Composite healthy lifestyle, socioeconomic deprivation, and mental well-being during the COVID-19 pandemic: a prospective analysis

Review population

We applied info from participants of the English Longitudinal Analyze of Ageing (ELSA), a longitudinal cohort that recruited a agent sample of grown ups aged 50 a long time and more mature living in non-public households in England, as specific elsewhere [12]. The to start with wave of data selection took area on March 1, 2002, with subsequent longitudinal assessments each and every 2 a long time (wave 2 to wave 9) to measure variations in the wellness, financial and social circumstances making use of confront-to-confront interviews and self-administered questionnaires, and additional nurse visits just about every 4 many years. The first sample centered on Wellness Survey for England (HSE) involved 11,391 members, and there have been additional refreshment samples dependent on HSE at various waves (waves 3, 4, 6, 7 and 9) with distinct age requirements to appropriate for the age profile as the authentic sample aged. As particular way of life variables this kind of as cigarette smoking and bodily action may have altered over a extensive period of time (e.g., a 10 years), the existing examine utilized the most latest data predated the COVID-19 pandemic (wave 9, 2018–19), and two waves of the ELSA COVID-19 substudy (COVID wave 1 and wave 2, collected in June/July and November/December 2020 94% longitudinal reaction price). Moral approval was obtained from the Nationwide Exploration and Ethics Committee.

Analyses of this examine are primarily based on knowledge from individuals who participated in both COVID-19 surveys with accessible information and facts in wave 9 study. In the two COVID-19 waves, individuals ended up asked about the self-isolation (described as not leaving household for any motive) and stay-at-residence (defined as only leaving house for incredibly restricted needs) situations in April 2020 (early-phase of the outbreak), June/July and November/December 2020 (center to late stage of the pandemic). The to start with and 2nd nationwide lockdown was enforced through the survey time period [13], and these aged ≥70 several years were being thought of clinically susceptible and recommended by the British isles Authorities to continue to be at home and shield [14]. Individuals (381, 6.8%) who were not in self-isolation and did not keep at home at any of the 3 time details in the course of the period of time ended up excluded.

Socioeconomic properties

Socioeconomic deprivation was characterized by specific factors these kinds of as income, wealth, and schooling, and by team-amount issue these types of as the Index of Numerous Deprivation (IMD). Education and learning level was categorized as very low (beneath secondary), center and high (college or earlier mentioned), according to the Intercontinental Common Classification of Schooling [15]. Money was calculated from paid do the job, condition benefits, pensions and property [12]. Prosperity was derived from web economic wealth that is gross economical prosperity (e.g., residence, possessions, housing, investments, cost savings) minus monetary financial debt [12]. The IMD, encompassing domains these kinds of as criminal offense, education and learning, employment, well being, housing, earnings, and dwelling natural environment, served as the official evaluate of relative deprivation in England, representing the socio-financial status of people and communities [16, 17]. These factors ended up then classified into reduced (lowest quintile), intermediate (quintiles 2 to 4), and higher (best quintile) teams to characterize socioeconomic disparities across various degrees. In the primary analyses, deprivation characterised by IMD was reported, which delivered a complete assessment of many socioeconomic characteristics. Personal socioeconomic elements, this sort of as profits and training, ended up used in the sensitivity analyses.

Nutritious life

We defined a composite wholesome life-style score which includes 7 modifiable healthy lifestyle elements dependent on previous evidence and Uk nationwide wellbeing service rules [7, 18,19,20]: BMI, smoking cigarettes status, alcohol usage, actual physical activity, sedentary time, slumber duration, and fruit and vegetable ingestion. If offered, we made use of British isles countrywide suggestions to crank out balanced and harmful groups for each lifestyle component [18]. 1 level was assigned for every single harmful way of life group, which include unhealthy physique pounds (BMI < 18.5 or ≥25), current smoker, high alcohol intake (daily or almost daily), moderate or vigorous physical activity less than once per week, <7 or>9 h of rest per day, ≥7 h of sedentary time for every working day, and <5 portions of fruit and vegetable per day. Individuals’ scores were summed to create an unweighted score, and then classed as favorable (score 0–1), intermediate (score 2–3), or unfavorable (score 4–7) lifestyle category. Detailed definition of lifestyle category is provided in Supplementary Table 1. Distributions of the lifestyle score and lifestyle categories are shown in Supplementary Table 2.

Mental health outcomes

The mental health outcomes in this analysis were depressive symptoms, anxiety and personal well-being. Depressive symptoms were measured by an abbreviated eight-item version of the validated Center for Epidemiologic Studies Depression Scale (CES-D 8) [21]. A score of ≥4 was used to define participants of elevated depressive symptoms [22]. Anxiety was measured by the seven-item Generalized Anxiety Disorder (GAD-7) scale [23], using a threshold score of ten to define clinically significant symptoms [24]. Although the results do not necessarily represent clinical diagnoses, the CES-D and GAD are validated scales that used in large-scale population-based studies to measure symptoms of depression and anxiety [21, 23]. Personal well-being was assessed by the four-item Office for National Statistics (ONS) well-being (ONS-4) scale that capture three types of well-being: evaluative, eudemonic and affective experience [25]. A score of ≤4 was used to define participants of low personal well-being [25].

Covariates

Models were adjusted for a series of pre-pandemic covariates measured at baseline (wave 9), including age, sex, ethnicity, marital status, employment, disability, education, income, wealth, comorbidities and related conditions (chronic lung disease, asthma, arthritis, osteoporosis, cancer, Parkinson’s disease, dementia, hypertension, diabetes), and pre-pandemic mental health conditions (including history of psychiatric disorders, anxiety measured by ONS anxiety scale, depressive symptoms, and personal well-being) where applicable. In the sensitivity analyses, we additionally adjusted for pre-pandemic loneliness and social isolation that are risk factors for mental health outcomes and are anticipated direct consequences of pandemic and associated social and physical distancing. Loneliness was measured by the UCLA 3-item Loneliness Scale [26], and social isolation was measured by a composite score as in previous ELSA studies [27], in which one point was allocated for each of the following: not being married or cohabiting having less than monthly contact with each child, other members of the family, and friends (one point for each) and not being a member of organizations, such as religious groups or social groups.

Statistical analysis

We assess the associations between lifestyle factors, socioeconomic deprivation, and subsequent mental health conditions using Cox proportional hazards model, with study wave as the timescale that was adjusted for covariates.

Proportional hazard assumptions were checked based on Schoenfeld residuals and were satisfied. First, we separately assessed the association of composite lifestyle score (0–7 continuous variable) and lifestyle category (favorable, intermediate, and unfavorable) with mental health conditions, with adjusted for the above covariates and additionally for socioeconomic characteristics (education, income, and wealth). Second, we examined whether socioeconomic deprivation modified the association of lifestyle factors and mental health conditions. Multiplicative interactions between lifestyle category and socioeconomic deprivation characterized by group-level factor (IMD) were tested, with P values reported. We quantified the association between lifestyle category and mental health conditions across groups of socioeconomic deprivation, with the favorable lifestyle category as the reference group. We also estimated the combined effect of lifestyle and socioeconomic deprivation using nine ordinal categories, with participants in the least deprived group who were in the favorable lifestyle category as the reference group. The hazard ratio (HR) for trend per one increment change in lifestyle category was calculated. All models were adjusted for confounders including age, sex, ethnicity, marital status, employment, disability, comorbidities and related conditions. To account for potential reverse causality, pre-pandemic mental health was also adjusted, including history of psychiatric disorders, symptoms of depression and anxiety, and personal well-being.

Several sensitivity analyses were conducted to assess the robustness of the main analyses. First, in addition to the IMD as the primary socioeconomic characteristics, individual-level factors including education, income, and wealth were used to examine the contribution of socioeconomic deprivation. Second, we assessed the association between individual lifestyle factors (e.g., past or never smoker vs current smoker) and mental health conditions. Third, we run analyses after excluding participants with history of mental disorders. Forth, we additionally adjusted for pre-pandemic level of loneliness and social isolation that may be associated with both exposures and outcomes or mediate the association between lifestyle and mental health conditions during the COVID-19 pandemic. Finally,

All analyses were performed using SAS version 9.4 (SAS Institute) and R version 4.2.2 (R Foundation), and all statistical tests were two-sided, with p < 0.05 considered significant.