Prospective Associations of Diet Quality With Incident Frailty in Older Adults

The Health, Aging, and Body Composition Study

Linda M. Hengeveld, MSc; Hanneke A. H. Wijnhoven, PhD; Margreet R. Olthof, PhD; Ingeborg A. Brouwer, PhD; Eleanor M. Simonsick, PhD; Stephen B. Kritchevsky, PhD; Denise K. Houston, PhD; Anne B. Newman, MD, MPH; Marjolein Visser, PhD


J Am Geriatr Soc. 2019;67(9):1835-1842. 

In This Article

Abstract and Introduction


Objective: To examine associations of diet quality indicators with 4-year incidence of frailty in community-dwelling older adults.

Design: Prospective cohort study.

Setting: Health, Aging, and Body Composition Study, United States.

Participants: Community-dwelling men and women, aged 70 to 81 years in 1998 to 1999 (first follow-up, present study's baseline; n = 2154).

Measurements: At first follow-up, dietary intake over the preceding year was assessed with a food frequency questionnaire. Indicators of diet quality include the Healthy Eating Index (categorized as poor, medium, and good), energy intake, and protein intake (a priori adjusted for energy intake using the nutrient residual model). Frailty status was determined using Fried's five-component frailty phenotype and categorized into "robust" (0 components present), "pre-frailty" (1 - 2 components present), or "frail" (3–5 components present). Cox proportional hazards analysis was used to examine associations of the diet quality indicators with 4-year incidence of (1) frailty and (2) pre-frailty or frailty. Competing risk analysis was used to examine associations with frailty by accounting for competing risks of death.

Results: During the 4-year follow-up, 277 of the 2154 participants, robust or pre-frail at baseline, developed frailty, and 629 of the 1020 participants, robust at baseline, developed pre-frailty or frailty. Among the robust and pre-frail, after adjustment for confounders including energy intake, those consuming poor- and medium-quality diets had a higher frailty incidence than those consuming good-quality diets (hazard ratio [HR] = 1.92 [95% confidence interval {CI} = 1.17-3.17] and HR = 1.40 [95% CI = 0.99-1.98], respectively). No associations for energy or protein intake were observed. Competing risk analyses yielded similar results. Among the robust, those with lower vegetable protein intake had a higher "pre-frailty or frailty" incidence (per −10 g/d: HR = 1.20; 95% CI = 1.04-1.39). No other associations were observed.

Conclusion: Poorer overall diet quality and lower vegetable protein intake may increase the risk of becoming frail in old age. We found no association for intakes of energy, total protein, or animal protein.


With the older population growing rapidly, an increase in the prevalence of frailty is to be expected. Given the components of frailty (ie, weight loss, weakness, exhaustion, slowness, and physical inactivity),[1] diet is considered an important determinant of its development. Older adults especially may benefit from dietary strategies as their diet is commonly observed to be of insufficient overall quality[2–4] or low in protein.[3,5]

Four prospective studies showed that better adherence to a Mediterranean diet, as assessed with the Mediterranean Diet Score (MDS) or the Elderly Dietary Index, was associated with lower frailty risk in older adults,[6–9] whereas one study[10] showed no association. Prospective studies investigating associations with adherence to general dietary guidelines, as assessed with the Diet Quality Index or the Healthy Diet Indicator, showed both inverse[10,11] and no associations.[7] Few studies have examined single dietary components. Lower energy intake was associated with higher risk of (pre-)frailty,[12] and lower protein intake was associated with higher risk of frailty in two[13,14] but not all prospective studies.[11,12]

None of the previous studies considered time to onset of frailty nor potential competing risks of death. The latter is especially important in older adults given their high mortality rate.[15] This study examines associations of diet quality indicators relevant in old age with 4-year incidence of frailty (accounting for competing risks) and pre-frailty in community-dwelling older adults. To explore underlying pathways, we examined associations with the individual frailty components as secondary analyses.