Association of Alternative Dietary Patterns with Osteoporosis and Fracture Risk in Older People: A Scoping Review

Purpose: Although the Mediterranean diet has been associated with a lower risk of hip fracture, the effect of other dietary patterns on bone density and risk of fracture is unknown. This scoping review aims to investigate the association between adherence to alternative dietary patterns (other than the traditional Mediterranean diet) and osteoporosis or osteoporotic fracture risk in older people. Methods: A systematic search was carried out on three electronic databases (Medline, EMBASE, and Scopus) to identify original papers studying the association between alternative dietary patterns (e.g., Baltic Sea Diet (BSD), modified/alternative Mediterranean diet in non-Mediterranean populations, Dietary Approaches to Stop Hypertension (DASH)) assessed using ‘prior’ methods (validated scores) and the risk of osteoporotic fracture or Bone Mineral Density (BMD) in people aged ≥50 (or reported average age of participants ≥ 60). Results from the included studies were presented in a narrative way. Results: Six observational (four prospective cohort and two cross-sectional) studies were included. There was no significant association between BMD and BSD or DASH scores. Higher adherence to DASH was associated with a lower risk of lumbar spine osteoporosis in women in one study, although it was not associated with the risk of hip fracture in another study with men and women. Higher adherence to aMED (alternative Mediterranean diet) was associated with a lower risk of hip fracture in one study, whereas higher adherence to mMED (modified Mediterranean diet) was associated with a lower risk of hip fracture in one study and had no significant result in another study. However, diet scores were heterogeneous across cohort studies. Conclusions: There is some evidence that a modified and alternative Mediterranean diet may reduce the risk of hip fracture, and DASH may improve lumbar spine BMD. Larger cohort studies are needed to validate these findings

Trends in incidence of recorded diagnosis of osteoporosis, osteopenia, and fragility fractures in people aged 50 years and above: retrospective cohort study using UK primary care data

Summary: This study used primary care data to estimate the incidence of recorded diagnosis of osteoporosis, osteopenia, and fragility fracture in the UK during 2000–2018 accounting for age, sex, calendar year and social deprivation. More than 3 million people aged 50–99 years were included. We found that men living in the most deprived areas had a 45% higher risk of being diagnosed with osteoporosis and 50% higher risk of fragility fracture compared to men living in the least deprived areas. Purpose: a) To estimate the incidence trends of a recorded diagnosis of osteoporosis, osteopenia, and fragility fracture in the UK over time; b) to describe differences according to age, sex, and social deprivation. Methods: This is a longitudinal population-based cohort study using routinely collected primary care data obtained via IQVIA Medical Research Database (IMRD). All patients aged 50–99 years registered with a practice participating in THIN (The Health Improvement Network) between 2000–2018 were included. The first recorded diagnosis of osteoporosis, osteopenia, or fragility fracture was used to estimate incidence rates (IR) per 10,000 person-years at risk. Poisson regression was used to provide Incidence Rate Ratios (IRR) adjusted by age, sex, social deprivation, calendar year, and practice effect. Results: The year-specific adjusted IRR of recorded osteoporosis was highest in 2009 in women [IRR 1.44(95%CI 1.38–1.50)], whereas in men it was highest in 2013–2014 [IRR 1.94(95%CI 1.72–2.18)] compared to 2000. The year-specific adjusted IRR of fragility fracture was highest in 2012 in women [IRR 1.77(95%CI 1.69–1.85)], whereas in men it was highest in 2013 [IRR 1.64(95%CI 1.51–1.78)] compared to 2000. Men in the most deprived areas had a higher risk of being diagnosed with osteoporosis [IRR 1.45(95%CI 1.38–1.53)], osteopenia [IRR 1.17(95%CI 1.09–1.26)], and fragility fracture [IRR 1.50(95%CI 1.44–1.56)] compared to those living in the least deprived areas, but smaller differences were seen in women. Conclusion: Use of fracture risk assessment tools may enhance the detection of osteoporosis cases in primary care. Further research is needed on the effect of social deprivation on diagnosis of osteoporosis and fractures

An online international comparison of palliative care identification in primary care using the Surprise Question.

BACKGROUND The Surprise Question ('Would I be surprised if this patient died within 12 months?') identifies patients in the last year of life. It is unclear if 'surprised' means the same for each clinician, and whether their responses are internally consistent. AIM To determine the consistency with which the Surprise Question is used. DESIGN A cross-sectional online study of participants located in Belgium, Germany, Italy, The Netherlands, Switzerland and UK. Participants completed 20 hypothetical patient summaries ('vignettes'). Primary outcome measure: continuous estimate of probability of death within 12 months (0% [certain survival]-100% [certain death]). A threshold (probability estimate above which Surprise Question responses were consistently 'no') and an inconsistency range (range of probability estimates where respondents vacillated between responses) were calculated. Univariable and multivariable linear regression explored differences in consistency. Trial registration: NCT03697213. SETTING/PARTICIPANTS Registered General Practitioners (GPs). Of the 307 GPs who started the study, 250 completed 15 or more vignettes. RESULTS Participants had a consistency threshold of 49.8% (SD 22.7) and inconsistency range of 17% (SD 22.4). Italy had a significantly higher threshold than other countries (p = 0.002). There was also a difference in threshold levels depending on age of clinician, for every yearly increase, participants had a higher threshold. There was no difference in inconsistency between countries (p = 0.53). CONCLUSIONS There is variation between clinicians regarding the use of the Surprise Question. Over half of GPs were not internally consistent in their responses to the Surprise Question. Future research with standardised terms and real patients is warranted

A Core Outcome Set for nutritional intervention studies in older adults with malnutrition and those at risk: a study protocol

BACKGROUND: Malnutrition (i.e., protein-energy malnutrition) in older adults has severe negative clinical consequences, emphasizing the need for effective treatments. Many, often small, randomized controlled trials (RCTs) testing the effectiveness of nutritional interventions for the treatment of malnutrition showed mixed results and a need for meta-analyses and data pooling has been expressed. However, evidence synthesis is hampered by the wide variety of outcomes and their method of assessment in previous RCTs. This paper describes the protocol for developing a Core Outcome Set (COS) for nutritional intervention studies in older adults with malnutrition and those at risk. METHODS: The project consists of five phases. The first phase consists of a scoping review to identify frequently used outcomes in published RCTs and select additional patient-reported outcomes. The second phase includes a modified Delphi Survey involving experienced researchers and health care professionals working in the field of malnutrition in older adults, followed by the third phase consisting of a consensus meeting to discuss and agree what critical outcomes need to be included in the COS. The fourth phase will determine how each COS outcome should be measured based on a systematic literature review and a second consensus meeting. This will be followed by a dissemination and implementation phase. Patient and Public Involvement (PPI) representatives will contribute to study design, oversight, consensus, and dissemination. CONCLUSIONS: The result of this project is a COS that should be included in any RCT evaluating the effect of nutritional interventions in older adults with malnutrition and those at risk. This COS will facilitate comparison of RCT results, will increase efficient use of research resources and will reduce bias due to measurement of the outcome and publication bias. Ultimately, the COS will support clinical decision making by identifying the most effective approaches for treating and preventing malnutrition in older adults

Perspectives of Non-Hospitalised Patients with COVID-19 Self-Isolating for 10 Days at Home: A Qualitative Study in Primary Care in Greece

The aim of this qualitative research, conducted in Spring 2021, was to identify the inconveniences and the psychological and social impact of 10 days of home isolation, required by law, in non-hospitalised COVID-19 patients in Greece and to improve management. Thirty-seven semi-structured telephone interviews were conducted, audio-recorded, and transcribed verbatim. Thematic analysis identified four key emergent themes, i.e., everyday life during self-isolation, psychological issues, social issues, and information and guidance. Food provisioning was of particular concern. Solidarity was expressed to individuals in need. Isolation was not always viable due to space constraints and the necessity to care for sick family members. Fear of transmission to vulnerable groups, hospitalisation, irreversible complications, and death as well as anxiety, insecurity, guilt, and alienation were articulated. COVID-19 disrupted the normal functioning of families and led to revision of interpersonal relationships. Patients avoided re-integration in society due to the transmitter stigma and to limit the risk of infection spread in the community. Over-information promoted fear. Mild illness raised doubts about information validity. Primary care provided monitoring and psychological support. Home isolation caused disruption in various aspects of participants’ life, ranging from logistic problems to dealing with the psychological burden of isolation and illness. Primary care could play a central role in supporting patients

Clinical and cost-effectiveness of a personalised health promotion intervention enabling independence in older people with mild frailty (‘HomeHealth’) compared to treatment as usual: study protocol for a randomised controlled trial

Background: Frailty is clinically associated with multiple adverse outcomes, including reduced quality of life and functioning, falls, hospitalisations, moves to long-term care and mortality. Health services commonly focus on the frailest, with highest levels of need. However, evidence suggests that frailty is likely to be more reversible in people who are less frail. Evidence is emerging on what interventions may help prevent or reduce frailty, such as resistance exercises and multi-component interventions, but few interventions are based on behaviour change theory. There is little evidence of cost-effectiveness. Previously, we co-designed a new behaviour change health promotion intervention (“HomeHealth”) to support people with mild frailty. HomeHealth is delivered by trained voluntary sector support workers over six months who support older people to work on self-identified goals to maintain their independence, such as strength and balance exercises, nutrition, mood and enhancing social engagement. The service was well received in our feasibility randomised controlled trial and showed promising effects upon outcomes. Aim: To test the clinical and cost-effectiveness of the HomeHealth intervention on maintaining independence in older people with mild frailty in comparison to treatment as usual (TAU).Methods: Single-blind individually randomised controlled trial comparing the HomeHealth intervention to TAU. We will recruit 386 participants from general practices and the community across three English regions. Participants are included if they are community-dwelling, aged 65+, with mild frailty according to the Clinical Frailty Scale. Participants will be randomised 1:1 to receive HomeHealth or TAU for 6 months. The primary outcome is independence in activities of daily living (modified Barthel Index) at 12 months. Secondary outcomes include instrumental activities of daily living, quality of life, frailty, wellbeing, psychological distress, loneliness, cognition, capability, falls, carer burden, service use, costs and mortality. Outcomes will be analysed using linear mixed models, controlling for baseline Barthel score and site. A health economic analysis and embedded mixed-methods process evaluation will be conducted. Discussion: This trial will provide definitive evidence on the effectiveness and cost-effectiveness of a home-based, individualised intervention to maintain independence in older people with mild frailty in comparison to TAU, that could be implemented at scale if effective

Moving upstream in health promoting policies for older people with early frailty in England? A policy analysis.

Objectives Globally, populations are rapidly ageing and countries have developed health promotion and wellbeing strategies to address increasing demand for health care and old-age support. The older population is not homogeneous however, and includes a large group in transition between being active and healthy to being frail, i.e. with early frailty. This review explores the extent to which policy in England has addressed this group with a view to supporting independence and preventing further progression towards frailty. Methods A narrative review was conducted of 157 health and social care policy documents current in 2014-2017 at three levels of the health and social care system in England. Findings We report the policy problem analysis, the shifts over time in language from health promotion to illness prevention, the shift in target populations to mid-life and those most at risk of adverse outcomes through frailty, and changes to delivery mechanisms to incentivize attention to the frailest rather than those with early frailty. We found that older people in general were not identified as a specific population in many of these policies. While this may reflect a welcome lack of age discrimination, it could equally represent omission through ageism. Only at local level did we identify some limited attention to preventative actions with people with early frailty. Conclusion The lack of policy attention to older people with early frailty is a missed opportunity to address some of the demands on health and social care services. Addressing the individual and societal consequences of adverse experiences of those with the greatest frailty should not distract from a more distinct public health perspective which argues for a refocusing upstream to health promotion and illness prevention for those with early frailty

Epidemiologic features, temporal trends of epidemiological indices and investigation of risk factors for myelodysplastic syndromes in Western Greece

Background: “Myelodysplastic syndromes (MDS) are a heterogenous group of acquired clonal disorders of the bone marrow, characterized by cytopenias, morphologic and functional abnormalities of hematopoietic cells, and a high risk of transformation to acute myeloid leukaemia (AML)”. The incidence of MDS varies significantly among countries according to different studies. Published epidemiologic data for MDS in Greece were not available by the time this study was conducted. Objective: The objective of the present study was to describe the demographic and clinical features of the patients diagnosed with MDS in Western Greece during the period 1990-2009, to estimate the incidence of MDS and its temporal trends throughout this period, as well as to investigate risk factors for MDS in the same area. This was achieved in two main parts: the first part involved the creation of a local MDS registry and a subsequent descriptive study, and the second part was a case-control study. Patients and methods: In the first part of the thesis, all patients diagnosed with MDS in Western Greece during the 20-year-period 1/1/1990-31/12/2009 were registered. Data were retrieved from the medical records of patients with a documented diagnosis of MDS, performed by an expert hematologist and/or hematopathologist, in all four hospitals situated in the geographical area of Western Greece. Demographic and clinical features of patients with MDS were collected and an electronic database was created, upon which descriptive analysis was performed. Date of diagnosis and date of death or date of last contact were also registered and survival analysis was performed. Comorbidities at diagnosis were also evaluated and comorbidity indices (Charlson Comorbidity Index and MDS-CI) were calculated. Incidence and prevalence of MDS was calculated for the well-defined geographical area of Western Greece, which consists of the prefectures Achaia, Ilia and Etolia-Akarnania. Temporal trend of incidence rates was also studied. The second part of the thesis was a hospital-based case-control study conducted in two hospitals in the city of Patras, Greece. MDS prevalent cases and proportionally age- and gender-matched controls were interviewed. The group of controls consisted of patients who were operated for cataract at the Department of Ophthalmology. The interview was based on a questionnaire regarding marital status, area of residence, profession, family history of cancer, occupational exposure to chemicals, smoking, alcohol consumption, nutrition, exposure to domestic risk factors, leisure activities, radiation for diagnostic purposes and stressful life events. Both parts of the study were approved by the Ethical and Scientific Committee of the participating hospitals. Statistical analysis was performed with the statistical software IBM SPSS Statistics 20.0. Results: A total of 855 patients with newly diagnosed MDS were identified. Refractory anemia was the most common subtype in both FAB and WHO classification systems and in both genders. Del(5q) and RARS were more commonly encountered among females and CMML-D among males. Trisomy 8 was the most common single cytogenetic abnormality. The crude mean annual incidence rate of MDS was 6.0 per 100,000 inhabitants aged ≥15 years old (all subtypes according to FAB), and it was 4.8 per 100,000 when CMML and RAEB-T were excluded. Crude incidence rate was higher in rural than in urban areas, but this finding was not confirmed after age-standardization. Age-standardized mean annual incidence rate of MDS was 7.9/100,000 in men and 3.4/100,000 in women. A continuously increasing incidence rate of MDS was observed, which essentially represented an increase in cases of RA and RARS throughout the study period. Mean survival of patients with MDS was 39.8 months and median survival was 22.4 months. Survival was significantly associated with age at diagnosis and with IPSS prognostic category. Univariate analysis with Cox regression model revealed that age, FAB subtype, the degree of anemia, leucopenia, neutropenia, thrombocytopenia, serum ferritin and LDH levels were all associated with overall survival. The presence of heart failure and/or chronic kidney disease at diagnosis proved to significantly affect survival, whereas Charlson Comorbidity Index and MDS-CI were not shown to correlate with survival. Two hundred and twenty four patients participated in the case control study (126 MDS cases and 98 controls). Cases and controls were proportionally matched by age and gender. Family history of hematologic malignancy and family history of solid tumour were significantly associated with MDS. Occupational exposure to agricultural chemicals, and especially herbicides and insecticides, was significantly associated with MDS. Consumption of meat ≥5 times a week and eggs ≥3 times a week, and alcohol consumption ≥15 drinks (alcohol equivalents) a week were also associated with MDS. In multivariate analysis, the only factors which eventually retained their statistical significance were family history of solid malignancy (p=0.014) and exposure to agricultural chemicals (p<0.0001).Εισαγωγή: Τα μυελοδυσπλαστικά σύνδρομα (ΜΔΣ) είναι μια ετερογενής ομάδα επίκτητων κλωνικών διαταραχών του πολυδύναμου αρχέγονου αιμοποιητικού κυττάρου, που χαρακτηρίζονται από κυτταροπενίες στο περιφερικό αίμα, μορφολογικές και λειτουργικές διαταραχές των αιμοποιητικών κυττάρων και αυξημένο κίνδυνο εκτροπής σε οξεία μυελογενή λευχαιμία (ΟΜΛ). Η επίπτωση των ΜΔΣ ποικίλλει σημαντικά μεταξύ διαφόρων χωρών με βάση δεδομένα από διάφορες μελέτες. Δεν υπήρχαν δημοσιευμένα επιδημιολογικά δεδομένα σχετικά με την επίπτωση των ΜΔΣ στον ελλαδικό χώρο μέχρι την πραγματοποίηση αυτής της διατριβής. Ασθενείς και μέθοδοι: Στο πρώτο σκέλος της διατριβής καταγράφηκαν όλοι οι ασθενείς που διαγνώστηκαν με ΜΔΣ κατά την 20-ετή περίοδο 1/1/1990-31/12/2009 στην περιοχή της Δυτικής Ελλάδας. Τα δεδομένα συλλέχθηκαν από τους ιατρικούς φακέλους των ασθενών με τεκμηριωμένη διάγνωση ΜΔΣ από ειδικό αιματολόγο ή αιμοπαθολογοανατόμο, και από τα τέσσερα νοσοκομεία την περιοχή της Δυτικής Ελλάδας (Πανεπιστημιακό Γενικό Νοσοκομείο Πατρών, Γενικό Νοσοκομείο «Ο Άγιος Ανδρέας», Θεραπευτήριο «Ολύμπιον» και Γενικό Νοσοκομείο Μεσολογγίου). Καταγράφηκαν τα δημογραφικά και κλινικά χαρακτηριστικά των ασθενών με ΜΔΣ και δημιουργήθηκε μια ηλεκτρονική βάση δεδομένων, επί της οποίας έγινε περιγραφική στατιστική ανάλυση. Καταγράφηκε επίσης η ημερομηνία αρχικής διάγνωσης και η ημερομηνία θανάτου ή τελευταίας επαφής/εξέτασης και έγινε ανάλυση επιβίωσης. Εκτιμήθηκε η παρουσία συννοσηρών παθήσεων κατά τη διάγνωση και υπολογίστηκαν οι δείκτες συννοσηρότητας Charlson Comorbidity Index και MDS-CI. Η επίπτωση και ο επιπολασμός των ΜΔΣ υπολογίστηκαν για την περιοχή της Δυτικής Ελλάδας που απαρτίζεται από τους νομούς Αχαΐας, Ηλείας και Αιτωλοακαρνανίας. Το δεύτερο σκέλος της διατριβής είναι μια μελέτη ασθενών-μαρτύρων που πραγματοποιήθηκε στο Πανεπιστημιακό Νοσοκομείο Πατρών και στο Γενικό Νοσοκομείο «Ο Άγιος Ανδρέας». Ελήφθησαν συνεντεύξεις βάσει ερωτηματολογίου από ασθενείς με ΜΔΣ και ομάδα μαρτύρων με αναλογική εξομοίωση ως προς φύλο και ηλικία. Η ομάδα των μαρτύρων συγκροτήθηκε από ασθενείς που υπεβλήθησαν σε επέμβαση καταρράκτη στην Οφθαλμολογική Κλινική του Πανεπιστημίου Πατρών. Η συνέντευξη βασίστηκε σε ερωτηματολόγιο αναφορικά με την οικογενειακή κατάσταση, την περιοχή κατοικίας, το επάγγελμα, το οικογενειακό ιστορικό καρκίνου, την επαγγελματική έκθεση σε χημικά, το κάπνισμα, την κατανάλωση αλκοόλ, τη διατροφή, την έκθεση σε οικιακούς παράγοντες κινδύνου, τις δραστηριότητες ελεύθερου χρόνου, την ακτινοβολία για διαγνωστικούς σκοπούς και τυχόν προηγηθέν ψυχοπιεστικό γεγονός. Και τα δύο ερευνητικά σκέλη της διατριβής έλαβαν την έγκριση του Επιστημονικού Συμβουλίου των συμμετεχόντων νοσοκομείων. Η στατιστική ανάλυση έγινε με το στατιστικό πρόγραμμα IBM SPSS Statistics (έκδοση 20.0). Αποτελέσματα: Συνολικά καταγράφηκαν 855 ασθενείς με ΜΔΣ. Η ανθεκτική αναιμία (RA) ήταν η πιο κοινή υποκατηγορία και στα δύο φύλα με βάση την ταξινόμηση τόσο κατά FAB όσο και κατά WHO. Οι κατηγορίες Del(5q) και RARS ήταν πιο συχνές στις γυναίκες, ενώ η CMML-D στους άνδρες. Η τρισωμία 8 ήταν η πιο κοινή μονήρης κυτταρογενετική ανωμαλία. Η αδρή μέση ετήσια επίπτωση ΜΔΣ ήταν 6 ανά 100.000 κατοίκους ηλικίας ≥15 ετών (όλες οι κατηγορίες ΜΔΣ κατά FAB), ενώ ήταν 4,8 ανά 100.000 όταν εξαιρέθηκαν CMML και RAEB-T. Η αδρή επίπτωση ήταν υψηλότερη στις αγροτικές από ό,τι στις αστικές περιοχές, αλλά αυτό το εύρημα δεν επιβεβαιώθηκε μετά από προτύπωση κατά ηλικία. Η προτυπωμένη κατά ηλικία μέση ετήσια επίπτωση ΜΔΣ ήταν 7,9 ανά 100.000 στους άνδρες και 3,4 ανά 100.000 στις γυναίκες. Παρατηρήθηκε μια συνεχώς αυξανόμενη επίπτωση ΜΔΣ, που ουσιαστικά αντιπροσωπεύει μια αύξηση στις περιπτώσεις RA και RARS κατά τη διάρκεια της μελετηθείσας περιόδου. Η μέση επιβίωση των ασθενών με ΜΔΣ ήταν 39,8 μήνες και η διάμεση επιβίωση ήταν 22,4 μήνες. Η επιβίωση συσχετίστηκε σημαντικά με την ηλικία κατά τη διάγνωση και με την προγνωστική κατηγορία κατά IPSS. Η μονοπαραγοντική ανάλυση με βάση το μοντέλο του Cox έδειξε ότι η ηλικία, η κατηγορία κατά FAB, η βαρύτητα της αναιμίας, της λευκοπενίας, της ουδετεροπενίας και της θρομβοπενίας και τα επίπεδα φερριτίνης και LDH στον ορό συσχετίστηκαν με τη συνολική επιβίωση. Η παρουσία καρδιακής ανεπάρκειας ή/και νεφρικής νόσου κατά τη διάγνωση φάνηκε να επηρεάζει σημαντικά την επιβίωση, ενώ οι δείκτες συννοσηρότητας Charlson Comorbidity Index και MDS-CI δε φάνηκε να συσχετίζονται με την επιβίωση των ασθενών με ΜΔΣ στην παρούσα μελέτη. Διακόσιοι είκοσι τέσσερις ασθενείς συμμετείχαν στη μελέτη ασθενών-μαρτύρων (126 ασθενείς με ΜΔΣ και 98 μάρτυρες). Οι ασθενείς και οι μάρτυρες εξομοιώθηκαν αναλογικά ως προς το φύλο και την ηλικία. Το οικογενειακό ιστορικό αιματολογικής νεοπλασίας ή/και συμπαγούς όγκου συσχετίστηκαν σημαντικά με τα ΜΔΣ. Η επαγγελματική έκθεση σε φυτοφάρμακα, ιδιαίτερα εντομοκτόνα και ζιζανιοκτόνα, συσχετίστηκε σημαντικά με τον κίνδυνο εμφάνισης ΜΔΣ. Η κατανάλωση κρέατος ≥5 φορές την εβδομάδα, αυγών ≥3 φορές την εβδομάδα και ποσότητας αλκοόλ ≥15 ποτά (ισοδύναμα) την εβδομάδα επίσης συσχετίστηκαν με ΜΔΣ. Ωστόσο, οι μοναδικοί παράγοντες που διατήρησαν τη στατιστική σημαντικότητά τους στην πολυπαραγοντική ανάλυση ήταν το οικογενειακό ιστορικό κακοήθειας (συμπαγούς όγκου) (p=0.014) και η έκθεση σε φυτοφάρμακα (p<0.0001)

Moving upstream in health promoting policies for older people with early frailty in England? A policy analysis

Objectives Globally, populations are rapidly ageing and countries have developed health promotion and wellbeing strategies to address increasing demand for health care and old-age support. The older population is not homogeneous however, and includes a large group in transition between being active and healthy to being frail, i.e. with early frailty. This review explores the extent to which policy in England has addressed this group with a view to supporting independence and preventing further progression towards frailty. Methods A narrative review was conducted of 157 health and social care policy documents current in 2014-2017 at three levels of the health and social care system in England. Findings We report the policy problem analysis, the shifts over time in language from health promotion to illness prevention, the shift in target populations to mid-life and those most at risk of adverse outcomes through frailty, and changes to delivery mechanisms to incentivize attention to the frailest rather than those with early frailty. We found that older people in general were not identified as a specific population in many of these policies. While this may reflect a welcome lack of age discrimination, it could equally represent omission through ageism. Only at local level did we identify some limited attention to preventative actions with people with early frailty. Conclusion The lack of policy attention to older people with early frailty is a missed opportunity to address some of the demands on health and social care services. Addressing the individual and societal consequences of adverse experiences of those with the greatest frailty should not distract from a more distinct public health perspective which argues for a refocusing upstream to health promotion and illness prevention for those with early frailty