Do lifestyle, health and social participation mediate educational inequalities in frailty worsening?

European Journal of Public Health, Apr 2015

Background: Lower educated older persons are at increased risk of becoming frail as compared with higher educated older persons. To reduce educational inequalities in the development of frailty, we investigated whether lifestyle, health and social participation mediate this relationship. Methods: Longitudinal data of 14 082 European community-dwelling persons aged 55 years and older participating in the Survey on Health, Ageing, and Retirement in Europe (SHARE) in 2004 and 2006, were used. Associations of lifestyle (smoking behaviour and alcohol consumption), health (depression, memory function, chronic diseases) and social participation, with educational level and frailty worsening were investigated using regression models. In multinomial logistic regression analysis, mediators were added to models in which educational level was associated with worsening in frailty over 2 years follow-up. Results: In all countries, frailty worsening was more prevalent among lower as compared with higher educated persons, although odds ratios were only statistically significant in five of the 11 countries included [ORs varying from 1.40 (95% CI: 1.06–1.84) to 1.61 (95% CI: 1.21–2.14)]. Except for smoking behaviour and memory function, the factors under study all showed associations with educational level and frailty worsening that met the conditions for mediation. After inclusion of the four relevant mediators, attenuation of odds ratios varied between 4.9 and 31.5%. Conclusion: While lifestyle, health and social participation were associated with frailty worsening over 2 years among European community-dwelling older persons, only small to moderate parts of educational inequalities in frailty worsening were explained by these factors.

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Do lifestyle, health and social participation mediate educational inequalities in frailty worsening?

European Journal of Public Health Do lifestyle, health and social participation mediate educational inequalities in frailty worsening? Astrid Etman 2 Carlijn B. M. Kamphuis 2 Tischa J. M. van der Cammen 0 1 3 Alex Burdorf 2 Frank J. van Lenthe 2 0 Department of Medicine, Brighton and Sussex Medical School , Brighton , UK 1 Department of Internal Medicine, Section of Geriatric Medicine, Erasmus MC, University Medical Center Rotterdam , Rotterdam , The Netherlands 2 Department of Public Health, Erasmus University MC , Rotterdam , The Netherlands 3 Faculty of Industrial Design Engineering, Delft University of Technology , Delft , The Netherlands 4 United Nations, Department of Economic and Social Affairs. World Population Prospects, the 2012 Revision [database]. Available at: 5 Mitchell TD, Carter TR, Jones PD, et al. A Comprehensive Set of High-resolution Grids of Monthly Climate for Europe and the Globe: The Observed Record (1901-2000) and 16 Scenarios (2001-2100). Tyndall Centre Working Paper 55, Tyndall Centre for Climate Change Research. Norwich: University of East Anglia , 2004. Dataset available at: 20 Eng H, Mercer JB. Mortality from cardiovascular diseases and its relationship to air temperature during the winter months in Dublin and Oslo/Akershus. Int J Circumpolar Health 2000;59:176-81. 24 United Nations Statistics Division. Composition of macro geographical (continental) regions, geographical sub-regions, and selected economic and other groupings. Available at: (22 March 2013, date last accessed). Introduction railty develops as a consequence of age-related decline in many Fphysiological systems, which collectively results in vulnerability to sudden health status changes.1 Due to ageing in Western populations, an increased number of older persons will become frail in the upcoming years. According to the often-used definition of Fried,2 currently, 37% of community-dwelling persons aged >55 years are pre-frail and about 4% are frail,3 with percentages increasing to 51 and 26% respectively for those aged >70 years.4 Among those aged 55 years, almost one quarter of the population in Western countries worsened in frailty over a relatively short period of 2 years.5 Because frailty can lead to falls, hospitalization, nursing home placement and death,1 it is important to find out how the frailty process develops to prevent or slow down this process from onset. Moreover, because the development of frailty is found to be a reversible process, appropriate interventions may contribute to frail older persons becoming pre-frail or even non-frail.5,6 Frailty is more prevalent among lower educated as compared with higher educated persons.7 Two recent longitudinal studies suggested a causation mechanism as lower educated persons aged 55 years showed an increased risk to worsen in frailty over time, compared with higher educated persons.4,6 Potential factors contributing to educational inequalities in worsening in frailty are largely unknown, but can be derived indirectly. There is evidence that an unhealthy lifestyle (e.g. smoking), limited social participation and health conditions are related to the frailty development process,2,8–11 although reverse causality cannot always be excluded. For example, frailty is associated with the onset of depression, but depression may also result in a worsening of frailty.12 Because educational differences in lifestyle,13,14 health15,16 and social participation15,17 are well known, these factors may likely contribute to the educational inequalities in frailty worsening; a quantification of their contribution, however, is currently lacking. The Survey of Health, Ageing, and Retirement in Europe (SHARE) aims at investigating population ageing processes across European countries. Longitudinal data on frailty and underlying determinants make the study suitable for research aimed at improving the understanding of educational inequalities in the frailty process. When investigating the role of lifestyle, health and social participation in educational inequalities in frailty worsening, possible differences between European countries in the extent to which potential mediators may contribute to inequalities in frailty worsening should be acknowledged. Therefore, this study adds knowledge by exploring whether lifestyle, health and social participation mediate the relationship between educational level and frailty worsening among community-dwelling elderly in 11 European countries. Method Design Data of persons participating in the SHARE in both 200 4 (wave one) and 2006 (wave two) were used. The SHARE study was designed to investigate population-ageing processes by looking at changes in health, economic situations and social networks of individuals aged 50 years. Nationally representative samples of 11 European countries (Sweden, Denmark, Germany, The Netherlands, Belgium, Switzerland, Austria, France, Italy, Spain and Greece) were interviewed face-to-face with structured computerized questionnaires. The household response in wave 1 varied from 38.8% in Switzerland to 79.2% in France. Details on this survey are described by Bo¨rsch-Supan et al. (2008, available online at http:// Subjects Subjects were eligible for the analyses if they were communitydwelling, aged 55 years at wave one, and participated in wave two as well. A total of 14 477 European community-dwelling persons fulfilled these inclusion criteria; however, 395 were excluded due to missing values for educational level, for 1 mediator(s), or because they had 3 missing Fried items at one or both waves. This resulted in a study population of 14 082 persons. Educational level Educational level was measured at wave one and was defined as the number of years a person received full time education (i.e. receiving tuition, engaging in practical work or supervised study or taking examinations). For international comparisons of education, SHARE used the 1997 International Standard Classification of Education (ISCED-97). Educational level was dichotomized in 0–10 years (which corresponds with ISCED level 0–2; ‘lower educated’) and 11–25 years (which corresponds with ISCED level 3–6; ‘higher educated’). Frailty worsening Physical frailty was based on the Fried’s criteria, i.e. weakness, slowness, low activity, weight loss and exhaustion. To make optimal use of the data available in the SHARE survey, we measured frailty level with an adapted version of Fried’s frailty scale as developed by Santos-Eggimann and colleagues.3 Weakness was defined as being below cut-off points (stratified by sex and body mass index2) for the highest of four measurements of hand grip strength. Participants were classified positive for slowness when mentioning having difficulty walking 100 meter or climbing one flight of stairs. Participants were classified as positive for low activity when answering the question ‘How often do you engage in activities that require a low or moderate state of energy, such as walking, gardening, cleaning the car, or doing a walk?’ with ‘one to three times a month’ or ‘hardly ever or never’. Unintentional weight loss was based on the answers ‘less’ or ‘diminution in desire for food’ to the question ‘what has your appetite been like?’ or the answer ‘less’ to the question ‘So you have been eating more, or less than usual?’. Exhaustion was based on the question ‘In the last month, have you had too little energy to do the things you wanted to do?’. Answering ‘yes’ was considered as being positive for exhaustion. Frailty states were based on the total number of criteria met: ‘frail’ ( 3 criteria), ‘pre-frail’ (1–2 criteria), ‘non-frail’ (0 criteria). Worsening in frailty was defined as changing from a lower to a higher frailty state after two years (i.e. from non-frail to pre-frail or frail, or from pre-frail to frail) with ‘no change in frailty’ as the reference group. Additional analyses were performed for improving in frailty, which was defined as changing from a high to a low frailty state after two years (results in Supplementary Appendix). Potential mediators: Lifestyle, health and social participation Self-reported lifestyle (smoking and alcohol consumption), health (presence of chronic diseases, memory function and depression) and social participation were measured at baseline. Smoking behaviour was measured with the question ‘Do you smoke?’ (current, former or never smoker). Alcohol consumption was based on the number of days per week participants were drinking alcohol during the last six months (<1 day, 3–4 days, 5 days per week). Chronic diseases were measured by questioning ‘Has a doctor ever told you that you have any of the following conditions?’, followed by a list of 14 chronic conditions, e.g. hypertension, arthritis, osteoporosis (none, 1 chronic diseases). Memory function was based on the maximum number of words (out of a 10-words list) a respondent was able to recall after a verbal and a numeric test [‘impaired’ ( 4 words), ‘good’ (>4 words)]. Depression was measured based on the EURO-D scale with 12 items on e.g. depression, pessimism, appetite and fatigue [‘not depressed’ (0–4 items), ‘probably depressed’ ( 5 items ‘yes’)].18 Social participation was measured with participating in social activities over the last month, e.g. voluntary work, cared for a sick person, participation at sports club (‘none’, ‘one or more’). Statistical analyses When scores for one or two of the five frailty criteria were missing, values were imputed through single random imputation, using software package R V.2.7.1. The scores of the population without missing values were used to replace missing values through a logistic regression model. Using this model, the probability of scoring ‘positive for frailty’ on a frailty indicator for every individual (with one or more missing values) was predicted and a random draw from the binomial distribution with that probability was made. To check the influence of random imputation, the procedure was repeated and no essential differences were found. Furthermore, a sensitivity analysis was conducted in which participants with missing outcome data were excluded (results available upon request). No substantial differences were found. Data were imputed for 2080 (14.8%) and 2312 (16.5%) individuals in waves one and two, respectively. Differences in sex, age and educational level between the study population and the excluded sample were investigated using Chi2 tests (sex, educational level) and a t-test (mean age). The association of educational level and frailty worsening was based on odds ratios [ORs, 95% confidence interval (CI)] from multinomial logistic regression analyses. Following conventional rules of mediation analysis,19 the associations of educational level with the possible mediators, and of the possible mediators with frailty worsening, were explored by binominal and or multinomial logistic regression analyses (depending on the number of categories of the mediating factor) among the total study sample. Finally, in multinomial logistic regression analyses, potential mediators were successively added to a model in which educational level was associated with frailty worsening, with ‘no change in frailty’ as the reference group, for each country separately. All analyses were adjusted for age and sex. Analyses concerning frailty changes were adjusted for baseline frailty state which has been found to be associated with subsequent changes in frailty.3,20 In all analyses, P-values of <0.05 were considered significant using SPSS V.20.0. To reduce potential selection bias generated by non-response, analyses were performed with individual longitudinal weights (SHARE Release guide 2.5.0). Results The study sample was younger and higher educated than those excluded from the analyses (P < 0.01, not tabulated). Within the study sample, most were women, in the younger age categories, and non-frail at wave one and wave two. After two years of follow-up, 22.1% worsened, 16.0% improved and 61.9% showed no change in frailty state. Lower educated persons (59.3%) were older, more often frail at both waves, and more often worsened in frailty after two years compared with higher educated persons. Among the higher educated persons 19.2% worsened compared with 24.0% among lower educated persons (table 1). The absolute prevalence of worsening in frailty during a 2-year period was up to 9.5% higher among lower educated persons compared with those with higher education (Germany) (figure 1). As shown in table 2, in the total study sample, lower educated persons had a lower probability to be a current or former smoker, to drink alcohol, or to participate in social activities as compared with higher educated persons. Furthermore, lower educated persons had a higher probability to be depressed, to have impaired memory or have one or more chronic diseases (table 2). Cross-national differences in the pattern of inequalities were found for smoking behaviour: in Sweden and The Netherlands, lower educated Table 3 Associations (odds ratios, 95% confidence intervals) between lifestyle, health and social participation and frailty worsening over 2 years follow-up, adjusted for age, sex, educational level, baseline frailty state and country (N = 14 082) Frailty worseninga persons more often were current smokers [ORs 1.62 (95% CI: 1.19–2.22) to 2.00 (95% CI: 1.45–2.76)], whereas in France, Spain, and Greece, lower educated persons less often were current smokers compared with higher educated persons [ORs varying 0.65 (95% CI: 0.47–0.88) to 0.54 (95% CI: 0.35–0.84)] (Supplementary Appendix 1). Being a current smoker, drinking no alcohol, having a depression, or one or more chronic diseases, and no social participation increased the likelihood of frailty worsening (table 3). Although not always significant for the separate countries, the direction of these associations was mostly comparable with that in the total study sample (Supplementary Appendix 2). Because alcohol consumption, chronic diseases, depression and social participation were associated with both educational level and frailty worsening, these factors were added as mediators to the explanatory models for educational inequalities in frailty worsening. Smoking was not added to the explanatory models, because smoking did increase the risk of worsening in frailty, but lower educated were doing better on this risk factor (i.e. less likely to be a current smoker) than higher educated. An increased probability of worsening in frailty in lower as compared with higher educated persons was found in 10 countries, but was only statistically significant in five countries [ORs varying from 1.40 (95% CI: 1.06–1.84) to 1.61 (95% CI: 1.21–2.14), see table 4]. Inclusion of lifestyle, health and social participation separately resulted in only a minor attenuation of the odds ratios which varied between 4.9% in The Netherlands to 31.5% in Germany (table 4). Discussion Among European community-dwelling older persons aged 55 years, lower educated were found to be at an increased risk of worsening in frailty over a 2-years follow-up. While low alcohol consumption, chronic diseases, depression and less social participation increased the probability of frailty worsening and were more prevalent among the lower educated, only small to modest parts of the educational inequalities in frailty worsening were explained by these factors. Our findings are in line with research in which lower educated older persons were found to be at an increased risk of worsening in frailty over an average 6.4 years period.7 Lifestyle factors are reported to be on the pathway of educational inequalities in health,21–23 which is supported by our finding that alcohol consumption contribute to educational differences in frailty changes. Our finding that the presence of chronic diseases explained part of educational inequalities in frailty worsening is supported by findings of Gobbens et al.24 who found that multimorbidity partly mediates the relationship between income and frailty. As mentioned, associations between health factors such as depression and frailty may be due to reverse causality.12 Our longitudinal approach, however, strengthens the evidence of the association between health factors and the development of frailty. Our finding that alcohol consumption was associated with a lower probability of frailty worsening is supported by studies in which alcohol consumption was found to protect against coronary heart disease and dementia.25,26 Smoking behaviour is associated with both the onset11,13 and worsening in frailty. Overall, associations with frailty worsening were found for certain health conditions, i.e. presence of depression and the presence of chronic diseases, which is supported by earlier research on the presence of frailty.2,8,13,27 Furthermore, persons who were not socially participating showed an increased risk of worsening in frailty. These results fit well with the findings of Cramm et al.28 who showed that the social environment (e.g. social cohesion, social support, contact with neighbours) plays an important role for the well-being of older persons. There is a possibility that two years is too short to detect an effect of the possible mediators on the frailty worsening process. Future research in this field should focus on follow up periods longer than 2 years, and search for additional explanations for the educational inequalities in frailty worsening. Previous studies addressed the importance of material (e.g. financial situation, housing conditions), psychosocial (e.g. life events, external locus of control) and environmental factors (e.g. neighbourhood characteristics) when studying educational inequalities in health.18,29–31 It therefore seems legitimate to further investigate how and when differential exposure to material circumstances, psychosocial factors and characteristics of the built environment over the life course between educational groups may translate into an increased risk of worsening in frailty among the lower educated. Some limitations of this study should be mentioned. First, frailty state was measured via self-report. Differential misclassification of frailty state by educational level may have led to incorrect associations. It is unknown, however, whether this would result in underor overestimations of the educational inequalities in frailty development. Second, the self-reported nature of the mediators may have resulted in an underestimation of their contribution to educational inequalities in frailty worsening. There is evidence of larger underreporting of chronic conditions32 and over-reporting of a healthy lifestyle33,34 among persons with lower as compared with higher educational levels. Furthermore, higher educated persons are more likely to participate in surveys as compared with lower educated persons which may also have resulted in an underestimation of educational inequalities in frailty worsening. Third, alcohol consumption was measured by the number of days drinking alcohol per week, without asking for the number of glasses per day. Therefore, this measure does not allow to differentiate between binge drinkers and regular drinkers. This may have underestimated the contribution of alcohol consumption to inequalities in frailty worsening, as binge drinking increases the likelihood of unfavourable health outcomes (e.g. functional limitations and death),35–37 and for example in Dutch persons, may be more common among lower than higher educated persons.38 Fourthly, among the non-responses at wave 2, some passed away between wave 1 and 2 (exact number is unclear). As some deaths could have been due to worsening in frailty, this may have resulted in an underestimation of the prevalence of frailty worsening. As lower educated persons were more likely to worsen in frailty, it may also have resulted in an underestimation of the educational inequalities in frailty worsening. In conclusion, our study showedthatalthoughlifestyle, healthandsocial participation were associated with the frailty development process, only small to moderate parts of educational inequalities in frailty worsening among older European persons were explained by these factors. Supplementary data Supplementary data are available at EURPUB online. Acknowledgements This paper uses data from SHARELIFE release 1, as of November 24th 2010 , and SHARE release 2.3.1, as of July 29th 2010. The SHARE data collection has been primarily funded by the European Commission through the 5th framework programme (project QLK6-CT-2001- 00360 in the thematic programme Quality of Life) , through the 6th framework programme (projects SHARE-I3, RII-CT- 2006-062193; COMPARE, CIT5-CT-2005028857; and SHARELIFE, CIT4-CT-2006-028812) and through the 7th framework programme (SHARE-PREP, 211909 and SHARELEAP, 227822). Additional funding from the U.S. National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, Y1-AG-4553-01 and OGHA 04-064, IAG BSR06-11, R21 AG025169) as well as from various national sources is gratefully acknowledged (see share/index.php for a full list of funding institutions). We would like to thank Caspar Looman for his statistical advice. Funding This study was financially supported by the Erasmus MC, University Medical Center Rotterdam. Conflicts of interest: None declared. Key points Lifestyle, health and social participation were associated with frailty development. Small to moderate parts of educational inequalities in frailty worsening were explained by lifestyle, health and social participation. To reduce educational inequalities in the development of frailty, intervention development should take lifestyle, health and social participation into account. 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Etman, Astrid, Kamphuis, Carlijn B. M., van der Cammen, Tischa J. M., Burdorf, Alex, van Lenthe, Frank J.. Do lifestyle, health and social participation mediate educational inequalities in frailty worsening?, European Journal of Public Health, 2015, 345-350, DOI: 10.1093/eurpub/cku093