Chronic atrophic gastritis (CAG) is a well-established precursor of intestinal gastric cancer. However, data on incidence of CAG are rare, especially from population-based studies. The aim of this analysis was to estimate the incidence of CAG in a large population-based study among older adults from Germany and to identify major risk factors associated with its development. In the baseline and 5-year follow-up examinations of the ESTHER study, serological measurements of pepsinogen (PG) I and II and Helicobacter pylori antibodies were performed in 5,229 women and men, aged 50-74 years at baseline. Information on additional potential risk factors was obtained by questionnaire. CAG was defined by PGI < 70 ng/mL and PGI/PGII < 3. In total, there were 58 (1.1%) incident CAG cases. CAG incidence increased with increasing age from 0.5% in age group 50-54 years to 2.1% in age group 70-74 years. Seropositivity with H. pylori was strongly associated with CAG incidence, with adjusted odds ratios of 5.0 [95% confidence interval (CI): 1.6-15.8] and 11.3 (95% CI: 4.2-30.0) for participants with cytotoxin associated gene A (cagA) negative and cagA positive H. pylori infection at both baseline and follow-up compared to those without H. pylori infection, respectively. Gender, education, smoking, alcohol consumption and family history of gastric cancer were not significantly associated with CAG incidence. Incidence of CAG is rather low in the German population. Older age and infection with H. pylori are key risk factors for the development of CAG.