, or 14% of older adults, report social isolation.¹⁴ Together, these conditions suggest that loneliness and social isolation in North Carolina are not simply individual problems of “social motivation.” They are outcomes of an ecosystem in which mobility, infrastructure, demographic change, and caregiving intersect. Treating social connection as a health determinant, therefore, requires cross-sector strategies, not only individual behavior change.

Distinguishing Social Isolation from Loneliness: Implications for Intervention

Nationally, social isolation (29%) and insufficient social connections (26%) increase the risk of premature death, commonly likened to the equivalent of smoking up to 15 cigarettes per day.³ While many older adults felt socially isolated and lonely before COVID-19, the pandemic has contributed to long-term social disconnection years after social distancing and lockdowns.¹⁵ Beyond the higher likelihood of serious mental and physical conditions, such as a 32% increased risk of stroke, research indicates that older adults with chronic social isolation and loneliness increase their risk of dementia by approximately 50%.³ These associations are rarely linear, straightforward paths, but rather regulated by pre-existing functional ability, health status, and social resources. The pathways are seemingly bidirectional and reinforcing: isolation can worsen physical health, while declining health may inhibit mobility and opportunities for engagement, thereby deepening the cycle of isolation. Although these causal mechanisms are complex, social disconnection is a risk marker that is both clinically salient and amenable to change, making it a high-leverage opportunity for public health intervention.

Yet, a foundational point in both research and practice is that social isolation and loneliness are notably interconnected but distinct constructs. The U.S. Surgeon General’s advisory defines social isolation as an objective condition characterized by few relationships, limited social roles, and infrequent interaction; meanwhile, loneliness is considered a state of subjective distress that arises from a perceived mismatch between desired and actual connection.³ North Carolina is a microcosm where nationally defined pathways and distinctions between isolation and loneliness unfold statewide and bidirectionally reinforce demographic inequities across the state.

This distinction indicates that causal pathways, measurement strategies, and intervention designs can diverge. While one older adult may have a small social network but feel content and adequately supported, another may have a large network and feel profoundly lonely due to low-quality relationships, grief, or unmet relational needs. Therefore, North Carolina initiatives that rely solely on structural risk indicators, such as living alone, risk misclassifying or missing someone’s need. However, at the same time, state initiatives that solely focus on expressed loneliness may overlook individuals with minimal support who are not currently distressed but are vulnerable during life shocks, like illness, bereavement, or financial insecurity.

Aging services and health systems in North Carolina can therefore benefit from adopting a dual-lens approach: (1) identify isolation risk (network insufficiency), and (2) assess loneliness (subjective experience). The intervention logic then becomes more precise: isolation often responds to connection-building and access strategies, like transportation and outreach, while loneliness may necessitate relational depth, grief support, mental health care, or meaning-centered engagement.

Existing Program Assets and Policies in North Carolina

Recent state investments and policies are bolstering North Carolina’s long-standing network of aging services, including the NC Department of Health and Human Service’s Division of Aging, Area Agencies on Aging, senior centers, and faith-based and community-based organizations, to facilitate connection and engagement among older adults.

In 2023, North Carolina budgeted an $835 million investment to expand behavioral health delivery and the workforce, develop community-based care services, increase Medicaid reimbursement rates for mental health services, and integrate behavioral care in primary care settings.¹⁶ Robust behavioral health investment can benefit both older adults and the future older adult population through early intervention touchpoints throughout one’s lifespan. These touchpoints can build resilience for healthy aging, whether by supporting middle-aged adults with depressive symptoms as they transition into older age, or children whose chronic loneliness may increase vulnerability to social isolation later in life.¹⁷

Alongside the North Carolina Center for Health and Wellness, the Division of Aging is continuing its Social Bridging NC program, a virtual hub first developed to combat COVID-driven social disconnection by emulating senior center benefits through online social engagement opportunities, resource sharing, self-assessments for social isolation and loneliness, and one-on-one support.¹⁸ Survey data published in the North Carolina Medical Journal identifies senior centers as trusted community hubs that positively improve social isolation, loneliness, and health management, highlighting the potential of a digitalized version for older adults with functional or transportation barriers.¹⁸

Integrating social isolation and loneliness identification within clinical workflows and care transitions is an opportunity the state should consider to improve outcomes and prevent unnecessary spending.⁵ However, success hinges on pairing screening with the capacity to respond, leveraging North Carolina’s Division of Aging to bridge clinical, bureaucratic, and community sectors in ways that strengthen referral infrastructure, clarify eligibility, and ensure “warm handoffs.” Social Bridging NC’s resources and self-assessment tools can help operationalize triage and linkage if incorporated into care management.

North Carolina’s current program landscape also highlights a core implementation challenge: federal disinvestments in Medicaid and the Substance Abuse and Mental Health Services Administration (SAMHSA), along with persistent barriers to senior centers or virtual programming (such as limited broadband, transportation, or functional capacity) may prevent these programs from reaching the older adults who need them most.^5,19 These complexities may undermine state-level investments and interventions unless North Carolina adapts or reallocates resources. Equity-focused considerations are essential in ongoing initiatives to ensure that, in practice, all older adults experience the benefits of behavioral health and social support.

Designing Heterogeneity-Aware Interventions

“One-size-fits-all” interventions often fail to address loneliness as a multi-causal and relationally complex issue. For North Carolina, this complexity is amplified by demographic and geographic heterogeneity, requiring more intentional design than one-size strategies. Three design principles are especially pertinent to consider:

Target connection quality, not only contact frequency. Loneliness reflects a perceived relational deficit. Programs that merely increase “touchpoints” may not reduce loneliness if interactions are transactional, patronizing, or stigmatizing. Interventions that cultivate reciprocity—volunteering, intergenerational conversations, peer mentoring—may create meaning and identity that limits loneliness in later life.²⁰

Bring connection to people by explicitly addressing access constraints. Social Bridging NC’s emphasis on virtual programming can help, but only if paired with strategies to reduce the digital divide. Transportation supports, mobile programming—where group programming is brought to remote communities—and hybrid participation options reduce inequity.

Leverage trusted local institutions. Many North Carolina communities value faith organizations, cooperative extensions, libraries, and local nonprofits as high-trust connectors. Partnering with these institutions can support outreach to older adults who distrust formal systems or who are not already engaged with senior centers and clinical care.

Measuring Progress: What North Carolina Should Treat as “Outcomes”

Although BRFSS-derived estimates help establish magnitude and trend, program evaluation requires more granular outcomes: perceived support, loneliness severity, participation frequency, network size, and downstream health utilization. Treating social connection as a public health priority requires clear measurement and interpretation.

At a minimum, a statewide strategy should aim for a measurement framework (Table 1) that captures population-level surveillance, equity and reach, implementation, patient-reported outcomes, and health system outcomes.

The policy point is straightforward: what North Carolina measures signals what it values. Underprioritizing loneliness and isolation outcomes invites underinvestment, whereas treating them as social determinants linked to mortality risk, dementia risk, and excess health spending supports sustained prioritization.

Conclusion

While loneliness and social isolation can affect individuals across the lifespan, they present a unique challenge for North Carolina’s older adults, defined by aging-related stressors, geographic dispersion, and infrastructural constraints. Left unresolved, social disconnection amplifies vulnerability to social withdrawal, chronic disease incidence, and cognitive decline, underscoring that it is not merely an individual issue, but a structural problem amenable to statewide policy change.

North Carolina’s rapidly aging and demographically heterogeneous profile creates an actionable opportunity to treat social connection as a public health priority and core element of the state’s aging infrastructure. Addressing this challenge involves expanding access to quality social connection resources, bridging clinical and trusted community supports, and designing programs with attention to equity and appropriate measurement. Prioritizing social connection subsequently prioritizes the health, resilience, and equity of North Carolina’s aging population.

Acknowledgments

The authors have no conflicts of interest to declare.

Correspondence

Address correspondence to Sierra J. Kaplan (Sierra.Kaplan@duke.edu).