JAMDA xxx (2016) 1e5

JAMDA
journal homepage: www.jamda.com

Original Study

Successful Aging and Frailty: Opposite Sides of the Same Coin?

Jean Woo MD a, *, Jason Leung MSc b, Tiemei Zhang PhD c
a

Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, N.T., Hong Kong
The Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, School of Public Health, Prince of Wales Hospital, N.T.,
Hong Kong
c
The Key Laboratory of Geriatrics, Beijing Hospital, Beijing Institute of Geriatrics, Ministry of Health, Beijing, China
b

a b s t r a c t
Keywords:
Frailty
successful aging
walking speed
physical activity
quality of life
appendicular fat

Objectives: Operational denitions of successful aging place a strong emphasis on functional capacity, and
strategies for successful aging include many factors common to frailty research. We explore the hypothesis that frailty and successful aging are two sides of the same coin and that walking speed may be
an objective indicator of successful aging.
Design: Observational study of two Chinese cohorts using one to dene fast walkers and applying this
criteria to another cohort to examine associated factors.
Setting: Community survey in cities in China.
Participants: A total of 1929 men and women aged 25 to 89 years of age in four cities in China and 4000
men and women 65 years old in Hong Kong SAR China.
Measurements: The top 25th percentile of walking speed for the whole cohort of 1929 men was determined, and the cutoff value was used to dene fast walkers. This value was applied to the Hong Kong
Chinese population to examine factors associated with fast walking speed. These factors include age,
gender, socioeconomic and lifestyle factors, medical history, quality of life, cognitive function, depressive
symptoms, body mass index, body composition, and telomere length.
Results: Fast walkers had better self-rated health, lower prevalence of stroke, hypertension, cataracts,
osteoporosis, and impaired cognitive function. They were more likely to be current alcohol users, more
physically active, consumed more vegetables, had better physical component of health-related quality of
life, and received more education. They also had lower body mass index, percentage whole body fat as
well as appendicular fat, and higher appendicular muscle mass index. In multivariate analysis, the signicant contributing variables were age, gender, current alcohol use, physical activity level, vegetable
intake, quality of life, and appendicular fat. The area under the curve value on receiver-operating characteristic analysis was 0.77 for these seven variables.
Conclusions: Frailty and successful aging may be considered two sides of the same entity, and fast walking
speed may be used as an objective indicator of successful aging.
2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

The term successful aging was introduced over 20 years ago,

encompassing three main factors: illness avoidance, high physical and
mental functioning, and active engagement with life.1 Subsequent
discourse placed much emphasis on the presence or absence of disease, such that proles of centenarians have been classied into
survivors, delayers, and escapers based on the presence of diseases and the age of onset before or after 80 years.2 Further research
taking into account older peoples views suggests a need to enlarge on

The authors declare no conicts of interest.

* Address correspondence to Prof. Jean Woo, Department of Medicine & Therapeutics, The Chinese University of Hong Kong, 9/F, Lui Che Woo Clinical Sciences
Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong.
E-mail address: jeanwoowong@cuhk.edu.hk (J. Woo).
http://dx.doi.org/10.1016/j.jamda.2016.04.015
1525-8610/ 2016 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

the essentially biomedical model to include social and psychological

factors.3,4 The lay model is broader with similar characteristics to the
domains of the Age-Friendly City Movement promoted by the World
Health Organization in 2007.5 Psychological components of successful
aging (such as self-efcacy and resilience) were the only components
in a model that predicted subsequent quality of life independently.6
Among Chinese people, active engagement has been further subdivided into two separate constructs of caring and/or productive
engagement,7 while a social support network was the predominant
factor in predicting well-being after 1 year.8
Studies into factors promoting successful aging examined genetic
and environmental contributors. Although it is thought that genetic
factors play a role, the contribution is small compared with environmental factors, but that the contribution may increase with increasing

J. Woo et al. / JAMDA xxx (2016) 1e5

age.9e11 Studies into contributors of successful aging highlighted

healthy lifestyle (physical activity, nutrition), environmental enrichment and stress avoidance, and methods to preserve cognitive function by measures that promote neuronal plasticity.12e19 The relative
importance of these factors are uncertain, but a study showed that
knowledge and development of a healthy lifestyle only correlated
weakly with the positive aging process, compared with income and
education.20 Nevertheless, the recurrent theme from these studies
suggests the importance of achieving higher levels of physical tness
through actual participation in physical activity, as well as cognitive
stimulation, and that these multimodal strategies are benecial for
maintaining physical as well as cognitive function.
At the same time, the concept of frailty began to evolve, predominantly in the biomedical literature, as a phenomenon quantifying the
speed of the aging trajectory. Frailty is considered a geriatric syndrome that represents age-related physiological decline in various
systems that result in increased vulnerability to any external stressors.
It also predicts many adverse outcomes including dependency, use of
hospital services, and mortality.21e23 Frailty also has physical, cognitive, and social components.24e26 It would be interesting to examine
whether determinants of frailty are the same as those factors associated with successful aging. Walking speed is a strong indicator of
frailty, because it reects physiological as well as pathological processes, in terms of neurodegeneration, cardiorespiratory tness, and
sarcopenia.27 In a national survey of 1929 people aged 25 to 89 years
without disabilities in four cities of China, gait speed was measured,
and a percentage of people in the older age groups was found to have
walking speed similar to younger age groups.28 Using the cutoff value
for walking speed in the top 25th percentile of the whole population
(
1.39 m/s) to represent the robust state (as oppose to frailty), we
examined the factors associated with this value of walking speed in
another Chinese cohort of 4000 men and women, to determine
whether these factors are similar to those described for successful
aging. The objective is to explore the hypothesis that frailty and successful aging are two sides of the same coin and that walking speed
above a certain value may be an objective indicator of successful aging.
Participants and Methods
Establishment of the Top 25th Percentile of Walking in a Chinese
Population of All Ages
A cross-sectional survey was conducted in four urban cities of
China from September 2013 to December 2014. One thousand nine
hundred twenty-nine people aged 25 to 89 years without physical
disabilities were recruited. Approximately half were from Northern
and half from Southern China. Forty-ve percent were women, and
53% were 60 years of age and older.
Participants were requested to begin walking at their usual pace
from a starting point and to continue on a straight course of 7 meters.
The total time taken from the starting point to the rst footfall over the
6-meter line was measured using a stopwatch. Gait speed was
calculated by dividing the distance in meters by the time taken in
seconds (m/s). The mean standard deviation (SD) walking speed for
the cohort was 1.55 (0.18) m/s. The cutoff value for the top 25th
percentile was
1.39 m/s.
Chinese Population Studied
Subjects were participants of a cohort study examining the risk
factors for osteoporosis in Hong Kong.29 Four thousand Chinese men
(n 2000) and women (n 2000) aged 65 years of age or older living
in the community were recruited in a health survey between August
2001 and December 2003 by recruitment notices and talks in community centers and housing estates. Participants were volunteers and

were able to walk or take public transport to the study site. They were
recruited using a stratied sampling method so that approximately
33% would be in each of these age groups: 65 to 69, 70 to 74, and 75.
This study was conducted in accordance with the Declaration of
Helsinki and was approved by the Clinical Research Ethics Committee
of the Chinese University of Hong Kong. Written informed consent
was obtained from all subjects.
Questionnaire
A standardized, structured interview was performed to collect
information on age, education level, smoking habits, and alcohol use.
Information on the duration and level of past and current use of cigarettes, cigars, and pipes was obtained. Smoking history was classied
in terms of former smoking (at least 100 cigarettes smoked in a lifetime), current smoking, or never smoking. Subjects were also asked
about their alcohol use, and drinking status was dened as never,
former, or current. The presence of known chronic disease was also
recorded, and participants were also asked to rate their health status
into ve categories from poor to excellent. Cognitive function was
assessed by the Mini-Mental Status Examination30 according to the
original osteoporosis study protocol.31 Health-related quality of life
was evaluated by the 12-Item Short Form Health Survey (SF-12). It
derives summary scores from specic items from the eight domains of
the SF-36, with physical component summary score (summary of
physical functioning, physical role, bodily pain, and general health)
and the mental component summary score summary of vitality, social
functioning, emotional role, and mental health,32 being highly correlated with that of the SF-36 (0.951 and 0.969, respectively). Depressive
symptoms were assessed using the Geriatric Depression Scale33 with a
score
8 representing depressive symptoms, validated in elderly
Chinese subjects.34
Self-rated SES was assessed by asking participants to place a mark
on a picture of an upright ladder with ten rungs, with the top rung
representing people who have the most money, the most education,
and the most respected jobs and the bottom rung representing people
at the other extreme (SES ladder). This is a subjective measure of social
status developed by the John D. and Catherine T. MacArthur Research
Network on Socioeconomic Status and Health. It has been associated
with key health outcomes in various population surveys of different
cultural and ethnic groups35 and had been applied in the Hong Kong
population to examine gender differences in socioeconomic status.36
Dietary intake was assessed at baseline using a validated semiquantitative food frequency questionnaire.37 A trained interviewer
asked each participant to report the frequency and the usual amount
of consumption of each food item over the past year. Portion size was
explained to participants using a catalogue of pictures of individual
food portions. The daily amount of consumption of major food groups
including cereal, egg and egg products, sh and shellsh, fruits and
dried fruits, legumes/nuts/seeds, meat and poultry, milk and milk
products, and vegetables was calculated. Mean daily nutrient intake
was calculated using food tables derived from McCance and Widdowson38 and the Chinese Medical Sciences Institute.39
Measurements and Methods
Body weight was measured with subjects wearing a light gown,
using the Physician Balance Beam Scale (Health o meter, McCook, IL).
Height was measured using the Holtain Harpenden stadiometer
(Holtain Ltd, Crosswell, Crymych, Pembs, Wales). Body mass index
(BMI) was calculated as (body weight in kg/[height in m2]). BMI
was divided into different categories to represent underweight
(<18.5 kg/m2), normal weight (18.5 to < 23 kg/m2), overweight (23 to
24.9 kg/m2), obesity I (25 to 29.9 kg/m2), and obesity II (
30 kg/m2),
using Asian criteria.40 Blood pressure was measured after a 5-minute

J. Woo et al. / JAMDA xxx (2016) 1e5

rest in the sitting position using a standard mercury sphygmomanometer (W.A. Baum Co. Inc., Copiague, NY) by trained staff. The rst
and fth Korotkoff phases were recorded as systolic and diastolic
blood pressure. The average of two readings was taken. Body
composition was measured by dual-energy X-ray absorptiometry
(Hologic QDR-4500W, software version 11.2: Hologice, Inc., Waltham,
MA). Total appendicular skeletal muscle mass was calculated by the
sum of lean mass measured in the four limbs, with the operator
adjusting the cut lines of the limbs according to specic anatomical
landmarks as described by Heymseld et al.41
Assessment of Telomere Length by a Real-Time Quantitative PCR
Method
Measurement of telomere length of DNA samples follows the
method published by Cawthon,42 with modication.43 The principle of
this technique is to measure the factor of the ratio between the telomere repeat copy number, and a single copy gene copy number is our
sample with respect to a reference DNA sample (known as T/S ratio).
Real-time quantitative polymerase chain reaction was performed on
Roche LightCycler 480 (Roche, Mannheim, Germany).
Statistical Analysis
Statistical analyses were performed using SAS software, version
9.2 (SAS Institute). Percentages of fast walkers (walking speed of

1.39 m/s) were compared between men and women by chi-square
tests. Associated factors of fast walkers were analyzed by t-tests for
continuous variables and chi-square tests for categorical variables.
Logistic regression was performed for signicant risk factors, using the
stepwise selection method. Receiver-operating characteristic (ROC)
curves were constructed using predicted probabilities to evaluate the
discriminative quality of the model. The area under the ROC curve
(AUC) was used to measure the concordance of predictive values with
actual outcomes. All statistical tests were two sided. P values less than
.05 were considered signicant.
Results
The frequency of people who had a walking speed of
1.39 m/s
(fast walkers) is shown by gender and three different age groups at
baseline and during different periods of follow-up (Table 1). For the

Table 1
Walking Speed
1.39 m/s (Fast Walkers) by Age Groups
Male
N
Walking speed
1.39 m/s
Age 65-74
Baseline
1372
2 y FU
1237
4 y FU
1154
Age 75-84
Baseline
585
2 y FU
478
4 y FU
386
Age
85
Baseline
43
2 y FU
28
4 y FU
20
All ages
Baseline
2000
2 y FU
1743
4 y FU
1560

Female
Freq

Freq

146
102
61

10.64%
8.25%
5.29%

1334
1159
1116

36
22
10

2.7%*
1.9%*
0.9%*

21
10
2

3.59%
2.09%
0.52%

608
487
432

6
3
3

0.99%*
0.62%*
0.69%

58
33
29

0
0
0

0%
0%
0%

2000
1679
1577

42
25
13

0
0
0
167
112
63

FU, follow-up.
*P value < .05 for chi-square test.

0%
0%
0%
8.35%
6.43%
4.04%

2.1%*
1.49%*
0.82%*

age group 65 to74 years, the prevalence of fast walkers is higher

among men; but in the age group of individuals 75 to 84, the prevalence had decreased by about threefold, although still higher in men
compared with women. No participant in the
85 age group achieved
this walking speed. The prevalence also declined during successive
follow-up by about half after 4 years. Fast walkers had better self-rated
health, lower prevalence of stroke, hypertension, cataracts, osteoporosis, and impaired cognitive function. They were more likely to be
current users of alcohol, more physically active, consumed more
vegetables, had a better physical component of quality of life, and
received more education (Table 2). They also had a lower body mass
index, percentage whole body fat as well as appendicular fat, and
higher appendicular muscle mass index. In multivariate analysis, the

Table 2
Baseline Characteristics
Walking Speed Using Best Time

1.39 m/s, Freq (%)/Mean (SD)
No (n 3791)
Age
Female
Self-rated health
Excellent
Good
Fair
Poor
Very poor
Diabetes
High/low thyroid
Stroke
Parkinson disease
Hypertension
Heart attack/coronary/
myocardial infarction
Angina
Congestive heart failure/
enlarged heart
COPD
Glaucoma
Cataracts
Gastrectomy
Arthritis
Osteoporosis
MMSE
Depression (GDS > 8)
SBP >160 and/or DBP > 90
Current smoking
Current alcohol use
PASE score
Fruits and dried fruits
intake (g/day)
Vegetables intake (g/day)
Protein intake (g/day)
SF-12dphysical
SF-12dmental
Education
Primary or below
Secondary/matriculation
University or above
SES ladderdHong Kong (> 5)
SES ladderdcommunity (> 5)
BMI (kg/m2)
Whole body % fat
Whole body fat (kg)
Appendicular fat (kg)
ASM/height squared (kg/m2)
Telomere length (kb)

72.63 (5.21)
1958 (51.7%)
342
1408
1751
260
30
554
157
174
16
1642
376

(9.0%)
(37.1%)
(46.2%)
(6.9%)
(0.8%)
(14.6%)
(4.1%)
(4.6%)
(0.4%)
(43.3%)
(9.9%)

333 (8.8%)
146 (3.9%)

P Value*

Yes (n 209)
69.77 (3.70)
42 (20.1%)
40
99
64
6
0
25
3
1
0
65
17

(19.1%)
(47.4%)
(30.6%)
(2.9%)
(0.0%)
(12.0%)
(1.4%)
(0.5%)
(0.0%)
(31.1%)
(8.1%)

19 (9.1%)
5 (2.4%)

<.0001
<.0001
<.0001

.2888
.052
.0047
.8856
.0005
.3989
.8788
.2813

321
161
1528
305
888
1139
25.53
356
650
258
463
90.34
259.50

(8.5%)
(4.3%)
(40.3%)
(8.1%)
(23.4%)
(30.0%)
(3.70)
(9.4%)
(17.2%)
(6.8%)
(12.2%)
(42.19)
(192.41)

12
6
68
19
34
34
27.22
16
35
17
59
109.11
286.36

(5.7%)
(2.9%)
(32.5%)
(9.1%)
(16.3%)
(16.3%)
(2.81)
(7.7%)
(16.8%)
(8.1%)
(28.2%)
(52.81)
(275.25)

.1649
.3329
.0255
.5897
.0168
<.0001
<.0001
.3992
.8787
.46
<.0001
<.0001
.1652

240.95
75.70
48.36
55.40

(157.86)
(33.25)
(8.48)
(7.32)

276.40
90.13
52.30
56.19

(202.55)
(35.21)
(6.35)
(6.66)

.0135
<.0001
<.0001
.1274
<.0001

2769
681
341
2044
3263
23.72
29.72
17.31
7.10
6.60
9.09

(73.0%)
(18.0%)
(9.0%)
(57.5%)
(89.9%)
(3.32)
(7.18)
(5.31)
(2.58)
(0.96)
(2.01)

94
66
49
129
190
23.12
24.98
15.17
5.89
7.06
9.05

(45.0%)
(31.6%)
(23.4%)
(62.9%)
(91.8%)
(2.91)
(6.36)
(4.70)
(2.03)
(0.91)
(1.77)

0.1258
0.3878
0.0048
<.0001
<.0001
<.0001
<.0001
0.8482

ASM, appendicular skeletal mass; BMI, body mass index; COPD, chronic obstructive
pulmonary disease; DBP, diastolic blood pressure; GDS, Geriatric Depressive Scale;
MMSE, Mini-Mental State Exam; SBP, systolic blood pressure; SES, social-economic
status; SF-12, 12-Item Short Form Health Survey.
Items in bold indicate P value < .05.
*P value of t-test for continuous or chi-square for categorical variables.

J. Woo et al. / JAMDA xxx (2016) 1e5

Table 3
Logistic Regression of Walking Speed
Walking Speed
1.39 m/s Freq (%)/Mean (SD)

Age
Female
Current alcohol use
PASE score
Vegetables intake (g/day)
SF-12dphysical
Appendicular fat (kg)

No (n 3791)

Yes (n 209)

72.63
1958
463
90.34
240.95
48.36
7.10

69.77
42
59
109.11
276.40
52.30
5.89

(5.21)
(51.7%)
(12.2%)
(42.19)
(157.86)
(8.48)
(2.58)

(3.70)
(20.1%)
(28.2%)
(52.81)
(202.55)
(6.35)
(2.03)

Unit*

Adj. odds Ratio (95%

Condence Interval)

Per 5.2 years decrease

Female/male
Yes/no
Per 43 unit increase
Per 161 g increase
Per 8.4 unit increase
Per 2.6 kg decrease

1.99
0.42
1.45
1.14
1.14
1.49
1.35

(1.64, 2.41)
(0.28, 0.64)
(1.03, 2.03)
(1.02, 1.29)
(1.01, 1.28)
(1.23, 1.81)
(1.1, 1.65)

SD, standard deviation; SF-12, 12-Item Short Form Health Survey.

*Unit SD for continuous variables.

signicant contributing variables were age, gender, current alcohol

use, physical activity level, vegetable intake, quality of life, and
appendicular fat. The AUC value on ROC analysis was 0.77 for these
seven variables (Table 3, Figure 1).
Discussion
The ndings show that older people who maintain a fast walking
speed were more likely to be men, of a younger age group, had a
higher quality of life, and healthier lifestyles. There are similarities in
variables signicantly associated with fast walkers and the attributes
of successful aging. Although the concept of successful aging is widely
accepted, there is no universal denition4 and no objective measure.
Factors contributing to successful aging were identied using questionnaires or focus groups. In a similar way, although the concept of
frailty is increasingly widespread, there is no universal denition for
research or clinical practice, although there have been recommendations to incorporate frailty into clinical practice.44
There is little controversy that successful aging is a desirable
outcome for aging populations, as is avoidance of the frail state.
Common to both states is a high level of physical and cognitive
functioning, which may inuence psychological and social outcomes.
Although there is a need for biomedical and psychosocial models of
successful aging, a systematic review of operational denitions of

Fig. 1. Receiver-operator characteristic curve of the fast walker; area under the
curve 0.772 (95% condence interval, 0.741e0.803).

successful aging showed that more than 90% of studies described a

physical construct, with approximately 50% including engagement
and well-being constructs and 25% including resilience.4 Thus, there is
strong emphasis on functional capacity, which facilitates active
engagement, social participation, and promotes self-efcacy. It may be
argued that fast walking speed, representing a robust state, would be a
good objective indicator of functioning, because neurodegenerative
conditions, poor cardiorespiratory tness and sarcopenia, conditions
that affect functioning, are represented by slow walking speed.27
Recent literature on the topic of successful aging has included a
broad perspective in terms of underlying contributory factors as well
as practical strategies to promote successful aging, such that the
boundaries between biomedical, psychological, and social factors are
increasingly blurred. Eaton et al10 describe the impact of genes,
environment, and personality on successful aging, while Pilling et al11
describe a genomics approach to tests and preventing the decline of
cellular function, with age covering muscle strength and muscle
repair, cognition, and beta-amyloid phagocytosis. Harmell et al12
proposed targeting of psychiatric illnesses as they directly have an
impact on biological aging trajectories through lifestyle, psychological,
and socioenvironmental factors, resulting in increased morbidity and
mortality. Interventions proposed for successful aging in the presence
or absence of psychiatric illnesses cover cognitive remediation,
physical activity, nutrition, and social engagement. Many studies
emphasized the importance of preserving cognitive function through
manipulating brain plasticity by diet, aerobic exercises, reduction in
chronic stress, cognitive exercises, and enhanced cognitive and social
interactions.13,14,16,45
Many of these factors are also observed to be associated with fast
walkers in univariate analysis in this study: chronic diseases, physical
and cognitive function, physical activity level, quality of life, healthy
diet, and socioeconomic indicators. Interestingly, depression was not a
signicant factor. Current alcohol intake was associated with faster
walking speed compared with teetotalers. The average quantity of
alcohol consumed was very low, however, being less than or equal to
one drink per day for 77% of men, while 97% of women did not
consume alcohol, likely representing alcohol use only in the context of
social activities. The independent variables in the multivariate analysis
support the role of healthy lifestyles in maintaining functional capacity, which enables active engagement, self-efcacy, and social
participation. Recommendations for promoting successful aging describes multimodal programs covering cognitive training, physical
activity to increase exercise capacity, as well as healthy diet.17e19
These recommendations are similar to those for the prevention of
frailty.46,47 Given that physical and cognitive functioning are key underlying factors to successful aging and frailty, we propose that successful aging and frailty are two facets of the same entity, and that
walking speed may be used as an objective measure.
There are limitations in this study. A prospective study may be
preferable in examining factors associated with fast walking speed
compared with a cross-sectional design. The psychosocial variables

J. Woo et al. / JAMDA xxx (2016) 1e5

included in the dataset were not comprehensive, compared with

those described in successful aging literature, such as various measures of well-being, resilience, and social engagement. An assumption
was made that good functioning is the dominant factor for psychosocial variables. However, it may be possible to have a good psychosocial prole in the presence of poor functioning, although most
successful aging discourse includes functioning as a component. It is
interesting that there is a tendency to use the term active aging in
recent years instead of successful aging, especially since the latter
implies that there are people who are unsuccessful.48
Conclusions
Despite these limitations, the study supports the idea that frailty
and successful aging are two sides of the same entity and that fast
walking speed may be used as an objective indicator of successful aging.
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