Our response to rising frailty in younger people must address prevention burden
Authors: Peter Hanlon, David N Blane, Sara Macdonald, Frances S Mair, Catherine A O'Donnell
Journal: The Lancet Healthy Longevity (2021)

We read with interest the Article by Joanna Blodgett and colleagues analysing severity and lethality of frailty in the USA between 1999 and 2018.1Blodgett JM Rockwood K Theou O Changes in the severity and lethality of age-related health deficit accumulation in the USA between 1999 and 2018: a population-based cohort study.The Lancet Healthy Longevity. 2021; 2: e96-e104Summary Full Text Full Text PDF Scopus (7) Google Scholar Their findings that frailty is increasing in prevalence and severity in adult men of all ages and in women over age 35 years has wide-reaching implications, and highlights the importance of primary prevention and the potential effect on health inequalities. In their accompanying commentary, Conroy and colleagues highlight that the key tenets of lifestyle change (ie, diet, exercise, smoking, and alcohol) are poorly adhered to, and argue that they must be tackled in combination, adding that "targeting of such interventions in a way that they are acceptable to the individuals they are intended to benefit… is an area that is much neglected".2Conroy S Maynou L Frailty: time for a new approach to healthcare.The Lancet Healthy Longevity. 2021; 2: e60-e61Summary Full Text Full Text PDF Scopus (2) Google Scholar We agree, but would further argue that our response must take account of prevention burden: the workload associated with tackling multiple risk factors in the context of an individual's capacity to undertake that work.3O'Donnell C Hanlon P Blane D Macdonald S Williamson A Mair F We should consider prevention burden in our approach to tackling NCDs.https://blogs.bmj.com/bmj/2020/09/20/we-should-consider-prevention-burden-in-our-approach-to-tackling-ncds/Date: Sep 20, 2020Date accessed: February 8, 2021Google Scholar This burden falls most heavily on people experiencing socioeconomic deprivation, in whom risk factors often cluster. Frailty, particularly at younger ages, is closely linked with lower socioeconomic status. In our analysis of UK Biobank participants aged 37–73 years, 42% of individuals living with frailty were within the most deprived 20% of the cohort.4Hanlon P Nicholl BI Jani BD Lee D McQueenie R Mair FS Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants.Lancet Public Health. 2018; 3: e323-e332Summary Full Text Full Text PDF PubMed Scopus (265) Google Scholar Furthermore, an analysis of the Whitehall II cohort revealed social inequalities were associated with increased risk of developing frailty, multimorbidity, and disability, but not with risk of mortality once these states had developed.5Dugravot A Fayosse A Dumurgier J et al.Social inequalities in multimorbidity, frailty, disability, and transitions to mortality: a 24-year follow-up of the Whitehall II cohort study.Lancet Public Health. 2020; 5: e42-e50Summary Full Text Full Text PDF PubMed Scopus (53) Google Scholar Therefore, if the rising prevalence of frailty in younger ages is to be addressed, it must be at the level of primary prevention, with particular attention to the multiple challenges of socioeconomic deprivation. If this challenge is to be faced, people must be supported to overcome prevention burden at individual, community, and societal levels.3O'Donnell C Hanlon P Blane D Macdonald S Williamson A Mair F We should consider prevention burden in our approach to tackling NCDs.https://blogs.bmj.com/bmj/2020/09/20/we-should-consider-prevention-burden-in-our-approach-to-tackling-ncds/Date: Sep 20, 2020Date accessed: February 8, 2021Google Scholar This support includes individualised approaches to identifying realistic targets for behaviour change and recognising deep-rooted health and cultural practices that contextualise these behaviours and how any response must respect and engage with this context. Crucially, health policies must confront upstream determinants and contextual or structural barriers to health, which often disadvantage those living with socioeconomic deprivation or experiencing social exclusion. These challenges are complex. However, as Blodgett and colleagues' findings highlight, failing to overcome these challenges risks exacerbating the already stark inequalities in health seen in many societies. If we are to age well as a society, prevention burden is a challenge we must address. We declare no competing interests. PH is funded by the Medical Research Council. The funder had no role in this piece or in the decision to submit. Changes in the severity and lethality of age-related health deficit accumulation in the USA between 1999 and 2018: a population-based cohort studyIncreasing frailty levels in more recent cohorts of middle-aged and older adults combined with stable frailty lethality between 1999 and 2018, suggest a challenge to healthy longevity, with the proportion of individuals with a high degree of frailty continuing to increase. Full-Text PDF Open Access