Healthy behaviors at age 50 years and frailty at older ages in a 20-year follow-up of the UK Whitehall II cohort: A longitudinal study.

Background Frailty is associated with increased risk of various health conditions, disability, and death. Health behaviors are thought to be a potential target for frailty prevention, but the evidence from previous studies is based on older populations with short follow-ups, making results susceptible to reverse causation bias. We examined the associations of healthy behaviors at age 50, singly and in combination, as well as 10-year change in the number of healthy behaviors over midlife with future risk of frailty. Methods and findings In this prospective cohort study of 6,357 (29.2% women; 91.7% white) participants from the British Whitehall II cohort, healthy behaviors-nonsmoking, moderate alcohol consumption, >= 2.5 hours per week of moderate to vigorous physical activity, and consumption of fruits or vegetables at least twice a day-were measured at age 50, and change in behaviors was measured between 1985 (mean age = 44.4) and 1997 (mean age = 54.8). Fried's frailty phenotype was assessed in clinical examinations in 2002, 2007, 2012, and 2015. Participants were classified as frail if they had >= 3 of the following criteria: slow walking speed, low grip strength, weight loss, exhaustion, and low physical activity. An illness-death model accounting for both competing risk of death and interval censoring was used to examine the association between healthy behaviors and risk of frailty. Over an average follow-up of 20.4 years (standard deviation, 5.9), 445 participants developed frailty. Each healthy behavior at age 50 was associated with lower risk of incident frailty: hazard ratio (HR) after adjustment for other health behaviors and baseline characteristics 0.56 (95% confidence interval [CI] 0.44-0.71; p < 0.001) in nonsmokers, 0.73 (95% CI 0.61-0.88; p < 0.001) for moderate alcohol consumption, 0.66 (95% CI 0.54-0.81; p < 0.001) for 2.5 hours of physical activity per week, and 0.76 (95% CI 0.59-0.98; p = 0.03) for consumption of fruits or vegetables at least twice a day. A greater number of healthy behaviors was associated with reduced risk of frailty, with the HR for each additional healthy behavior being 0.69 (95% CI 0.62-0.76; p < 0.001) and the HR for having all versus no healthy behaviors at age 50 being 0.28 (95% CI 0.15-0.52; p < 0.001). Among participants with no or 1 healthy behavior in 1985, those who increased the number of healthy behaviors by 1997 were at a lower risk of frailty (mean follow-up = 16 years) compared with those with no such increase: the HR was 0.64 (95% CI 0.44-0.94; p = 0.02) for change to 2 healthy behaviors and 0.57 (95% CI 0.38-0.87; p < 0.001) for change to 3-4 healthy behaviors in 1997. The primary limitation of this study is potential selection bias during the follow-up due to missing data on frailty components. Conclusions Our findings suggest that healthy behaviors at age 50, as well as improvements in behaviors over midlife, are associated with a lower risk of frailty later in life. Their benefit accumulates so that risk of frailty decreases with greater number of healthy behaviors. These results suggest that healthy behaviors in midlife are a good target for frailty prevention. Author summary Why was this study done? Frailty is a clinical syndrome associated with increased risk of several adverse health outcomes, including fracture, disability, and mortality. Health behaviors at older ages have been found to be associated with risk of frailty, but short follow-up in these studies raises the concern that the findings may reflect changes in health behaviors consequent to health-related conditions occurring in the years preceding frailty onset rather than a causal association between health behaviors and incident frailty. What did the researchers do and find? Data on smoking, alcohol consumption, physical activity, and fruits and vegetables consumption at age 50 were assessed among 6,357 participants of the Whitehall II study who were followed for incident frailty over 20.4 years. Frailty assessed at clinical examinations in 2002, 2007, 2012, and 2015 was defined as having 3 or more of the following criteria: slow walking speed, low grip strength, weight loss, exhaustion, and low physical activity. Each healthy behavior at age 50-nonsmoking, moderate alcohol consumption, practice of physical activity at least 2.5 hours per week, and consumption of fruits and vegetables at least twice a day-was associated with lower risk of frailty onset at older ages. In addition, participants with a greater number of healthy behaviors at age 50 had lower risk of frailty later in life, with those presenting all 4 healthy behaviors being at around 70% lower risk of developing frailty than those with none of these behaviors. Change in healthy behaviors between mean ages 44.4 and 54.8 years suggests that among individuals with no or only 1 healthy behavior, engagement in a greater number of healthy behaviors was associated with a reduced subsequent risk of frailty. What do these findings mean? Our findings suggest that health behaviors at age 50 are important determinants of frailty at older ages. We also found a dose-response association, such that the benefits for frailty are higher among those with a greater number of healthy behaviors. In our cohort, improvement in health behaviors over midlife was associated with reduced risk of developing frailty, suggesting that lifestyle interventions in midlife may be beneficial in frailty prevention.