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A. Zamudio-Rodríguez1, J.-F. Dartigues1, H. Amieva1, K. Pérès1

1. University of Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France.
Corresponding author: Alfonso Zamudio Rodríguez. Centre de recherche Inserm, UMR 1219. Rue Léo Saignat, 33076 Bordeaux cedex, France. Phone: +33 (5) Fax: +33 (5), E-mail: alfonso.zamudio-rodriguez@u-bordeaux.fr

J Frailty Aging 2020;in press
Published online November 24, 2020, http://dx.doi.org/10.14283/jfa.2020.62


The population of older adults over 60 years is growing faster than any other age group and will more than double between 2020 and 2050. This increase has led to clinical, public health, and policy interest in how to age “successfully”. Before the Rowe and Kahn’s model proposed thirty years ago, aging was seen as a process of losses associated with diseases and disability. However, since the emergence of this model, there has been a shift towards a more positive view, serving for promoting diverse medical or psychosocial models, and personal perspectives. Several technical terms of “success” (e.g. “successful aging”, “healthy aging”, “active aging”, “aging well”…) coexist and compete for the meaning of the concept in the absence of a consensual definition. Our literature review article aims to study discrepancies and similarities between the main technical terms through quantitative or qualitative studies. A literature review using PubMed, SCOPUS, PsycINFO, Psycarticles, Psychology, and Behavioral Sciences Collection, Cochrane database, and clinicaltrials.gov databases was conducted. A total of 1057 articles were found and finally, 43 papers were selected for full extraction. We identified several components in these definitions, which reveal considerable inconsistency. The results particularly suggest that lay personals perspectives could bridge the gap between biomedical and psychosocial models in successful aging. In conclusion, an optimal definition would be a multidimensional one that could combine functional capacities, psychosocial abilities, environmental factors and subjective assessments of one’s own criteria to discriminate older adults at potential risk of “unsuccessful” aging to healthy aging trajectories.

Key words: Healthy aging, public health, review, successful aging, theorical models.



More people than ever before are reaching older ages. The proportion of people over 60 years is growing faster than any other age group due to both increasing longevity and declining fertility rates. Furthermore, in many industrialized countries, the first generations after the Second World War are currently reaching old age, the so-called baby boomers. The current aging population will more than double between 2020 and 2050, whereas the oldest old one –those aged over 80 years- should be multiplied by 5 in the same period (1). This demographic revolution has led to clinical, public health, policy, and individual interest regarding how to age “successfully”. The first key element in order to determine this “success” was established in 1948 when the World Health Organization (WHO) Member States adopted a new definition of health as “a state of complete physical, mental, and social well-being and not merely the absence of diseases” (2). However, despite this framework, the conception of aging was viewed as a period of degradation associated with disease and dependency, where little attention was given to people with healthy trajectories.
In 1961, the introduction of the term “Successful Aging” (SA) induced a fundamental shift, even though the consensus over the definition of this new concept and the way to measure it was (and to a certain extent still is) far from being reached (3). Actually, the word “successfully” is commonly used in the literature as a universal reference term for older people with healthy trajectories. Moreover, this concept brought a step that fostered the development of a positive view of aging and promoted research in order to demonstrate a possibly high level of functioning across several domains in old age. Consequently, different technical terms have emerged. These terms co-exist and compete to define this concept, including successful, healthy, active, well-being and others; terms that are often overlapping (4).
In 1987, Rowe and Kahn proposed in the normal category of aging, an additional distinction between usual and SA as nonpathological states. Eventually, ten years later, they summarized the central findings of that work, proposing the first model of “SA”, which was defined as “a low probability of disease and disability, high cognitive and physical functioning, as well as productive activity and activity involving relations with others” (5). This model has been essential in our understanding of the healthy aging process. Nonetheless, this model mainly relied on a biomedical approach underestimating the contribution of psychosocial, or personal perspectives on the aging process.
On the other hand, after Rowe and Kahn’s model of SA, numerous holistic theories have been proposed to improve the concept using different approaches involving environmental factors, security, and social active engagement models (6), until more recently ones based on subjective criteria, such as life-satisfaction or well-being (7, 8). These theories suggest a shift to a more holistic vision of SA (9, 10). In this vein, the WHO introduced in 2002 the concept of “active aging”, defined as: “Process of optimizing opportunities of health, participation, and security, seeking to improve life quality as people get older. Active aging consists of a health policy, influenced by gender and culture, and that is composed of behavioral, personal, physical, social, and economic determinants, as well as health and social service” (4).
Even though, more than half a century has passed since the introduction of the different technical terms of SA (“healthy”, “active”, “successful”, “well-being”, …), no universal operationalization or standardized definition has emerged (11). A variety of objective and subjective measures have been proposed in order to operationalize it (12) and several essential components have been identified, such as cognitive, physical, psychosocial, or environmental dimensions (13–15). Our literature review article aims to identify discrepancies and convergences between the main technical terms of SA through quantitative or qualitative or mixed methodology.



Search strategy

A literature review through PubMed, SCOPUS, PsycINFO, Psycarticles, Psychology and Behavioral Sciences Collection, Cochrane database, and clinicaltrials.gov databases was conducted. The comprehensive research strategy included six successful technical terms: “successful aging”, “healthy aging”, “active aging”, “aging well”, “self-perceived successful aging”, and “subjective well-being in late life”.
These terms were used in orthography conventions of both “aging” and “ageing”. In addition, where possible, some restrictions were used in the database such as “original articles” type of publication, “English” language, articles involving only “humans”, and the age of the participants “65 years and older” at the time of assessment of SA. This process was replicated where possible through the seven databases mentioned above by using the successful technical terms sequentially followed by the three keywords: “Definition” OR “concept” OR “determinant”. A wildcat operator, i.e. “*”, was inserted as a suffix to capture all permutations. The research included all the articles published before July 2019. A total of 1,057 articles were found, of which 650 were screened after deleting 407 duplicates.

Study inclusion

Peer-reviewed research articles on the SA concept, conducted through quantitative, qualitative, or mixed methodology in community-dwelling older adults, were included. When an author published several articles with the same techical term, the most relevant ones were taken into account according to the inclusion criteria. Included articles were then rated for relevance to our study objective.

Exclusion criteria

We excluded book reviews, short comments, letters, and papers which had a specialized focus solely on biology, physiology, immunology, genetics, laboratory or animal research, practical therapy, etc. Studies conducted in older adults with specific pathological conditions (e.g., HIV, frailty, cancer, Alzheimer’s disease) were excluded since the perspective of this review is the SA in the general older population.

Data extraction

The title (first) and abstract (second) of each article were reviewed in order to identify relevancy for full-text extraction. Forty-three articles were selected for full extraction (Figure 1).

Figure 1
Inclusion flowchart of the screening process for study inclusion

*Specific subject on biology, physiology, immunology, genetics, laboratory or animal research, practical therapy, odontology, nutrition, etc. †Specific pathological conditions e.g., HIV, frailty, cancer, Alzheimer’s disease.


Included studies

The global search strategy identified 1,057 articles. After exclusion of the duplicates, the screening on title (n=650) and abstract (n=218) finally led to 43 studies that met inclusion criteria for full-text extraction (Figure 1). We distinguished 19 quantitative, 23 qualitative and 1 mixed-method studies that are summarized in tables 1 and 2 displaying: Authors, year, country, age population, study design (cross-sectional/longitudinal), sample size, models, operational definition, and main results.

Study characteristics

As may be seen in tables 1 and 2, the majority of the studies (19 of the 43 studies) were conducted in the United States. The sample size ranged widely from 15 to 17,886 and the age of participants from 15 to 102 years. Nearly half of the studies used quantitative methods and half qualitative methods (one study used mixed). Interestingly, the two thirds were published in the last ten years.

Table 1
Operationalization of SA and the Outcome Measures of Quantitative Studies

OR= odds ratio; IC= confidence interval; Non-standardized coefficients; HR: hazard ratio; SA=Successful Aging, QoL= quality of life; RR= relative risk; MCI= mild cognitive impairment; Receiver operating characteristic= ROC; AUC = Area Under the ROC Curve

Table 2
The Conception of SA by Integrating Older People’s Views in Qualitative Studies


A healthy aging trajectory could be more than only “successfully”?

Our literature review highlighted three main approaches of successful aging: 1) The biomedical models “focusing largely in terms of absence of disease, frailty or dependence and the continued maintenance of the physical and cognitive functions” as the main elements; 2) The psychosocial perspectives which emphasize the quality of life, engagement in social activities, and personal or community support; 3) The laypersons’ perspectives models which refers to people’s conceptions regarding what it means to age well.

Models mainly biomedical

The biomedical models of SA are mainly based on “the optimization of life expectancy, taking into account high physical and mental functional performance, mobility, and high levels of independence” (16, 17).
In this sense, an approach combining both mortality and morbidity would be relevant to define SA, such as the Disability-Free Life Expectancy, the Disability-Adjusted Life Years (DALYs) (18) or the Disability-Adjusted Life Expectancy (DALE) (19) (Table 3). Those global measures of population health provide a useful assessment of the impact of premature death and disability and other non-fatal health outcomes in the short and long term, but these indicators are probably not subtle enough to cover all the dimensions of SA.
This multidimensionality is proposed in the Rowe and Kahn’s model which is a reference in the literature of SA. It relies on disease and disability, cognitive and physical functioning, and participation in social activities (5). Even though this model has been widely applied, it has several important limitations. First of all, on “normal” aging (non-pathological) the model distinguishes “usual” or “successful” aging, excluding aging people with diseases (pathological aging) from SA. Considering SA as disease-free is quite unrealistic and too restrictive. Indeed, as recently underlined by the WHO (20), above a certain age category, most of older persons have one or more diseases, which, when well controlled, have no or little influence on their wellbeing. This approach which only considers two non-pathologic groups of older people, i.e. “usual” or “successful”, does not reflect the considerable heterogeneity among older adults (21). The group called “usual” (non-pathologic but at high risk) involves people presenting a normal decrease in physical, cognitive, and social functioning concerning age whereas the group called “successful” (at low risk and high functioning) refers to high levels of physiological and cognitive functioning. Finally, this model does not take into account the self-perceived dimension of SA, making it primarily medical and objective (22) (Table 3).

Table 3
Multiple models of technical terms in Successful Aging with respect to operationalizations and outcomes

Note: LY= year prevalence; Q= disability weight; PYLL= years of life lost due to premature death; BWB: Physical well-being; RMSEA= Root mean square error of approximation. *=Weights closer to 1 imply that a year spent in that condition is perceived as being more equivalent to death than to a state of health; †=Percentage of Participants Aging. Successfully by Definition of Successful Aging and Individual Characteristics for; ‡= These five domains are each individually well documented in the research literature; §= Percentages are weighted; **= p<0.001 for age groups. 1= Northern: Denmark, Sweden, Estonia; 2= Western: Austria, Belgium, France, Germany, Luxembourg, Holland /The Netherlands, Switzerland; 3= Southern: Italy, Spain; 4= Eastern: Czech Republic, Slovenia


Towards a more holistic approach: the introduction of psychosocial and environment factors

The current view relies on an holistic conception of SA that encompasses physical and cognitive functioning (23, 24), autonomy (25), independence (26), environment factors (living environment) (27), financial security (28), social, family and couple relationships (29, 30).
In this context, an initiative emerged from the 21st-century aging research agenda developed by the United Nations and the International Association of Gerontology and Geriatrics in 2004, the Global Research Network on Ageing (GARNet) (31) (Table 3). GARNet is a collaborative project of “aging-well” which uses the GARNet index that measures the five following domains: physical health and dependency; mental/cognitive effectiveness; social support resources; daily life activity (engagement), and material security. This initiative promotes the adoption of aging-well strategies that enable health and well-being, which is essential for extending life span and quality of life. Aging-well, it relies on individual behaviors and life-course material and social environments that limit functional decline (mainly caused by chronic conditions) to help older adults maintaining their independence and health (31). In this sense, it progressively decenters the approach from pure health; well-being becoming the central goal of the model along with quality of life, which increases the scope for enjoying the additional years of life. Showing high levels of well-being in older adults should not be overlooked since it is becoming an increasingly important goal for older adults themselves, caregivers, and also physicians (15). In fact, it has been shown that up to 45-50% of older people express satisfaction with their aging process even though they are poorly performing on objective measures (6). This finding can be seen at first sight as a paradox since with advancing age, older adults experience higher levels of well-being, until about 3-5 years near the end of life (26). Well-being is an integral component of adding life to years in an increasing longevity context, emphasizing the need for a multidimensional definition of SA (32).
In 2014, the WHO’s term proposed in a policy framework such as Active and Healthy Aging (AHA), as “the process of optimizing opportunities for health, participation and security in order to enhance quality of life as people age” (33) which became widely accepted, but without general agreement on what its application really means. So, the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) provided the use of operational tools to serve this purpose (34) with a focus on the relationship between activity and health. Since then, the concept was enriched with the addition of “active” as an extension of the concept for “healthy aging” being still more holistic and inclusive, encompassing different domains (e.g. social, economic, cultural, spiritual and civic affairs) (35) (Table 3). The AHA aims to lengthen life expectancy and delay functional dependency, thus preserving autonomy. The AHA working definition lists several steps to achieve these goals: 1) a multilevel approach of the AHA is necessary in order to determine the different items that must be considered; 2) it is necessary to find the tools that allow achieving the multilevel definition; 3) tools should be used in a single questionnaire; and 4) psychometric measurement capacities should be evaluated. However, at the same time, the AHA definition raises fundamental concerns both on structural and economic barriers. In addition, active aging and SA focuses on “youthful” activities that emphasize health and independence in a very ambitious way, which could lead to a form of stigmatization, i.e. “youthism”, if this level of activity is not reached. On the other hand, the economic downturn in different parts of the world could lead to material difficulties and with the resulting loss of opportunities for activity.
More recently, in 2016, the World Health Assembly reframed the components of healthy aging as part of the global strategy and plan of action on aging and health. This framework views healthy aging from a functional rather than a disease-based perspective as “the process of developing and maintaining functional ability that leads to well-being in old age” (20). Functional ability is determined by the person’s intrinsic capacity (i.e. all the individual physical and mental capacities that a person can draw on in daily life), the relevant environmental factors (i.e., all the resources or barriers that will determine whether a person can engage him/herself in activities or not) and the interaction between the two. Functional ability is defined as the health-related attributes that enable people to be and do what they have reason to value (i.e., meeting basic needs; learning, growing and making decisions; moving around; building and maintaining relationships; and contributing). Using the International Classification of Functioning, Disability and Health (ICF) (36) framework as background in order to facilitate the translation of the current theoretical model into practice, it is important to identify the inner nature of its constituting constructs, in particular, the constituent elements of the central construct of intrinsic capacity (i.e. locomotion, vitality, cognition, psychological, vision or hearing) (Table 3).to know where to observe, what to measure and how to monitor. Consequently, healthy aging shows the continuous interaction between intrinsic capacity of individuals in link with the environments they inhabit (supportive or barrier): appropriate and integrated care (technical and medical products, artificial replacements, transplants…), technical aids (auxiliary device, such as a walking stick, wheelchair…), social resources on which the older person can rely on, the use of technologies or support for multiple services (accessible stores, banks and professional services) (20, 37). The health policy of the Global Strategy and Action in this area is generally in the framework of the notion of age-friendly environments, involving both physical and social components (20).

Laypersons’ perspectives

Qualitative research contributed to improving the conception of SA by integrating older people’s views (38) which have essential implications of what individuals consider as SA for complementing traditional models (39), which are predominantly studied by models based on quanlitative approach.
Lay perspectives include a broad framework of criteria that combine basic resources (Table 2 and 3) (functioning (23), social health (40), financial security (41), family and intergenerational care (42) psychological factors (mental) (29), personal attitudinal (43), life satisfaction (35), positive outlook (44), self-consciousness (45), behavioral strategies (resilience (42), coping (44), contribution to life (26), accomplishments (29), productivity (35), learning new things (46), adaptation to an aging body (28) and beliefs (spirituality (27), having a sense of purpose (47), cultural variations (9), among others.
On the one hand, studies suggest that lay perspectives in SA give a great value to the importance of the psychological aspects of older adults, as accepting oneself, including the development of a realistic self-appraisal and a review of one’s past experiences “I’ve never felt more authentically me, ever, than I do right now. And it’s just so cool…” (45). On the other hand, this approach also focuses on social environments of older adults, the importance of active engagement with life and growth, including novel, productive, and social engagement, and the value of a positive attitude: “Keep your old friends, make some new ones, don’t isolate yourself” (45, 48). As a result of these model, the concept of SA is explored across cultures experiences and values that the population can express, as individuals provided with a conscience, language, and will (what is capable of value).
To illustrate the complementarity of older people’s perspectives with other traditional approaches of SA. A Dutch research on octogenarians with qualitative interviews compared the meaning of SA between two approaches; one based on laypersons’ perspectives and the other on the bio-psychosocial approach (major disability, cognitive impairment, depression, and regular social activities). According to this latter definition, only 10% of the participants were categorized as SA, compared to 81% of the participants as SA rated by laypersons’ perspectives definition. As a conclusion of this study, older persons view SA as a process of adaptation (e.g., thanks to strategy of coping or resilience) and maintain high levels of well-being despite disease or disability (42). Rather than a state of sole physical or mental efficiency, where the presence of a disease in old age excludes from successful aging. SA should also integrate laypersons’ perspectives, as recently recommended by the WHO (20), where healthy aging is based on what people have reason to value and not the absence of disease. According to this approach, more persons could be considered to be successfully aged.
An essential resource for both personal and community development is the aspects of sustainability, which promote a more dynamic process of well-being in aging, such as financial security, which allows the use of resources such as health services, social activity, and civic participation (49).
However, despite its increasing importance in the literature, limited evidence has been provided to assess how the views of laypeople on SA brings added value to the concept of SA.



Our literature review aims to identify divergences and convergences from different technical terms of “successful aging” across quantitative and qualitative studies. This review confirms that since the initial coining of the term SA more than 50 years ago, the conceptualization and operationalization of the concept remains controversial and tricky to achieve. Many definitions of SA emerged and with them, multiple research methods, including unidimensional (14) or multidimensional (32) approaches, models based on objective or subjective (50)criteria, with qualitative or quantitative or mixed methodology, following a continuum (51) or through dichotomous profiles.
One of the lessons learned is the increasing importance given to the personal perspectives of the older persons. A recent review of operational definitions of SA reveals that there are more than twice as many studies that postulate operational definitions of SA as studies that examine lay perspectives of SA (52). As recommended in the Healthy Aging concept proposed by the WHO (20),the SA approach should be centered on what is important to the person and the ways (medical and environmental) to reach this goal. As they age, individual’s place a high value in the achievement of social goals, frequently related to family (partner, children and brothers/sisters) and leisure activities, or receiving emotional care (e.g. the care of the partner) (28, 43, 53, 54). In this sense, SA needs to be multi-dimensional and be seen as a continuum instead of dichotomized (successful versus unsuccessful) category, and needs to incorporate layperson’s perspectives for social significance, to be sensitive to differences in opportunities to age successfully and to variations in values between cultures (29, 55, 56).
This review also evidences the profound heterogeneity in the operationalization of the SA concept. The activity and social engagement elements (6) were identified as those reported most frequently. In addition, elements as economy and nature are absent in most conceptualizations of the SA. In this field, many authors addressed the topic of SA with their own outcome measures, assuming an adequate approach without much attempt at conceptual or theoretical definition. The SA models vary from pure biomedical (57, 58) (solely based on physical and cognitive parameters -e.g., studies on healthy life expectancy-) (59), to pure psychosocial (holistic conception –e.g., age-friendly environments-) or the lay models (older people’s views), while, some others, postulate intrinsic interactions among the different dimensions, which evidence the complexity of the term “successfully” in the aging process. Finally, another issue results from the fact that some parameters are used to define SA in some studies, whereas in others they are considered as outcomes. For instance, life satisfaction is assumed to be an essential predictor of SA while it is also defined as a significant outcome of SA (35).
This review has limitations. First, it was not possible to classify studies by technical term, due to the wide overlapping of the approaches used and the lack of clarity regarding the theoretical definitions, as mentioned above. We also limited our research after 65 years of age and only focused on the most frequently used models of the literature (limiting our research on six successful technical terms).
The main strength of our review is that it included both quantitative and qualitative studies. Considering such a range of studies allowed highlighting significant divergences between biomedical conceptualizations of SA and layperson’s perspectives approaches.



Healthy aging is an interrelated multidimensional process profoundly heterogeneous, with significant variations between individuals in the experiences lived. For healthy aging trajectories, an optimal approach should be one’s in terms of functional capacity, psychosocial abilities, environmental factors across the life course and also subjective assessments of one’s own criteria. This operationalized definition is crucial to provide pragmatic tools able to identify older adults with potential risk of “unsuccessful” aging and also ways to improve healthy aging trajectories of individuals. Therefore, the need for a consensual and operational definition is becoming a necessity not to say an emergency to face the public health, social, economic and individual challenges induced by our fast-aging populations.


Acknowledgments: The authors thank Coralie Thore for providing assistance with documentary support. AZR in appreciation of Mr. Pierre and Mrs. Aline Costet for your splendid hospitality during the summer of 2020.
Author Contributions: AZR and KP planned the review and search protocol; AZR wrote the paper review and conducted the data extraction. KP contributed to draft revisions. JFD and HA reviewed this paper.
Funding: The Fondation pour la Recherche Médicale (DOC20161136217 to AZR) supported this work. Funding has no role in the design, analysis, or preparation of this manuscript.
Ethical approval: Not required.
Data sharing statement: No additional data are available.



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1. Centre for Age-Related Medicine (SESAM), Stavanger University Hospital. Stavanger, Norway; 2. Semillero de Neurociencias y Envejecimiento, Instituto de Envejecimiento, Facultad de Medicina, Pontificia Universidad Javeriana, Unidad de Geriatría Hospital Universitario San Ignacio, Bogotá, D.C., Colombia; 3. Faculty of Health Sciences, University of Stavanger, Stavanger, Norway; 4. Geriatric Epidemiology Research Department, Instituto Nacional De Geriatría, Av. Contreras 428, Col. San Jerónimo Lídice, Del. La Magdalena Contreras, Ciudad de México C.P. 10200, ciudad de México, México; 5. Geriatric Medicine Research, Dalhousie University and Nova Scotia Health Authority, CHVMB Rm 2562, 5955 Veterans’ Memorial Lane, Halifax, NS, B3H 2E1, Canada; 6. The University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas, USA; 7. Clínica de Geriatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, calle Vasco de Quiroga 15, col. Sección XVI, del. Tlalpan, ciudad de México, México; 8. Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, F-33000 Bordeaux, France.
Corresponding author: M.U. Pérez-Zepeda MD, PhD, Geriatric Epidemiology Research Department, Instituto Nacional De Geriatría, Av. Contreras 428, Col. San Jerónimo Lídice, Del. La Magdalena Contreras, Ciudad de México C.P. 10200, ciudad de México, México, Phone +52 55 5655 1921, Email: mperez@inger.gob.mx

J Frailty Aging 2020;9(3)144-149
Published online October 30, 2019, http://dx.doi.org/10.14283/jfa.2019.37



Background: Frailty is a clinical state defined as an increase in an individual’s vulnerability to developing adverse health-related outcomes. Objectives: We propose that healthy behaviors could lower the incidence of frailty. The aim is to describe the association between healthy behaviors (physical activity, vaccination, tobacco use, and cancer screening) and the incidence of frailty.  Design: This is a secondary longitudinal analysis of the Mexican Health and Aging Study (MHAS) cohort. Setting: MHAS is a population-based cohort, of community-dwelling Mexican older adults. With five assessments currently available, for purposes of this work, 2012 and 2015 waves were used. Participants: A total of 6,087 individuals 50-year or older were included. Measurements: Frailty was defined using a 39-item frailty index. Healthy behaviors were assessed with questions available in MHAS. Individuals without frailty in 2012 were followed-up three years in order to determine their frailty incidence, and its association with healthy behaviors. Multivariate logistic regression models were used to assess the odds of frailty occurring according to the four health-related behaviors mentioned above. Results: At baseline (2012), 55.2% of the subjects were male, the mean age was 62.2 (SD ± 8.5) years old. The overall incidence (2015) of frailty was 37.8%. Older adults physically active had a lower incidence of frailty (48.9% vs. 42.2%, p< 0.0001). Of the activities assessed in the adjusted multivariate models, physical activity was the only variable that was independently associated with a lower risk of frailty (odds ratio: 0.79, 95% confidence interval 0.71-0.88, p< 0.001). Conclusions: Physically active older adults had a lower 3-year incidence of frailty even after adjusting for confounding variables. Increasing physical activity could therefore represent a strategy for reducing the incidence of frailty. Other so-called healthy behaviors were not associated with incident frailty, however there is still uncertainty on the interpretation of those results.

Key words: Frailty, age, healthy lifestyle, epidemiology of aging, healthy aging.



The aging of the human population is one of the most challenging problems in health of our times. Moreover, as the population becomes older, the prevalence and incidence of chronic diseases increases (1). Poorly controlled chronic diseases along with psychosocial factors can lead to many conditions, including frailty, disability, a lower quality of life, and increased mortality rates (2). Frailty is a geriatric condition defined as an increase in an individual’s vulnerability with poor resilience that leads to the development of adverse health-related outcomes (e.g., falls, institutionalization, functional decline, and an increased use of health services) when exposed to stressful events (3). Previous studies have shown that the prevalence of frailty in Latin America is very high (4-8), when compared to other regions. Frailty is a relevant public health issue because it has multiple consequences for both individuals and society (9).
Regarding its causes, apart from biological paths, frailty has been related to socio-demographic, psychological, and lifestyle behaviors (10, 11). In particular, lifestyle behaviors (e.g., physical activity, diet, tobacco use, risk alcohol drinking, etc.), have shown amenable to be intervened and change frailty’s trajectory (12). Moreover, a recent systematic review aimed at identifying factors that impact frailty (13) described a number of variables that could represent either risk or protective factors during the development of frailty. For example, socio-demographic factors (e.g., older age or no health insurance), physical factors (e.g., obesity or functional limitations), psychological factors (e.g., depression) and biological factors (e.g., elevated levels of serum uric acid) increased the risk of developing frailty. On the other hand, lifestyle behaviors, such as a balanced diet rich in fruits and vegetables, were protective against frailty (14).
Specific lifestyle behaviors, such as physical activity, cancer screening, vaccination or smoking cessation, can play important roles in preventing frailty (12, 13, 15). In the context of active aging, they have been widely described as having a positive influence on the overall health status of older adults. However, few studies have explored the associations between frailty and these potentially protective factors; in particular in Latin American older adults. It is imperative to identify the factors associated with incidental frailty and thoroughly describe the epidemiological characteristics of frailty in order to design interventions aimed at preventing it [8, 16]. In the current study, we analyze the relationship between four lifestyle behaviors and the 3-year incidence of frailty among community-dwelling older Mexican adults.



We conducted a longitudinal analysis using data obtained during the third (2012) and fourth (2015) waves of the Mexican Health and Aging Study (MHAS), a prospective nationally representative panel study conducted in Mexico. The aims and design of the MHAS have been published elsewhere (17). Briefly, the MHAS contains a representative sample of community-dwelling Mexican adults over 50 years of age. Questionnaires from different topics, including socio-demographic characteristics, health-related conditions, accessibility to health services, cognitive performance, functional status, and financial resources, were used to interview all participants in their households.


Data were collected from 18,465 participants in 2012. In the present study, we included data collected from 6,087 subjects without frailty (see below how frailty was defined) in the third wave to assess the relationship between healthy behaviors and the incidence of frailty in 2015.


Dependent variable

Frailty was defined using the frailty index (FI), as recommended by Searle et al [18]. The FI was constructed with reference to 39 deficits in different domains: self-rated health, current health compared with prior health status (2 years), self-reported chronic diseases (hypertension, diabetes mellitus, cancer, respiratory illness, heart failure, heart attack, stroke, arthritis, falls, fractures, and visual impairment), difficulty in basic activities during daily living (ADL) and instrumental ADL (IADL), self-reported common symptoms in the previous two years (pain, fatigue, depressive symptoms, restless sleep, loneliness, sadness, lack of energy, memory loss, appetite loss, and weight loss). As previously mentioned, the FI was composed according to a standardized procedure, which included transforming each variable into a score of 0 (deficit absent) to 1 (deficit present), including a range of possible intermediate scores. All deficit scores were added, and the total was then divided by 39 (total number of deficits in the current list) for each participant. The total scores for the FI therefore ranged from 0 (no deficit present, indicating the lowest possible frailty burden) to 1 (all deficits present, indicating the highest possible frailty burden). Older adults with an FI score of 0.21 or higher were considered frail, as previously validated in this population (19).

Healthy behaviors

Healthy behaviors were considered based on the policy framework for active aging proposed by the World Health Organization using the following questions: for screening activities for prostate (for males), breast, and cervical cancer (for females), “In the last 2 years, have you had a prostate cancer screening test/self-breast exam/pap smear?”; for smoking status, “Did you smoke in the last two years?”; for physical activity “In the last 2 years, have you exercised or performed hard physical work 3 or more times per week?”; and for vaccination, “In the past two years, have you had any of the following tests or medical procedures: Influenza vaccine and/or pneumococcal vaccine”. Finally, we created a variable based on the sum of the healthy behaviors that were present in the subjects (0, 1, 2, 3 or 4), and this variable was analyzed using an ordinal statistical approach. See Supplementary Table 2 for a detailed description of the variables.

Confounding variables

Because the objective was to test the independent relationships between healthy behaviors and frailty, we adjusted our analysis for the following variables: socio-demographic variables (age, sex, marital status, financial status [self-rated], and education level [completed years in school]). We also included physician visits (“Have you visited a physician within the last 2 years?”) because healthy behaviors are associated with increased exposure to health services.

Statistical analysis

Descriptive analyses are shown as frequencies and percentages for categorical variables and means and standard deviations for continuous variables. For bivariate comparative analyses, chi-square tests or Student’s t-tests were used as appropriate, depending on the variable distribution. Multivariate logistic regression models were fitted to obtain an odds ratio (OR) with 95% confidence interval (CI) for the relationship between the incidence of frailty and the independent variable being tested. The results were adjusted for confounding variables and are presented as non-adjusted and adjusted models. The level of statistical significance was set at p<0.05. All data were analyzed using STATA 16.0 ® for Mac OS (StataCorp, 4905 Lakeway Drive, College Station, Texas 77845 USA).

Ethical issues

The Institutional Review Boards of the University of Texas Medical Branch, the Instituto Nacional de Estadística y Geografía and the Instituto Nacional de Salud Pública of Mexico approved this study. All study subjects signed an informed consent form. The study adhered to the ethical guidelines of the Declaration of Helsinki.



Table 1 shows the characteristics of the sample population, according to frailty status. Of the total sample of 6,087 non-frail older adults, 55.2% were male, the mean age was 62.2 (SD ± 8.5) years old, and the mean years of education was 7.8 (SD ± 10.7). During the previous 2 years, a total of 72.4% of the individuals visited a physician, 69.8% had a fair to poor financial status.

Table 1 Descriptive data obtained for non-frail subjects in 2012

Table 1
Descriptive data obtained for non-frail subjects in 2012

n (%) or mean ± SD


Table 2 shows the results of the bivariate analysis of healthy behaviors reported: 55.6% had received a flu vaccine, 51.5% had used at least one of the included screening procedures, 46.4% had a low level of physical activity, and 83.2% had not smoked. The healthy behavior score showed that most of the sample had performed at least 3 healthy activities (53.4%). The incidence of frailty for the cohort was 37.8%. Compared to frail older adults, non-frail older adults performed more physical activities (48.9% vs. 42.2%, p < 0.001). There was no difference between the populations in vaccinations, medical screening activities, or the sum of the two.

Table 2 Bivariate analysis of healthy behaviors reported in 2012 by frailty status reported in 2015

Table 2
Bivariate analysis of healthy behaviors reported in 2012 by frailty status reported in 2015

n (%)


Table 3 shows the results of the multivariate analyses. The unadjusted logistic regression model showed that the sum of activities (with 0 used as the reference), vaccination and screening activities were not significant predictors of frailty. Not smoking, however, increased the odds of becoming frail (OR 1.2 95% IC 1.1-1.4, p = 0.001), while physical activity decreased the odds (OR 0.7 95% IC 0.6-0.8, p<0.001). In the adjusted model, only physical activity remained significantly associated with a lower risk of developing frailty (OR 0.7 95% IC 0.7-0.8 p <0.001). When grouping according to the number of healthy behaviors, having 2 or 3 healthy habits was also associated with lower frailty incidence (OR 0.8, p<0.001). Having more than three had a border significance (OR 0.8, p=0.08).

Table 3 Logistic regression models to predict frailty in 2015

Table 3
Logistic regression models to predict frailty in 2015

* p≤0.001; Model adjusted for: age, sex, marital status, financial status, education level and physician visits



Frailty in older adults is a major public health problem and a challenge to healthcare professionals (8). Frailty exacerbates declines in physical function and predisposes individuals to several negative health-related outcomes (20). In this longitudinal analysis of the MHAS, our main finding is that being physically active in the previous two years was associated with a lower incidence of frailty three years later. Physical activity, as evaluated in our study, decreased the risk of developing frailty by 21%. In the total sample, the incidence of frailty in 2012 was 37.8%. When the population was divided into those who performed physical activity and those who did not, the group that had not performed physical activity had a higher incidence of frailty (40.6% vs. 34.4%, p <0.001).
The term physical activity indicates any bodily movement produced by skeletal muscles that requires energy expenditure and includes exercise, which is defined as a regularly structured program of physical activity aimed at maintaining an optimal level of fitness (21). These activities are recommended in the elderly for achieving good health and optimal physical function (22). There is evidence showing that being physically active may alter the course of many frequently occurring diseases among older adults and that physical activity and exercise are important factors that reduce overall morbidity and mortality (23). Nevertheless, a better option for this population, especially for preventing adverse health consequences, should be maintaining a healthy status (for example, by preventing frailty) and using physical activity as an important tool to do so.

Hence, physical activity should be considered a public health target and part of an important strategy aimed at preventing the onset of frailty and the numerous negative health-related outcomes that come with this condition. This is of particular importance in developing countries, such as the one (Mexico) from which data was obtained for this study, that have a shortage of specialized professionals trained to care for older adults. Physical activity has been shown to be economically and readily available, even for individuals with a high burden of disability. A sedentary lifestyle has been associated with a higher frequency of frailty (24). Our results support this notion and are consistent with other reports showing that physical activity is independently associated with delaying the onset and progression of frailty (25).
Some studies report that exercise and physical activity have the potential to prevent frailty (26). Our results support the notion that adults who perform physical activity reduce their risk of frailty. In addition, other studies have shown that physical activity and exercise are effective interventions for frailty, and this should open the door for future research (27). These findings argue against the common belief that older frail adults should be excluded from physical activity programs because they are unlikely to adhere to the program and could experience adverse events.
However, there are many barriers, both real and perceived, that represent obstacles to the adoption and maintenance of regular physical activity. In our sample, 46.4% of the people performed physical activities. Reports in the literature show that a percentage ranging from 11.7% to 77.2% of adults perform regularly physical activities. This variation is due to differences in the definitions and types of physical activity that were included in these studies (28).
It was particularly evident in our study that the development of frailty was not prevented solely by the sum of several healthy behaviors. A positive trend was observed in both the unadjusted and adjusted models, suggesting that performing more healthy behaviors had a larger impact on outcomes (29).
Smoking status in older adults (i.e. current smokers, new smokers, and past smokers) had an important effect on health-related outcomes. However, those who never smoked or were former smokers had higher odds of developing frailty when compared to current smokers; this might be due to the fact that frailer older adults not smoking may have some medical conditions that precludes them from smoking tobacco. Nevertheless, Ottenbacher et al. reported a higher incidence (operationalized with the frailty phenotype) of frailty along those who had ever smoked (30); on the one hand this could be misleading by having in the same group both current and former smokers, as stated previously; and on the other hand, even that the population is similar (i.e., Mexican Americans), health conditions along with sociocultural features are quite different between Mexico and the United States. Further analyses using other sources of data are needed to better characterize the relationship between smoking and frailty.
With regard for vaccination, a cross-sectional study performed in Mexico of 927 participants aged 70 years old or older also reported that there was no association between frailty and having an incomplete vaccination scheme (15).
Interestingly, when grouping older adults according to the number of healthy behaviors, having two or more (regardless which), was associated with a lower incidence of frailty. Having four or more had a border significance, maybe due to power issues, since that group represents only 12% of the sample. Nevertheless, it is a hint on how sum of actions could work in favor of positive outcomes in older adults, and the importance on the potential of simultaneous preventive strategies rather than isolated ones.
It is important to emphasize that our results arise from a 3-year follow-up study and may therefore not capture the long-term impact of other health-related behaviors. Nevertheless, frailty and healthy behaviors are dynamic and tend to change over short periods of time. Additional work aimed at analyzing healthy behaviors and frailty trajectories will allow us to better analyze these relationships. Another limitation of our study was the fact that the data were self-reported, and there is therefore the potential for memory bias, which can lead to lower rates of evaluated conditions. Second, it was not possible to define the type of physical activity performed by participants or its intensity and duration, and this resulted in a large range of activities being referred to as physical activities by the participants. Third, most of the subjects were asked questions about healthy behaviors performed during the previous two years but were not asked about the duration or current status of the behavior, which made it difficult to interpret some of these data. Finally, the use of a secondary analysis, in which a number of fixed variables were adjusted for, left out a number of other conditions that would have been of interest.
In spite of these limitations, our study adds to the limited body of evidence available regarding the relationship between healthy behaviors and frailty in Latin America. These data could help to better characterize groups of immigrants from these regions who currently live in other countries outside Latin America. To perform physical activity three times or more per week provides a benefit in terms of decreasing the 3-year incidence of frailty. These results are very important and need to be conveyed to the policy makers who establish public health strategies. Physical activity has the potential to improve the quality of life of the aging population in the study region. Further research is required to determine how to implement the strategies that can best achieve these interventions in all populations and prevent negative outcomes.
The results of the present study show that there is a relationship between physical activity and a lower incidence of frailty within a period of 3 years. These findings should lead to the generation of proposals aimed at formulating new studies that can support the creation of public policies aimed at preventing the appearance of frailty in the elderly.


Acknowledgements: We thank Jenny Osa for her support in English style correction.
Funding: This work was supported by the Sealy Center on Aging at the University of Texas Medical Branch in Galveston, Claude D. Pepper OAIC grant # P30-AG024832 and The Mexican Health and Aging Study grant # R01AG018016 of the National Institutes of Health/National Institute on Aging.
Conflict of interest: The authors declare that they have no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.



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