Overlap of depressive symptoms and low physical activity affects the risk of social frailty in Japanese community-dwelling older adults

Overlap of depressive symptoms and low physical activity affects the risk of social frailty in Japanese community-dwelling older adults | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Overlap of depressive symptoms and low physical activity affects the risk of social frailty in Japanese community-dwelling older adults Tomoya Shimabukuro, Masaki Nagamatsu, Tomohiro Nishimura, Aiko Imai, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8846872/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Although depressive symptoms (DS) and physical activity (PA) have each been associated with social frailty (SF), their combined effects remain unclear. This study examined the independent and interactive associations of DS and objectively measured PA with SF in community-dwelling older adults. This cross-sectional study included 147 adults aged ≥ 65 years. DS were assessed using the Japanese version of 15-item Geriatric Depression Scale, and PA was measured objectively via accelerometer-based daily step counts, classified as < 4,000 or ≥ 4,000 steps/day. SF was evaluated using the five-item criteria proposed by Makizako et al. A two-way analysis of covariance was performed with DS (yes/no) and step count (≥ 4,000/<4,000) as independent variables and the total number of positive SF components (0–5) as the dependent variable, adjusting for relevant covariates. A significant interaction between DS and step count on SF was observed (P = 0.006). Significant main effects were also found, with higher SF scores among participants with DS and those walking < 4,000 steps/day (both P < 0.001). These findings indicate that both DS and low PA are independently associated with SF, and that the overlap of these two factors may be linked to an increased risk of SF among older adults. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research Health sciences/Risk factors depressive symptoms objectively-measured physical activity social frailty Figures Figure 1 Introduction Frailty is common among older adults and is associated with an increased risk of falls, disability, hospitalization, and mortality 1 – 3 . While most studies have focused on its physical aspects, frailty involves also social factors 4 , 5 . One systematic review has shown that social frailty (SF) is significantly associated with adverse outcomes such as mortality and functional decline 6 . As SF increases the use of medical and long-term care services, its prevention is essential for extending healthy life expectancy and reducing healthcare costs. Moreover, the prevalence of SF tends to exceed that of physical or cognitive frailty and has continued to increase in recent years 7 , underscoring the need to identify factors that contribute to its prevention and early intervention. Focusing on depressive symptoms (DS) may be particularly effective when considering strategies to prevent SF. A recent systematic review identified DS as one of the most frequently examined and consistently reported correlates of SF 7 . Moreover, a comparative study evaluating DS in relation to sarcopenia, oral frailty, and SF demonstrated that SF showed the strongest association with DS 8 . Taken together, these findings suggest that clarifying the relationship between DS and SF may yield important insights for developing effective prevention strategies. In addition to psychological factors such as DS, physical activity (PA) has also been identified as a key correlate of SF 7 . More recently, the combined presence of chronic back pain and low step counts has been reported to increase the risk of SF 9 . Moreover, engaging in routine outdoor mobility is considered a relatively simple health-promoting behavior for older adults, especially when compared with other lifestyle behaviors such as smoking cessation, structured exercise, or maintaining a healthy diet 10 . Taken together, these findings indicate that low PA is negatively associated with SF and represents a feasible and accessible behavior for older adults to incorporate into their daily lives. PA can be assessed either objectively using accelerometers or subjectively through self-reported questionnaires. Although both methods are widely accepted worldwide, a systematic review examining the associations between DS, and PA reported that subjectively assessed PA tends to be overestimated, whereas sedentary time tends to be underestimated compared with objectively measured PA. Moreover, this discrepancy was particularly pronounced among individuals with DS 11 . Considering these tendencies, it is desirable to objectively assess PA when examining its association with SF. However, no studies have yet examined how the combination of DS and objectively measured PA assessed by accelerometers is associated with SF, nor have they evaluated their potential interaction effects. Therefore, the present study aimed to investigate the relationships among DS, objectively measured PA, and SF in community-dwelling older adults, and to examine whether the coexistence of DS and low PA has an interactive association with SF Methods Design and Participants This cross-sectional study was conducted among community-dwelling older adults residing in Usa City, Oita Prefecture, and Nagahama City, Shiga Prefecture, Japan. The recruitment period was from July 5, 2021, to August 23, 2023, for Usa City, Oita Prefecture, and from November 26, 2022, to March 6, 2024, for Nagahama City Shiga Prefecture. Participants were verbally informed about the study’s purpose and procedures. A total of 215 participants (73 men and 142 women) agreed to participate and provided written informed consent. The following exclusion criteria were applied: active or suspected COVID-19 infection; inability to complete the questionnaire due to cognitive decline; certification for long-term care (care level ≥ 1); history of psychiatric illness; history of orthopedic surgery or movement restrictions; determination by a physician that participation was inappropriate due to illness; missing data on DS or SF; and insufficient wear time of the tri-axial accelerometer. After applying these criteria, 147 participants (55 men and 92 women; mean age, 74.0 ± 5.8 years) were included in the final analysis. Ethical Considerations This study was approved by the Ethics Review Committee for Medical Research Involving Human Subjects at Ritsumeikan University (approval number: BKC-LSMH-2022-075-1). All procedures were conducted in accordance with the principles of the Declaration of Helsinki and relevant institutional guidelines and regulations. Participants were informed of the study purpose and procedures both verbally and in writing. They were notified that participation was voluntary, that they could decline to answer any question or withdraw from the study at any time without penalty, and that all data would be anonymized to ensure confidentiality. Participants provided written informed consent prior to completing the study questionnaire. Written informed consent was obtained from all participants. Depressive Symptoms DS were assessed using the 15-item Japanese version of the Geriatric Depression Scale (GDS-15-J), a self-administered questionnaire 12 . The GDS-15-J has been validated for use in cross-cultural research, including studies involving older Japanese adults 13 . Participants who completed all 15 items were included in the analysis, and a score of ≥ 6 was used to define the presence of DS, based on previous research 13 . Physical Activity (PA) PA was evaluated based on the number of steps measured using an Active Style Pro (HJA-750C, Omron Healthcare, Kyoto, Japan), a device equipped with a tri-axial accelerometer. This device is smaller (40 × 52 × 12 mm; 23 g including battery) than the first model (Active Style Pro HJA-350IT) 14 , 15 ; however, the algorithm remains unchanged 16 . The average number of daily steps was calculated, and participants were classified into two groups according to their step counts: ≥4,000 and < 4,000 steps per day. The cutoff of 4,000 steps was adopted because it is used as a benchmark for all-cause mortality in older adults (17), and previous studies have also examined this threshold in relation to both physical (18) and psychological (19) health outcomes. Moreover, this criterion is considered a practical and easily interpretable target for use in community and clinical settings (17). Participants were instructed to wear the accelerometer on either side of the waist for seven consecutive days, removing it only during sleep or water-related activities such as swimming, bathing, or showering. Following established guidelines for measuring habitual PA in older adults, data were considered valid when participants had at least four days with a minimum wear time of 10 hours per day (20). This accelerometer protocol (≥ 4 days, ≥ 10 hours/day) has been validated and is widely accepted in previous studies (15, 16). Social Frailty (SF) SF was assessed using five components : “going out less frequently compared with last year” (yes), “sometimes visiting friends” (no), “feeling helpful toward friends or family” (no), “living alone” (yes), and “talking with someone every day” (no). Participants were classified into three categories according to the number of applicable components: Non-SF (0 components), Pre-SF (1 component), and SF (2 or more components) (4). Covariates Based on previous studies, potential confounders were identified as follows: age, sex, body mass index (BMI), and accelerometer wear time (20). Statistical Analysis Continuous variables were expressed as mean (± standard deviation), and categorical variables were expressed as numbers (percentages). Participants were classified into two categories for each factor: step count DS (no/yes) and (≥ 4,000/<4,000 steps per day). Student’s t -test was used to compare continuous variables, and the chi-square test or Fisher’s exact test was applied to compare categorical variables. A two-way analysis of covariance (ANCOVA) was conducted with DS (no/yes) and step count (≥ 4,000/<4,000) as independent variables, and the total number of positive SF components (range: 0–5) as the dependent variable. Age, sex, BMI, and accelerometer wear time were included as covariates, and simple main effects were used to assess the main effects of each factor. Bonferroni correction was applied for multiple comparisons. In addition, for Fisher’s exact test examining the distribution of responses for each of the five SF components, participants were divided into four groups according to the combination of step count (≥ 4,000/<4,000) and DS (no/yes). All statistical analyses were performed using SPSS Statistics version 29 for Mac (IBM Japan, Tokyo, Japan). Statistical significance was set at a two-tailed p value of < 0.05. Results Participant characteristics were compared between the “No DS” and “DS” groups, and between the “≥4,000 steps” and “<4,000 steps” groups, using Student’s t -test for continuous variables and the chi-square test or Fisher’s exact test for categorical variables (Tables 1 , Table 2 ). In the total sample of 147 participants, the mean GDS-15-J score was 2.5 ± 2.6, the average daily step count was 5,336.9 ± 2,604.7 steps, and the proportions of SF categories were as follows: Non-SF, n = 67 (45.6%); Pre-SF, n = 49 (33.3%); and SF, n = 31 (21.1%). Table 1 Comparisons of Participants’ Characteristics Between the No DS and DS groups No DS (n = 128, 87.1%) DS (n = 19, 12.9%) P Age (years) 74 ± 5.7 73.9 ± 6.9 0.941 Sex, n (%) 0.337 Male 46 (35.9) 9 (47.4) Female 82 (64.1) 10 (52.6) BMI (kg/m 2 ) 23.2 ± 3.2 23.1 ± 3.5 0.500 Percentage of SF, n (%) 0.002 Non-SF 63 (49.2) 4 (21.1) Pre-SF 44 (34.4) 5 (26.3) SF 21 (16.4) 10 (52.6) Table 2 Comparisons of Participants’ Characteristics Between the ≥ 4,000 and < 4,000 Steps Groups ≥ 4,000 Steps <4,000 Steps P (n = 104, 70.7%) (n = 43, 29.3%) Age (years) 72.7 ± 5.0 77.2 ± 6.4 < 0.001 Sex, n (%) 0.733 Male 38 (36.5) 17 (39.5) Female 66 (63.5) 26 (60.5) BMI (kg/m 2 ) 23.2 ± 3.2 23.1 ± 3.5 0.785 Percentage of SF, n (%) 0.027 Non-SF 54 (51.9) 13 (30.2) Pre-SF 33 (31.7) 16 (37.2) SF 17 (16.3) 17 (32.6) Wearing time (min/day) 798.0 ± 106.7 787.6 ± 97.5 0.582 A two-way ANCOVA was performed to examine how DS and step count (≥ 4,000/<4,000 steps), both individually and in combination, were associated with the risk of SF. Based on the combination of DS and step count, participants were categorized into four groups: No DS + ≥ 4,000 steps (n = 91, 61.9%), DS + ≥ 4,000 steps (n = 13, 8.8%), No DS + < 4,000 steps (n = 37, 25.2%), and DS + < 4,000 steps (n = 6, 4.1%). The ANCOVA, adjusted for age, sex, BMI, and accelerometer wear time, revealed a significant interaction between DS and step count on the number of positive SF components (P = 0.006, η² = 0.054). Significant simple main effects were observed for both DS and step count, with higher SF scores in participants with DS (P < 0.001, η² = 0.205) and in those walking fewer than 4,000 steps per day (P < 0.001, η² = 0.100). Post hoc Bonferroni analyses indicated that step count did not significantly affect SF among participants without DS (P = 0.081), whereas participants with DS and low step counts showed significantly higher SF scores compared with those with higher step counts (P < 0.001). The mean number of positive SF components in the four groups classified by DS and step count was 0.59 (95% CI: 0.40–0.79) in the No DS + ≥ 4,000 steps group, 1.34 (95% CI: 0.82–1.86) in the DS + ≥ 4,000 steps group, 0.92 (95% CI: 0.61–1.23) in the No DS + < 4,000 steps group, and 3.08 (95% CI: 2.32–3.85) in the DS + < 4,000 steps group (Fig. 1 ). In addition, to examine the association of the four groups—“No DS + ≥ 4,000 steps,” “DS + ≥ 4,000 steps,” “No DS + < 4,000 steps,” and “DS + < 4,000 steps”—with each of the five components of SF, Fisher’s exact test was performed. As shown in Table 3 , the DS + < 4,000 steps group consistently showed the highest proportion of participants meeting each SF component. Significant group differences were observed in four of the five components—"going out less frequently compared with last year,” “feeling helpful toward friends and family,” “living alone,” and “talking with someone every day”—whereas no significant difference was found for “sometimes visiting friends”. Table 3 Associations Between DS and Step Count (< 4,000/≥4,000 steps) and Each Component of SF Total No DS + ≥ 4000 Steps DS + ≥ 4000 Steps No DS + < 4000 Steps DS + < 4000 Steps P n = 147 n = 91 (61.9%) n = 13 (8.8%) n = 37 (25.2%) n = 6 (4.1%) Going out less frequently compared with last year No = 109 (74.1%) 75 (82.4%) 6 (46.2%) 26 (70.3%) 2 (33.3%) 0.003 Yes = 38 (25.9%) 16 (17.6%) 7 (53.8%) 11 (29.7%) 4 (66.7%) Sometimes visiting friends Yes = 96 (65.3%) 65 (71.4%) 8 (61.5%) 21 (56.8%) 2 (33.3%) 0.139 No = 51 (34.7%) 26 (28.6%) 5 (38.5%) 16 (43.2%) 4 (66.7%) Feeling helpful toward friends and family Yes = 134 (91.2%) 87 (95.6%) 9 (69.2%) 36 (97.3%) 2 (33.3%) < 0.001 No = 13 (8.8%) 4 (4.4%) 4 (30.8%) 1 (2.7%) 4 (66.7%) Living alone No = 132 (89.8%) 84 (92.3%) 12 (92.3%) 33 (89.2%) 3 (50%) 0.011 Yes = 15 (10.2%) 7 (7.7%) 1 (7.7%) 4 (10.8%) 3 (50%) Talking with someone everyday Yes = 138 (93.9%) 88 (96.7%) 12 (92.3%) 35 (94.6%) 3 (50%) < 0.001 No = 9 (6.1%) 3 (3.3%) 1 (7.7%) 2 (5.4%) 3 (50%) BMI: body mass index; DS: depressive symptoms; SF: social frailty Discussion This cross-sectional study examined the combined association of DS and low daily step count (< 4,000 steps) on SF. To the best of our knowledge, this is the first study to simultaneously investigate the independent associations of DS and daily step count with SF, as well as their interactive effect. In the present study, the prevalence of DS was 12.9%, the proportion of participants walking fewer than 4,000 steps per day was 29.3%, the mean daily step count was 5,336.9 steps, and the prevalence of SF was 21.1%. The prevalence of DS observed in our sample is consistent with previous research using the GDS-15, which has reported an estimated prevalence of approximately 13% 21 . However, it is lower than the pooled prevalence of 19.2% (95% CI: 13.0–27.5) reported in a systematic review of DS among older adults 22 . These findings suggest that the participants in this study may have been relatively mentally healthy, possibly due to the strict exclusion criteria applied or differences in the depression measures used across studies. In contrast, the mean daily step count 23 , 24 and the prevalence of SF 7,25 align closely with values reported in prior studies. In this study, both DS and a low daily step count were independently associated with an increased risk of SF. Furthermore, individuals exhibiting both factors tended to show a particularly high risk of SF, suggesting that their overlap may indicate a more vulnerable subgroup among older adults. A notable strength of this study is that participants presenting with both DS and fewer than 4,000 steps per day exhibited a mean number of positive SF components whose lower bound of the 95% confidence interval exceeded the threshold of two components used to define SF, suggesting a particularly high-risk profile. Furthermore, a previous study focusing on nursing home residents examined the mediating role of DS in the relationship between sedentary behavior (SB) and SF, demonstrating that prolonged SB may exacerbate SF through the worsening of DS 26 . Taken together with this prior evidence, the present findings suggest that the coexistence of DS and low PA—such as low step counts or prolonged sedentary time—may represent a particularly high-risk condition for the development of SF. However, only six participants fell into this category, which inevitably reduced the statistical power. Increasing the sample size will therefore be essential to draw more robust conclusions. Nevertheless, a systematic review has confirmed the wide use and predictive validity of this five-item SF scale across numerous studies, supporting the relevance of the outcomes observed in the present analysis 27 . In addition, one previous systematic review identified depression as the most frequently reported risk factor for SF (cited in eight studies), followed by physical inactivity as the third most common factor (cited in three studies) 7 . Thus, the findings of the present study align with and extend the existing literature. Previous studies have reported that DS substantially increase the risk of SF, with an odds ratio of 2.24 (95% CI: 1.45–3.44) 28 . Another study demonstrated that each one-point increase in the GDS-15 score was associated with a 1.33-fold higher odds of SF (95% CI: 1.19–1.49) 29 . The findings of the present study further support these earlier reports by reinforcing the evidence that DS are strongly associated with SF. Taken together with the current results, these findings suggest that reducing depressive tendencies may be a key strategy for preventing SF. Regarding PA, a previous investigation reported that exercise-based interventions improved SF 30 , and physical frailty has also been identified as a risk factor for SF 31 . Additionally, studies on habitual PA have shown that performing low-to-moderate PA less than once per week increases the risk of SF 32 . Moreover, evaluations using the Kihon Checklist—including social aspects—have demonstrated that individuals classified as frail show significantly lower step counts than those classified as non-frail, with frail individuals averaging approximately 3,470 steps per day, partially consistent with the present findings 33 . Conversely, other research has indicated that walking fewer than 6,000 steps per day becomes a risk factor for SF when accompanied by chronic low back pain 9 . This study also suggested that the volume of steps, rather than the intensity of PA, may play a more important role in determining SF risk. Considering both previous literature and the present findings, exercise prescriptions aimed at preventing SF may need to incorporate not only short-term intervention approaches but also strategies that promote sustained increases in daily activity, while also taking into account DS and chronic pain. In addition, systematic reviews have identified 4,000 steps per day as an effective threshold for reducing all-cause mortality 17 . In this study, step counts above 4,000 per day were statistically associated with a lower risk of SF; however, the clinical significance of this association remains to be clarified. Furthermore, in considering the relationships among DS, PA, and SF, it is important to acknowledge the possibility of reverse causality. A previous study has suggested that SF may itself serve as a risk factor for DS 34 . In addition, SF has been reported as a predictor of physical frailty 35 , implying that social restrictions may negatively affect mental health and reduce opportunities for engaging in PA. In addition, several studies have suggested that improving social health requires not only individual efforts but also broader community- and society-level support 36 , 37 . Given these complex and potentially bidirectional relationships, large-scale and longitudinal investigations will be essential to clarify the underlying pathways. Moreover, the combined presence of DS and fewer than 4,000 daily steps was also associated with several individual components of SF. Although the number of participants in the overlapping group (n = 6) was small and the results should therefore be interpreted cautiously, this group showed the highest percentage of applicability for each SF item. In particular, significant differences were found for four components—“going out less frequently compared with last year,” “feeling helpful toward friends or family,” “living alone,” and “not talking with someone every day”—all of which were negatively associated with DS and low step counts. Previous studies have demonstrated similar patterns. Research on mobility and mental health has reported negative associations between DS and the extent of one’s life-space mobility 38 as well as between neighborhood walkability and PA 39 . In addition, aspects related to loneliness and social isolation—such as perceived lack of usefulness, living alone, and reduced conversational opportunities—have been linked to lower life satisfaction and poorer physical health 40 . Among older adults living in rural areas, living alone has further been associated with an increased risk of DS 41 . Conversely, one study has suggested that living alone may promote greater life-space mobility because individuals must perform daily activities independently, potentially increasing their movement relative to those living with others 42 . These findings underscore the complexity of the relationships among social isolation, mobility, and psychosocial health. Given this complexity, examining each SF component individually may provide valuable insights for developing more targeted SF prevention strategies. However, to establish more precise and reliable evidence regarding these associations, larger sample sizes as well as intervention and longitudinal studies will be necessary. Additionally, several studies investigating exercise frequency and health outcomes have shown that, even when the frequency of activity is the same, engaging in group-based rather than individual exercise yields greater benefits for older adults. Group-based participation has been linked to a lower risk of falls 43 , enhanced cognitive function 44 , and better subjective health 45 . When considered alongside these previous results, the findings of the present study further emphasize that achieving extended healthy life expectancy in older adults requires a comprehensive strategy that integrates physical, psychological, and social perspectives. This study has several limitations. First, its cross-sectional design limits the interpretation of causality, and reverse relationships—such as SF affecting DS or PA—cannot be ruled out. Longitudinal studies are needed to clarify causal pathways. Second, the sample size was small, particularly in the group with both DS and fewer than 4,000 steps per day (n = 6), which restricted adjustment for confounders such as ADL, socioeconomic status. Larger samples will be required to enable more detailed analyses. Third, the study relied on voluntary participation, which may have resulted in a healthier sample and introduced selection bias. Additionally, the long recruitment periods in both regions were not adjusted for potential seasonal or temporal effects. Therefore, the observed associations between DS, step counts, and SF should be interpreted with caution. Conclusion In conclusion, this study suggests that both DS and lower daily step count are individually associated with increased risk of SF. Notably, their coexistence may characterize a subgroup of older adults at particularly elevated risk for SF, highlighting the importance of addressing both factors in prevention strategies. Declarations Acknowledgements We thank all the participants and municipal staff involved in the data collection. Author Contributions Tomoya Shimabukuro (1,2,3,4,5), Masaki Nagamatsu (3,5), Tomohiro Nishimura (3,5), Aiko Imai (5), Keiko Kishigami (3), Kaito Hashimoto (3,5), Toshiyuki Kurihara (5), Takeshi Hashimoto (2,3,5), Kiyoshi Sanada (1,2,3,5) 1.Conceptualization; 2.Methodology; 3.Data curation; 4.Writing - Original Draft; 5.Writing - Review & Editing; Competing Interests The authors declare no competing interests. Data Availability Statement Please contact corresponding author for data requests. Funding Declaration No funding was received for this paper. 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Public. Health . 12 , 1423391. 10.3389/fpubh.2024.1423391 (2024). Makizako, H. et al. Social Frailty Leads to the Development of Physical Frailty among Physically Non-Frail Adults: A Four-Year Follow-Up Longitudinal Cohort Study. Int. J. Environ. Res. Public. Health . 15 (3), 490. 10.3390/ijerph15030490 (2018). Hoang, P. et al. Interventions Associated With Reduced Loneliness and Social Isolation in Older Adults: A Systematic Review and Meta-analysis. JAMA Netw Open . (2022). 5(10):e2236676 10.1001/jamanetworkopen.2022.36676 (2022). O'Rourke, H. M., Collins, L. & Sidani, S. Interventions to address social connectedness and loneliness for older adults: a scoping review. BMC Geriatr. 18 (1), 214. 10.1186/s12877-018-0897-x (2018). Miyashita, T., Tadaka, E. & Arimoto, A. Cross-sectional study of individual and environmental factors associated with life-space mobility among community-dwelling independent older people. Environ. Health Prev. Med. 26 (1), 9. 10.1186/s12199-021-00936-2 (2021). Amagasa, S. et al. Associations of neighborhood walkability with intensity- and bout-specific physical activity and sedentary behavior of older adults in Japan. Geriatr. Gerontol. Int. 19 (9), 861–867 (2019). Coundouris, S. P. et al. How social frailty is operationalized matters: Relationships with health and wellbeing in late adulthood. Int. Psychogeriatr. 37 (4), 100032. 10.1016/j.inpsyc.2024.100032 (2025). Fukunaga, R. et al. Living alone is associated with depression among the elderly in a rural community in Japan. Psychogeriatrics 12 (3), 179–185 (2012). Hayashi, C., Tanaka, H. & Ogata, S. Assessing timewise changes over 15 months in life-space mobility among community-dwelling elderly persons. BMC Geriatr. 20 (1), 502. 10.1186/s12877-020-01882-4 (2020). Hayashi, T. et al. Differences in Falls between Older Adult Participants in Group Exercise and Those Who Exercise Alone: A Cross-Sectional Study Using Japan Gerontological Evaluation Study (JAGES) Data. Int. J. Environ. Res. Public. Health . 15 (7), 1413. 10.3390/ijerph15071413 (2018). Nagata, K. et al. Impact of exercising alone and exercising with others on the risk of cognitive impairment among older Japanese adults. Arch. Gerontol. Geriatr. 7 , 104908. 10.1016/j.archger.2022.104908 (2023). Kanamori, S. et al. Exercising alone versus with others and associations with subjective health status in older Japanese: The JAGES Cohort Study. Sci. Rep. 6 , 39151. 10.1038/srep39151 (2016). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 18 May, 2026 Reviews received at journal 28 Feb, 2026 Reviewers agreed at journal 27 Feb, 2026 Reviewers invited by journal 20 Feb, 2026 Editor assigned by journal 20 Feb, 2026 Editor invited by journal 19 Feb, 2026 Submission checks completed at journal 16 Feb, 2026 First submitted to journal 16 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8846872","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":595595709,"identity":"26c4f942-7e33-49ce-affd-fcdb43b3435f","order_by":0,"name":"Tomoya Shimabukuro","email":"","orcid":"","institution":"Ritsumeikan University","correspondingAuthor":false,"prefix":"","firstName":"Tomoya","middleName":"","lastName":"Shimabukuro","suffix":""},{"id":595595710,"identity":"fdf36e18-ec7c-4e34-addc-8659fc3bdc52","order_by":1,"name":"Masaki Nagamatsu","email":"","orcid":"","institution":"Ritsumeikan University","correspondingAuthor":false,"prefix":"","firstName":"Masaki","middleName":"","lastName":"Nagamatsu","suffix":""},{"id":595595712,"identity":"c1b1b5b3-ccfe-4bcf-8152-ae8012574566","order_by":2,"name":"Tomohiro Nishimura","email":"","orcid":"","institution":"Ritsumeikan University","correspondingAuthor":false,"prefix":"","firstName":"Tomohiro","middleName":"","lastName":"Nishimura","suffix":""},{"id":595595713,"identity":"044e4282-e89a-4931-b4ec-b8f289707b13","order_by":3,"name":"Aiko Imai","email":"","orcid":"","institution":"Ritsumeikan University","correspondingAuthor":false,"prefix":"","firstName":"Aiko","middleName":"","lastName":"Imai","suffix":""},{"id":595595714,"identity":"76927a5d-cf5c-4746-9cf0-d42c5c540c60","order_by":4,"name":"Keiko Kishigami","email":"","orcid":"","institution":"Ritsumeikan University","correspondingAuthor":false,"prefix":"","firstName":"Keiko","middleName":"","lastName":"Kishigami","suffix":""},{"id":595595716,"identity":"3deaae78-42ed-4e12-8dcf-dac2709832e8","order_by":5,"name":"Kaito Hashimoto","email":"","orcid":"","institution":"Ritsumeikan University","correspondingAuthor":false,"prefix":"","firstName":"Kaito","middleName":"","lastName":"Hashimoto","suffix":""},{"id":595595717,"identity":"a5237ec0-f40a-49f4-9e66-49f4dedc5891","order_by":6,"name":"Toshiyuki Kurihara","email":"","orcid":"","institution":"Ritsumeikan University","correspondingAuthor":false,"prefix":"","firstName":"Toshiyuki","middleName":"","lastName":"Kurihara","suffix":""},{"id":595595719,"identity":"b71efda3-15d1-4cc5-ab3f-da71921e8084","order_by":7,"name":"Takeshi Hashimoto","email":"","orcid":"","institution":"Ritsumeikan University","correspondingAuthor":false,"prefix":"","firstName":"Takeshi","middleName":"","lastName":"Hashimoto","suffix":""},{"id":595595720,"identity":"d7c1a153-0b66-428b-91a0-4af4419994e1","order_by":8,"name":"Kiyoshi Sanada","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEklEQVRIiWNgGAWjYBACCTDJxiDH3gCkE8A8RhCTgZmQFmOeAyAtCSRoSewBaYFagx9I9h9+9uBHmV16D/sBtg8Pf9Qlrm1vbmD4UcPAbo5Di7REmrlhz7nk3B6eBOYZCQmHE7edOdjA2HOMgdmyAbsWOQkGMwneNubc/RJA1yckHEjcdiOxgYG3gYHZ4AAOLfzHv0n+batP54FoqUvcdv9hA+NfPFqkGXLMpHnbDidAtTADbWFsYMZni+SMnDJpmXPHDXt4EpsZEtIOG287k9hwWOaYBE6/SJw/vk3yTVm1PA/74cOMP2zqZLcdP/7w4Zsam2RcIYYEGBGmAp0kkWxAWAsasCNdyygYBaNgFAxTAABEcVcv2GtfOAAAAABJRU5ErkJggg==","orcid":"","institution":"Ritsumeikan University","correspondingAuthor":true,"prefix":"","firstName":"Kiyoshi","middleName":"","lastName":"Sanada","suffix":""}],"badges":[],"createdAt":"2026-02-11 04:08:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8846872/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8846872/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103438906,"identity":"7c99f370-fbee-4c2c-901c-e191c1ecde8e","added_by":"auto","created_at":"2026-02-25 16:56:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":18531,"visible":true,"origin":"","legend":"\u003cp\u003eAssociation between DS and step count (≥4,000/\u0026lt;4,000 steps) with SF. BMI: body mass index; DS: depressive symptoms; SF: social frailty. The error bars indicate 95% confidence intervals.\u003c/p\u003e","description":"","filename":"Onlinefloatimage11.png","url":"https://assets-eu.researchsquare.com/files/rs-8846872/v1/3aeacafab438dd5f35a3756c.png"},{"id":103438928,"identity":"616a5b98-9178-409d-a319-0d47b6efeff6","added_by":"auto","created_at":"2026-02-25 16:56:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":802273,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8846872/v1/e9a2167e-b47b-4723-a8ae-18e9eb1517a9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Overlap of depressive symptoms and low physical activity affects the risk of social frailty in Japanese community-dwelling older adults","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFrailty is common among older adults and is associated with an increased risk of falls, disability, hospitalization, and mortality\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. While most studies have focused on its physical aspects, frailty involves also social factors\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. One systematic review has shown that social frailty (SF) is significantly associated with adverse outcomes such as mortality and functional decline\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. As SF increases the use of medical and long-term care services, its prevention is essential for extending healthy life expectancy and reducing healthcare costs. Moreover, the prevalence of SF tends to exceed that of physical or cognitive frailty and has continued to increase in recent years\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, underscoring the need to identify factors that contribute to its prevention and early intervention.\u003c/p\u003e \u003cp\u003eFocusing on depressive symptoms (DS) may be particularly effective when considering strategies to prevent SF. A recent systematic review identified DS as one of the most frequently examined and consistently reported correlates of SF\u003csup\u003e7\u003c/sup\u003e. Moreover, a comparative study evaluating DS in relation to sarcopenia, oral frailty, and SF demonstrated that SF showed the strongest association with DS\u003csup\u003e8\u003c/sup\u003e. Taken together, these findings suggest that clarifying the relationship between DS and SF may yield important insights for developing effective prevention strategies.\u003c/p\u003e \u003cp\u003eIn addition to psychological factors such as DS, physical activity (PA) has also been identified as a key correlate of SF\u003csup\u003e7\u003c/sup\u003e. More recently, the combined presence of chronic back pain and low step counts has been reported to increase the risk of SF\u003csup\u003e9\u003c/sup\u003e. Moreover, engaging in routine outdoor mobility is considered a relatively simple health-promoting behavior for older adults, especially when compared with other lifestyle behaviors such as smoking cessation, structured exercise, or maintaining a healthy diet\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Taken together, these findings indicate that low PA is negatively associated with SF and represents a feasible and accessible behavior for older adults to incorporate into their daily lives.\u003c/p\u003e \u003cp\u003ePA can be assessed either objectively using accelerometers or subjectively through self-reported questionnaires. Although both methods are widely accepted worldwide, a systematic review examining the associations between DS, and PA reported that subjectively assessed PA tends to be overestimated, whereas sedentary time tends to be underestimated compared with objectively measured PA. Moreover, this discrepancy was particularly pronounced among individuals with DS\u003csup\u003e11\u003c/sup\u003e. Considering these tendencies, it is desirable to objectively assess PA when examining its association with SF.\u003c/p\u003e \u003cp\u003eHowever, no studies have yet examined how the combination of DS and objectively measured PA assessed by accelerometers is associated with SF, nor have they evaluated their potential interaction effects.\u003c/p\u003e \u003cp\u003eTherefore, the present study aimed to investigate the relationships among DS, objectively measured PA, and SF in community-dwelling older adults, and to examine whether the coexistence of DS and low PA has an interactive association with SF\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and Participants\u003c/h2\u003e \u003cp\u003eThis cross-sectional study was conducted among community-dwelling older adults residing in Usa City, Oita Prefecture, and Nagahama City, Shiga Prefecture, Japan. The recruitment period was from July 5, 2021, to August 23, 2023, for Usa City, Oita Prefecture, and from November 26, 2022, to March 6, 2024, for Nagahama City Shiga Prefecture. Participants were verbally informed about the study\u0026rsquo;s purpose and procedures.\u003c/p\u003e \u003cp\u003e A total of 215 participants (73 men and 142 women) agreed to participate and provided written informed consent. The following exclusion criteria were applied: active or suspected COVID-19 infection; inability to complete the questionnaire due to cognitive decline; certification for long-term care (care level\u0026thinsp;\u0026ge;\u0026thinsp;1); history of psychiatric illness; history of orthopedic surgery or movement restrictions; determination by a physician that participation was inappropriate due to illness; missing data on DS or SF; and insufficient wear time of the tri-axial accelerometer. After applying these criteria, 147 participants (55 men and 92 women; mean age, 74.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8 years) were included in the final analysis.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e This study was approved by the Ethics Review Committee for Medical Research Involving Human Subjects at Ritsumeikan University (approval number: BKC-LSMH-2022-075-1). All procedures were conducted in accordance with the principles of the Declaration of Helsinki and relevant institutional guidelines and regulations. Participants were informed of the study purpose and procedures both verbally and in writing. They were notified that participation was voluntary, that they could decline to answer any question or withdraw from the study at any time without penalty, and that all data would be anonymized to ensure confidentiality. Participants provided written informed consent prior to completing the study questionnaire. Written informed consent was obtained from all participants.\u003c/p\u003e\n\u003ch3\u003eDepressive Symptoms\u003c/h3\u003e\n\u003cp\u003eDS were assessed using the 15-item Japanese version of the Geriatric Depression Scale (GDS-15-J), a self-administered questionnaire\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. The GDS-15-J has been validated for use in cross-cultural research, including studies involving older Japanese adults\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Participants who completed all 15 items were included in the analysis, and a score of \u0026ge;\u0026thinsp;6 was used to define the presence of DS, based on previous research\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003ePhysical Activity (PA)\u003c/h3\u003e\n\u003cp\u003ePA was evaluated based on the number of steps measured using an Active Style Pro (HJA-750C, Omron Healthcare, Kyoto, Japan), a device equipped with a tri-axial accelerometer. This device is smaller (40 \u0026times; 52 \u0026times; 12 mm; 23 g including battery) than the first model (Active Style Pro HJA-350IT)\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e; however, the algorithm remains unchanged\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. The average number of daily steps was calculated, and participants were classified into two groups according to their step counts: \u0026ge;4,000 and \u0026lt;\u0026thinsp;4,000 steps per day. The cutoff of 4,000 steps was adopted because it is used as a benchmark for all-cause mortality in older adults (17), and previous studies have also examined this threshold in relation to both physical (18) and psychological (19) health outcomes. Moreover, this criterion is considered a practical and easily interpretable target for use in community and clinical settings (17). Participants were instructed to wear the accelerometer on either side of the waist for seven consecutive days, removing it only during sleep or water-related activities such as swimming, bathing, or showering. Following established guidelines for measuring habitual PA in older adults, data were considered valid when participants had at least four days with a minimum wear time of 10 hours per day (20). This accelerometer protocol (\u0026ge;\u0026thinsp;4 days, \u0026ge;\u0026thinsp;10 hours/day) has been validated and is widely accepted in previous studies (15, 16).\u003c/p\u003e\n\u003ch3\u003eSocial Frailty (SF)\u003c/h3\u003e\n\u003cp\u003eSF was assessed using five components : \u0026ldquo;going out less frequently compared with last year\u0026rdquo; (yes), \u0026ldquo;sometimes visiting friends\u0026rdquo; (no), \u0026ldquo;feeling helpful toward friends or family\u0026rdquo; (no), \u0026ldquo;living alone\u0026rdquo; (yes), and \u0026ldquo;talking with someone every day\u0026rdquo; (no). Participants were classified into three categories according to the number of applicable components: Non-SF (0 components), Pre-SF (1 component), and SF (2 or more components) (4).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCovariates\u003c/h2\u003e \u003cp\u003eBased on previous studies, potential confounders were identified as follows: age, sex, body mass index (BMI), and accelerometer wear time (20).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were expressed as mean (\u0026plusmn;\u0026thinsp;standard deviation), and categorical variables were expressed as numbers (percentages). Participants were classified into two categories for each factor: step count DS (no/yes) and (\u0026ge;\u0026thinsp;4,000/\u0026lt;4,000 steps per day). Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test was used to compare continuous variables, and the chi-square test or Fisher\u0026rsquo;s exact test was applied to compare categorical variables. A two-way analysis of covariance (ANCOVA) was conducted with DS (no/yes) and step count (\u0026ge;\u0026thinsp;4,000/\u0026lt;4,000) as independent variables, and the total number of positive SF components (range: 0\u0026ndash;5) as the dependent variable. Age, sex, BMI, and accelerometer wear time were included as covariates, and simple main effects were used to assess the main effects of each factor. Bonferroni correction was applied for multiple comparisons. In addition, for Fisher\u0026rsquo;s exact test examining the distribution of responses for each of the five SF components, participants were divided into four groups according to the combination of step count (\u0026ge;\u0026thinsp;4,000/\u0026lt;4,000) and DS (no/yes). All statistical analyses were performed using SPSS Statistics version 29 for Mac (IBM Japan, Tokyo, Japan). Statistical significance was set at a two-tailed \u003cem\u003ep\u003c/em\u003e value of \u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant characteristics were compared between the \u0026ldquo;No DS\u0026rdquo; and \u0026ldquo;DS\u0026rdquo; groups, and between the \u0026ldquo;\u0026ge;4,000 steps\u0026rdquo; and \u0026ldquo;\u0026lt;4,000 steps\u0026rdquo; groups, using Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test for continuous variables and the chi-square test or Fisher\u0026rsquo;s exact test for categorical variables (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the total sample of 147 participants, the mean GDS-15-J score was 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6, the average daily step count was 5,336.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2,604.7 steps, and the proportions of SF categories were as follows: Non-SF, n\u0026thinsp;=\u0026thinsp;67 (45.6%); Pre-SF, n\u0026thinsp;=\u0026thinsp;49 (33.3%); and SF, n\u0026thinsp;=\u0026thinsp;31 (21.1%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of Participants\u0026rsquo; Characteristics Between the No DS and DS groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eNo DS \u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;128, 87.1%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eDS \u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;19, 12.9%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.941\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.337\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e46 (35.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e9 (47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e82 (64.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e10 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercentage of SF, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e63 (49.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e4 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e44 (34.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e5 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e21 (16.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e10 (52.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparisons of Participants\u0026rsquo; Characteristics Between the \u0026ge;\u0026thinsp;4,000 and \u0026lt;\u0026thinsp;4,000 Steps Groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;4,000 Steps\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e\u0026lt;4,000 Steps\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;104, 70.7%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;43, 29.3%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e77.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.733\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e38 (36.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e17 (39.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e66 (63.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e26 (60.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.785\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercentage of SF, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.027\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e54 (51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e13 (30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-SF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e33 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e16 (37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e17 (16.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003e17 (32.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWearing time (min/day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e798.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e106.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e787.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026plusmn;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e97.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.582\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA two-way ANCOVA was performed to examine how DS and step count (\u0026ge;\u0026thinsp;4,000/\u0026lt;4,000 steps), both individually and in combination, were associated with the risk of SF. Based on the combination of DS and step count, participants were categorized into four groups: No DS\u0026thinsp;+\u0026thinsp;\u0026ge;\u0026thinsp;4,000 steps (n\u0026thinsp;=\u0026thinsp;91, 61.9%), DS\u0026thinsp;+\u0026thinsp;\u0026ge;\u0026thinsp;4,000 steps (n\u0026thinsp;=\u0026thinsp;13, 8.8%), No DS\u0026thinsp;+\u0026thinsp;\u0026lt;\u0026thinsp;4,000 steps (n\u0026thinsp;=\u0026thinsp;37, 25.2%), and DS\u0026thinsp;+\u0026thinsp;\u0026lt;\u0026thinsp;4,000 steps (n\u0026thinsp;=\u0026thinsp;6, 4.1%). The ANCOVA, adjusted for age, sex, BMI, and accelerometer wear time, revealed a significant interaction between DS and step count on the number of positive SF components (P\u0026thinsp;=\u0026thinsp;0.006, η\u0026sup2; = 0.054). Significant simple main effects were observed for both DS and step count, with higher SF scores in participants with DS (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, η\u0026sup2; = 0.205) and in those walking fewer than 4,000 steps per day (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001, η\u0026sup2; = 0.100). Post hoc Bonferroni analyses indicated that step count did not significantly affect SF among participants without DS (P\u0026thinsp;=\u0026thinsp;0.081), whereas participants with DS and low step counts showed significantly higher SF scores compared with those with higher step counts (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The mean number of positive SF components in the four groups classified by DS and step count was 0.59 (95% CI: 0.40\u0026ndash;0.79) in the No DS\u0026thinsp;+\u0026thinsp;\u0026ge;\u0026thinsp;4,000 steps group, 1.34 (95% CI: 0.82\u0026ndash;1.86) in the DS\u0026thinsp;+\u0026thinsp;\u0026ge;\u0026thinsp;4,000 steps group, 0.92 (95% CI: 0.61\u0026ndash;1.23) in the No DS\u0026thinsp;+\u0026thinsp;\u0026lt;\u0026thinsp;4,000 steps group, and 3.08 (95% CI: 2.32\u0026ndash;3.85) in the DS\u0026thinsp;+\u0026thinsp;\u0026lt;\u0026thinsp;4,000 steps group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn addition, to examine the association of the four groups\u0026mdash;\u0026ldquo;No DS\u0026thinsp;+\u0026thinsp;\u0026ge;\u0026thinsp;4,000 steps,\u0026rdquo; \u0026ldquo;DS\u0026thinsp;+\u0026thinsp;\u0026ge;\u0026thinsp;4,000 steps,\u0026rdquo; \u0026ldquo;No DS\u0026thinsp;+\u0026thinsp;\u0026lt;\u0026thinsp;4,000 steps,\u0026rdquo; and \u0026ldquo;DS\u0026thinsp;+\u0026thinsp;\u0026lt;\u0026thinsp;4,000 steps\u0026rdquo;\u0026mdash;with each of the five components of SF, Fisher\u0026rsquo;s exact test was performed. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the DS\u0026thinsp;+\u0026thinsp;\u0026lt;\u0026thinsp;4,000 steps group consistently showed the highest proportion of participants meeting each SF component. Significant group differences were observed in four of the five components\u0026mdash;\"going out less frequently compared with last year,\u0026rdquo; \u0026ldquo;feeling helpful toward friends and family,\u0026rdquo; \u0026ldquo;living alone,\u0026rdquo; and \u0026ldquo;talking with someone every day\u0026rdquo;\u0026mdash;whereas no significant difference was found for \u0026ldquo;sometimes visiting friends\u0026rdquo;.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociations Between DS and Step Count (\u0026lt;\u0026thinsp;4,000/\u0026ge;4,000 steps) and Each Component of SF\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo DS\u0026thinsp;+\u0026thinsp;\u0026ge;\u0026thinsp;4000 Steps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDS\u0026thinsp;+\u0026thinsp;\u0026ge;\u0026thinsp;4000 Steps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo DS\u0026thinsp;+\u0026thinsp;\u0026lt;\u0026thinsp;4000 Steps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDS\u0026thinsp;+\u0026thinsp;\u0026lt;\u0026thinsp;4000 Steps\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;147\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;91 (61.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;13 (8.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;37 (25.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;6 (4.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGoing out less frequently\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ecompared with last year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u0026thinsp;=\u0026thinsp;109 (74.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (82.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (46.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26 (70.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u0026thinsp;=\u0026thinsp;38 (25.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (17.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (53.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (29.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSometimes visiting friends\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u0026thinsp;=\u0026thinsp;96 (65.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65 (71.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (61.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (56.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.139\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u0026thinsp;=\u0026thinsp;51 (34.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (28.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (38.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (43.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFeeling helpful toward \u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003efriends and family\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u0026thinsp;=\u0026thinsp;134 (91.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (95.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (69.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36 (97.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u0026thinsp;=\u0026thinsp;13 (8.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (4.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (30.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (66.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eLiving alone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u0026thinsp;=\u0026thinsp;132 (89.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e84 (92.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (92.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33 (89.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u0026thinsp;=\u0026thinsp;15 (10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTalking with someone\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e everyday\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u0026thinsp;=\u0026thinsp;138 (93.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88 (96.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12 (92.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35 (94.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u0026thinsp;=\u0026thinsp;9 (6.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (5.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3 (50%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eBMI: body mass index; DS: depressive symptoms; SF: social frailty\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis cross-sectional study examined the combined association of DS and low daily step count (\u0026lt;\u0026thinsp;4,000 steps) on SF. To the best of our knowledge, this is the first study to simultaneously investigate the independent associations of DS and daily step count with SF, as well as their interactive effect. In the present study, the prevalence of DS was 12.9%, the proportion of participants walking fewer than 4,000 steps per day was 29.3%, the mean daily step count was 5,336.9 steps, and the prevalence of SF was 21.1%. The prevalence of DS observed in our sample is consistent with previous research using the GDS-15, which has reported an estimated prevalence of approximately 13%\u003csup\u003e21\u003c/sup\u003e. However, it is lower than the pooled prevalence of 19.2% (95% CI: 13.0\u0026ndash;27.5) reported in a systematic review of DS among older adults\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. These findings suggest that the participants in this study may have been relatively mentally healthy, possibly due to the strict exclusion criteria applied or differences in the depression measures used across studies. In contrast, the mean daily step count\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e and the prevalence of SF\u003csup\u003e7,25\u003c/sup\u003e align closely with values reported in prior studies.\u003c/p\u003e \u003cp\u003eIn this study, both DS and a low daily step count were independently associated with an increased risk of SF. Furthermore, individuals exhibiting both factors tended to show a particularly high risk of SF, suggesting that their overlap may indicate a more vulnerable subgroup among older adults. A notable strength of this study is that participants presenting with both DS and fewer than 4,000 steps per day exhibited a mean number of positive SF components whose lower bound of the 95% confidence interval exceeded the threshold of two components used to define SF, suggesting a particularly high-risk profile. Furthermore, a previous study focusing on nursing home residents examined the mediating role of DS in the relationship between sedentary behavior (SB) and SF, demonstrating that prolonged SB may exacerbate SF through the worsening of DS\u003csup\u003e26\u003c/sup\u003e. Taken together with this prior evidence, the present findings suggest that the coexistence of DS and low PA\u0026mdash;such as low step counts or prolonged sedentary time\u0026mdash;may represent a particularly high-risk condition for the development of SF. However, only six participants fell into this category, which inevitably reduced the statistical power. Increasing the sample size will therefore be essential to draw more robust conclusions. Nevertheless, a systematic review has confirmed the wide use and predictive validity of this five-item SF scale across numerous studies, supporting the relevance of the outcomes observed in the present analysis\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. In addition, one previous systematic review identified depression as the most frequently reported risk factor for SF (cited in eight studies), followed by physical inactivity as the third most common factor (cited in three studies)\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Thus, the findings of the present study align with and extend the existing literature.\u003c/p\u003e \u003cp\u003ePrevious studies have reported that DS substantially increase the risk of SF, with an odds ratio of 2.24 (95% CI: 1.45\u0026ndash;3.44)\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Another study demonstrated that each one-point increase in the GDS-15 score was associated with a 1.33-fold higher odds of SF (95% CI: 1.19\u0026ndash;1.49)\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. The findings of the present study further support these earlier reports by reinforcing the evidence that DS are strongly associated with SF. Taken together with the current results, these findings suggest that reducing depressive tendencies may be a key strategy for preventing SF. Regarding PA, a previous investigation reported that \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eexercise-based interventions\u003c/span\u003e improved SF\u003csup\u003e30\u003c/sup\u003e, and physical frailty has also been identified as a risk factor for SF\u003csup\u003e31\u003c/sup\u003e. Additionally, studies on habitual PA have shown that performing low-to-moderate PA less than once per week increases the risk of SF\u003csup\u003e32\u003c/sup\u003e. Moreover, evaluations using the Kihon Checklist\u0026mdash;including social aspects\u0026mdash;have demonstrated that individuals classified as frail show significantly lower step counts than those classified as non-frail, with frail individuals averaging approximately 3,470 steps per day, partially consistent with the present findings\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Conversely, other research has indicated that walking fewer than 6,000 steps per day becomes a risk factor for SF when accompanied by chronic low back pain\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. This study also suggested that the volume of steps, rather than the intensity of PA, may play a more important role in determining SF risk. Considering both previous literature and the present findings, exercise prescriptions aimed at preventing SF may need to incorporate not only short-term intervention approaches but also strategies that promote sustained increases in daily activity, while also taking into account DS and chronic pain. In addition, systematic reviews have identified 4,000 steps per day as an effective threshold for reducing all-cause mortality\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. In this study, step counts above 4,000 per day were statistically associated with a lower risk of SF; however, the clinical significance of this association remains to be clarified.\u003c/p\u003e \u003cp\u003eFurthermore, in considering the relationships among DS, PA, and SF, it is important to acknowledge the possibility of reverse causality. A previous study has suggested that SF may itself serve as a risk factor for DS\u003csup\u003e34\u003c/sup\u003e. In addition, SF has been reported as a predictor of physical frailty\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, implying that social restrictions may negatively affect mental health and reduce opportunities for engaging in PA. In addition, several studies have suggested that improving social health requires not only individual efforts but also broader community- and society-level support\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Given these complex and potentially bidirectional relationships, large-scale and longitudinal investigations will be essential to clarify the underlying pathways.\u003c/p\u003e \u003cp\u003eMoreover, the combined presence of DS and fewer than 4,000 daily steps was also associated with several individual components of SF. Although the number of participants in the overlapping group (n\u0026thinsp;=\u0026thinsp;6) was small and the results should therefore be interpreted cautiously, this group showed the highest percentage of applicability for each SF item. In particular, significant differences were found for four components\u0026mdash;\u0026ldquo;going out less frequently compared with last year,\u0026rdquo; \u0026ldquo;feeling helpful toward friends or family,\u0026rdquo; \u0026ldquo;living alone,\u0026rdquo; and \u0026ldquo;not talking with someone every day\u0026rdquo;\u0026mdash;all of which were negatively associated with DS and low step counts. Previous studies have demonstrated similar patterns. Research on mobility and mental health has reported negative associations between DS and the extent of one\u0026rsquo;s life-space mobility\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e as well as between neighborhood walkability and PA\u003csup\u003e39\u003c/sup\u003e. In addition, aspects related to loneliness and social isolation\u0026mdash;such as perceived lack of usefulness, living alone, and reduced conversational opportunities\u0026mdash;have been linked to lower life satisfaction and poorer physical health\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. Among older adults living in rural areas, living alone has further been associated with an increased risk of DS\u003csup\u003e41\u003c/sup\u003e. Conversely, one study has suggested that living alone may promote greater life-space mobility because individuals must perform daily activities independently, potentially increasing their movement relative to those living with others\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. These findings underscore the complexity of the relationships among social isolation, mobility, and psychosocial health. Given this complexity, examining each SF component individually may provide valuable insights for developing more targeted SF prevention strategies. However, to establish more precise and reliable evidence regarding these associations, larger sample sizes as well as intervention and longitudinal studies will be necessary.\u003c/p\u003e \u003cp\u003eAdditionally, several studies investigating exercise frequency and health outcomes have shown that, even when the frequency of activity is the same, engaging in group-based rather than individual exercise yields greater benefits for older adults. Group-based participation has been linked to a lower risk of falls\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e, enhanced cognitive function\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e, and better subjective health\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. When considered alongside these previous results, the findings of the present study further emphasize that achieving extended healthy life expectancy in older adults requires a comprehensive strategy that integrates physical, psychological, and social perspectives.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, its cross-sectional design limits the interpretation of causality, and reverse relationships\u0026mdash;such as SF affecting DS or PA\u0026mdash;cannot be ruled out. Longitudinal studies are needed to clarify causal pathways. Second, the sample size was small, particularly in the group with both DS and fewer than 4,000 steps per day (n\u0026thinsp;=\u0026thinsp;6), which restricted adjustment for confounders such as ADL, socioeconomic status. Larger samples will be required to enable more detailed analyses. Third, the study relied on voluntary participation, which may have resulted in a healthier sample and introduced selection bias. Additionally, the long recruitment periods in both regions were not adjusted for potential seasonal or temporal effects. Therefore, the observed associations between DS, step counts, and SF should be interpreted with caution.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study suggests that both DS and lower daily step count are individually associated with increased risk of SF. Notably, their coexistence may characterize a subgroup of older adults at particularly elevated risk for SF, highlighting the importance of addressing both factors in prevention strategies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the participants and municipal staff involved in the data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTomoya Shimabukuro (1,2,3,4,5), Masaki Nagamatsu (3,5), Tomohiro Nishimura (3,5), Aiko Imai (5), Keiko Kishigami (3), Kaito Hashimoto (3,5), Toshiyuki Kurihara (5), Takeshi Hashimoto (2,3,5), Kiyoshi Sanada (1,2,3,5)\u003c/p\u003e\n\u003cp\u003e1.Conceptualization; 2.Methodology; 3.Data curation; 4.Writing - Original Draft; 5.Writing - Review \u0026amp; Editing;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePlease contact corresponding author for data requests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for this paper.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFried, L. 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Exercising alone versus with others and associations with subjective health status in older Japanese: The JAGES Cohort Study. \u003cem\u003eSci. Rep.\u003c/em\u003e \u003cb\u003e6\u003c/b\u003e, 39151. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/srep39151\u003c/span\u003e\u003cspan address=\"10.1038/srep39151\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (2016).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"depressive symptoms, objectively-measured physical activity, social frailty","lastPublishedDoi":"10.21203/rs.3.rs-8846872/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8846872/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAlthough depressive symptoms (DS) and physical activity (PA) have each been associated with social frailty (SF), their combined effects remain unclear. This study examined the independent and interactive associations of DS and objectively measured PA with SF in community-dwelling older adults. This cross-sectional study included 147 adults aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years. DS were assessed using the Japanese version of 15-item Geriatric Depression Scale, and PA was measured objectively via accelerometer-based daily step counts, classified as \u0026lt;\u0026thinsp;4,000 or \u0026ge;\u0026thinsp;4,000 steps/day. SF was evaluated using the five-item criteria proposed by Makizako et al. A two-way analysis of covariance was performed with DS (yes/no) and step count (\u0026ge;\u0026thinsp;4,000/\u0026lt;4,000) as independent variables and the total number of positive SF components (0\u0026ndash;5) as the dependent variable, adjusting for relevant covariates. A significant interaction between DS and step count on SF was observed (P\u0026thinsp;=\u0026thinsp;0.006). Significant main effects were also found, with higher SF scores among participants with DS and those walking\u0026thinsp;\u0026lt;\u0026thinsp;4,000 steps/day (both P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings indicate that both DS and low PA are independently associated with SF, and that the overlap of these two factors may be linked to an increased risk of SF among older adults.\u003c/p\u003e","manuscriptTitle":"Overlap of depressive symptoms and low physical activity affects the risk of social frailty in Japanese community-dwelling older adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-25 16:55:48","doi":"10.21203/rs.3.rs-8846872/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"317929400715419417218240586899515482354","date":"2026-05-18T20:02:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-28T11:59:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"327272385041885497216318127882193527184","date":"2026-02-28T03:05:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-20T13:18:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-20T13:15:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-19T12:01:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-17T00:54:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-02-17T00:50:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4bdebe88-757e-4d03-b4ab-7ad01d9ce77e","owner":[],"postedDate":"February 25th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"317929400715419417218240586899515482354","date":"2026-05-18T20:02:35+00:00","index":108,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":63372613,"name":"Health sciences/Diseases"},{"id":63372614,"name":"Health sciences/Health care"},{"id":63372615,"name":"Health sciences/Medical research"},{"id":63372616,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2026-02-25T16:55:48+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-25 16:55:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8846872","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8846872","identity":"rs-8846872","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}