Relationships and public health Couple relationships in the UK – a public health emergency The renewed focus on public health occasioned by recent reforms to the health and social care commissioning landscape offers commissioners and policy-makers an invaluable opportunity to think radically and creatively about how to bring about much-needed improvements in people’s health and well-being. The Tavistock Centre for Couple Relationships believes that viewing public health through the lens of the couple relationship is a perspective which offers great potential for effecting change in public health and well-being. The Office for National Statistics recently published results of a survey showing that respondents felt that personal relationships and mental wellbeing are most important to them in terms of subjective well-being (ONS, 2011). Such findings chime with what we intuitively know, namely that relationships – and in particular our intimate adult partnerships – are of fundamental importance to our health and well-being. Indeed, research evidence has also accumulated in recent years establishing a scientific basis for what we believe to be true. We now know, for example, that the quality of relationships affects how much alcohol we drink, fundamental aspects of our physical health such as blood pressure, and our mental health. And we also know that isolation and loneliness – that is, the absence of loving relationships of any sort – are also detrimental to our health, being associated with increased risk for cardiovascular disease, diabetes, stroke, obesity and mortality (see, for example, Whisman, 2010). This policy briefing paper brings together research findings on four major public health concerns – alcohol use, cardiovascular disease, childhood obesity and diabetes – to show why public health commissioning must place the couple relationship centre stage in order to effect lasting improvements in the nation’s health and well-being. However, it is not only on these four areas – as major as they are – where the impact of couple relationships are felt. TCCR believes that, at a conservative estimate, at least three-quarters of the indicators contained in the Government’s Public Health Outcomes Framework (Department of Health, 2011) are directly or indirectly influenced by the quality of people’s couple relationships. Alcohol use Alcohol consumption in the UK has doubled in the past forty years. During this period, according to the Faculty of Public Health, the death rate from liver cirrhosis has more than quadrupled. In addition to a number of cancers, obesity, high blood pressure, coronary heart disease, pancreatitis and mental health problems such as depression and alcohol dependency are all conditions to which alcohol misuse can be a significant contributory factor (Faculty of Public Health, 2008). Given the public health implications of alcohol use, it is perhaps surprising that there are so few studies on the impact of relationship difficulties on alcohol consumption (as opposed to a plethora of studies which investigate the impact of alcohol consumption on marital and relationship satisfaction). However, those studies which have been done point to a clear link between relationship dissatisfaction and alcohol misuse. One study of 69 heterosexual couples, for example, found that women tend to drink more than men in response to relationship difficulties and low levels of intimacy from their partner (Levitt, 2010). This finding corroborated those from earlier studies which indicated that women whose relationships lacked intimacy reported increased drinking problems over time compared to women with more intimate relationships (Wilsnack, 1984). A longitudinal study however – which followed couples over a period of nine years – found that husbands, not wives, tend to drink in response to marital problems (Romelsjo, Lazarus, Kaplan, & Cohen, 1991). The thrust of these findings is supported by two studies conducted in 2006. The first of these demonstrated a greater likelihood of people abusing alcohol one year after scoring highly on a rating of marital dissatisfaction, leading the authors of the study to observe that “if marital dissatisfaction is related to the course of alcohol use disorders, then reducing marital dissatisfaction should reduce the likelihood of onset or recurrence of alcohol use disorders” (Whisman, 2006). While the second study, of nearly 5,000 adults aged 18 to 64, showed that the marital discord underlying a divorce (rather than the divorce itself) to be associated with the onset of alcohol abuse, social phobia and chronic low mood (Overbeek, 2006). Taken together, these studies on the impact of relationship difficulties on alcohol consumption suggest that supporting couples, and thereby improving couple relationships, has substantial potential for reducing the physical and mental health problems which result from alcohol misuse. Cardiovascular disease The research picture on cardiovascular disease and relationship satisfaction is richer than that regarding alcohol and relationships, with numerous studies linking marital and relationship dissatisfaction with increased incidence of cardiovascular disease (Kiecolt-Glaser, 2001). In essence, the research picture reveals just how profoundly affairs of the heart affect heart health. For example, marital stress may increase the risk of recurrent coronary events, according to one study (Orth-Gomer, 2000), while marital quality, according to another, predicts patient survival among patients with chronic heart failure (Coyne, 2001). The quality of couple relationships also has a remarkable impact on survival rates after bypass surgery, with married people being 2.5 times more likely to be alive 15 years after coronary artery bypass grafting (CABG) than those who are not married, and those in high-satisfaction marriages being 3.2 times more likely to be alive 15 years after CABG compared with those reporting low marital satisfaction (King, 2011). In relation to blood pressure, people with mild hypertension who report higher levels of marital satisfaction exhibit decreased left ventricle mass and lower diastolic blood pressure after 3 years than people with lower levels of marital satisfaction (Baker, 2003). In addition, relationship quality is a better predictor of daily blood pressure, affect and stress than partner status, research has shown, with high relationship quality being linked to lower blood pressure (Grewen, 2005). Similarly, one study has shown that high marital quality is associated with lower ambulatory blood pressure, lower stress, less depression, and higher satisfaction with life; but that single individuals had lower ambulatory blood pressure than their unhappily married counterparts (Holt-Lunstad, 2008). The results of one study point to satisfaction with one’s sex life rather than one's love relationship being linked to reduced risk of coronary heart disease (Boehm, 2011) (although in older people these two things are likely to be highly correlated). However, another study has found that women in satisfying marriages have significantly less hardening of the arteries (atherosclerosis) than woman in low-satisfying marriages. “Women in satisfying marriages”, the authors write, “also tended to show less rapid progression of carotid atherosclerosis relative to women in low-satisfying marriages”, leading the authors of the study to claim that high-quality marriages may protect against cardiovascular disease for women (Gallo, 2003). Recent studies focusing on a constellation of features called Metabolic Syndrome – i.e. central obesity, high cholesterol, elevated blood pressure, and disorders of blood sugar metabolism, all of which are associated with increased risk for cardiovascular disease, diabetes, stroke, and mortality – may be one mechanism by which poor marital adjustment increases risk for poor health outcomes in women. “Improving marital adjustment”, the researchers observe, “may help prevent the incidence of Metabolic Syndrome and improve health, particularly for women” (Whisman, 2010) (Whisman, 2011). Childhood obesity Various environmental factors have been identified as contributing to obesity in children from an early age, including breastfeeding (associated with lower levels of childhood and adult obesity), family lifestyles and food choices, parental neglect, and sedentary lifestyle and television viewing (SEBCHU, 2008). Looking at these from a couple relationships perspective, it is interesting to note that support from the father of a baby – through active participation in the breastfeeding decision, together with a positive attitude by him and knowledge about the benefits of breastfeeding – has been shown to have a strong influence on the initiation and duration of breastfeeding, and that low-income women in particular suggest that male support is crucial in their decision to breastfeed (Fatherhood Institute, 2007). The impact of the quality of the couple relationship has also been highlighted by research into parental behaviour during children’s eating activities which suggests that “the emotional climate created by these behaviours can significantly impact the eating behaviours of the developing child in a positive or a negative way depending upon the feeding style of the parent” (Hughes, 2011), while another study found that “mothers of obese youth reported significantly greater psychological distress, higher family conflict, and more mealtime challenges” (Zeller, 2007). However, it may be that the most fruitful area of investigation regarding childhood obesity involves the links between parenting style and marital satisfaction. Children raised by parents who have an authoritative parenting style eat more healthily, are more physically active and have lower BMI levels compared to children raised with other styles (authoritarian, permissive/indulgent, uninvolved/neglectful) (Sleddens, 2011); while indulgent (Olvera, 2009) and authoritarian (Rhee, 2006) parenting predicts overweight in children. Given that permissive and authoritarian parenting styles are associated with lower marital satisfaction (Devito, 2001) and that marital dissatisfaction results in more authoritarian and less authoritative parenting (Cowan, 1992), it follows that the quality of the parental relationship may have a significant bearing on childhood overweight and obesity. Furthermore, some evidence suggests that exposure to stressful events and circumstances, such as inter-parental conflict, may trigger a physiological response in children that may contribute to higher rates of obesity (Bjorntorp, 2001) (Booth, 2000) (Dimitriou, 2003). Given the Government’s concerns about both parenting skills and childhood obesity, it would appear a matter of some urgency that further research is carried out to further establish the relationship between these two areas. Diabetes Although the research evidence on couple relationships and diabetes/blood glucose control is relatively sparse, those studies which do exist suggest that there may be a link between relationship satisfaction and better disease management. For example, one study of 134 adults with diabetes and their partners found that while at the beginning of the study higher marital stress correlated with poorer blood glucose control and higher depression, and lower marital cohesion correlated with higher systolic blood pressure, analysis after one year showed that marital satisfaction predicted improved blood glucose control (Trief, 2006). In a previous study of insulin-treated adults with diabetes, the same researchers had found that the quality of marriage is associated with adaptation to diabetes and other aspects of health-related quality of life and that marital adjustment may relate to blood glucose control (Trief, 2001). A study of adults with type 2 diabetes investigated, among other aspects of disease management, patients' appraisal of the degree of respect they received from their spouse regarding diabetes; they found that this is linked to general satisfaction in the relationship. “These findings”, the study authors suggest, “have implications for intervention because they suggest that management of a chronic disease cannot easily be separated from the general emotional context of the couple relationship. Programs that focus on enhancing spousal collaboration in the context of disease management may also need to include broader relationship factors rather than keeping the intervention focused on the disease exclusively” (Fisher, 2004). Summary We intuitively know that the quality of our relationships – and in particular our intimate adult partnerships – are of fundamental importance to our health and well-being. Research is increasingly showing that the quality of our relationships affects factors which impact on our health such as how much alcohol we drink, whether or not we have high blood pressure, and our mental health. Studies also indicate that isolation and loneliness – that is, the absence of loving relationships of any sort – are detrimental to our health, being associated with increased risk for cardiovascular disease, diabetes, stroke, obesity and mortality. Couple relationships play a significant, but little understood, role in a great many of the public health problems which clinical commissioning groups, local authorities and directors of public health will be charged with tackling. Indeed, TCCR believes that couple relationships have a bearing on the vast majority of the Public Health Outcomes Framework’s indicators. The evidence referred to in this briefing suggests that directors of public health, health and social care commissioners, and health and well-being boards can make significant improvements to public health by placing couple relationships centre stage as they undertake joint strategic needs assessments and prepare their commissioning plans. References Baker, B., Szalai, J. P., Paquette, M., & Tobe, S. (2003). Marital support, spousal contact and the course of mild hypertension. Journal of Psychosomatic Research, 55, 229–233. Bjorntorp, P. (2001). Do stress reactions cause abdominal obesity and comorbidities? 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Health Psychology, Vol 29(5), Sep, 2010. pp. 550-554 Whisman, Mark A.; Uebelacker, Lisa A.; A longitudinal investigation of marital adjustment as a risk factor for metabolic syndrome. Health Psychology, Oct 17, 2011. Wilsnack, R., Wilsnack, C, Klassen, A. Women's Drinking and Drinking Problems: Patterns from a 1981 National Survey. AJPH November 1984, Vol. 74, No. 11 Zeller MH, Reiter-Purtill J, Modi AC, Gutzwiller J, Vannatta K, Davies WH. Controlled study of critical parent and family factors in the obesigenic environment. Obesity (Silver Spring). 2007 Jan;15(1):126-36. Download the full briefing paper: What do couple relationships have to do with public health - a policy briefing paper from TCCR.pdf Feedback Click here to provide feedback on this policy document.