Exercise and protein intake to combat frailty

What is frailty?

Frailty is a common and important geriatric syndrome characterized by age-associated decline in physiologic reserve and function across multiple organ systems. This often leads to increased vulnerability for poor health outcomes - including falls, bony fractures, fatigues, and even depression. Decline in cardiovascular health and frailty also often goes hand-in-hand, with increase in the future risk of heart attacks and strokes.

Multiple frailty models have been described in the literature. The frailty phenotype defines frailty as a distinct clinical syndrome meeting three or more of five phenotypic criteria: weakness, slowness, low level of physical activity, self-reported exhaustion, and unintentional weight loss.

The overall prevalence of frailty in community-dwelling older adults aged 65 years and over in the US ranges from 7% to 12%. It increases with age from 3.9% in the age-group 65–74 years to 25% in the age group older than 85 years. (1) In other words, nearly a quarter of the population over 85 years is clinically frail with all its associated comorbidities.


How to effectively stave off frailty?

A recent systematic review published in the British Journal of General Practice  (2) trawled through published international research database on the practical approaches to prevent frailty in primary care. The authors identified and included 46 studies, involving nearly 16,000 participants, in their meta-analysis.

Nearly two thirds of studies included more than one intervention. Half involved physical exercises and 10 involved a mixture of exercises, such as a combination of aerobic, strength, balance, and coordination exercises.  Six featured strength exercises as the core component. Ten studies included health education on nutrition, medication, falls prevention, and social support.

The authors found a significant improvement in over 70% of the 14 studies in which frailty status was measured. Approaches combining strength training and dietary protein supplementation were consistently ranked the most effective in improving the frailty scores.


What can physios do to help combat frailty?

Starting an exercise programme with nutritional counselling is important, but keeping up the anti-frailty programme is even more challenging. Older adults and physically deconditioned patients often find it difficult to exert themselves to maintain an exercise programme. They are also more prone to injury from exercise. Consistent encouragement, guidance, and exercise programme prescription with dietary support from professional physiotherapists are crucial to sustain momentum and help this vulnerable group to effectively combat frailty.


Practical advice

Based on the meta-analysis of above, researchers recommend 20 to 25 minutes of physical activity to delay or reverse frailty. This could be executed four days a week at home, made up of multiple exercises to strengthen arms and legs and to improve balance and coordination. Diets should include plenty of daily good quality protein, such as milk, eggs, tuna or chicken; or formula protein to supplement meals.

Frailty is a complex syndrome and anti-frailty intervention needs to be multi-faceted to tackle the many layers of physical, social, and psychological challenges. Activity prescription should be personalised in the community for individual circumstances, and may benefit from the use of technologies such as bespoke apps and group chats.


[*After thoughts - the title photo above was a night scene by the Barcelona Beach in Spain. It was taken by yours truly during a conference trip in 2014. Dancing - which combines arm/leg/aerobic exercises that also trains one's balance and coordination - seems to have it all! May be we should encourage our frail patients to watch and join Strictly Come Dancing...!!]



(1) Fried LP, et al. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. 2004;59:255–263

(2) Travers J, et al. Delaying and reversing frailty: a systematic review of primary care interventions. Br J Gen Pract 2019; 69 (678): e61-e69. DOI:


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