The moderating role of anti-inflammatory diet on the relationship between chronic obstructive pulmonary disease and frailty in older adults: a nationwide cross-sectional and longitudinal study

Xiaohui Ye; Qian Zhao; Meina Zhang; Haiyan Zhang; Chunyan Wu

doi:10.1186/s12877-026-07937-2

. 2026 Jul 7;26:1234. doi: 10.1186/s12877-026-07937-2

The moderating role of anti-inflammatory diet on the relationship between chronic obstructive pulmonary disease and frailty in older adults: a nationwide cross-sectional and longitudinal study

Xiaohui Ye ¹, Qian Zhao ², Meina Zhang ³, Haiyan Zhang ^1,^✉, Chunyan Wu ¹

PMCID: PMC13628765 PMID: 42414905

Abstract

Objective

To explore the moderating role of anti-inflammatory diet on the association between chronic obstructive pulmonary disease (COPD) and frailty, and to provide evidence-based basis for the management of frailty and nutritional intervention strategies for COPD patients.

Methods

Based on the data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS) from 2011 to 2018, 2,473 older adults aged 65 and above were included. A cross-sectional and longitudinal combined design was adopted to assess the relationships between COPD (based on self-reported diagnosis), anti-inflammatory diet (scored by a 10-item food frequency questionnaire), and frailty (defined by a frailty index ≥ 0.20). A multivariate logistic regression model was used to analyze the moderating effect of anti-inflammatory diet on the association between COPD and frailty.

Results

The cross-sectional analysis showed that the odds of frailty in COPD patients significantly increased (OR = 5.29, 95% CI: 3.64–7.65), while the high anti-inflammatory diet score group (Q4) was associated with a 40% reduction in the odds of frailty (OR = 0.60, 95% CI: 0.36–0.97), and the interaction was significant (P < 0.001). In the longitudinal analysis, the risk of new-onset frailty in COPD patients increased by 58% (OR = 1.58, 95% CI: 1.11–2.23), and the risk of persistent frailty increased by 6.8 times (OR = 6.80, 95% CI: 4.24–10.9); the high anti-inflammatory diet score group was associated with a 51% reduction in the risk of persistent frailty (OR = 0.49, 95% CI: 0.26–0.89), and significantly regulated the strength of the association between COPD and persistent frailty (interaction P = 0.003). Stratified analysis further indicated that compared with the low anti-inflammatory diet score group, the impact of COPD on persistent frailty was relatively weakened in the high anti-inflammatory diet score group.

Conclusion

COPD is an important risk factor for the occurrence and persistence of frailty in older adults. Anti-inflammatory diets may provide independent protection against persistent frailty and might attenuate the adverse impact of COPD on persistent frailty risk, though further direct comparative analyses are warranted. It is recommended to incorporate anti-inflammatory diet intervention into the comprehensive management plan for COPD patients to reduce the risk of frailty occurrence and progression.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12877-026-07937-2.

Keywords: Chronic obstructive pulmonary disease, Frailty, Anti-inflammatory diet, Moderating effect, Cohort study, Older adults

Introduction

Frailty is a clinical syndrome characterized by a severe decline in stress resistance due to multi-dimensional physiological reserve reduction, which increases susceptibility and weakens recovery ability in individuals when facing internal and external pressures, constituting a key pathological state between normal aging and functional dependence [1]. According to a meta-analysis by Veronese et al., the prevalence of frailty among community-dwelling older adults is approximately 10%–15%, while the proportion of those in the pre-frailty stage reaches as high as 40%–50%, indicating that over half of older adults is at risk of frailty [2]. In China, with the accelerated pace of population aging, frailty has become an increasingly prominent public health issue. Multiple population-based longitudinal studies have reported frailty prevalence rates of 8%–20% among Chinese community-dwelling older adults, with notable regional and urban–rural disparities [3, 4]. Frailty not only severely impairs quality of life but also serves as a significant predictor of disability, falls, hospitalization, cognitive impairment, and mortality [5, 6]. Given its dynamic nature and partial reversibility, early identification and systematic intervention are essential for achieving healthy aging.

Chronic Obstructive Pulmonary Disease (COPD) is a common chronic respiratory disease characterized by persistent airflow limitation, often accompanied by systemic inflammation and multi-system involvement. Currently, it ranks as the third leading cause of death worldwide, posing a significant public health challenge [7]. With the deepening of population aging, COPD and frailty, as two typical geriatric syndromes, have increasingly attracted clinical attention [8, 9]. Studies have confirmed a close association between COPD and frailty. Based on Mate analysis and longitudinal research data, the prevalence of frailty among COPD patients is approximately 30% to 47%, and the risk of occurrence is about twice that of non-COPD populations, with specific differences influenced by assessment tools and population heterogeneity [10, 11]. On the other hand, meta-analyses and cohort study results have confirmed that frailty is significantly associated with decreased lung function, reduced quality of life, increased frequency of acute exacerbations, increased risk of hospitalization, and significantly increased all-cause mortality in COPD patients [12, 13]. Although the relationship between frailty and COPD has been confirmed, current research still has obvious limitations. Firstly, most evidence comes from cross-sectional studies, making it difficult to reveal the dynamic evolution process of the relationship between the two. There is limited research on the continuous state of COPD and frailty relationship. Secondly, there is insufficient research on potential moderating factors between COPD and frailty.

In this context, it is of great significance to explore the modifiable lifestyle factors between COPD and frailty, especially the dietary patterns, as they may regulate the conditions of COPD and frailty. Two previous community cohort studies have shown that dietary classification is closely associated with the state of frailty [14, 15]. Anti-inflammatory diet is a dietary pattern centered on reducing systemic inflammation levels. It is characterized by rich dietary fiber, polyphenols, ω-3 polyunsaturated fatty acids (such as from fish and nuts), and limiting the intake of refined carbohydrates, saturated fats, and processed meats [16]. Recent studies have gradually revealed the protective effect of anti-inflammatory diet on frailty. A cohort study showed that the risk of new-onset frailty in older adults with pro-inflammatory dietary patterns was 2.03 times that of those with anti-inflammatory dietary patterns [17]. Studies based on the Chinese older adults have also confirmed that a higher frequency of anti-inflammatory diet not only helps improve metabolic indicators but also significantly reduces the risk of frailty-related phenotypes [18, 19]. However, there is currently a lack of direct research exploring whether anti-inflammatory diet plays a moderating role in the relationship between COPD and frailty.

To fill the aforementioned research gap, this study, based on the China Longitudinal Healthy Longevity Survey (CLHLS), a large-scale national sample data, adopted a combined cross-sectional and longitudinal research design to systematically explore the relationship between COPD and the incidence of cross-sectional frailty, the new occurrence and persistent state of frailty at the longitudinal level, and focused on evaluating the moderating role of anti-inflammatory diet in these associations.

Methods

Study design and participants

The data for this cohort study were obtained from the China Longitudinal Healthy Longevity Survey (CLHLS). The CLHLS is a nationally representative longitudinal cohort study targeting the older adults aged 65 and above, conducted by the Health Aging and Development Research Center of the National Development Research Institute of Peking University. It employs a multi-stage cluster random sampling method and conducts continuous follow-up surveys in 23 provinces across China. The sample covers 85% of the national population, aiming to systematically explore the correlations between the factors influencing the health of Chinese older adults and their health outcomes, and providing scientific basis for promoting healthy aging [20, 21]. The study conducts follow-ups every 2 to 4 years, systematically collecting multi-dimensional information including basic demographic characteristics, social characteristics, lifestyle, and health status [22, 23].

This study utilized data extracted from the CLHLS from 2011 to 2018. A total of 9,679 participants with a baseline age of 65 years or older were initially included. Exclusion criteria included those who lacked baseline data on anti-inflammatory diet assessment, frailty index (FI) assessment data, COPD diagnosis information, or key covariate data; and those who had missing frailty status assessment information in the 2018 follow-up. In the end, a total of 2,473 participants were included in this analysis (the participant screening process is shown in Fig. 1). To assess potential selection bias due to the exclusion of participants with missing data, we compared the baseline characteristics of included (n = 2,473) and excluded (n = 7,206) participants. Differences between the two groups were examined using chi-square tests for categorical variables and t-tests for continuous variables. The results of this comparison are presented in Supplementary Table S1. The proportion of missing values for each variable—including anti-inflammatory diet score, frailty index components, COPD diagnosis, and all covariates was calculated. The detailed missing data proportions are presented in Supplementary Table S2. The CLHLS obtained ethical approval from the Chinese Peking University Biomedical Ethics Committee (IRB00001052-13074) and all participants gave informed consent.

Assessment of anti-inflammatory diet

The anti-inflammatory diet of the participants was evaluated based on the 10 dietary items covered in the CLHLS food frequency questionnaire, and the 10 items selected for this study were chosen a priori based on their established anti-inflammatory properties as reported in the literature and their availability within the CLHLS dataset [24, 25]. The food frequency questionnaire used in the CLHLS has been previously employed in numerous studies to assess dietary patterns and their associations with health outcomes in the Chinese older adults [18, 26]. These items included dairy products, eggs, seafood, garlic, soy products, mushrooms, nuts, multivitamin supplements, medicinal plants, and tea. The selection of these 10 items was based on a priori evidence of their anti-inflammatory properties [27, 28]. For example, omega-3 polyunsaturated fatty acids in seafood and nuts can downregulate pro-inflammatory pathways; polyphenols and other bioactive compounds found in tea, garlic, and mushrooms exert antioxidant and anti-inflammatory effects; and soy products and dairy contain components that may modulate inflammation. Eggs provide various nutrients, and while their role is complex, they are included in many healthy dietary patterns. For each of the 10 items, participants reported their consumption frequency on a 5-point scale, which we scored from 0 to 4. We then summed these scores to create a total anti-inflammatory diet score (range: 0–40). All items were equally weighted in this sum. This approach assumes that each food item contributes equally to the overall anti-inflammatory potential of the diet. While this is a simplification, and more sophisticated approaches like the Dietary Inflammatory Index (DII) [29] use different weights for different nutrients, our equal-weighting method is transparent and easily replicable in this dataset. Conceptually, this score is intended to reflect an overall dietary pattern rich in foods commonly associated with reduced inflammation, aligning with principles of recognized healthy dietary patterns such as the Mediterranean diet, which is also high in many of these components (e.g., nuts, seafood, plant-based foods). The quartiles of the anti-inflammatory diet in this study were: Q1 ≤ 10 points, 10 points < Q2 ≤ 14 points, 14 < Q3 ≤ 19 points, and Q4 > 19 points.

Definition of COPD

Based on the previous relevant studies of CLHLS [30, 31] by Xie et al., the definition of COPD for the participants was based on self-reported diagnosis. We acknowledge that this definition relies on self-report and is not confirmed by spirometry, the gold standard for COPD diagnosis. While self-reported physician-diagnosed COPD has been shown to have high specificity [32] but variable sensitivity in older adult populations, the lack of objective confirmation remains a limitation. Specifically, we answered the question in the questionnaire “Have you been diagnosed with COPD (chronic bronchitis, chronic emphysema, etc.)?” If the answer was “Yes”, it was defined as having COPD; if the answer was “No”, it was defined as not having COPD.

Frailty

This study included the frailty index (FI) [33], and conducted a comprehensive assessment using 35 health-related variables covering physiological, psychological, functional status, and chronic diseases (see Table S3). Each variable was assigned a standardized score ranging from 0 to 1 based on the participants’ responses. The self-assessment of health status used a five-level rating system (healthy = 0, moderately healthy = 0.25, average = 0.5, unhealthy = 0.75, very unhealthy = 1). It is particularly important to note that the study included a major disease item: those who experienced ≥ 2 major diseases in the past two years would receive an additional 2 points. The calculation of FI followed a standardized mathematical definition: the total health score actually included in the assessment was divided by the total number of effective variables. For data missing situations, the method of simultaneously eliminating the corresponding variables from the numerator and denominator was adopted; when the proportion of missing variables exceeded 30% of the total variables, it was determined that the FI data of this sample was missing. Based on previous studies on frailty [5, 33–35], we divided the FI into three clinical grades: FI ≤ 0.10 represents a healthy state, 0.10 < FI ≤ 0.20 represents a pre-frail state, and FI > 0.20 represents a frail state. In this study, FI ≤ 0.20 was defined as no frailty state, and FI > 0.20 was defined as a frail state. The selection criterion for this cutoff value is as follows: in multiple large-scale studies on older adults in China, including CLHLS, FI value > 0.20 has been widely used to define frailty and is significantly associated with adverse health outcomes (such as disability, death) [36, 37]. While a cutoff of 0.25 is also used in some populations, the 0.20 threshold is frequently employed in population-based studies, including those using the CLHLS data, as it is sensitive to identifying an at-risk population in the pre-disability stage and has been strongly predictive of adverse outcomes such as mortality and hospitalization in this cohort [5]. To test the robustness of our findings to the choice of frailty cutoff, we conducted a sensitivity analysis by re-defining frailty using a more stringent cutoff of FI > 0.25, which is also commonly employed in frailty research. All main analyses—including the cross-sectional and longitudinal associations of COPD and anti-inflammatory diet with frailty outcomes, as well as their interaction—were repeated using this alternative definition. Participants were classified into four states based on the presence or absence of frailty at baseline and during follow-up: healthy, new-onset frailty, persistent frailty state, and frailty remission state.

Covariates

Based on the established risk factors for frailty in previous studies [11, 15], this study systematically included multiple-dimensional covariates: age (< 75, ≥ 75), sex (male, female), residency (urban, rural), living conditions (household member(s), alone, institution), marital status (married, single), education levels (illiteracy, primary school or above), financial situation (sufficient, unsufficient), smoking status (never, previous, current), drinking status (never, previous, current), physical activity status (never, previous, current), and body mass index. BMI was obtained through standardized anthropometric measurements and classified according to WHO standards into underweight, normal range, overweight, and obese categories [38]. The height and weight of all participants were measured uniformly using calibrated instruments and calculated and classified according to the standard formula (BMI = weight [kg] / height [m]²).

Statistical analysis

Descriptive statistics were conducted on the sample characteristics. Categorical data were presented as frequencies and percentages, while measurement data were presented as means and standard deviations. The populations in the healthy group, the new-onset frailty state group, and the persistent frailty state group were described separately, and chi-square tests or one-way ANOVA were used to compare the differences in characteristics among the groups. Multivariate logistic regression analysis was employed to explore the relationships between COPD and anti-inflammatory diet and frailty at the cross-sectional level and longitudinal changes. Firstly, the relationships between COPD and anti-inflammatory diet and frailty at the cross-sectional level were investigated, and two models were constructed. Model 1 adjusted for age and sex, and Model 2 further adjusted for residency, living conditions, marital status, education levels, financial situation, smoking status, drinking status, physical activity status, and BMI, and calculated the interaction P value of the effects of COPD and anti-inflammatory diet on frailty. Secondly, using the healthy group as a reference, the relationships between COPD and anti-inflammatory diet and the new-onset or persistent frailty were explored, and the above two models were constructed, and the interaction P value was calculated. Next, restricted cubic spline (RCS) curves were used to explore the dose-response relationship between baseline anti-inflammatory diet score and baseline frailty status, frailty new-onset or persistent status. Finally, based on the above research results, participants were divided into the low anti-inflammatory diet score group (Q1) and the high anti-inflammatory diet score group (Q4), and the relationships between COPD and frailty changes were explored in both groups. We assessed effect modification (statistical interaction) by including a product term (COPD × anti-inflammatory diet score) in the regression models. This analysis tests whether the association between COPD and frailty differs significantly across levels of anti-inflammatory diet. We tested the interaction between COPD and anti-inflammatory diet on three distinct outcomes (cross-sectional frailty, new-onset frailty, and persistent frailty). Additionally, we performed a subgroup analysis restricted to participants with COPD at baseline to evaluate the association between anti-inflammatory diet and frailty outcomes within this specific population. Given the hypothesis-generating and exploratory nature of this moderation analysis, we did not apply corrections for multiple testing. Consequently, the interaction p-values should be interpreted with caution, as the risk of a Type I error is increased. These findings are intended to generate hypotheses for future confirmatory research. All statistical analyses were completed using R (4.5.0), and a two-sided P value < 0.05 was considered statistically significant.

Results

Characteristics of the study participants

A total of 2,473 participants were included in this study (see Table 1), among whom 1,193 were male (48.2%) and 1,280 were female (51.8%); 996 were aged 60 to 75 years (40.3%), and 1,477 were aged 75 years or older (59.7%); 187 lived in urban areas (8.6%), and 1,981 lived in rural areas (91.4%); 1,943 lived with family members (79.2%), 489 were living alone (19.9%), and 20 were in nursing homes (0.8%); 1,384 were married (56.1%), and 1,082 were single (43.9%); 576 had education levels of primary school or above (23.4%), and 1,889 had education levels below primary school (76.6%); 1979 could meet their needs (80.3%), and 486 could not (19.7%); 516 were currently smoking (21.0%), 341 had smoked in the past (13.9%), and 1,600 had never smoked (65.1%); 512 were currently drinking (21.0%), 306 had drunk in the past (12.5%), and 1,624 never drank (66.5%); 976 had exercise habits currently (40.0%), 180 had had habits in the past (7.4%), and 1,282 had never exercised (52.6%); the average BMI was 22.32 kg/m² (SD: 4.25).

Table 1.

Characteristics of all participants (N = 2473)

Characteristics	n (%) or mean (SD)
Sex, n (%)
Male	1193 (48.2)
Female	1280 (51.8)
Age, n (%)
< 75	996 (40.3)
≥ 75	1477 (59.7)
Residency, n (%)
Urban	187 (8.6)
Rural	1981 (91.4)
Living conditions, n (%)
Household member(s)	1943 (79.2)
Alone	489 (19.9)
Institution	20 (0.8)
Marital status, n (%)
Married	1384 (56.1)
Single	1082 (43.9)
Education levels, n (%)
Illiteracy	1889 (76.6)
Primary school or above	576 (23.4)
Financial situation, n (%)
Sufficient	1979 (80.3)
Insufficient	486 (19.7)
Smoking status, n (%)
Never	1600 (65.1)
Previous	341 (13.9)
Current	516 (21.0)
Drinking status, n (%)
Never	1624 (66.5)
Previous	306 (12.5)
Current	512 (21.0)
Physical activity status, n (%)
Never	1282 (52.6)
Previous	180 (7.4)
Current	976 (40.0)
BMI, mean (SD)	22.32 (4.25)
Frailty status at baseline, n (%)
Normal	2233 (90.3)
Frailty	240 (9.7)
Frailty status in 2018 follow-up, n (%)
Normal	1656 (67.0)
Frailty	817 (33.0)
COPD status at baseline, n (%)
No	2230 (90.2)
Yes	243 (9.8)
Frailty status change, n (%)
Healthy	1575 (63.7)
New-onset	658 (26.6)
Persist	159 (6.4)
Remission	81 (3.3)
Anti-inflammatory diet score, mean (SD)	14.62 (6.57)
Anti-inflammatory diet group, n (%)
Q1	721 (29.2)
Q2	534 (21.6)
Q3	673 (27.2)
Q4	545 (22.0)

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Abbreviations: BMI body mass index, COPD chronic obstructive pulmonary disease, IQ Interquartile Range

In the baseline survey, 240 individuals (9.7%) were found to be in a state of frailty, 243 individuals (9.8%) were diagnosed with COPD, and the mean score of anti-inflammatory diet was 14.62 (SD: 6.57). The follow-up survey results indicated that 817 individuals (33.0%) were in a state of frailty. According to the changes in frailty status between the baseline and follow-up, the results showed that there were 1575 individuals (63.7%) in the healthy group, 658 individuals (26.6%) in the new-onset frailty group, 159 individuals (6.4%) in the persistent frailty group, and 81 individuals (3.3%) in the frailty relief group.

We further elaborated on the sample characteristics of the healthy group, the new-onset frailty group, and the persistent frailty group. There were significant differences among the different frailty change groups in terms of age, sex, residency, living conditions, marital status, education levels, financial situation, smoking status, drinking status, physical activity status, and body mass index (see Table S4).

Cross-sectional analysis

In the multivariate adjustment model (Model 2), it was found that the risk of having a frail state at baseline for COPD patients was significantly higher than that for non-COPD patients (OR = 5.29, 95% CI: 3.64–7.65, P < 0.001). At the same time, compared with the lowest group (Q1) with the lowest anti-inflammatory diet score, the highest group (Q4) had a 40% lower risk of developing frailty (OR = 0.60, 95% CI: 0.36–0.97, P = 0.042). Moreover, there was a significant interaction between COPD and the anti-inflammatory diet score in influencing the risk of frailty (interaction P < 0.001) (see Table 2).

Table 2.

Cross-sectional associations of COPD and Anti-inflammatory diet with the odds of frailty among Chinese older adults ^a

	Model 1			Model 2
	OR	95% CI	p-Value	OR	95% CI	p-Value
COPD
No	Reference			Reference
Yes	5.06	3.36–7.01	< 0.001	5.29	3.64–7.65	< 0.001
Anti-inflammatory diet
Q1	Reference			Reference
Q2	0.62	0.43–0.90	0.013	0.67	0.43–1.03	0.071
Q3	0.69	0.49–0.97	0.032	0.76	0.50–1.14	0.185
Q4	0.53	0.35–0.79	< 0.001	0.60	0.36–0.97	0.042
COPD×Anti-inflammatory diet			0.014			< 0.001

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Abbreviations: CI confidence interval, OR odds ratio

^a The associations are presented as ORs (95% CI)

Longitudinal analysis

When the outcome was a new-onset of frailty, after fully adjusting for all covariates, compared with the population without COPD at baseline, the risk of developing new-onset frailty among older adults with COPD at baseline increased by 1.58 times (95% CI: 1.11–2.23, P = 0.010). However, in terms of anti-inflammatory diets, compared with the group with the lowest anti-inflammatory diet score (Q1), the risk of developing new-onset frailty in the other anti-inflammatory diet score groups (Q2, Q3, Q4) did not show significant changes, and the interaction P value between COPD and anti-inflammatory diet scores was also not significant (See Table 3).

Table 3.

Longitudinal associations of COPD and anti-inflammatory diet with the odds of new-onset frailty among Chinese older adults ^a

	Model 1			Model 2
	OR	95% CI	p-Value	OR	95% CI	p-Value
COPD
No	Reference			Reference
Yes	1.74	1.25–2.40	< 0.001	1.58	1.11–2.23	0.010
Anti-inflammatory diet
Q1	Reference			Reference
Q2	0.85	0.65–1.10	0.212	0.93	0.69–1.24	0.602
Q3	0.89	0.69–1.12	0.302	0.97	0.73–1.27	0.800
Q4	0.92	0.71–1.20	0.553	0.95	0.70–1.28	0.717
COPD×Anti-inflammatory diet			0.307			0.131

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Abbreviations: CI confidence interval, OR odds ratio

^a The associations are presented as ORs (95% CI)

When the outcome was a state of continuous decline, after fully adjusting for all covariates, compared with the population without COPD at baseline, older adults with COPD at baseline had a significantly 6.8-fold increased risk of developing a state of continuous decline during follow-up (95% CI: 4.24–10.9, P < 0.001). In terms of anti-inflammatory diet, compared with the lowest level of anti-inflammatory diet score group Q1, the highest level of anti-inflammatory diet score group Q4 had a significantly 51% lower risk of developing a state of continuous decline (95% CI: 0.26–0.89, P = 0.022). Additionally, the interaction between COPD and anti-inflammatory diet score was P = 0.003 (See Table 4).

Table 4.

Longitudinal associations of COPD and anti-inflammatory diet with the odds of persist frailty among Chinese older adults ^a

	Model 1			Model 2
	OR	95% CI	p-Value	OR	95% CI	p-Value
COPD
No	Reference			Reference
Yes	6.73	4.45–10.1	< 0.001	6.8	4.24–10.9	< 0.001
Anti-inflammatory diet
Q1	Reference			Reference
Q2	0.50	0.31–0.80	0.004	0.50	0.28–0.87	0.016
Q3	0.73	0.48–1.10	0.133	0.73	0.45–1.19	0.214
Q4	0.46	0.27–0.76	0.003	0.49	0.26–0.89	0.022
COPD×Anti-inflammatory diet			0.010			0.003

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Abbreviations: CI confidence interval, OR odds ratio

^a The associations are presented as ORs (95% CI)

Dose-response relationship

In the baseline cross-sectional survey, there was a negative linear dose-response relationship between the anti-inflammatory diet score and the frailty status (P overall < 0.001, P for non-linearity = 0.517). In the overall population, no dose-response relationship was observed between the anti-inflammatory diet score and the new-onset frailty status (P overall = 0.066, P for non-linearity = 0.261), and there was a linear negative response relationship between the anti-inflammatory diet score and the persistent frailty (P overall < 0.001, P for non-linearity = 0.180) (Fig. 2).

Fig. 2 — Dose-response relationship between anti-inflammatory diet and frailty status. A cross-sectional frailty prevalence. B New-onset frailty. C Persist frailty

Stratification analysis

In the low-level anti-inflammatory diet score group (Q1), after fully adjusting for all covariates, compared with the population without COPD at baseline, the risk of persistent frailty in individuals with COPD at baseline during the follow-up was 10.2 times (95% CI: 4.15–25.7, P < 0.001) (see Table 5).

Table 5.

Longitudinal associations between COPD and with the odds of persist frailty among Chinese older adults with low levels of anti-inflammatory diet ^a

	Model 1			Model 2
	OR	95% CI	p-Value	OR	95% CI	p-Value
COPD
No	Reference			Reference
Yes	10.0	4.43–23.2	< 0.001	10.2	4.15–25.7	< 0.001

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Model 1 adjusted for age and sex. Model 2 further adjusted for residency, living conditions, marital status, education levels, financial situation, smoking status, drinking status, physical activity status, and BMI based on Model 1. The odds ratios presented in Tables 5 and 6 are derived from separate subgroup analyses (low vs. high anti-inflammatory diet groups) and are not directly statistically comparable

Abbreviations: CI confidence interval, OR odds ratio

^a The associations are presented as ORs (95% CI)

In the high-level anti-inflammatory diet score group (Q4), after fully adjusting for all covariates, compared with the population without COPD at baseline, the risk of persistent frailty in older adults with COPD at follow-up was only 6.01 times (95% CI: 1.58–21.3, P = 0.006) lower than that of the baseline population without COPD, suggesting that the association between COPD and persistent frailty appeared weaker in the high anti-inflammatory diet group (Q4) compared to the low anti-inflammatory diet group (Q1); however, direct cross-group comparison of odds ratios should be interpreted with caution as they are derived from separate subgroup analyses (See Table 6).

Table 6.

Longitudinal associations between COPD and with the odds of persist frailty among Chinese older adults with high levels of anti-inflammatory diet ^a

	Model 1			Model 2
	OR	95% CI	p-Value	OR	95% CI	p-Value
COPD
No	Reference			Reference
Yes	6.28	2.15–17.4	< 0.001	6.01	1.58–21.3	0.006

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Abbreviations: CI confidence interval, OR odds ratio

^a The associations are presented as ORs (95% CI)

Sensitive analysis

We re-ran our main analyses defining frailty as FI > 0.25. The results, presented in full as Supplementary Table S5-S9, show that the direction and significance of our primary findings (the association of COPD and anti-inflammatory diet with frailty outcomes and their interaction) remained consistent, albeit with slightly attenuated odds ratios for some associations, which supports the robustness of our conclusions to the choice of cutoff.

To further evaluate the association between anti-inflammatory diet and frailty specifically among individuals with COPD, we performed an additional analysis restricted to participants with baseline COPD (n = 243). As shown in Supplementary Table S10, among COPD patients, higher anti-inflammatory diet scores were significantly associated with a lower risk of persistent frailty. Compared with the lowest quartile (Q1), the highest quartile (Q4) was associated with a 67% reduction in the odds of persistent frailty (OR = 0.33, 95% CI: 0.13–0.81, P = 0.019). However, no significant association was observed between anti-inflammatory diet and new-onset frailty among COPD patients (Q4 vs. Q1: OR = 1.01, 95% CI: 0.69–1.46, P = 0.973).

Discussion

This study, for the first time, based on the nationally representative large sample data from the CLHLS, systematically analyzed the moderating role of anti-inflammatory diet in the relationship between COPD and frailty. Through a research design combining cross-sectional and longitudinal analyses, the main findings were as follows: First, in the cross-sectional analysis, the incidence of COPD and frailty was significantly correlated, while anti-inflammatory diet was significantly correlated with the reduction of frailty, and there was a significant interaction between the two in influencing frailty; Second, the longitudinal analysis further indicated that COPD was significantly associated with new-onset frailty and persistent frailty states, while anti-inflammatory diet was only negatively correlated with persistent frailty states; Third, stratified analysis showed that among participants with high anti-inflammatory diet scores, the odds ratio for the association between COPD and persistent frailty was numerically lower than that among those with low anti-inflammatory diet scores. While these estimates are derived from separate subgroup analyses and should be compared with caution, this pattern suggests a potential moderating role of anti-inflammatory diet that warrants further investigation. These findings provide a new nutritional intervention perspective for the management of frailty in COPD patients.

COPD is an independent risk factor for the occurrence and progression of frailty. The cross-sectional analysis results of this study show that the risk of frailty in COPD patients is 5.29 times that of non-COPD patients, which is highly consistent with the results of many international studies [39, 40]. A meta-analysis of observational studies revealed that based on the FI frailty index assessment, the prevalence of frailty in COPD patients was as high as 62.5%, which was twice the risk compared to the non-COPD population [41]. In the longitudinal analysis, we found that not only did the risk of new-onset frailty in COPD patients increase by 58%, but the risk of persistent frailty was even 6.8 times that of non-COPD patients. This is similar to the results observed by Wijnant et al. In older adults in the Netherlands, that is, the risk of frailty progression in COPD patients was significantly higher than that in the non-COPD population [42].

The mechanism underlying the association between COPD and frailty may involve multiple systems and multiple levels of pathological physiological processes. Firstly, the systemic inflammatory state of COPD patients is the core link connecting pulmonary function impairment and systemic manifestations. Studies have confirmed that the levels of pro-inflammatory cytokines (such as IL-6, TNF-α, CRP) in the serum of COPD patients remain persistently elevated. These inflammatory mediators promote the degradation of skeletal muscle proteins and inhibit protein synthesis, leading to the occurrence of sarcopenia [43]. Secondly, the chronic hypoxia associated with COPD aggravates oxidative stress responses, damages mitochondrial function, and further exacerbates muscle atrophy and functional impairment [44]. Thirdly, COPD patients often have insufficient nutrient intake and increased energy consumption, resulting in increased nutritional risk, especially deficiency of protein and antioxidant nutrients [45]. Fourthly, the reduction in physical activity due to breathing difficulties accelerates muscle atrophy and functional decline [44]. These mechanisms work together to make COPD patients more prone to frailty (These mechanisms jointly increase frailty risk in COPD patients). It is worth noting that the association strength between COPD and persistent frailty (OR = 6.80) in this study is much higher than that with new-onset frailty (OR = 1.58), suggesting that COPD may accelerate the maintenance and deterioration of frailty states through continuous systemic inflammation and metabolic disorders [42]. Further, the biological link between COPD and frailty is increasingly understood to be driven by chronic low-grade systemic inflammation, a phenomenon often termed ‘inflammaging’ in geroscience [46]. COPD is now recognized not merely as a lung disease but as a systemic inflammatory condition, characterized by elevated levels of pro-inflammatory cytokines that spill over into the circulation. These same inflammatory mediators are central to the pathogenesis of frailty, promoting sarcopenia, anemia, and neuroendocrine dysregulation. Therefore, systemic inflammation serves as a key shared biological pathway connecting the pulmonary disease to its systemic consequences, including the development and persistence of frailty.

This study found that a high-level anti-inflammatory diet was associated with a lower incidence and persistent risk of frailty, which is consistent with the results of several recent studies [47–50]. According to the Dietary Inflammatory Index (DII), an anti-inflammatory diet may weaken the strength of the association between poor sleep quality and frailty [51]. The empirical Anti-inflammatory Dietary Index (eADI) used for predicting low-grade chronic inflammation may potentially play a role in the assessment of chronic diseases in the future [52]. A longitudinal analysis study conducted on older adults in a Greek community showed that adhering to the Mediterranean diet (a typical anti-inflammatory dietary pattern) could reduce the risk of frailty by 41% [53]. Another study in Japan pointed out that insufficient intake of anti-inflammatory diet led to a 2.03-fold increase in new-onset frailty [17]. These consistent results suggest that the protective effect of anti-inflammatory diet on frailty may have a universal nature across different populations. Notably, our approach of creating a simplified anti-inflammatory diet score based on 10 selected food items differs from more comprehensive and validated indices such as the Dietary Inflammatory Index (DII) or the energy-adjusted DII (E-DII), which are calculated from detailed dietary intake data and have been robustly linked to inflammatory biomarkers [29]. While our score incorporates key components of an anti-inflammatory diet common in Chinese culture (e.g., tea, garlic, mushrooms), it may not capture the full complexity of dietary patterns or the inflammatory potential of the entire diet, including pro-inflammatory components like processed meats and refined grains. This might partly explain the null findings for new-onset frailty, as our simplified measure may be less sensitive than a full DII.

The protective mechanisms of the anti-inflammatory diet may be achieved through several pathways: (1) Regulating systemic inflammation levels: Foods rich in omega-3 polyunsaturated fatty acids (such as fish and nuts), polyphenolic compounds (such as tea and fruits), and dietary fibers can downregulate the activity of inflammatory pathways such as NF-κB, and reduce the levels of pro-inflammatory markers such as IL-6, TNF-α, and CRP [54]; (2) Improving oxidative stress status: Antioxidants such as vitamin C, vitamin E, and carotenoids in anti-inflammatory foods can alleviate free radical damage and protect cell membranes and mitochondrial functions [55]; (3) Maintaining intestinal flora balance: Dietary fibers and polyphenols can act as prebiotics, promoting the growth of beneficial bacteria, reducing intestinal permeability and endotoxin translocation, thereby alleviating systemic low-grade inflammation [24]; (4) Optimizing metabolic regulation: Anti-inflammatory diets help improve insulin sensitivity, regulate lipid metabolism, and reduce the occurrence of metabolic inflammation [56].

However, this study did not find a significant association between the anti-inflammatory diet and new-onset frailty, which differs from the results of some prospective studies [17, 53]. The possible reasons for this difference include: Firstly, the influence of follow-up time. The average follow-up time of this study was approximately shorter, while frailty is a slowly developing process. Longer follow-up periods may better reveal the protective effect of diet on new-onset frailty [17]; Secondly, population specificity. The dietary structure, lifestyle, and genetic background of Chinese older adults differ from those of European and American populations, which may affect the manifestation pattern of the relationship between diet and frailty [57].

One of the major findings of this study is the observed pattern suggesting a potential moderating role of anti-inflammatory diet in the relationship between COPD and persistent frailty. In stratified analyses restricted to each dietary subgroup, the odds ratio for COPD-associated persistent frailty was 10.2 (95% CI: 4.15–25.7) among participants with low anti-inflammatory diet scores and 6.01 (95% CI: 1.58–21.3) among those with high scores. However, because these estimates come from separate subgroup models, direct statistical comparison is not appropriate. This pattern should be interpreted as hypothesis-generating rather than confirmatory evidence of effect modification, and future studies with formal interaction testing in adequately powered samples are needed to validate this finding. Although COPD remains an important risk factor for frailty, a high level of anti-inflammatory diet may mitigate its negative impact on the risk of persistent frailty.

The potential mechanisms of this moderating effect are likely rooted in the attenuation of this shared inflammatory burden. The bioactive components of an anti-inflammatory diet—such as omega-3 fatty acids, polyphenols, and dietary fiber—are known to directly suppress key inflammatory pathways (e.g., NF-κB) and reduce circulating levels of IL-6 and CRP. By doing so, an anti-inflammatory diet may directly counter the inflammaging process exacerbated by COPD. This attenuation of systemic inflammation can, in turn, protect against the downstream consequences of muscle protein degradation, mitochondrial dysfunction, and metabolic dysregulation that drive the frailty syndrome. Thus, an anti-inflammatory diet can be conceptualized as a modifiable lifestyle factor that mitigates the ‘fuel’ (systemic inflammation) that feeds the fire linking COPD to persistent frailty [58].

This finding is in line with the recent research trends regarding the role of nutritional intervention in the management of COPD. A cross-sectional and longitudinal combined study indicated that a diet rich in antioxidants and anti-inflammatory components can reduce the occurrence of COPD, improve the lung function of COPD patients, alleviate systemic inflammation, and possibly delay functional decline [59]. Another meta-analysis showed that dietary polyphenols can significantly reduce the levels of inflammatory markers in COPD patients and improve the course of the disease [60]. From another perspective [58], the observed regulatory effect of the anti-inflammatory diet may reflect its potential to reduce the overall inflammatory burden, thereby weakening the association between COPD and frailty (particularly persistent frailty). Taken together, these studies support the potential value of dietary intervention in the comprehensive management of COPD. Nevertheless, given the exploratory nature of our subgroup analyses, these findings should be considered preliminary and require confirmation in future studies specifically designed to test the interaction between anti-inflammatory diet and COPD on frailty outcomes.

The distinction between new-onset and persistent frailty is clinically important. While new-onset frailty represents a transition from a robust state to a vulnerable one, persistent frailty signifies a more entrenched and severe condition. In COPD populations, persistent frailty has been strongly linked to a cascade of adverse outcomes. Studies have shown that individuals with persistent frailty are at a markedly higher risk of incident disability in activities of daily living, more frequent and longer hospitalizations, accelerated cognitive decline, and significantly increased all-cause and COPD-specific mortality [12, 61]. Our finding that COPD is much more strongly associated with persistent frailty (OR = 6.80) than with new-onset frailty (OR = 1.58) aligns with this, suggesting that COPD not only triggers the onset of frailty but also drives its perpetuation and clinical worsening. Therefore, interventions like an anti-inflammatory diet that can weaken this link to persistent frailty hold particular promise for improving hard clinical outcomes in this vulnerable population.

This study has significant clinical practice and public health implications. At the clinical level, medical staff should: (1) conduct regular screening for the risk of frailty in patients with COPD, especially those with an unbalanced diet; (2) incorporate nutritional assessment and dietary guidance into the comprehensive management plan for COPD patients, recommending foods rich in anti-inflammatory components (such as dark vegetables, berry fruits, nuts, fish, etc.); (3) for COPD patients who have shown signs of frailty, develop individualized nutritional support plans, and consider the rational use of nutritional supplements when necessary; (4) carry out multidisciplinary collaboration, integrating respiratory rehabilitation, nutritional support, and exercise training to form a comprehensive intervention plan. At the public health level, it is recommended: (1) promote the concept of anti-inflammatory diet in community health education to enhance the awareness and practical ability of older adults regarding healthy diet; (2) add nutritional intervention content to the management guidelines for COPD patients, clearly defining the recommended standards and implementation paths for anti-inflammatory diets; (3) strengthen the monitoring capacity of grassroots medical and health institutions for the frailty and nutritional status of older adults; (4) promote the standardized development of nutritional services in the “medical-nursing integration” model.

The strengths of this study are as follows: (1) Based on a large-scale longitudinal dataset with national representativeness, the results have good external validity; (2) By combining cross-sectional and longitudinal designs, it comprehensively reveals the relationship between COPD, anti-inflammatory diet and frailty; (3) Systematically controlled a large number of potential confounding factors, thereby enhancing the credibility of the results; (4) For the first time, it explores the moderating role of anti-inflammatory diet in the relationship between COPD and frailty among older adults in China, filling the research gap in this field. However, this study also has several limitations: Firstly, as an observational study, it cannot determine causal relationships, and the possibility of residual confounding still exists; Secondly, the diagnosis of COPD, dietary information, and some covariates are based on self-reports, which may lead to recall bias and social expectation bias. COPD was defined based on self-reported diagnosis, which is subject to recall bias and lacks confirmation by spirometry, the gold standard for diagnosis. This misclassification could potentially bias our results. If individuals without true COPD (based on spirometry) reported having the disease (false positives), this would likely dilute the observed association between COPD and frailty, biasing our results towards the null. Conversely, if individuals with mild or undiagnosed COPD failed to report it (false negatives), this could also underestimate the true effect. Furthermore, the absence of spirometric data precludes us from assessing the severity of airflow limitation, which likely has a dose-response relationship with systemic inflammation and, consequently, frailty risk. Future studies incorporating objective lung function measures are necessary to confirm these findings and explore severity-based associations; Thirdly, the assessment of anti-inflammatory diet was based on a simplified 10-item food frequency questionnaire (FFQ). This approach has several limitations: (a) it has not been formally validated against objective inflammatory biomarkers (e.g., CRP, IL-6) or comprehensive 24-hour dietary recalls in this cohort; (b) it may not fully capture the complexity and synergy of all dietary components that constitute a true anti-inflammatory dietary pattern, potentially leading to non-differential misclassification and a bias toward the null; (c) as with all self-reported dietary data, it is susceptible to recall bias, which may be more pronounced in older adults; (d) importantly, diet was assessed only at baseline, and we could not account for changes in dietary habits over the 7-year follow-up period. Such changes could have led to an underestimation or overestimation of the long-term protective effects. Moreover, while our choice of the FI ≥ 0.20 cutoff is well-justified in the literature and in previous CLHLS studies, we acknowledge that different frailty index cutoffs (e.g., ≥ 0.25) exist. The selection of a cutoff can influence frailty prevalence and, potentially, the magnitude of observed associations. However, our sensitivity analysis using the more stringent FI ≥ 0.25 cutoff yielded results consistent with our primary findings, reinforcing the robustness of our conclusions regarding the moderating effect of anti-inflammatory diet. Fourthly, although the sample is nationally representative, China has a vast territory and significant differences in dietary culture, and the generalizability of the results still needs further verification; Fifthly, there is a lack of objective inflammatory marker data, and it is impossible to directly verify the moderating effect of anti-inflammatory diets on inflammatory levels. Finally, a significant proportion (74.5%) of the initial sample was excluded due to missing data on key variables at baseline or follow-up, which introduces the potential for selection bias. As shown in Table S1, compared to included participants, those excluded were more likely to be older, female, living in urban areas. This suggests that our analytical sample may represent a somewhat healthier and more robust subset of the original cohort. If the excluded, less healthy individuals had different associations between COPD, diet, and frailty, our results could be biased, potentially overestimating the protective effects of diet. Therefore, our findings may be most generalizable to relatively healthier, community-dwelling older adults with more complete data profiles and should be extrapolated to the entire older adult population with caution.

Given these limitations, future research can delve deeper in the following directions: (1) Conduct randomized controlled trials targeting patients with COPD to evaluate the impact of anti-inflammatory dietary interventions on the progression of frailty, quality of life, and clinical outcomes; (2) Utilize multi-omics techniques (such as metabolomics and microbiomics) [62], to deeply explore the molecular mechanisms by which anti-inflammatory diets affect COPD-related frailty; (3) Conduct validation studies in populations with different ethnic and cultural backgrounds to investigate the influence of dietary cultural differences on the research results; (4) Carry out long-term follow-up studies to observe the long-term effects of anti-inflammatory diets on the frailty trajectory of COPD patients; (5) Explore individualized nutritional intervention strategies, formulating precise nutritional plans based on patients’ genotypes, metabolic characteristics, and microbial composition [63].

Conclusion

This study is the first to systematically confirm in Chinese older adults that COPD is an important risk factor for the occurrence and persistence of frailty, and anti-inflammatory diets have a protective effect on frailty, especially more significant in the state of persistent frailty. More importantly, our exploratory stratified analyses suggest that anti-inflammatory diets may weaken the strength of the association between COPD and persistent frailty, as indicated by the numerically lower odds ratio in the high dietary score subgroup. However, direct cross-subgroup statistical comparisons were not performed, and these findings should be interpreted with caution pending confirmation in future studies. These findings provide new scientific basis for formulating comprehensive management plans for COPD, emphasizing the importance of nutritional assessment and dietary intervention in the management of respiratory diseases in older adults. More high-quality intervention studies are still needed to further verify the actual effect and optimal implementation path of anti-inflammatory diets in the prevention and control of COPD-related frailty.

Supplementary Information

Supplementary Material 1.^{(53.5KB, docx)}

Acknowledgements

We sincerely appreciate the CLHLS database for all of the data.

Clinical trial number

Not applicable.

Abbreviations

BMI: Body mass index
CLHLS: Chinese Longitudinal Healthy Longevity Survey
ORs: Odds Ratio
95% CIs: 95% Confidence Intervals
IQ: Interquartile Range
FI: Frailty index
COPD: Chronic obstructive pulmonary disease
ANOVA: Analysis of variance
RCS: Restricted cubic spline

Authors’ contributions

Xiaohui Ye and Meina Zhang designed this study. The data collection work was handled by Xiaohui Ye and Qian Zhao, while the analysis work was done by Xiaohui Ye and Meina Zhang. The manuscript was reviewed and revised by Xiaohui Ye, Meina Zhang and all the authors.

Funding

None.

Data availability

The data for this study were sourced from the Chinese Longitudinal Healthy Longevity Survey (CLHLS), conducted by the Peking University Research Center for Healthy Aging and Development, data is accessible at http://opendata.pku.edu.cn/.

Declarations

Ethics approval and consent to participate

The CLHLS study received ethical approval from the Peking University Institutional Review Board (IRB00001052-13074), and written informed consent was obtained from each participant or their authorized representative. Participation in the CLHLS is voluntary, and respondents are free to withdraw from the study at any time without any consequences.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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49.Dominguez LJ, Donat-Vargas C, Sayon-Orea C, Barberia-Latasa M, Veronese N, Rey-Garcia J, Rodríguez-Artalejo F, Guallar-Castillón P, Martínez-González M, Barbagallo M. Rationale of the association between Mediterranean diet and the risk of frailty in older adults and systematic review and meta-analysis. Exp Gerontol. 2023;177:112180. [DOI] [PubMed] [Google Scholar]
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52.Kaluza J, Hellerström L, Kaluza D, Chabok A, Åkesson A, Michaëlsson K, Wolk A. Development of empirical anti-inflammatory diet index: a cross-sectional study. Nutr J. 2025;24(1):97. [DOI] [PMC free article] [PubMed] [Google Scholar]
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55.Iddir M, Brito A, Dingeo G, Fernandez Del Campo SS, Samouda H, La Frano MR, Bohn T. Strengthening the Immune System and Reducing Inflammation and Oxidative Stress through Diet and Nutrition: Considerations during the COVID-19 Crisis. Nutrients. 2020;12(6). [DOI] [PMC free article] [PubMed]
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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material 1.^{(53.5KB, docx)}

Data Availability Statement

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[CR48] 48.Kuczmarski MF, Beydoun MA, Georgescu MF, Noren Hooten N, Mode NA, Evans MK, Zonderman AB. Pro-Inflammatory Diets Are Associated with Frailty in an Urban Middle-Aged African American and White Cohort. Nutrients. 2023;15(21). [DOI] [PMC free article] [PubMed]

[CR49] 49.Dominguez LJ, Donat-Vargas C, Sayon-Orea C, Barberia-Latasa M, Veronese N, Rey-Garcia J, Rodríguez-Artalejo F, Guallar-Castillón P, Martínez-González M, Barbagallo M. Rationale of the association between Mediterranean diet and the risk of frailty in older adults and systematic review and meta-analysis. Exp Gerontol. 2023;177:112180. [DOI] [PubMed] [Google Scholar]

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[CR55] 55.Iddir M, Brito A, Dingeo G, Fernandez Del Campo SS, Samouda H, La Frano MR, Bohn T. Strengthening the Immune System and Reducing Inflammation and Oxidative Stress through Diet and Nutrition: Considerations during the COVID-19 Crisis. Nutrients. 2020;12(6). [DOI] [PMC free article] [PubMed]

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[CR58] 58.Hirano T, Doi K, Matsunaga K, Takahashi S, Donishi T, Suga K, Oishi K, Yasuda K, Mimura Y, Harada M, et al. A Novel Role of Growth Differentiation Factor (GDF)-15 in Overlap with Sedentary Lifestyle and Cognitive Risk in COPD. J Clin Med. 2020;9(9). [DOI] [PMC free article] [PubMed]

[CR59] 59.Gong H, Zhang K, Choi S, Huang S. The association between Planetary Health Diet Index (PHDI) and chronic obstructive pulmonary disease (COPD): the mediating role of dietary inflammatory index (DII). BMC Pulm Med. 2025;25(1):53. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR60] 60.Wu D, Dong Y, Zhang D, Wang T, Ye H, Zhang W. Efficacy and safety of dietary polyphenol supplements for COPD: a systematic review and meta-analysis. Front Immunol. 2025;16:1617694. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR61] 61.Ye F, Zhou W, Pu J, Chen H, Wang X, Lee JJ. Association of Longitudinal Trajectories of Physical Frailty With Dementia Status in Older Adults: A National Cohort Study. Int J Geriatr Psychiatry. 2025;40(2):e70051. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR62] 62.Ghosh TS, Rampelli S, Jeffery IB, Santoro A, Neto M, Capri M, Giampieri E, Jennings A, Candela M, Turroni S, et al. Mediterranean diet intervention alters the gut microbiome in older people reducing frailty and improving health status: the NU-AGE 1-year dietary intervention across five European countries. Gut. 2020;69(7):1218–28. [DOI] [PMC free article] [PubMed] [Google Scholar]

[CR63] 63.Yan F, Wu T, Meng Q, Qu F. Bidirectional genetic links between chronic obstructive pulmonary disease and frailty: Genome-wide association study insights. PLoS ONE. 2025;20(5):e0320304. [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

The moderating role of anti-inflammatory diet on the relationship between chronic obstructive pulmonary disease and frailty in older adults: a nationwide cross-sectional and longitudinal study

Xiaohui Ye

Qian Zhao

Meina Zhang

Haiyan Zhang

Chunyan Wu

Abstract

Objective

Methods

Results

Conclusion

Supplementary Information

Introduction

Methods

Study design and participants

Fig. 1.

Assessment of anti-inflammatory diet

Definition of COPD

Frailty

Covariates

Statistical analysis

Results

Characteristics of the study participants

Table 1.

Cross-sectional analysis

Table 2.

Longitudinal analysis

Table 3.

Table 4.

Dose-response relationship

Fig. 2.

Stratification analysis

Table 5.

Table 6.

Sensitive analysis

Discussion

Conclusion

Supplementary Information

Acknowledgements

Clinical trial number

Abbreviations

Authors’ contributions

Funding

Data availability

Declarations

Ethics approval and consent to participate

Consent for publication

Competing interests

Footnotes

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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