THE LINK BETWEEN HEALTHY LIFESTYLE AND PSYCHOLOGICAL WELL-BEING IN LITHUANIAN ADULTS AGED 45-72: A CROSS-SECTIONAL STUDY For peer review only

Transcription

1 THE LINK BETWEEN HEALTHY LIFESTYLE AND PSYCHOLOGICAL WELL-BEING IN LITHUANIAN ADULTS AGED -: A CROSS-SECTIONAL STUDY Journal: BMJ Open Manuscript ID bmjopen-0-00 Article Type: Research Date Submitted by the Author: -Sep-0 Complete List of Authors: Sapranaviciute-Zabazlajeva, Laura; Lietuvos sveikatos mokslu universitetas, Institute of cardiology; Lietuvos sveikatos mokslu universitetas, Health psychology department Luksiene, Dalia; Lietuvos sveikatos mokslu universitetas, Virviciute, Dalia; Lietuvos sveikatos mokslu universitetas Medicinos fakultetas, Institute of Cardiology Bobak, Martin; University College London, Department of Epidemiology and Public Health Tamosiunas, Abdonas; Lithuanian University of Health Sciences, Institute of Cardology <b>primary Subject Heading</b>: Secondary Subject Heading: Keywords: Public health Mental health, Epidemiology, Smoking and tobacco, Nutrition and metabolism EPIDEMIOLOGY, MENTAL HEALTH, NUTRITION & DIETETICS, PREVENTIVE MEDICINE, PUBLIC HEALTH BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright. -

2 Page of BMJ Open THE LINK BETWEEN HEALTHY LIFESTYLE AND PSYCHOLOGICAL WELL-BEING IN LITHUANIAN ADULTS AGED -: A CROSS- SECTIONAL STUDY Laura Sapranaviciute-Zabazlajeva*, Dalia Luksiene, Dalia Virviciute, Martin Bobak, Abdonas Tamosiunas Institute of Cardiology, Health Psychology Department, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania; Institute of Cardiology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania; Department of Epidemiology and Public Health, University College London, London, United Kingdom *A. Mickeviciaus str., LT-0 Kaunas, Lithuania. Tel laura.sapranaviciute@lsmuni.lt Keywords: psychological well-being, healthy lifestyle, CVD risk factors, elderly. Word count: - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

3 Page of ABSTRACT Objective: This study uses a cross-sectional study design to analyse the connection between psychological well-being (PWB) and components of the healthy lifestyle in Lithuanian population aged -. The purpose of our study is to establish the links between psychological well-being and lifestyle factors such as physical activity, smoking, alcohol consumption and dietary patterns in older age. Participants: A stratified sample of,0 urban citizens aged - years were randomly selected from the National population register. The response rate was %. Methods: PWB was evaluated by a CASP- questionnaire. The standard questionnaire included questions regarding the respondent s socio-demographic, socio-economic and social status. Lifestyle questionnaire evaluated behavioural factors as smoking status, alcohol consumption, nutrition habits, and physical activity. Objective measurements of CVD risk factors were taken. Results: Adjusted for socio-demographic, socio-economic, social and biological CVD risk factors, the probability of good PWB increased for physically active men and women and former smokers men. The good PWB were directly associated with consumption of fresh vegetables and fruits. Responders who consumed potatoes, meat, boiled vegetables and eggs less frequent than average, had higher probability of good PWB. Direct association was ascertained between PWB and consumption of chicken and fish and backwards connection between PWB and consumption of sweets in women. Conclusion: Healthy lifestyle promotion efforts should focus on increasing physical activity, controlling smoking and improving food diversity, with particular targeting of people with worse PWB in the older age. BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright. -

4 Page of BMJ Open Strengths and limitations of the study: In Baltic countries this is the first study to assess the links between PWB and lifestyle factors at a population level. The large study sample with availability of multiple self-reported lifestyle and objective biological risk factors. Adjusted logistic regression models for the evaluation of an association between lifestyle factors and good PWB. Limited to one country. Cross-sectional study limits study finding to associations, no causal interpretations. Self-reported measures of healthy lifestyle. INTRODUCTION Results of the previous studies suggest that adoption of healthy lifestyle might improve happiness in older people. Studies reveal that healthy lifestyle is positively connected with psychological well-being (PWB) and negatively connected with psychological symptoms []. Australian longitudinal study concluded that aging well is associated with such a lifestyle factors as restful sleep, physical activity, nutrition, giving up smoking and a range of social activities []. So older adults can maintain their well-being by implementing healthy lifestyle even confronting age related diseases and other social stressors []. PWB is being linked with lifestyle factors such as physical activity, healthy eating, alcohol consumption and smoking. However, results are quit inconsistent. Most of the studies show that people with high PWB is less likely to smoke [,, ]. However, there is a limited amount of - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

5 Page of results []. Also there is no clear evidence about associations between alcohol consumption and PWB []. Physical exercise has been linked with psychological health long before []. Exercises not only prevent weight gain and promote well-being []. It is even believed that physical activity mediates the connection between PWB and mortality from cardiovascular diseases (CVD) []. Most of the studies analyzing associations between dietary patterns and well-being, explore connections between consumption of fruits, vegetables and well-being [, ]. Although many studies prove role of fruits and vegetables for promotion of PWB, evidence is inconclusive []. It has been suggested that lifestyle interventions have a beneficial effect for well-being in the elderly []. However, there is unclear which lifestyle factors are associated with higher PWB. So the purpose of our study is to establish the links between PWB and lifestyle factors such as physical activity, smoking, alcohol consumption and dietary patterns. We hypothesize that good PWB is being associated with physical activity, no smoking status, less frequent alcohol consumption and healthy dietary patterns, such as more frequent consumption of fruits and vegetables and less frequent consumption of sweets. METHODS Study sample Our study presents data collected from the survey within the framework of the international project HAPIEE (Health, Alcohol and Psychosocial Factors in Eastern Europe) []. Study data presents results of the cross-sectional study. The baseline survey was conducted in A random sample of,0 urban men and women from Kaunas city (Lithuania) aged years, stratified by sex and age, were randomly selected from the National population register. The response rate was %, so, respondents participated in the survey. Some participants BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright. -

6 Page of BMJ Open refused or were not able to answer all questions in the questionnaire. So data of male and female participants were deleted from the analysis because of the missing data. A total of, subjects were available for statistical analysis after the exclusion of the missing data. Clinical and demographic characteristics of the sample by gender are presented in Table. The study was approved by the Regional Biomedical Research Ethics Committee at the Lithuanian University of Health Sciences and by the UCLH Research Ethics Committee Alpha at University College London, UK. Table Baseline characteristics of the study population Variables Men Women p Age, years, mean (SD) 0. (.) 0. (.) 0. Body mass index, % (% CI) < kg/m. (0.-.). (.0-0.) < kg/m.0 (.-.). (.-.) 0 kg/m. (.-.). (.-.0) Arterial hypertension, % (% CI).0 (.-.). (.-.) <0.00 Triglycerides, % (% CI) <. mmol/l. (.-.). (.-.) 0.. mmol/l. (.-.). (.-.) HDL cholesterol, % (% CI) <. mmol/l. (.-.). (.-.0) <0.00. mmol/l. (.-.). (.0-.) LDL cholesterol, % (% CI) <.00 mmol/l. (.-.). (.-.0) < mmol/l. (.-.). (0.0-.). mmol/l. (0.-.). (.-0.) Glucose, % (% CI) <. mmol/l. (.-.0).0 (.-.) mmol/l. (.-.0). (.-.). mmol/l. (.-.). (.-.) Smoking status, % (% CI) Current 0. (.0-.). (.-.) <0.00 Former 0. (.-.). (.-.) Never. (.-0.). (.-.) Alcohol consumption, % (% CI) Every day.0 (.-.).0 (0.-.) < times per week. (.-.). (.-.) Once a week. (.-.). (.-.) - times per month. (.-.) 0. (.-0.0) Less than once a month. (.0-.0) 0. (.-.) Never. (.-.). (.0-.) Physically active, % (% CI).0 (.-.) 0. (.-.) <0.00 Nutrition habits % (% CI) - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

7 Page of Fresh vegetables and fruit consumption 0. (.-.). (.-.) <0.00 Sweets consumption. (.-0.). (.-.) 0.00 Porridge, cereals, curd, cheese consumption. (.-.). (0.-.) <0.00 Potatoes, meat, boiled vegetables and eggs.0 (0.-.). (.0-.) <0.00 Chicken and fish consumption. (.-.0) 0. (.-.) <0.00 Marital status, % (% CI) Married. (.-.). (.-.) <0.00 Single. (.-.). (.0-.) Cohabiting. (.-.) 0. (0.-.) Divorced. (.-.).0 (.-.) Widowed. (.-.). (.-.) Number of children, % (% CI) 0. (.0-.). (.-.) < (.-.). (.-0.). (.-.) 0. (.0-.) and more.0 (.-.). (.-.) Education level, % (% CI) Primary. (.-.0). (.-.) <0.00 Vocational. (.-.). (.-.) Secondary 0. (.-.). (.-.) College.0 (.-.). (.-.) University. (.-.0).0 (0.-.) Employment status, % (% CI) employed 0. (.-.). (0.-.) <0.00 employed-retired. (.-.0). (.-.) employed-disabled. (.-.). (.-.) unemployed. (.-.). (.-.0) retired. (.-.). (.-.) disabled. (.-.). (.-.) Social participation, % (% CI). (.-.). (.-.0) <0.00 Social activity, % (% CI) Low. (.-.). (.-.) <0.00 Moderate. (.-.). (.-.) High. (.-.). (0.-.) CHD, % (% CI). (.0-.) 0.0 (.-.) 0.0 Depressive symptoms, % (% CI). (.-.). (.-.) <0.00 Better PWB, % (% CI) median. (.0-.). (.-.) 0.0 BMI body mass index; HDL high density lipoprotein; LDL low density lipoprotein; CHD coronary heart disease; PWB psychological well-being. Measures Psychological well-being measures PWB was evaluated by a CASP- questionnaire Control Autonomy Self-realization and Pleasure []. It is composed of statements. Participants indicate how often (often, - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

8 Page of BMJ Open sometimes, not often, never) each statement applies to them. The total score ranges from to, there a higher score represents better PWB. Participants were labelled, as having a good PWB if CASP- score was higher or equal to median: 0 in men and in women. Depressive symptoms Depressive symptoms were measured using the -item Center for Epidemiologic Studies Depression Scale (CESD-) []. Subjects were asked to evaluate the presence of depressive symptoms during the past week on a two-point scale from (yes) to 0 (no), resulting in a total score between 0 and. Based on prior recommendations, subjects with CESD- scores of or more were classified as having depressive symptoms, and participants with a CESD- score lower than as without depressive symptoms [, ]. Socio-demographic, socio-economic, social and lifestyle factors The standard questionnaire included questions regarding the respondent s socio-demographic factors as age, marital status and number of children, socio-economic factors as education, employment status. Five categories of marital status (married, cohabiting, single, widowed, and divorced) and five levels of education (university, college, vocational, primary, secondary) were listed in the questionnaire. Participants were classified as not having children, having one, two or three and more children. Classifying participants into employed, employed-retired, employeddisabled, disabled, retired, and unemployed. Also, study participants were classified by social activity and social participation. Social activity was evaluated by statements about participating in clubs, going to church, restaurants, theatres, sports clubs, etc. Participants were divided into three groups: low, moderate and high social activity. Social participation shows the percentage of the study population being a member of a social organizations. BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright. -

9 Page of Also questionnaire evaluated behavioural factors as smoking status, alcohol consumption, nutrition habits, and physical activity. Smoking habits were assessed by classifying participants into three groups: current, former and never smokers. Alcohol consumption was measured by asking participants how often they drink alcohol: every day, - times per week, once per week, - times per month, less than once per month, never. Physical activity was determined by the mean length of time spent per week during leisure time in winter and summer for walking, moderate and hard work like gardening, and other physical activities. The respondents were categorized into two groups according to their physical activity in leisure time: physically active ( h or more) and inactive (less than h). Nutrition habits were evaluated using food frequency questionnaire. Those food groups were included into the food frequency questionnaire: potatoes, porridges and cereals, cheese, curd cheese, chicken, fish, meat, sausage, eggs, fresh carrots, other fresh vegetables, boiled vegetables, fresh fruit, natural juice, candies, chocolate and cakes. There were possible responses for all food groups: rarely or never; - times per month; once per week - times per week; - times per week; every day. Factor analysis was employed to reduce the number of food items. Data on exploratory factor analysis are presented in our previous paper []. Factor analysis of the main dietary patterns revealed a five-factor nutrition habits: consumption of fresh vegetables and fruit, consumption of sweets, consumption of porridge and cereals, consumption of potatoes, meat, boiled vegetables and eggs, and consumption of chicken and fish. A dichotomous dependent variable was constructed by dividing factor scores into two groups ( more frequent than average consumption of particular food group, 0 less frequent than average consumption). Cardiovascular diseases - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

10 Page of BMJ Open Coronary heart disease (CHD) was determined through the following procedures first, documented history of myocardial infarction (MI) and (or) ischemic changes on electrocardiogram (ECG) coded by the Minnesota codes (MC) or []; second, angina pectoris was defined by the G. Rose questionnaire (without MI and (or) MC or ; ) [0]; third, ECG findings by MC,,,,,,,,,, (without MI and (or) MC, and without angina pectoris). Arterial hypertension was defined as systolic blood pressure > mmhg and/or diastolic blood pressure >0 mmhg, or normal blood pressure (</0 mmhg) if the person had taken antihypertensive drugs within the last weeks. Objective measurements Blood pressure was measured three times, using an oscillometric device (Omron M-I) after min rest. The mean of three systolic and diastolic blood pressure tests was used. Waist circumference was measured by a standard meter within accuracy of 0. cm. Body mass index (BMI) was calculated as weight (kilograms) divided by the square of height (meters). Biochemical analyses were done for participants on an empty stomach. Serum samples from the baseline survey were analysed in one batch in the WHO Regional Lipid Reference Centre, Institute of Clinical and Experimental Medicine, Prague (Czech Republic). Lipid concentrations in serum were measured by conventional enzymatic method. Concentration of glucose in capillary blood was determined by an individual glucometer Glucotrend []. Statistical analysis The Statistical analyses were performed using the statistical software package SPSS.0 for Windows. Analysis was performed separately for men and women. The prevalence of lifestyle factors was compared in gender groups via χ tests. Mean differences were tested via t test. BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright. -

11 Page of Proportions were compared using z tests. The difference was considered to be statistically significant when p<0.0. For multivariate analysis we entered all variables which were significantly associated with good PWB in univariate logistic regression analysis. Multiple logistic regression analysis using the likelihood ratio criterion was used to analyse risk factors associated with PWB at a significance level of 0. (p<0.0). Odds ratios (OR) and % confidence intervals (CI) were estimated by the multivariate logistic regression for good eudemonic PWB. Two models were assessed. Model included age, lifestyle (smoking, alcohol consumption, physical activity, nutrition factors), and biological (BMI, blood lipids, glucose level, and arterial hypertension) CVD risk factors. Model included variables of Model plus socio-demographic and socio-economic factors, depressive symptoms, and CHD. RESULTS Table presents characteristics of the study population. The CVD risk factors such as obesity (BMI 0kg/m ), low HDL cholesterol level (<. mmol/l), high LDL cholesterol level (. mmol/l) and increased glucose level (. mmol/l) were more prevalent in women as compared to men (p<0.0). The CHD was more prevalent in women also. However, arterial hypertension and some unhealthy lifestyle habits such as frequent alcohol consumption and regular smoking status were more prevalent in men (p<0.00). Women were more physically active and their nutrition habits were healthier than men. They also had a better PWB compared to men. Moreover, women were higher educated and more socially active. Nevertheless, the prevalence of depressive symptoms was significantly higher in women compared to men. Also the proportions of divorced and widowed participants were higher among women. There were more employed men and more retired women in the study population. - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

12 Page of BMJ Open Table shows descriptive characteristics of the study participants by PWB groups (worse PWB and good PWB). Table Distribution of the lifestyle factors according to the psychological well-being (PWB) Lifestyle factors Worse PWB < median Men Good PWB median Worse PWB < median Women Good PWB median Smoking status, % Current..***.. Former Never..**.0. Alcohol consumption, % Every day..** times per week..*.. Once a week....** - times per month.0...** Less than once a month....0** Never..0..** Physically active, %..***..*** Nutrition habits % More frequent fresh vegetables, fruit consumption..***..*** More frequent sweets consumption..**.. More frequent porridge, cereals, curd..*.. and cheese consumption More frequent potatoes, meat, boiled.0 0.*..** vegetables and eggs consumption More frequent chicken and fish consumption....0*** *p<0.0; **p<0.0; ***p<0.00 compared with worse PWB group. Significant associations were found in the distribution of the four major lifestyle habits across the two categories of PWB. Men in the good PWB group were more likely to be never smokers, physically active and to report about healthier nutrition habits, such as, higher intake of fresh vegetables and fruit; porridge, cereals, curd and cheese. However, they tent to use sweets more frequent. Men in good PWB group consumed alcohol less frequent compared to the men in worse PWB group. Women in the good PWB group were more likely to be physically active and to report about healthier nutrition habits, such as, higher intake of fresh vegetables and fruits, - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

13 Page of chicken and fish, low intake porridge, cereals, curd and cheese. Thus they were more likely to drink alcohol more frequent. Multivariable adjusted odds ratio of good PWB according to the lifestyle habits are presented in Table. Odds ratios for having good PWB were increased for former smoker s men and women; never smokers and less frequent alcohol consumers men. Physical activity increased probability of good PWB in both genders (Model ). Logistic regression analysis revealed that dietary habits were differently associated with good PWB. Model included variables of Model plus sociodemographic, socio-economic and social factors, depressive symptoms, and CHD. The probability of good PWB increased for former smokers only in men. However, physical activity increased probability of good PWB in both genders. The good PWB were directly associated with consumption of fresh vegetables and fruits both in men and women. Conversely, responders who consumed potatoes, meat, boiled vegetables and eggs less frequent than average, had higher probability of good PWB. Chicken and fish consumption was directly associated with good PWB in women. Also women consuming more sweets tent to have worse PWB (Table ). Table Multivariable adjusted odds ratio of good psychological well-being (PWB) according to the lifestyle factors Odds ratios and % confidence intervals Lifestyle factors Model Model Men Women Men Women Smoking status Current Former. (.0-.)*.0 (0.-.). (.0-.)*. (0.-.) Never. (.0-.)*. (.0-.)*. (0.-.).0 (0.-.) Alcohol consumption Every day - times per week. (.-.)**. (0.-.). (0.-.).0 (0.-.) Once a week. (.0-.0). (0.-.). (0.-.0).0 (0.-.) - times per. (0.-.).0 (0.-.). (0.-.) 0. (0.-.) month Less than once a. (0.-.) 0.0 (0.-.). (0.-.0) 0. (0.-.0) month Never. (0.-.) 0. (0.-.0). (0.-.) 0.0 (0.0-.) Physically active. (.-.)***. (.-.)***. (.0-.)**. (.-.)** - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

14 Page of BMJ Open More frequent fresh. (.-.)***.0 (.-.)***. (.-.)***. (.-.)*** vegetables and fruit consumption More frequent sweets. (.00-.)* 0.0 (0.-.0).0 (0.-.) 0. (0.0-0.)* consumption More frequent. (0.-.).0 (0.0-.). (0.-.0) 0. (0.-.) porridge, cereals, curd, cheese consumption More frequent 0. (0.-0.)* 0.0 (0.-0.)** 0. (0.-0.)** 0. (0.-0.)* potatoes, meat, boiled vegetables, eggs consumption Chicken, fish consumption. (0.-.).(.-.)***. (0.-.). (.0-.)** *p<0.0; **p<0.0; ***p<0.00 Model included age, lifestyle (smoking, alcohol consumption frequency, physical activity, and nutrition habits), and biologic (body mass index, triglycerides, HDL cholesterol, LDL cholesterol, glucose level, and arterial hypertension) CVD risk factors. Model included variables of Model plus socio-demographic, social and socio-economic factors (education, marital status, number of children, employment status, and membership of social organization, social activity), depressive symptoms, CHD. DISCUSSION Our study of older Lithuanians established associations between PWB and lifestyle factors such as physical activity, healthy eating, alcohol consumption and smoking. Relationship between smoking habits and PWB is dependent from a gender of the responders. Men in good PWB group were more likely to be never smokers as compared to men in worse PWB group. After adjustment to socio-demographic, socio-economic and social factors, depressive symptoms and CHD, the probability of good PWB significantly increased for former smokers men as compared with regular smokers. It can be assumed, that the association is significant only among men because the prevalence of regular smoking in middle-aged and elderly women is quite low (lower than %). Moreover, the study revealed that the association between smoking habits and PWB is quite weak. It may be considered that smoking is more strongly related with mental disorders and negative factors of mental health as compared with positive PWB which was an object in our study. Longitudinal type of epidemiological studies enables the evaluation and - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

15 Page of demonstration of the prognostic impact of smoking habits on PWB [,, ]. The crosssectional type of our analysis enabled the demonstration of the association between the PWB and smoking habits only. The association between alcohol consumption and PWB was also related to gender. Among men who drank alcohol - times per week the odds of good PWB were significantly higher as compared to men drinking alcohol every day. Even after adjustment to other factors, the odds of good PWB among non-drinkers was higher as compared to drinkers. While alcohol consumption was not significantly related with PWB in women after adjustment to other factors. The relationship between drinking large amounts of alcohol and lower PWB has been also demonstrated by other studies []. However, we did not find any study presenting results about association between alcohol drinking and PWB dependently from sex of responders. It may be suggested that significant association between alcohol drinking and PWB is more characteristic for men because the prevalence of problematic alcohol use among women is rather low. Previous research also reported similar association between depressive symptoms and problematic alcohol drinking []. The results of other studies showed that people having a higher level of negative affect are more likely to engage in harmful alcohol use []. Physical activity increased probability of good PWB in both genders (data adjusted by socio-demographic, socio-economic and social factors, depressive symptoms, and CHD). Several previous epidemiologic studies in middle-aged and elderly population also found that physical activity was related with PWB. The study in U.K. showed higher levels of PWB in physically active persons as compared to inactive persons []. The meta-analysis of the results from studies also revealed the relationship between physical activity and PWB in older adults. Social-cognitive theory is used by authors of the meta-analysis to explain the effect of physical activity on PWB: PWB is represented by the self-efficacy and perceived individual abilities to meet their needs. With - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

16 Page of BMJ Open age, the ability to perform daily activities weakens; therefore, the physical activity allows feeling the self-efficacy and sense of control over life []. It can be assumed that physical activity also reveals person's ability to move and better cope with everyday activities, which leads to better PWB. Unfortunately, the performance of daily activities was not evaluated in our study. However, after adjustment to the disability and other health-related variables, the significant association between physical activity and PWB persisted. This indicates to the independent association between physical activity and PWB. Good PWB were directly associated with consumption of fresh vegetables and fruits both in men and women. Responders who consumed it more frequent had higher probability of good PWB. Also it was indicated that responders who consumed potatoes, meat, boiled vegetables, eggs less frequent than average, had higher probability of good PWB. Chicken and fish consumption were directly associated with good PWB and sweets consumption was inversely associated with good PWB in women. Previous studies advocate for strong evidence of causal relationship between fruits and vegetables consumption and positive well-being []. Well-being especially increases with a more frequent consumption of fruits and vegetables per day [,, ]. However, scientific evidence of an association between PBW and other nutrition habits (meat, fish or sweets) is not clear enough. Strengths and limitations To the best of our knowledge, this is the first study to assess at a population level the links between PWB and lifestyle factors in the Baltic countries. The strengths of this study include the large study sample with availability of multiple lifestyle and biologic risk factors. We used adjusted logistic regression models for the evaluation of an association between lifestyle factors and good PWB. Not only self-reported variables such as smoking, alcohol consumption, physical activity, nutrition factors, PWB social, socio-economic, socio-demographic factors, but also objectively measured - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

17 Page of variables such as BMI, blood lipids, glucose level and blood pressure were included into logistic regression models. Although some limitations need to be addressed to our study. Firstly, due to the crosssectional type of the study, it is still not clear whether smoking, low physical activity and some nutrition habits reduces the level of PWB or whether reduction in PWB leads to unhealthy lifestyle. The longitudinal studies should be held. Secondly, the self-reported evaluation of the lifestyle factors like physical activity and nutrition habits may be an imprecise method for estimating the type and duration of physical activity and dietary habits. More precise measures should be involved in the future studies. Moreover, it might be some potential confounders which were not analyzed in our study also. Our study results represent only one country, so the results can not be generalized. However, this study involves quit big urban older population and many potential confounders associated with healthy aging and PWB were included. CONCLUSIONS Former smoking status, physical activity and healthy nutrition habits increased probability of good PWB. Healthy lifestyle education efforts should focus on increasing physical activity, controlling smoking and improving food diversity, with particular targeting of people with worse PWB in older. Contributors. LS, DL, AT contributed to the concept and design of the manuscript, data interpretation and writing. DV contributed to the data analysis and interpretation. LS, AT, MB contributed to the final approval of the manuscript. Funding. Wellcome Trust (grant no. 0/Z/0/Z), the US National Institute on Aging (grant no. R0I AG), Research Council of Lithuania (No SEN-0/0). - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

18 Page of BMJ Open Competing interest. None declared. Data sharing statement. No additional data available. Provenance and peer review Not commissioned; externally peer reviewed. REFERENCES. Pahl K, Brook JS, Koppel J, et al. Unexpected benefits: pathways from smoking restrictions in the home to psychological well-being and distress among urban black and Puerto Rican Americans. Nicotine Tob Res 0;:0-.. Kendig H, Browing CJ, Thomas SA, et al. Health, lifestyle, and gender influences on aging well: an Australian longitudinal analysis to guide health promotion. Front Public Health 0;:-.. Kahana E, Kelley-Moore J, Kahana B. Proactive aging: a longitudinal study of stress, resources, agency, and well-being in late life. Aging Ment Health 0;:-.. Sagara T, Hitomi Y, Kambayashi Y, et. al. Common risk factors for changes in body weight and psychological well-being in Japanese male middle-aged workers. Environ Health Prev Med 00;:-.. Barros VV, Kozasa EH, Formagini TD, et al. Smokers show lower levels of psychological well-being and mindfulness than non-smokers. PloS One 0;:e0. Doi:./journal.pone.0. Boehm JK, Kubzansky LD. The Hearts Content: The Association between Positive Psychological Well-Being and Cardiovascular Health. Psychological Bulletin 0;: BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

19 Page of Scully D, Kremer J, Meade MM, et al. Physical exercise and psychological well-being: a critical review. Br J Sports Med ;:-0.. Hoogwest MT, Versteeg H, Hansen T, et al. Exercise mediates the association between positive affect and -year mortality in patients with ischemic heart disease. Circ Cardiovasc Qual Outcomes 0;:-.. Blanchflower DG, Oswald AJ, Stewart-Brown SL. Is psychological well-being linked to the consumption of fruit and vegetables? Working Paper. Coventry: Economics Department, University of Warwick. (Warwick economics research paper series (TWERPS). 0; No... Conner TS, Brookie KL, Richardson AC, et al. On carrots and curiosity: eating fruit and vegetables is associated with greater flourishing in daily life. Br J Health Psychol 0;0:-.. Rooney C, McKinley MC, Woodside JV. The potential role of fruit and vegetables in aspects of psychological well-being: a review of the literature and future directions. Proc Nutr Soc 0;:0-.. Clark F, Jackson J, Carlson M, et al. Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: results of the Well Elderly Randomized Controlled Trial. J Epidemiol Community Health 0;:-0.. Peasey A, Bobak M, Kubinova R, et al. Determinants of cardiovascular disease and other non-communicable diseases in Central and Eastern Europe: rationale and design of the HAPIEE study. BMC Public Health 00;doi: Hyde M, Wiggins RD, Blane D, et al. A measure of quality of life in early old age: The theory, development and properties of a needs satisfaction model. Aging Ment Health 00;:. - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

20 Page of BMJ Open Carpenter JS, Andrykowski MA, Hall L, et al. Psychometrics for two short forms of the center for epidemiologic studies: depression scale. Iss Mentl Health Nurs ;:.. Sapranaviciute-Zabazlajeva L, Reklaitiene R, Tamosiunas A, et al. Correlates of depressive symptoms in urban middle-aged and elderly Lithuanians. Soc Psychiatry Psychiatr Epidemiol 0;:-0.. Irwin M, Artin KH, Oxman MN. Screening for depression in the older adult. Criterion validity of the ten-item center for epidemiological studies depression scale. Arch Intern Med ;:0 0.. Luksiene DI, Baceviciene M, Tamosiunas A, et al. Health, alcohol and psychosocial factors in Eastern Europe study: dietary patterns and their association with sociodemographic factors in the Lithuanian urban population of Kaunas city. Int J Public Health 0;:0-.. Prineas RJ, Crow RS, Blackburn H. The Minnesota code. Manual of electrocardiographic findings. John Wright, London,. 0. Rose GA, Blackburn H, Gillum RF, et al. Cardiovascular survey methods. Cardiovascular Disease Unit, WHO, Geneva,.. Norkus A, Ostrauskas R, Sulcaite R, et al. D. Classification and diagnostics of diabetes mellitus. Kaunas, Lithuania, Yaffe K, Fiocco AJ, Lindquist K, et al. Predictors of maintaining cognitive function in older adults: The Health ABC study. Neurology 00;:0-0.. Chodzko-Zajko W. National Blueprint: Increasing Physical Acivity Among Adults 0 and Older: Implications for Future Physical Activity and Cognitive Functioning Research. In - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

21 Page 0 of Poon LW, Chodzko-Zajko W, Tomporowski PD, editors. Active Living, Cognitive Functioning and Aging. Champaign: Human Kinetics; 00.. Nooyens AC, van Gelder BM, Verschuren MW. Smoking and cognitive decline among middle-aged men and women: the Deotinchem Cohort Study. Am J Public Health 00;:-0.. Stranges S, Samaraweera PC, Taggart F, et al. Major health-related behaviors and mental well-being in the general population: the Health Survey for England. BMJ Open 0;:e00.. Watts M. Understanding the coexistence of alcohol misuse and depression. Br J Nurs 00;:.. Gorka SM, Ali B, Daughters SB. The role of distress tolerance in the relationship between depressive symptoms and problematic alcohol use. Psychol Addict Behav 0;:.. Steptoe A, Demakakos P, Oliveira C, et al. Distinctive Biological Correlates of Positive Psychological Well-Being in Older Men and Women. Psychosom Med 0;:0-0.. Netz Y, Wu MJ, Becker BJ, et al. Physical activity and psychological well-being in advanced age: a meta-analysis of intervention studies. Psychol Aging 00;0: BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

22 Page of BMJ Open Section/Topic Item # STROBE 00 (v) Statement Checklist of items that should be included in reports of cross-sectional studies Recommendation Reported on page # Title and abstract (a) Indicate the study s design with a commonly used term in the title or the abstract - Introduction (b) Provide in the abstract an informative and balanced summary of what was done and what was found Background/rationale Explain the scientific background and rationale for the investigation being reported - Objectives State specific objectives, including any prespecified hypotheses Methods Study design Present key elements of study design early in the paper Setting Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection Participants (a) Give the eligibility criteria, and the sources and methods of selection of participants Variables Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. Give diagnostic criteria, if Data sources/ measurement applicable * For each variable of interest, give sources of data and details of methods of assessment (measurement). Describe comparability of assessment methods if there is more than one group Bias Describe any efforts to address potential sources of bias - Study size Explain how the study size was arrived at - Quantitative variables Explain how quantitative variables were handled in the analyses. If applicable, describe which groupings were chosen and why Statistical methods (a) Describe all statistical methods, including those used to control for confounding - Results on January 0 by guest. Protected by copyright. (b) Describe any methods used to examine subgroups and interactions - (c) Explain how missing data were addressed - (d) If applicable, describe analytical methods taking account of sampling strategy - (e) Describe any sensitivity analyses BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from

23 Page of Participants * (a) Report numbers of individuals at each stage of study eg numbers potentially eligible, examined for eligibility, - confirmed eligible, included in the study, completing follow-up, and analysed (b) Give reasons for non-participation at each stage Descriptive data (c) Consider use of a flow diagram - * (a) Give characteristics of study participants (eg demographic, clinical, social) and information on exposures and potential confounders (b) Indicate number of participants with missing data for each variable of interest - Outcome data * Report numbers of outcome events or summary measures - Main results (a) Give unadjusted estimates and, if applicable, confounder-adjusted estimates and their precision (eg, % confidence - interval). Make clear which confounders were adjusted for and why they were included (b) Report category boundaries when continuous variables were categorized - (c) If relevant, consider translating estimates of relative risk into absolute risk for a meaningful time period - Other analyses Report other analyses done eg analyses of subgroups and interactions, and sensitivity analyses - Discussion Key results Summarise key results with reference to study objectives - Limitations Discuss limitations of the study, taking into account sources of potential bias or imprecision. Discuss both direction and magnitude of any potential bias Interpretation 0 Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from - similar studies, and other relevant evidence Generalisability Discuss the generalisability (external validity) of the study results Other information Funding Give the source of funding and the role of the funders for the present study and, if applicable, for the original study on which the present article is based *Give information separately for cases and controls in case-control studies and, if applicable, for exposed and unexposed groups in cohort and cross-sectional studies. Note: An Explanation and Elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting. The STROBE checklist is best used in conjunction with this article (freely available on the Web sites of PLoS Medicine at Annals of Internal Medicine at and Epidemiology at Information on the STROBE Initiative is available at BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright. -

24 THE LINK BETWEEN HEALTHY LIFESTYLE AND PSYCHOLOGICAL WELL-BEING IN LITHUANIAN ADULTS AGED -: A CROSS-SECTIONAL STUDY Journal: BMJ Open Manuscript ID bmjopen-0-00.r Article Type: Research Date Submitted by the Author: -Dec-0 Complete List of Authors: Sapranaviciute-Zabazlajeva, Laura; Lietuvos sveikatos mokslu universitetas, Institute of cardiology; Lietuvos sveikatos mokslu universitetas, Health psychology department Luksiene, Dalia; Lietuvos sveikatos mokslu universitetas, Virviciute, Dalia; Lietuvos sveikatos mokslu universitetas Medicinos fakultetas, Institute of Cardiology Bobak, Martin; University College London, Department of Epidemiology and Public Health Tamosiunas, Abdonas; Lithuanian University of Health Sciences, Institute of Cardology <b>primary Subject Heading</b>: Secondary Subject Heading: Keywords: Public health Mental health, Epidemiology, Smoking and tobacco, Nutrition and metabolism EPIDEMIOLOGY, MENTAL HEALTH, NUTRITION & DIETETICS, PREVENTIVE MEDICINE, PUBLIC HEALTH BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright. -

25 Page of BMJ Open THE LINK BETWEEN HEALTHY LIFESTYLE AND PSYCHOLOGICAL WELL-BEING IN LITHUANIAN ADULTS AGED -: A CROSS- SECTIONAL STUDY Laura Sapranaviciute-Zabazlajeva*, Dalia Luksiene, Dalia Virviciute, Martin Bobak, Abdonas Tamosiunas Institute of Cardiology, Health Psychology Department, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania; Institute of Cardiology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania; Department of Epidemiology and Public Health, University College London, London, United Kingdom *A. Mickeviciaus St., LT-0 Kaunas, Lithuania. Tel laura.sapranaviciute@lsmuni.lt Keywords: psychological well-being, healthy lifestyle, CVD risk factors, elderly. Word count: BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

26 Page of ABSTRACT Objective: This study uses a cross-sectional study design to analyse the connection between psychological well-being (PWB) and components of a healthy lifestyle in the Lithuanian population aged -. The purpose of our study is to establish the links between psychological well-being and lifestyle factors such as physical activity, smoking, alcohol consumption and dietary patterns in people above the age of. Participants: A stratified sample of,0 urban citizens aged - years were randomly selected from the National Population Register. The response rate was %. Methods: PWB was evaluated by a CASP- questionnaire. The standard questionnaire included questions regarding the respondent s socio-demographic, socio-economic and social status. The lifestyle questionnaire evaluated behavioural factors as smoking status, alcohol consumption, nutrition habits, and physical activity. Objective measurements of cardiovascular disease (CVD) risk factors were taken. Results: Adjusted for socio-demographic, socio-economic, social and biological CVD risk factors, the probability of higher PWB increased for physically active men and women and male former smokers. Higher PWB was directly associated with consumption of fresh vegetables and fruits. Responders who consumed potatoes, meat, boiled vegetables and eggs less frequently than average were more likely to have higher PWB. A direct association was ascertained between PWB and consumption of chicken and fish, as well as an inverse association between PWB and consumption of sweets in women. BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright. -

27 Page of BMJ Open Conclusion: Healthy lifestyle promotion efforts should focus on increasing physical activity, controlling smoking and improving diversity in food consumption, with a particular focus on people with lower PWB in this age group. Strengths and limitations of the study: Amongst the Baltic countries, this is the first study to assess the links between PWB and lifestyle factors at a population level. Large sample size consisting of a diversity of self-reported lifestyles and objective biological risk factors. Adjusted logistical regression models controlling for various socio-demographic, social and CVD risk factors for precise evaluation of the association between lifestyle factors and PWB. Limited to one country. Cross-sectional study limits findings only to associations between factors. No conclusions about causation can be made. Self-reported measures of healthy lifestyle used in the study may not sufficiently reflect clinical standards for healthy living. The dataset analysed is from the period of 00-00, however the findings are still relevant because according to the data from Health Behavior among Lithuanian Adult Population in 0, socio-economic situation and lifestyle habits did not significantly changed from 00 to 0 []. - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.

28 Page of INTRODUCTION Results from previous studies suggest that the adoption of a healthy lifestyle might improve happiness in older people []. Studies also reveal that healthy lifestyle is positively associated with psychological well-being (PWB) and negatively associated with psychological symptoms []. An Australian longitudinal study concluded that aging well is associated with such a lifestyle factors as restful sleep, increased physical activity, better nutrition, smoking cessation and a range of social activities []. In this way, older adults can maintain their well-being by implementing a healthy lifestyle, even as they confront age-related diseases and other social stressors []. However, although PWB has been linked with lifestyle factors, results have been quite inconsistent. Most studies show that people with high PWB are less likely to smoke [,, ], however there are a limited number of results []. There is also no clear evidence of an association between alcohol consumption and PWB []. Physical exercise has long been linked with psychological health []. Exercise not only prevents weight gain and promotes well-being [], it is even believed to impact the association between PWB and mortality from cardiovascular diseases (CVD) []. Most of the studies analyzing associations between dietary patterns and well-being explore connections between consumption of fruits, vegetables and well-being [, ]. Although many studies point to the positive role of fruits and vegetable consumption in increasing PWB, the evidence is still inconclusive [, ]. The purpose of our study is to establish whether there are direct associations between PWB and the following selected lifestyle factors: physical activity, smoking, alcohol consumption and dietary patterns. We hypothesize that higher PWB is associated with physical activity, no - BMJ Open: first published as./bmjopen-0-00 on April 0. Downloaded from on January 0 by guest. Protected by copyright.