10 April, 2017: 

The title of this commentary is not a joke. Marital status seems to have a major impact on health. Traditionally, stability in intimate relations has positive effects on health and quality of life parameters, especially in old age. This assumption even translates into smaller insurance costs of married versus divorced persons. But recent data from the WHI observational study now challenges this accepted belief [1]. Among 79,094 postmenopausal women, transitions into marriage/marriage-like relationship after menopause were associated with greater increase in body mass index (BMI) and alcohol intake relative to remaining unmarried. Divorce/separation was associated with a reduction in BMI and waist circumference, changes that were accompanied by improvements in diet quality and physical activity, relative to women who remained married. The message coming from these results is that, contrary to earlier literature, in a cohort of well-educated, predominantly non-Hispanic white women, marital transitions after menopause are accompanied by modifiable health outcomes/behaviors that are more favorable for women experiencing divorce/separation than those entering a new marriage.

Comment

Marital status is a major parameter in every history-taking that health-care providers do. Thousands of articles have displayed all aspects of quality of life in health, as well as the potential impact on various disease situations adjusted to the marital status. Having a partner and intimate relations are considered as health promotors, while accordingly, marital disruption is perceived as a negative factor. For example, most studies on cardiovascular disease showed better outcomes for married persons, and men who were single generally had the poorest results [2]. Moreover, being married was associated with lower risk factors and better health status, even in the presence of many confounding effects. Physiological processes, such as cardiovascular reactivity, hormonal functionality, inflammatory manifestations and sleep patterns behave differently in the subsets of marital status, and so do many psychological variables [3, 4]. Even bone density was mentioned in this respect, as marriage before age 25 and marital disruptions seem deleterious to bone health in men, whereas marital quality was associated with better bone health in women [5].

There are several theories which try to explain why such correlates exist between marital status and health. Secured, low-stress surroundings, typical of good marriage, are among the main suggested mechanisms. But the search to understand goes further down even to our genes, with the finding that people who were separated or divorced had shorter salivary telomeres than people who were continuously married or had never been married [6]. Shortening of the telomere is a sign of aging and is associated with poorer health status and survival [7]. Evidently, evaluation of the health outcomes of marital status is highly complex since so many factors are involved. One's age, gender, quality of marriage, relations with the broader family, individual social network and support, economical status, etc., are all part of this multifaceted issue. Thus, it is not surprising that the expected benefits are sometimes small or even non-existent [3]. Past reviews made suggestive, but not strong claims about the empirical status of gender differences vis-a-vis marital quality and health outcomes, while newer ones fail to detect overall gender differences in the relationship between marital quality and health endpoints [3].

Apart from the potential effect of gender, several studies introduced menopause as another parameter in this anyway complicated situation. Predictors of the quality of life of women in the perimenopausal period included marital status as an independent causative, being poorer among single than married women [8]. Chinese women in Hong Kong, aged 40–59 years, reported on better quality of life when married [9]. A study from Turkey found that divorced marital status was a significant risk factor for early menopause (odds ratio 1.79) [10]. Satisfaction from marriage was addressed in the US Healthy Women Study, which concluded that women experiencing satisfying marriages had the least atherosclerosis in the carotid arteries and aorta, especially relative to those in low-satisfying marriages, during a long follow-up period [11]. As found in the study by Kutob and colleagues [1], the Healthy Women Study showed that women who did not have a partner had intermediate levels of atherosclerosis. Risk factors measured at baseline contributed to the differences between the satisfied and low-satisfied groups, but not those between the satisfied and unmarried groups.
So it seems that having bad intimate relations may be associated with poorer physical and mental health status, whereas living alone, rather than with a partner, probably increases the need and awareness of healthier lifestyle. Divorce or separation is certainly a very stressful life event, which might have ill-health consequences, yet most people cope well and are resilient after their marriage or long-term relationship ends [12]. Despite the fact that resilience is the most common response, a small percentage of people (approximately 10–15%) struggle quite substantially, and it seems that the overall elevated adverse health risks are driven by the poor functioning of this particular group.

Amos Pines
Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel

References

1. Kutob RM, Yuan NP, Wertheim BC, et al. Relationship between marital transitions, health behaviors, and health indicators of postmenopausal women: results from the Women's Health Initiative. J Womens Health (Larchmt) 2017 Jan 10. Epub ahead of print
http://www.ncbi.nlm.nih.gov/pubmed/28072926

2. Manfredini R, De Giorgi A, Tiseo R, et al. Marital status, cardiovascular diseases, and cardiovascular risk factors: a review of the evidence. J Womens Health (Larchmt) 2017 Jan 27. Epub ahead of print
http://www.ncbi.nlm.nih.gov/pubmed/28128671

3. Robles TF, Slatcher RB, Trombello JM, McGinn MM. Marital quality and health: a meta-analytic review. Psychol Bull 2014;140:140-87
http://www.ncbi.nlm.nih.gov/pubmed/23527470

4. Robles TF, Kiecolt-Glaser JK. The physiology of marriage: pathways to health. Physiol Behav 2003;79:409-16
http://www.ncbi.nlm.nih.gov/pubmed/12954435

5. Miller-Martinez D, Seeman T, Karlamangla AS, et al. Marital histories, marital support, and bone density: findings from the Midlife in the United States Study. Osteoporos Int 2014;25:1327-35
http://www.ncbi.nlm.nih.gov/pubmed/24424630

6. Whisman MA, Robustelli BL, Sbarra DA. Marital disruption is associated with shorter salivary telomere length in a probability sample of older adults. Soc Sci Med 2016;157:60-7
http://www.ncbi.nlm.nih.gov/pubmed/27062452

7. Telomere length and telomerase activity in the context of menopause. Menopause Live June 24, 2013

8. Kanadys K, Wiktor-Stoma A, Lewicka M, Sulima M, Wiktor H. Predictors of the quality of life of women in peri-menopausal period. Ann Agric Environ Med 2016;23:641-8
http://www.ncbi.nlm.nih.gov/pubmed/28030937

9. Li S, Ho SC, Sham A. Relationship between menopause status, attitude toward menopause, and quality of life in Chinese midlife women in Hong Kong. Menopause 2016;23:67-73
http://www.ncbi.nlm.nih.gov/pubmed/26671191

10. Sarac F, Oztekin K, Celebi G. Early menopause association with employment, smoking, divorced marital status and low leptin levels. Gynecol Endocrinol 2011;27:273-8
http://www.ncbi.nlm.nih.gov/pubmed/20528208

11. Gallo LC, Troxel WM, Kuller LH, et al. Marital status, marital quality, and atherosclerotic burden in postmenopausal women. Psychosom Med 2003;65:952-62
http://www.ncbi.nlm.nih.gov/pubmed/14645772

12. Sbarra DA. Divorce and health: current trends and future directions. Psychosom Med 2015;77:227-36
http://www.ncbi.nlm.nih.gov/pubmed/25829240