Moderate-to-Vigorous Physical Activity and Frailty Progression: Evidence from Two Prospective Cohorts

Abstract

Purpose

To characterize bidirectional frailty transitions among older adults, quantify deterioration and recovery rates, and examine whether physical activity, pain, age, body mass index (BMI), and history of falls are associated with frailty dynamics across two diverse populations.

Methods

We analyzed longitudinal data from two prospective cohorts: 8435 participants from the China Health and Retirement Longitudinal Study (CHARLS, Waves 1–4, 2011–2018) and 6021 from the English Longitudinal Study of Ageing (ELSA, Waves 2–9, 2004–2019). Frailty was defined using a 32-item Frailty Index and classified as robust, pre-frail, or frail. Multi-state Markov models estimated transition intensities and covariate effects, and a Transformer-based deep learning model with SHAP analysis explored nonlinear feature contributions.

Results

Over follow-up, the proportion of robust participants declined (CHARLS: 48.83% to 39.95%; ELSA: 54.26% to 36.19%) while frailty increased (CHARLS: 12.79% to 21.60%; ELSA: 12.89% to 24.42%). The highest deterioration intensity was from robust to pre-frail (CHARLS: 0.231; ELSA: 0.168), with substantial recovery from pre-frail to robust (CHARLS: 0.178; ELSA: 0.131). Pain, age and BMI were the strongest contributors to frailty risk. Vigorous and moderate activity were associated with lower frailty progression, whereas light activity showed an unexpected positive association with frailty risk that warrants further investigation.

Conclusion

Frailty transitions are bidirectional, with meaningful recovery potential, particularly from the pre-frail state. Moderate-to-vigorous physical activity is associated with slower frailty progression, supporting its role as a candidate target for intervention in aging populations.

Clinical Trial Registration

Not applicable.

Keywords

Frailty / Aging / Physical activity / State transitions / CHARLS / ELSA

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