Defining frailty using a modified Fried's Frailty Phenotype in a Southern African context
Defining frailty using a modified Fried's Frailty Phenotype in a Southern African context
INTRODUCTION: Frailty leads to disability, morbidity, and mortality in older persons. The Fried's Frailty Phenotype (FFP), derived in the American Cardiovascular Health Study (CHS), is widely used around the world to define frailty, but lacks adaptation in African populations.
OBJECTIVE: To derive a modified FFP definition which best identifies frailty in a Southern African context.
METHODS: A population-based cross-sectional study of adults aged ≥40 years collected data from questionnaires and physical assessments. Original CHS, population-dependent, European Working Group on Sarcopenia in Older People2 (EWGSOP2) and Sarcopenia Definitions and Outcomes Consortium (SDOC) and independent thresholds were all applied to the five FFP criteria (weight loss, exhaustion, low physical activity [PA], low grip strength [GS] and slow walking speed [WS]) to assess non-differentiality, internal consistency, and plausibility.
RESULTS: The 919 participants had a median age of 59 years [IQR 50-70], 53.3% were female. Self-reported exhaustion was reported by 37.5%nd self-reported weight loss by 34.9%. Using the lowest quintile of body mass index (BMI), missed 15.2% of overweight and obese participants who reported weight loss. Using CHS thresholds, low PA was present in 36.7%. Grip strength correlated better with age (r = -0.45) than BMI (r = -0.19). Therefore, the sex-specific tenth percentile of the 40-49-years-age band of the study population was used rather than the CHS approach. The modified SDOC threshold identified slow WS in almost all (85.8%) and was therefore non-differential. The EWGSOP2 and CHS thresholds identified slow WS in 52.9% and 22.9%, respectively, compared to 34.5% using the study population's lowest quintile.
CONCLUSION: Culture and language sensitive questions for self-reported exhaustion and weight loss, CHS thresholds for low PA, and population dependent thresholds for GS and WS were the most suitable modifications in a Southern African setting, highlighting the need for region-specific adaptations when diagnosing frailty.
Humans, Female, Male, Middle Aged, Frailty/diagnosis, Aged, Cross-Sectional Studies, Phenotype, Hand Strength, Body Mass Index, Adult, Weight Loss, Geriatric Assessment/methods, South Africa/epidemiology
Madela, E I Y
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Gregson, C L
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Paruk, F
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Burton, A J
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Patel, R
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Wilson, H
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Habana, F
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Manyara, A M
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Mbanjwa, B
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Gates, L
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Grundy, C
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Ward, K A
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Cassim, B
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Madela, E I Y
935acce0-ce6f-4b9e-82ce-bd649d424e1a
Gregson, C L
9e28df51-89ec-4a1e-88ff-c6010a986e96
Paruk, F
4d803eaa-cdfe-4029-af69-f2d23b0ba99b
Burton, A J
975a69aa-d1d4-424e-93cc-5895e7576daf
Patel, R
e64684a5-911f-46cd-b1e3-04ed1593f290
Wilson, H
455c90de-7903-433b-99b6-f08a02b0e3a3
Habana, F
58ed0388-7e49-4447-9fc4-b5fc04493741
Manyara, A M
56bbb87a-db38-49a6-82a6-8beded4dca6e
Mbanjwa, B
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Gates, L
bc67b8b8-110b-4358-8e1b-6f1d345bd503
Grundy, C
c6c51267-b3f5-41aa-a3ca-75a09c18793d
Ward, K A
39bd4db1-c948-4e32-930e-7bec8deb54c7
Cassim, B
dd5001e2-eff9-4254-a369-736621bf724d
Madela, E I Y, Gregson, C L, Paruk, F, Burton, A J, Patel, R, Wilson, H, Habana, F, Manyara, A M, Mbanjwa, B, Gates, L, Grundy, C, Ward, K A and Cassim, B
(2026)
Defining frailty using a modified Fried's Frailty Phenotype in a Southern African context.
PLoS ONE, 21 (2), [e0340723].
(doi:10.1371/journal.pone.0340723).
Abstract
INTRODUCTION: Frailty leads to disability, morbidity, and mortality in older persons. The Fried's Frailty Phenotype (FFP), derived in the American Cardiovascular Health Study (CHS), is widely used around the world to define frailty, but lacks adaptation in African populations.
OBJECTIVE: To derive a modified FFP definition which best identifies frailty in a Southern African context.
METHODS: A population-based cross-sectional study of adults aged ≥40 years collected data from questionnaires and physical assessments. Original CHS, population-dependent, European Working Group on Sarcopenia in Older People2 (EWGSOP2) and Sarcopenia Definitions and Outcomes Consortium (SDOC) and independent thresholds were all applied to the five FFP criteria (weight loss, exhaustion, low physical activity [PA], low grip strength [GS] and slow walking speed [WS]) to assess non-differentiality, internal consistency, and plausibility.
RESULTS: The 919 participants had a median age of 59 years [IQR 50-70], 53.3% were female. Self-reported exhaustion was reported by 37.5%nd self-reported weight loss by 34.9%. Using the lowest quintile of body mass index (BMI), missed 15.2% of overweight and obese participants who reported weight loss. Using CHS thresholds, low PA was present in 36.7%. Grip strength correlated better with age (r = -0.45) than BMI (r = -0.19). Therefore, the sex-specific tenth percentile of the 40-49-years-age band of the study population was used rather than the CHS approach. The modified SDOC threshold identified slow WS in almost all (85.8%) and was therefore non-differential. The EWGSOP2 and CHS thresholds identified slow WS in 52.9% and 22.9%, respectively, compared to 34.5% using the study population's lowest quintile.
CONCLUSION: Culture and language sensitive questions for self-reported exhaustion and weight loss, CHS thresholds for low PA, and population dependent thresholds for GS and WS were the most suitable modifications in a Southern African setting, highlighting the need for region-specific adaptations when diagnosing frailty.
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journal.pone.0340723
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Accepted/In Press date: 24 December 2025
e-pub ahead of print date: 4 February 2026
Additional Information:
Copyright: © 2026 Madela et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Keywords:
Humans, Female, Male, Middle Aged, Frailty/diagnosis, Aged, Cross-Sectional Studies, Phenotype, Hand Strength, Body Mass Index, Adult, Weight Loss, Geriatric Assessment/methods, South Africa/epidemiology
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Local EPrints ID: 509037
URI: http://eprints.soton.ac.uk/id/eprint/509037
ISSN: 1932-6203
PURE UUID: 5492eb54-d38b-43ca-b674-8785e6cd7f57
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Date deposited: 10 Feb 2026 17:46
Last modified: 11 Feb 2026 02:49
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Author:
E I Y Madela
Author:
C L Gregson
Author:
F Paruk
Author:
A J Burton
Author:
R Patel
Author:
H Wilson
Author:
F Habana
Author:
A M Manyara
Author:
B Mbanjwa
Author:
C Grundy
Author:
B Cassim
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