Midlife physical activity trajectories are associated with reduced physical pre-frailty/frailty in older age: insights from the prospective ATTICA sub-study 2002-2024

Background Although physical activity in older adults has been associated with lower risk of frailty, it is unclear if midlife physical activity patterns are associated with pre-frailty/frailty status in older age. Objectives To investigate whether longitudinal midlife physical activity trajectories are associated with physical pre-frailty/frailty development in older age, independent of cardiometabolic risk and other lifestyle factors. Design Population-based prospective cohort study. Settings In-person assessments and telephone interviews of persons living in urban communities in Attica, Greece. Participants Surviving participants of the ATTICA cohort study (2002-2024) who were older than 33 years at baseline. Measurements Demographic, anthropometric, clinical, and lifestyle parameters were recorded at baseline and throughout the study. According to binary self-reported physical activity levels (<600 vs ≥600 metabolic equivalent minutes per week) at baseline, 5-year and 10-year follow-up, 4 ordered trajectories of physical activity were defined: persistently inactive, declining activity, inclining activity, and persistently active, and their association with the odds of pre-frailty/frailty development according to the phenotypic (FRAIL scale) model were investigated by applying multivariable logistic regression models. Results Relative to persistent inactivity, persistently active and inclining physical activity lifestyles were associated with 80% and 79% decreased odds of pre-frailty/frailty at 22-year follow-up, respectively, after adjusting for age, sex, years of education, baseline body mass index, hypertension, diabetes, and hypercholesterolemia. The population fraction of pre-frailtand frailty that could be attributed to unhealthy physical activity trajectories throughout midlife is 49.5% (95% confidence interval, 36.3 to 59.9), rising to 64.8% (95% confidence interval, 49.6 to 75.4) when also considering hypertension, diabetes mellitus, hypercholesterolemia, and obesity. Conclusion Steadily high or rising physical activity trajectories during midlife were associated with lower odds of physical pre-frailty/frailty in older age, independently of cardiometabolic risk factors. These findings support that achieving and maintaining higher physical activity levels across midlife may be one of the keys to healthy aging.