Original Study| Volume 21, ISSUE 5, P710.e1-710.e9, May 2020

Download started.


Combined Impact of Traditional and Nontraditional Healthy Behaviors on Frailty and Disability: A Prospective Cohort Study of Older Adults

Published:October 19, 2019DOI:



      To assess the short- and long-term association of 6 healthy behaviors (not smoking, vigorous to moderate physical activity, healthy diet, adequate sleeping duration, not being sedentary, and daily social interaction) with incident frailty and disability.


      Prospective population-based study.

      Settings and Participants

      In 2001, 4008 community-dwelling individuals aged ≥60 years in Spain were recruited. Participants were followed up until 2003, when a short-term phone interview of the remaining 3235 individuals was performed. Then, the participants were followed up until 2009, when a long-term phone interview was conducted with 1309 participants.


      At baseline, a home interview and a physical examination were conducted to assess healthy behaviors. At baseline and at follow-ups, we ascertained frailty and 4 domains of disability: limitation in instrumental activities of daily living, restriction in daily activities, limitation in mobility, and self-care limitation.


      In the short-term analyses, vigorous to moderate physical activity and not being sedentary were associated with a reduction in frailty, multivariable odds ratios (OR) (95% confidence interval) 0.55 (0.35-0.85) and 0.43 (0.26-0.72). Vigorous to moderate physical activity and adequate sleeping duration decreased instrumental activities of daily living limitation OR 0.63 (0.44–0.91) and 0.69 (0.53–0.89) as well as self-care limitation OR 0.62 (0.41–0.92) and 0.65 (0.45-0.94). Adequate sleep duration and not being sedentary decreased restriction in daily activities OR 0.67 (0.49–0.90) and 0.57 (0.36–0.91). Vigorous to moderate physical activity and healthy diet decreased limitation in mobility OR 0.58 (0.35–0.96) and 0.73 (0.54–0.97). Considering these 5 healthy behaviors, participants who scored 5 (vs ≤ 2) in the combined score had a lower risk of frailty and disability. In the long-term analyses, results showed the same direction as in short-term analyses.

      Conclusions and Implications

      The combination of healthy behaviors is associated with a substantial reduction in the risk of frailty and of most disability outcomes in older adults.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Fried L.P.
        • Ferrucci L.
        • Darer J.
        • et al.
        Untangling the concepts of disability, frailty, and comorbidity: Implications for improved targeting and care.
        J Gerontol A Biol Sci Med Sci. 2004; 59: 255-263
        • Lafortune G.
        • Balestat G.
        Trends in Severe Disability Among Elderly People: Assessing the Evidence in 12 OECD Countries and the Future Implication.
        OECD Publishing, Paris, France2007
        • Jagger C.
        • Matthews F.E.
        • Wohland P.
        • et al.
        A comparison of health expectancies over two decades in England: Results of the cognitive function and ageing study I and II.
        Lancet. 2016; 387: 779-786
        • Rodriguez-Manas L.
        • Feart C.
        • Mann G.
        • et al.
        Searching for an operational definition of frailty: A Delphi method based consensus statement: The frailty operative definition-consensus conference project.
        J Gerontol A Biol Sci Med Sci. 2013; 68: 62-67
        • De Lepeleire J.
        • Iliffe S.
        • Mann E.
        • Degryse J.M.
        Frailty: An emerging concept for general practice.
        Br J Gen Pract. 2009; 59: e177-e182
        • Morley J.E.
        • Vellas B.
        • van Kan G.A.
        • et al.
        Frailty consensus: A call to action.
        J Am Med Dir Assoc. 2013; 14: 392-397
        • Fried L.P.
        • Guralnik J.M.
        Disability in older adults: Evidence regarding significance, etiology, and risk.
        J Am Geriatr Soc. 1997; 45: 92-100
        • Seeman T.E.
        • Merkin S.S.
        • Crimmins E.M.
        • Karlamangla A.S.
        Disability trends among older Americans: National Health and Nutrition Examination Surveys, 1988-1994 and 1999-2004.
        Am J Public Health. 2010; 100: 100-107
        • Leon-Munoz L.M.
        • Garcia-Esquinas E.
        • Lopez-Garcia E.
        • et al.
        Major dietary patterns and risk of frailty in older adults: A prospective cohort study.
        BMC Med. 2015; 13: 11
        • Klijs B.
        • Mackenbach J.P.
        • Kunst A.E.
        Obesity, smoking, alcohol consumption and years lived with disability: A Sullivan life table approach.
        BMC Public Health. 2011; 11: 378
        • Hirsch C.H.
        • Diehr P.
        • Newman A.B.
        • et al.
        Physical activity and years of healthy life in older adults: Results from the cardiovascular health study.
        J Aging Phys Act. 2010; 18: 313-334
        • Poli S.
        • Cella A.
        • Puntoni M.
        • et al.
        Frailty is associated with socioeconomic and lifestyle factors in community-dwelling older subjects.
        Aging Clin Exp Res. 2017; 29: 721-728
        • Song J.
        • Lindquist L.A.
        • Chang R.W.
        • et al.
        Sedentary behavior as a risk factor for physical frailty independent of moderate activity: Results from the Osteoarthritis Initiative.
        Am J Public health. 2015; 105: 1439-1445
        • Dunlop D.D.
        • Song J.
        • Arntson E.K.
        • et al.
        Sedentary time in US older adults associated with disability in activities of daily living independent of physical activity.
        J Phys Activity Health. 2015; 12: 93
        • da Silva A.A.
        • de Mello R.G.B.
        • Schaan C.W.
        • et al.
        Sleep duration and mortality in the elderly: A systematic review with meta-analysis.
        BMJ Open. 2016; 6: e008119
        • Soler-Vila H.
        • García-Esquinas E.
        • León-Muñoz L.M.
        • et al.
        Contribution of health behaviours and clinical factors to socioeconomic differences in frailty among older adults.
        J Epidemiol Commun Health. 2016; 70: 354-360
        • Lafortune L.
        • Martin S.
        • Kelly S.
        • et al.
        Behavioural risk factors in mid-life associated with successful ageing, disability, dementia and frailty in later life: A rapid systematic review.
        PloS One. 2016; 11: e0144405
        • Martinez-Gomez D.
        • Guallar-Castillon P.
        • Leon-Munoz L.M.
        • et al.
        Combined impact of traditional and non-traditional health behaviors on mortality: A national prospective cohort study in Spanish older adults.
        BMC Med. 2013; 11: 47
        • Hernández-Aceituno A.
        • Pérez-Tasigchana R.F.
        • Guallar-Castillón P.
        • et al.
        Combined healthy behaviors and healthcare services ose in older adults.
        Am J Prev Med. 2017; 53: 872-881
        • Liao W.C.
        • Li C.R.
        • Lin Y.C.
        • et al.
        Healthy behaviors and onset of functional disability in older adults: Results of a national longitudinal study.
        J Am Geriatr Soc. 2011; 59: 200-206
        • Guallar-Castillon P.
        • Santa-Olalla Peralta P.
        • Banegas J.R.
        • et al.
        Med Clin (Barc). 2004; 123: 606-610
        • Balboa-Castillo T.
        • Leon-Munoz L.M.
        • Graciani A.
        • et al.
        Longitudinal association of physical activity and sedentary behavior during leisure time with health-related quality of life in community-dwelling older adults.
        Health Qual Life Outcomes. 2011; 9: 47
        • Morley J.E.
        • Malmstrom T.K.
        • Miller D.K.
        A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans.
        J Nutr Health Aging. 2012; 16: 601-608
        • Woo J.
        • Yu R.
        • Wong M.
        • et al.
        Frailty screening in the community using the FRAIL Scale.
        J Am Med Dir Assoc. 2015; 16: 412-419
        • Guallar-Castillón P.
        • Sagardui-Villamor J.
        • Banegas J.R.
        • et al.
        Waist circumference as a predictor of disability among older adults.
        Obesity. 2007; 15: 233-244
        • Lawton M.
        • Brody E.
        Assessment of older people: Self-maintaining and instrumental activities of daily living.
        Nurs Res. 1970; 19: 278
        • Katz S.
        • Ford A.B.
        • Moskowitz R.W.
        • et al.
        Studies of illness in the aged: The index of ADL: A standardized measure of biological and psychosocial function.
        Jama. 1963; 185: 914-919
        • Forsén L.
        • Loland N.W.
        • Vuillemin A.
        • et al.
        Self-administered physical activity questionnaires for the elderly.
        Sports Med. 2010; 40: 601-623
        • Fernandez-Ballart J.D.
        • Pinol J.L.
        • Zazpe I.
        • et al.
        Relative validity of a semi-quantitative food-frequency questionnaire in an elderly Mediterranean population of Spain.
        Br J Nutr. 2010; 103: 1808-1816
        • Mesas A.E.
        • Lopez-Garcia E.
        • Leon-Munoz L.M.
        • et al.
        Sleep duration and mortality according to health status in older adults.
        J Am Geriatr Soc. 2010; 58: 1870-1877
        • Guallar-Castillón P.
        • Rodríguez-Artalejo F.
        • Gañán L.D.
        • et al.
        Consumption of alcoholic beverages and subjective health in Spain.
        J Epidemiol Commun Health. 2001; 55: 648-652
        • Gutiérrez-Fisac J.L.
        • López E.
        • Banegas J.R.
        • et al.
        Prevalence of overweight and obesity in elderly people in Spain.
        Obes Res. 2004; 12: 710-715
        • Ostbye T.
        • Taylor D.H.
        • Jung S.H.
        A longitudinal study of the effects of tobacco smoking and other modifiable risk factors on ill health in middle-aged and old Americans: Results from the health and retirement study and asset and health dynamics among the oldest old survey.
        Prev Med. 2002; 34: 334-345
        • Kenfield S.A.
        • Wei E.K.
        • Rosner B.A.
        • et al.
        Burden of smoking on cause-specific mortality: Application to the Nurses' Health Study.
        Tobacco Control. 2010; 19: 248-254
        • Kojima G.
        • Iliffe S.
        • Walters K.
        Smoking as a predictor of frailty: A systematic review.
        BMC Geriatr. 2015; 15: 1
        • Pirie K.
        • Peto R.
        • Reeves G.K.
        • et al.
        • For the Million Women Study Collaborators
        The 21st century hazards of smoking and benefits of stopping: A prospective study of one million women in the UK.
        Lancet. 2013; 381: 133-141
        • Landi F.
        • Abbatecola A.M.
        • Provinciali M.
        • et al.
        Moving against frailty: Does physical activity matter?.
        Biogerontology. 2010; 11: 537-545
        • Malmberg J.J.
        • Miilunpalo S.I.
        • Pasanen M.E.
        • et al.
        Associations of leisure-time physical activity with mobility difficulties among middle-aged and older adults.
        J Aging Phys Act. 2006; 14: 133-153
        • Patel K.V.
        • Coppin A.K.
        • Manini T.M.
        • et al.
        Midlife physical activity and mobility in older age: The InCHIANTI study.
        Am J Prev Med. 2006; 31: 217-224
        • Miller M.E.
        • Rejeski W.J.
        • Reboussin B.A.
        • et al.
        Physical activity, functional limitations, and disability in older adults.
        J Am Geriatr Soc. 2000; 48: 1264-1272
        • Perez-Tasigchana R.F.
        • Leon-Munoz L.M.
        • Lopez-Garcia E.
        • et al.
        Mediterranean diet and health-related quality of life in two cohorts of community-dwelling older adults.
        PLoS One. 2016; 11: e0151596
        • Kim J.
        • Lee Y.
        • Lee S.Y.
        • et al.
        Dietary patterns and functional disability in older Korean adults.
        Maturitas. 2013; 76: 160-164
        • Feart C.
        • Peres K.
        • Samieri C.
        • et al.
        Adherence to a Mediterranean diet and onset of disability in older persons.
        Eur J Epidemiol. 2011; 26: 747-756
        • Lee J.S.
        • Auyeung T.W.
        • Leung J.
        • et al.
        Long sleep duration is associated with higher mortality in older people independent of frailty: A 5-year cohort study.
        J Am Med Dir Assoc. 2014; 15: 649-654
        • Grandner M.A.
        • Patel N.P.
        From sleep duration to mortality: Implications of meta-analysis and future directions.
        J Sleep Res. 2009; 18: 145-147
        • Chien M.Y.
        • Chen H.C.
        Poor sleep quality is independently associated with physical disability in older adults.
        J Clin Sleep Med. 2015; 11: 225-232
        • Park M.
        • Buchman A.S.
        • Lim A.S.
        • et al.
        Sleep complaints and incident disability in a community-based cohort study of older persons.
        Am J Geriatr Psychiatry. 2014; 22: 718-726
        • Biswas A.
        • Oh P.I.
        • Faulkner G.E.
        • et al.
        Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: A systematic review and meta-analysis.
        Ann Intern Med. 2015; 162: 123-132
        • Christensen U.
        • Stovring N.
        • Schultz-Larsen K.
        • et al.
        Functional ability at age 75: Is there an impact of physical inactivity from middle age to early old age?.
        Scand J Med Sci Sports. 2006; 16: 245-251
        • Etman A.
        • Kamphuis C.B.
        • van der Cammen T.J.
        • et al.
        Do lifestyle, health and social participation mediate educational inequalities in frailty worsening?.
        Eur J Public Health. 2015; 25: 345-350
        • McLaughlin D.
        • Leung J.
        • Pachana N.
        • et al.
        Social support and subsequent disability: It is not the size of your network that counts.
        Age Ageing. 2012; 41: 674-677
        • Sabia S.
        • Singh-Manoux A.
        • Hagger-Johnson G.
        • et al.
        Influence of individual and combined healthy behaviours on successful aging.
        Can Med Assoc J. 2012; 184: 1985-1992
        • Artaud F.
        • Dugravot A.
        • Sabia S.
        • et al.
        Unhealthy Behaviours and Disability in Older Adults: Three-City Dijon Cohort Study.
        BMJ. 2013; 347: f4240
        • May A.M.
        • Struijk E.A.
        • Fransen H.P.
        • et al.
        The impact of a healthy lifestyle on disability-adjusted life years: A prospective cohort study.
        BMC Med. 2015; 13: 39
        • Kelaiditi E.
        • van Kan G.A.
        • Cesari M.
        Frailty: Role of nutrition and exercise.
        Curr Opin Clin Nutr Metab Care. 2014; 17: 32-39