REVIEW

Healthy Aging—Nutrition Matters: Start Early and

Screen Often
Susan B Roberts,1 Rachel E Silver,1 Sai Krupa Das,1 Roger A Fielding,1 Cheryl H Gilhooly,1 Paul F Jacques,1 Jennifer M Kelly,1
Joel B Mason,1 Nicola M McKeown,1 Meaghan A Reardon,1 Sheldon Rowan,1 Edward Saltzman,2 Barbara Shukitt-Hale,1
Caren E Smith,1 Allen A Taylor,1 Dayong Wu,1 Fang Fang Zhang,2 Karen Panetta,3 and Sarah Booth1
1 JeanMayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, MA, USA; 2 Friedman School of Nutrition Science and Policy, Tufts
University, Boston, MA, USA; and 3 School of Engineering, Tufts University, Medford, MA, USA

ABSTRACT
The amount of time spent in poor health at the end of life is increasing. This narrative review summarizes consistent evidence indicating that healthy
dietary patterns and maintenance of a healthy weight in the years leading to old age are associated with broad prevention of all the archetypal
diseases and impairments associated with aging including: noncommunicable diseases, sarcopenia, cognitive decline and dementia, osteoporosis,
age-related macular degeneration, diabetic retinopathy, hearing loss, obstructive sleep apnea, urinary incontinence, and constipation. In addition,
randomized clinical trials show that disease-specific nutrition interventions can attenuate progression—and in some cases effectively treat—
many established aging-associated conditions. However, middle-aged and older adults are vulnerable to unhealthy dietary patterns, and typically
consume diets with inadequate servings of healthy food groups and essential nutrients, along with an abundance of energy-dense but nutrient-
weak foods that contribute to obesity. However, based on menu examples, diets that are nutrient-dense, plant-based, and with a moderately low
glycemic load are better equipped to meet the nutritional needs of many older adults than current recommendations in US Dietary Guidelines. These
summary findings indicate that healthy nutrition is more important for healthy aging than generally recognized. Improved public health messaging
about nutrition and aging, combined with routine screening and medical referrals for age-related conditions that can be treated with a nutrition
prescription, should form core components of a national nutrition roadmap to reduce the epidemic of unhealthy aging. Adv Nutr 2021;12:1438–
1448.

Keywords: aging, nutrition, noncommunicable diseases, sarcopenia, cognition, age-related macular degeneration, diabetic retinopathy,
obstructive sleep apnea, urinary incontinence, constipation

Background: Living Longer Compared with evident during the current coronavirus disease-19 (COVID-
Living Healthier 19) pandemic, because the association of COVID-19 severity
Leading a long and healthy life is a goal that is embraced and age is substantially weakened when comorbidities are
worldwide (1), and fear of death has long been proposed taken into account (8), and highlights the need to identify
to be a defining characteristic of humans (2, 3). From these ways to support healthy aging (9). This review summarizes
perspectives, the 30-y increase in life expectancy during the current knowledge of the underrecognized role of diet in
20th century is a transformational advance. Furthermore, life prevention and treatment of diseases and functional losses
expectancy continues to increase for adults aged >65 y (4), that become increasingly prevalent during aging, with a focus
and adults >85 y are the fastest growing demographic (5). on data available from research conducted in North America
However, a little-recognized corollary of the recent trends and Europe.
is that older adults are now living in an ill and disabled There is no single definition of “healthy aging” or the
state for longer: the mean duration of disability at the end related term “healthspan” (1, 10, 11), but it is generally
of life was just 5.3 y in the 1960s (6), whereas more recent taken to mean the absence of the archetypal diseases and
calculations indicate that the duration of poor health and functional impairments associated with old age. The specific
functional impairments has increased from 8.9 to 10.2 y diseases and functional losses associated with aging have
between 1990 and 2017 (7). This extension of unhealthy been defined as those conditions where there is a quadratic
life is unprecedented in human history, and presents major relation between disease prevalence and chronological age
personal and public health burdens. This is particularly (12). These include: sarcopenia [loss of skeletal muscle (13)],

1438 
C The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition. All rights reserved. For permissions, please e-mail:

journals.permissions@oup.com. Adv Nutr 2021;12:1438–1448; doi: https://doi.org/10.1093/advances/nmab032.

wasting, and osteoporosis (14, 15), which are linked to frailty
and falls (16); impaired cognitive function and increased
risk of dementia (17, 18); impaired vision via age-related
macular degeneration, cataracts, and diabetic retinopathy
(19); hearing loss (20); noncommunicable diseases (NCDs)
such as type 2 diabetes, cardiovascular disease, and cancer
(12); obstructive sleep apnea (21, 22) and poor sleep quality
(22, 23); and urinary incontinence (24) and chronic consti-
pation (25, 26). The prevalence of these problems is often
>50% in adults aged >85 y, especially in racial and ethnic
minorities (26–28). The proposed underlying mechanisms
of the aging-associated pathologies include inflammation,
oxidative stress, and limited capacity for removal of damaged
proteins and DNA repair (29–34). Because these changes
affect all organ systems, aging with multiple comorbidities is
the norm (35, 36).

Current Status of Knowledge

Unhealthy nutrition throughout life, but especially in
old age
American adults of all ages typically eat a broadly unhealthy
FIGURE 1 Dietary adequacy in different age-groups. (A)
diet relative to national recommendations (37). Figure 1A Percentage of adults consuming below the estimated average
illustrates the percentage of adults in different age groups requirement (EAR), or at or below the adequate intake (AI) when
who consume less than the estimated average requirements EAR values are not available, based on reported usual intakes in the
(EARs) of micronutrients (38). Mean intakes of choline, NHANES 2009–2012. Includes nonconsumers of supplements
vitamin B-6, zinc, magnesium, and calcium are increasingly examined in NHANES 2009–2012. Figure adapted from published
inadequate as adults age. In addition, 21% of women and 13% information (39, 43). (B) Percentage of adults consuming above,
of men aged >70 y consume less than the RDA for protein below, or at the recommended intakes for food groups in the
(39), which is an important concern because emerging evi- 2020–2025 Dietary Guidelines (44) by sex and age group, based on
dence suggests that protein levels higher than the RDA (1.0– dietary data obtained from the 2007–2010 NHANES. A: Whole
grains, B: Dairy, C: Seafood, D: Vegetables, E: Fruit, F: Oils, G: Nuts,
1.2 g/kg) can be optimal for older adults to prevent muscle
seeds, soy, H: Protein, I: Meat, poultry, eggs, J: Refined grains, K:
wasting (40) due to factors such as decreased muscle uptake
SoFAS. Note: Total vegetables includes beans and peas. Protein
of dietary amino acids and reduced anabolic signaling for excludes beans and peas (45). SoFAS, solid fats and added sugars.
protein synthesis (41). These findings of broadly low intakes
of essential nutrients throughout adult life and especially in
older adults are based on self-reported diet, but are consistent
(46), indicating this is likely a global, rather than a specifically
with nationally representative biochemical data showing
US, phenomenon.
that 30–36% of older adults have ≥1 micronutrients in the
The dietary patterns of older adults are also broadly
deficient range (42). Low micronutrient intakes have also
inadequate compared with food-based recommendations.
been documented in older adults living in other countries
Figure 1B shows that adults of all ages typically consume
less than the 2020–2025 Dietary Guidelines recommended
Supported by the AARP Foundation, and the USDA, Agricultural Research Service under
Cooperative Agreement No. 58-8050-7-005. Any opinions, findings, conclusions, or
portions of most healthy food groups including whole grains,
recommendations expressed in this publication are those of the authors and do not necessarily dairy, seafood, vegetables, fruits, nuts, seeds, and legumes
reflect the views of the USDA. (44). The figure also shows consumption of excess amounts
Author disclosures: SBR receives grant support from Danone, serves on the advisory board of
Integrative Phenomics, and founded www.theidiet.com. RAF serves on advisory boards for
of meats, saturated fats, and added sugars compared with
Amazentis, Segterra, Acella Health, Juvicell, and Biophytis, has consulted for Pfizer, GSK, Nestlé, the recommendations. Using currently available nutritional
and Rejuvenate Biomed, and has equity in Axcella Health, Juvicell, and Segterra. PFJ receives benchmarks, the majority of adults aged >50 y consume
grant support from Danone and serves on the Danone North America Essential Dairy and
Plant-Based Advisory Board. JBM serves on the advisory board of Care/of; NMM receives grant
diets that fall far short of recommendations (37, 39, 43).
support from Danone, Proctor & Gamble, ILSI North America, and the General Mills Bell Some groups are especially vulnerable, including low-income
Institute of Health & Nutrition, serves on the advisory board of the Whole Grains Council, and and minority populations (37), those participating in the
has consulted for General Mills, Canned Manufacturers Association, Nestlé Nutrition Fund, and
Alliance for Potato Research & Education. All other authors report no conflicts of interest.
national supplemental nutrition assistance program (47),
Supplemental Tables 1 and 2 and Supplemental Information on Menu Calculations are and older adults with obesity (41% of adults >60 y)
available from the “Supplementary data” link in the online posting of the article and from the (48, 49).
same link in the online table of contents at https://academic.oup.com/advances/.
Address correspondence to SBR (e-mail: susan.roberts@tufts.edu).
In relation to these observations, it should be noted that
Abbreviations used: COVID-19, coronavirus disease-19; DASH, Dietary Approaches to Stop current dietary recommendations for older adults are largely
Hypertension Trial; EAR, Estimated Average Requirement; NCD, noncommunicable disease. based on requirements measured in young adults. Thus,

Nutrition for broadly healthy aging 1439

 US Dietary Guidelines for 2020–2025 (44) give examples
of healthy dietary patterns designed for all Americans, and
include portion guidelines for adults with requirements
of ≥1600 kcal/d (lower-calorie menus are illustrated for
children, who have different nutritional needs). However, as
illustrated in Figure 2, many older individuals, particularly
women, require <1600 kcal/d to maintain a healthy weight,
and some frail older adults will need as little as 1000 kcal/d
to maintain a healthy weight depending on their age,
weight, and height and health status. Thus, current Dietary
Guidelines do not provide adequate guidance on healthful
dietary patterns for the increasing population of older
adults.

FIGURE 2 Energy requirements for individuals in the healthy Functional losses are contributors to unhealthy
weight range at different ages. Data are based on the Institute of nutrition in older adults
Medicine’s equations for predicting energy requirements of There is a negative cycle between functional losses and in-
individuals with typical heights (for men: 1.58–1.9 m; for women: adequate nutrition in older adults that accelerates unhealthy
1.45–1.78 m), a BMI in the healthy range of 18.5–25 kg/m2 , and aging. Sarcopenia, the age-associated loss in skeletal muscle
sedentary or light activity levels (38). The dotted line represents the
mass and function, is a key underlying cause of decreases
lowest energy menu examples in the US Dietary Guidelines.
in movement, physiological capacity, and functional perfor-
mance, and increased disability and mortality observed with
further research is needed to refine essential nutrient and advancing age (55, 56). The causes of sarcopenia are multifac-
food group recommendations for healthy aging (50). Never- torial but include inadequate nutrition, low physical activity,
theless, empirical considerations suggest that mean require- inflammation, and multiple NCDs and other comorbidities
ments for protein and several micronutrients can increase (57, 58). Sarcopenia also has a profoundly negative impact on
during aging, with only a few energy-related vitamins (such nutritional status in older adults, because decreased muscle
as thiamin) decreasing (51–53). mass contributes to reduced energy requirements, and can
also limit the ability to shop for food and prepare meals (58).
Low energy requirements contribute to unhealthy As summarized below, poor vision in old age also limits
nutrition in older adults the capability to purchase, prepare, and consume healthy
An important yet underrecognized factor in unhealthy food. For example, many older adults cannot see clearly
dietary patterns in old age is that there is a large decrease the food on their plate. Similarly, reduced dental health,
in typical energy requirements as individuals age (54). taste, smell, and hunger are associated with aging and also
Figure 2 shows the Institute of Medicine’s estimated energy reduce the drive to eat (54, 59–62). Older adults are also
requirements of men and women of different ages and heights more likely to take medications that impact food intake
for the healthy weight range (BMI = 18.5–25.0 kg/m2 ), (63) and have digestive problems including gastric atrophy,
which were based on measurements of energy expenditure chronic constipation, and/or malabsorption (64, 65) that
using the gold-standard doubly labeled water method (38). negatively impact appetite and nutrient absorption. Older
The equations used to generate the figure are given in adults additionally have changes in homeostatic mechanisms
Supplemental Table 1. As shown, the decrease in energy regulating thirst sensation and renal water absorption,
requirements to maintain healthy weight during adult life resulting in a higher risk of dehydration, (66, 67), which can
is substantial, with a typical reduction of ≥500–700 kcal/d be exacerbated by the use of common diuretics and fear of
between early adulthood and late life in healthy women and incontinence due to limited mobility (68).
men. This creates the challenge that to meet the same or
increased absolute intakes of protein and micronutrients in a Socioeconomic factors are contributors to unhealthy
diet containing a diminishing level of energy, the proportion nutrition in older adults
of nutrient-dense foods in the diet has to keep increasing over In addition to physiological and genetic factors influencing
time, with a parallel decrease of greater magnitude in the nutritional status during aging, there are widely recognized
quantity of low-nutrient foods. In other words, a healthier demographic and social factors that increase the risk of
diet is needed in older age to counterbalance decreasing consuming an unhealthy diet as adults grow older. These
energy requirements. Supplemental Table 2 shows EARs for include poverty and food insecurity, which make it harder
protein and micronutrients as a percentage of 1000 kcal of to purchase the nutrient-rich foods that are both more
typical energy requirements, illustrating that the density of necessary and more expensive (69, 70). Older adults are also
most micronutrients needs to increase in older adults by 50%, more likely to live alone and be socially isolated, factors that
and by nearly 100% for nutrients that are required in greater limit food preparation and predict unhealthy dietary intake
absolute amounts. (61, 62).

1440 Roberts et al.

TABLE 1 Consistent evidence for nutrition parameters and prevention and treatment of common aging-associated diseases and
functional losses1

Prevention(derived from expert consensus Reduced disease progression and or

reports, or umbrella/systematic reviews, or remission(derived from expert consensus
meta analyses) reports, or powered randomized trials)
Musculoskeletal
Frailty/sarcopenia, risk falls • Healthy BMI (18.5–25 kg/m2 ) (71) • Specific nutrients: High protein: 1.3–1.5 g/kg
• Dietary patterns: “Prudent” (72), protein alone or combined with exercise
Mediterranean (73) (74–76)
• Specific nutrients: Recommended protein • For sarcopenic obesity: high-protein and
(77), high total antioxidants (40, 78) weight loss with or without exercise (79)
Osteoarthritis • Healthy BMI (80) • Weight loss (81)
Osteoporosis • Specific nutrients: Adequate intakes of • Specific nutrients: 1200 mg Ca + 800 IU
calcium (82), protein (83), vitamin D (84) vitamin D + weight-bearing exercise (85, 86)
Cognition
Cognitive decline • Healthy BMI (87) • Weight loss (88)
• Dietary patterns: Mediterranean diet (89, 90),
HEI, WHO’s Healthy Diet Indicator (91)
Dementia/Alzheimer disease • Healthy BMI (87)
• Dietary patterns: Mediterranean diet (90, 92)
• Specific nutrients: Low saturated fat (92, 93)
Sense-organ diseases
Age-related macular degeneration • Healthy BMI (7, 94) • Nutrients: High vitamins C + E, lutein,
• Dietary patterns: Mediterranean diet, oriental zeaxanthin, zinc, copper (96)
diet, low-glycemic-index diet (95)
Cataracts • Healthy BMI (97), healthy glycemic control in
type 2 diabetes (98)
• Specific nutrients: Multivitamin-mineral
supplement (99, 100)
Hearing loss • Healthy BMI (101) • Nutrients: Folic acid in individuals with high
• Dietary patterns: HEI, low-glycemic-index homocysteine (104)
carbohydrates (102, 103)
Noncommunicable diseases
Type 2 diabetes • Healthy BMI (105, 106) • Lifestyle intervention with weight loss,
• Dietary patterns: Mediterranean (107, 108), healthy diet, and exercise (105, 112, 113)
DASH, and HEI (109), plant-based (110), low • Dietary patterns: Mediterranean, plant based
glycemic index, and low glycemic load (111) (114, 115), low-carbohydrate (116, 117)
Cardiovascular disease • Healthy BMI, weight loss if obesity (105, • Weight loss with healthy diet, exercise (105,
106) 118)
• Dietary patterns: Mediterranean (107, 119, • Dietary patterns: Mediterranean (123), DASH
120), DASH, and HEI (121, 119, 109), (124)
plant-based (119) [not low-carbohydrate
(122)]
Cancers • Healthy BMI (125, 126)
• Dietary patterns: Mediterranean (107,
127–129, 120), DASH/HEI (109), plant-based
diet (130, 131)
Sleep
Obstructive sleep apnea • Healthy BMI (21) • Weight loss (132)
Gastrointestinal
Chronic constipation • Specific nutrients: Recommended fiber • Specific nutrients: Coarse wheat bran fiber,
intake, including coarse wheat bran fiber adequate fluid (133)
(133–135)
Urinary incontinence • Healthy BMI (136) • Weight loss (24)
1
DASH, Dietary Approaches to Stop Hypertension Trial; HEI, Healthy Eating Index.

Dietary patterns, nutrients, and weight management BMI with prevention of age-related diseases and functional
for prevention and treatment of aging-associated impairments. Table 1 also summarizes data from random-
diseases and conditions ized controlled trials of nutritional treatments for specific
Dietary patterns and nutrients. conditions.
Table 1 summarizes the evidence from recent consensus A variety of dietary patterns and indices have been
reports, umbrella and systematic reviews, and meta-analyses evaluated for their association with age-associated diseases
for the associations of specific dietary patterns, nutrients, and and conditions, including Mediterranean-style diets (137),

Nutrition for broadly healthy aging 1441

US Dietary Guidelines and the related Healthy Eating Index of deficiency due to chronic atrophic gastritis [present in
(138, 139), the WHO’s Healthy Diet Indicator (140), Dietary 30–50% of older adults (152)] and the widespread use of
Inflammatory Index (29), the MIND diet (141), and low gastric acid–blocking drugs that inhibit digestion of food-
glycemic index carbohydrate and high-fiber diets (142). based vitamin B-12 to an absorbable form (153).
These dietary profiles are associated with prevention of
a broad range of age-associated diseases and conditions Weight management.
including: frailty and risk of falls, osteoporosis, cogni- BMI values above the healthy range (>25.0) are strongly
tive decline, dementia, age-related macular degeneration, associated with increased risk of a wide range of age-
cataracts, hearing loss, NCDs (including type 2 diabetes, associated diseases (Table 1). Older adults with obesity
cardiovascular disease, and many cancers), and chronic [41% of adults >60 y (154)] are at higher risk of frailty
constipation (72, 73, 89–92, 95, 102, 103, 107, 108, 121, and osteoarthritis, and consequently have more functional
119, 109, 127–129, 120, 130, 131). In some cases, these limitations than those who are not obese (155). Obesity also
associations are confirmed with randomized trials (143, 123). increases the risk of all the major NCDs, cognitive decline
In addition Table 1 highlights specific nutrients associated and dementia, obstructive sleep apnea, sensory impair-
with preventing unhealthy aging including: dietary protein ments (age-related macular degeneration, cataracts, diabetic
at least equal to current RDAs for preventing sarcopenia, retinopathy, and hearing loss), and urinary incontinence (7,
frailty, and falls in combination with exercise (77); adequate 21, 156, 105, 106, 136, 71, 80, 87, 94). It should also be noted
calcium and vitamin D intake with recommended protein that unhealthy dietary patterns with high intakes of sugar-
for preventing osteoporosis (82–84); and whole grains sweetened beverages, processed snack foods, and red meat,
and dietary fiber (in particular, coarse wheat bran fiber) and low intakes of vegetables, whole grains, fruits, and nuts
for preventing type 2 diabetes and chronic constipation are associated with weight gain (157), which emphasizes the
(133, 134). key link between diet, BMI, and health. As observed with
There is also evidence that healthy aging is fostered by dietary patterns, the risks of obesity for unhealthy aging
the cumulative effects of healthy nutrition earlier in life. For increase over time, and there is a progressive increase in the
example, for prevention of osteoporosis late in life, attaining risks of type 2 diabetes (158), cardiovascular disease (159),
a high peak bone mineral density by age 30 is required (after and cancer (160) with every year that obesity is maintained.
which bone mineral density falls) and this requires consum- Conversely, reduced energy intake promotes healthy aging,
ing recommended levels of calcium throughout childhood with data from studies of nonhuman primates (161) and a
and young adulthood (144). Similarly, high dietary flavanol 2-y trial of calorie restriction in nonobese humans (162, 163)
intakes over 2 decades are associated with a reduced risk of indicating that low energy intake promotes favorable changes
Alzheimer disease and related dementias (145), and greater in a broad range of age-related biomarkers of healthspan
adherence to a Mediterranean diet for >5 y is associated (162, 164).
with a 1–3-fold reduction in risk of frailty (146, 147), a 30% Weight loss is also an effective first-line therapy for
reduction in risk of a major cardiovascular event (123), and treatment of several age-related diseases and conditions in
a 41% reduced risk of incident advanced age-related macular individuals with obesity, including urinary incontinence and
degeneration (148). sleep apnea (24, 132). Furthermore, a mean weight loss of
In addition there are a number of age-related diseases 10% has been reported to achieve remission of type 2 diabetes
and conditions that randomized trials indicate can be in 50% of cases when implemented within 7 y of onset,
treated to attenuate progression (and in some cases support providing a remarkable example of the potential for nutrition
remission) with a nutrition regimen (Table 1). These include to impact age-related disease more effectively than current
sarcopenia, osteoporosis and fractures, age-related macular medication regimens (112).
degeneration, type 2 diabetes, and chronic constipation (133, It is also important to note that recommendations for
74–76, 85, 86, 96). However, not all age-related diseases and maintaining physical activity into old age can play a valuable
conditions that are apparently prevented by healthy nutrition role in supporting nutritional health in old age, not only
can also be treated after their diagnosis. For example, by preserving musculoskeletal health (165, 166) but also by
randomized trials have indicated no significant effect of attenuating the decline in energy requirements with aging.
omega-3 fatty acids, B vitamins, vitamin D, or soy protein on These findings are consistent with a recent federal report
recurrence of various cancers (149, 150). noting the lack of specificity in nutrition assistance programs
Although food-based nutrition is the focus of this report, to support healthy aging in current government programs
a strong case can be made for targeted supplementation with (50).
specific nutrients that are hard to achieve in old age through
a healthy diet. In particular, the mean intake of vitamin D in Are All Generally Healthy Dietary Patterns
US women aged 51–70 is only about one-fourth of the RDA, Equivalent for Achieving Nutritional Health in
and lower intakes are reported for ages ≥71 y (151). Similarly, Old Age?
mean calcium intake is less than one-third of the RDA in There is currently insufficient information to categorically
older adults (151). Some older adults can also benefit from differentiate the effects of consuming the different broadly
supplemental vitamin B-12 because they are at increased risk healthy dietary patterns discussed above. This is because they

1442 Roberts et al.

 energy ≥1600 kcal/d, all of the healthy dietary patterns could
provide recommended portions of different recommended
food groups, and also provide a calorie allowance for
other “discretionary” foods of 32 (Mediterranean-style) to
246 (Vegetarian) kcal/d. However, for the lower dietary
energy requirements observed in many older adults, the
menus increasingly did not provide recommended portions
of all healthy foods without exceeding total energy re-
quirements, even when discretionary calories were reduced
to zero (which is unrealistic). The Vegetarian menu was
the one that best met portion recommendations for all
food groups and protein at lower energy levels (including
possibly higher protein needs than current US RDAs), and
is consistent with the United Nations’ calls for greater
reliance on plant-based foods (167). Among MyPlate and
Mediterranean menus, reducing dairy and grain servings
(selectively removing refined grains to preserve whole grain
intake) resulted in moderately low carbohydrate options that
did allow proteins, fruits, and vegetable servings to be as
recommended at the lower calorie levels. These calculations
FIGURE 3 Illustration of the adequacy of healthy food group suggest that lower-carbohydrate Dietary Guidelines menus
servings that can be achieved with different dietary patterns at provide another practical approach to meeting healthy
lower levels of energy requirements in older adults. Typical menu nutrition guidelines for older adults at lower levels of energy
examples were used to calculate the number of servings per day of intake.
foods in key healthy food groups (fruit, vegetables, proteins, dairy,
grains, and oils) for 3 healthy dietary patterns (US Dietary Opportunities for a National Nutrition Strategy
Guidelines, Mediterranean, and Vegetarian) implemented at 4 to Reduce Unhealthy Aging
energy levels (1600, 1400, 1200, and 1000 kcal/d). Suggested The United States currently ranks only #55 in a global
servings reflect a mean of 3 different menus that adhere to the
assessment of years of age-related disease burden at the
respective dietary pattern and are shown relative to the serving
size recommendations outlined in the Dietary Guidelines for
end of life (#1 being best-ranked) (12) despite health
Americans for each dietary pattern at 1600 kcal/d intakes. The care expenditures that are approximately twice those of
vertical black line represents 100% of the recommended servings other affluent nations (168). This striking public health
for the specified dietary patterns, and for discretionary calories ∗ (all failure has occurred despite acknowledgement of the general
calories not included in healthy food group servings) represents importance of nutrition across the lifespan (11, 169–171).
200 kcal/d. Note: Legumes are included in the protein category not The breadth of healthy aging benefits achievable with healthy
vegetables, and oils do not reflect oils included in food items (e.g., nutrition described herein clarifies the broad and important
avocado, nuts). Discretionary calories reflect calories that remain for role that nutrition can play to keep older adults healthy, and
other uses after meeting recommended servings of fruit, supports the development of a national nutrition strategy
vegetables, protein, dairy, and grains. with clinical involvement for healthy aging.
One important element of a successful nutrition strat-
egy for healthy aging would be increasing investment in
share multiple common features including an emphasis on federal nutrition research directed to this goal (172), with
regular consumption of vegetables and fruits, whole grains, coordination among stakeholders to maximize research
legumes, nuts and seeds, seafood, and liquid oils such as olive efficiency. This would recognize a strong role for nutrition
and canola, and with low intakes of saturated fat and nutrient- in supporting healthy aging (as summarized here), the
weak foods such as sugar-sweetened beverages. However, relative shortage of data from conventional randomized
different dietary patterns can differ in the extent to which ad- trials of specific interventions, and the need for fresh
equate portion sizes of healthy foods can be achieved despite approaches to conduct rapid, rigorous testing of different
the decreased energy requirements associated with aging. We dietary interventions in diverse populations. Stakeholders in
therefore created typical example menus for 3 healthy dietary a national nutrition strategy for healthy aging would include
patterns (Dietary Guidelines MyPlate, a Mediterranean-style consumers, government agencies, food producers, the food
diet, and a Vegetarian diet) and analyzed them for their ability industry, health professionals, and community organizations.
to support nutritional sufficiency for older adults at different Health professionals would play a pivotal role by lead-
levels of energy requirements. ing the development of consensus recommendations (e.g.,
A summary of the results is provided in Figure 3, with within societies for nutrition, geriatric medicine, primary
descriptions of the menu items given in the Supplemental care, nursing, physician assistant, occupational therapy) that
Information on Menu Calculations. As shown, for dietary would aid diagnosis and evidence-based treatments based

Nutrition for broadly healthy aging 1443

on existing knowledge and identify priorities for next- and approved the final manuscript. JMK and RES also
generation research. This work could also be a springboard performed literature reviews and summaries, and prepared
for developing training modules and continuing education figures.
for health care professionals.
Another important key to healthy aging would be the
development of routine nutrition screening, implemented References
years before age-related diseases become prevalent, com- 1. World Health Organization. Ageing: Healthy ageing and functional
bined with research initiatives to develop and refine lifestyle ability. 2020 [Internet]. [cited 15 Jan 2021]. Available from: https:
//www.who.int/ageing/healthy-ageing/en/
interventions supporting aging-focused healthy behavior 2. Joachim HH, Rees DA. Aristotle: the Nicomachean ethics. Oxford:
changes in different population groups. Direct nutrition Clarendon Press; 1952.
screening is currently not performed in primary care and 3. Becker E. The denial of death. New York (NY): Simon and Schuster;
current indirect measures, such as BMI and lipid panels, 2007.
do not provide adequate information to understand the 4. Woolf SH, Schoomaker H. Life expectancy and mortality rates in the
United States, 1959–2017. JAMA 2019;322(20):1996–2016.
specific nutritional vulnerabilities of individuals. Ideally, the 5. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older
development and use of broad nutrition screening panels to population in the United States. United States Census Bureau,
support healthy aging would allow for identification of at-risk Economics and Statistics Administration; 2014.
individuals within primary care and either treatment within 6. Sullivan DF. A single index of mortality and morbidity. HSMHA
primary care or referral to specialized services (11, 70, 169, Health Rep 1971;86(4):347–54.
7. US Burden of Disease Collaborators, Mokdad AH, Ballestros K, Echko
173). In addition, artificial intelligence could be used to add M, Glenn S, Olsen HE, Mullany E, Lee A, Khan AR, Ahmadi A, et al.
nutrition screening data in real time, for rapid identification The state of US health, 1990–2016: burden of diseases, injuries, and
of time-sensitive nutritional risks, and such information risk factors among US states. JAMA 2018;319(14):1444–72.
could also be used as the basis for artificial intelligence– 8. Romero Starke K, Petereit-Haack G, Schubert M, Kämpf D, Schliebner
enabled personalized interventions. As well as evaluating A, Hegewald J, Seidler A. The age-related risk of severe outcomes
due to COVID-19 infection: a rapid review, meta-analysis, and meta-
dietary intake, screening assessments could include BMI and regression. Int J Environ Res Public Health 2020;17(16):5974.
weight change. This inclusion would recognize both that 9. Dzau VJ, Inouye SK, Rowe JW, Finkelman E, Yamada T. Enabling
obesity is a major risk factor for unhealthy aging (105), and healthful aging for all – the National Academy of Medicine
that weight loss and protein-energy malnutrition with a low grand challenge in healthy longevity. N Engl J Med 2019;381(18):
BMI are increasingly prevalent as adults age (174) and are 1699–701.
10. Kaeberlein M. How healthy is the healthspan concept? Geroscience
similarly linked to reduced independence and greater risk 2018;40(4):361–4.
of poor health. The apparent paradox that both obesity and 11. Beard JR, Officer A, de Carvalho IA, Sadana R, Pot AM, Michel J-P,
weight loss with low BMI are risk factors emphasizes the Lloyd-Sherlock P, Epping-Jordan JE, Peeters G, Mahanani WR, et al.
importance of screening to allow for personalized nutrition The world report on ageing and health: a policy framework for healthy
support for healthy aging. There is currently no validated ageing. Lancet 2016;387(10033):2145–54.
12. Chang AY Skirbekk VF, Tyrovolas S, Kassebaum NJ, Dieleman JL.
screening tool for the range of dietary intakes, BMI, and Measuring population ageing: an analysis of the Global Burden of
weight change seen in community-dwelling adults beginning Disease Study 2017. Lancet Public Health 2019;4:e159–67.
in midlife on, but scales used in hospitalized patients (175) 13. Fielding RA, Vellas B, Evans WJ, Bhasin S, Morley JE, Newman
have potential for adaptation to standardized instruments for AB, van Kan GA, Andrieu S, Bauer J, Breuille D. Sarcopenia: an
primary care. undiagnosed condition in older adults. Current consensus definition:
prevalence, etiology, and consequences. International working group
on sarcopenia. J Am Med Dir Assoc 2011;12(4):249–56.
Conclusions 14. Roubenoff R, Hughes VA. Sarcopenia: current concepts. J Gerontol A
Maintenance of functional independence and quality of life Biol Sci Med Sci 2000;55(12):M716–24.
are of primary importance to older adults. Although aging 15. von Haehling S, Morley JE, Anker SD. An overview of sarcopenia: facts
is clearly programmed and progressive, a cohesive body of and numbers on prevalence and clinical impact. J Cachexia Sarcopenia
Muscle 2010;1(2):129–33.
research finds that a healthy diet and weight management
16. Kalyani RR, Corriere M, Ferrucci L. Age-related and disease-related
are able to not only reliably delay the onset of most typical muscle loss: the effect of diabetes, obesity, and other diseases. Lancet
diseases and functional losses in aging, but also arrest Diabetes Endocrinol 2014;2(10):819–29.
progression and severity, and even support remission for 17. Plassman BL, Langa KM, Fisher GG, Heeringa SG, Weir DR, Ofstedal
some conditions. Public health measures to facilitate healthy MB, Burke JR, Hurd MD, Potter GG, Rodgers WL. Prevalence of
cognitive impairment without dementia in the United States. Ann
aging are currently lacking, but can be developed based on
Intern Med 2008;148(6):427.
existing research to reduce the growing burden of poor health 18. Langa KM, Larson EB, Crimmins EM, Faul JD, Levine DA, Kabeto
in old age. MU, Weir DR. A comparison of the prevalence of dementia in the
United States in 2000 and 2012. JAMA Intern Med 2017;177(1):51–8.
Acknowledgments 19. Quillen DA. Common causes of vision loss in elderly patients. Am Fam
We thank Peggy Connolly for expert support during prepa- Physician 1999;60(1):99–108.
20. National Institute on Deafness and Other Communication Disorders
ration of this review. (NIDCD). Hearing loss and older adults [Internet]. 2019 [cited
The authors’ responsibilities were as follows—All authors 15 Jan 2021]. from: https://www.nidcd.nih.gov/health/hearing-loss-
contributed material within their area of expertise and read older-adults

1444 Roberts et al.

21. Franklin KA, Lindberg E. Obstructive sleep apnea is a common 43. Blumberg JB, Frei B, Fulgoni VL, Weaver CM, Zeisel SH. Contribution
disorder in the population—a review on the epidemiology of sleep of dietary supplements to nutritional adequacy in various adult age
apnea. J Thorac Dis 2015;7(8):1311–22. groups. Nutrients 2017;9(12):1325.
22. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc 44. U.S. Department of Agriculture and U.S. Department of Health and
Am Thorac Soc 2008;5(2):136–43. Human Services. Dietary Guidelines for Americans, 2020–2025. 9th ed
23. Miner B, Kryger MH. Sleep in the aging population. Sleep Med Clin [Internet]. 2020. Available from: https://www.dietaryguidelines.gov/
2017;12(1):31–8. 45. National Cancer Institute. Usual dietary intakes: food intakes,
24. Subak LL, Whitcomb E, Shen H, Saxton J, Vittinghoff E, Brown JS. U.S. population, 2007–10 [Internet]. Epidemiology and Genomics
Weight loss: a novel and effective treatment for urinary incontinence. Research Program; Updated October 31, 2019 [cited 15 Jan 2021].
J Urol 2005;174(1):190–5. Available from: https://epi.grants.cancer.gov/diet/usualintakes/
25. De Giorgio R, Ruggeri E, Stanghellini V, Eusebi LH, Bazzoli F, national-data-usual-dietary-intakes-2007-to-2010.pdf#search=
Chiarioni G. Chronic constipation in the elderly: a primer for the usual%20dietary%20intakes
gastroenterologist. BMC Gastroenterol 2015;15(1):130. 46. Ruxton CH, Derbyshire E, Toribio-Mateas M. Role of fatty acids and
26. Higgins PD, Johanson JF. Epidemiology of constipation in North micronutrients in healthy ageing: a systematic review of randomised
America: a systematic review. Am J Gastroenterol 2004;99(4):750–9. controlled trials set in the context of European dietary surveys of older
27. Bandeen-Roche K, Seplaki CL, Huang J, Buta B, Kalyani RR, Varadhan adults. J Hum Nutr Diet 2016;29(3):308–24.
R, Xue Q-L, Walston JD, Kasper JD. Frailty in older adults: a nationally 47. Zhang FF, Liu J, Rehm CD, Wilde P, Mande JR, Mozaffarian D. Trends
representative profile in the United States. J Gerontol A Biol Sci Med and disparities in diet quality among US adults by Supplemental
Sci 2015;70(11):1427–34. Nutrition Assistance Program participation status. JAMA Netw Open
28. Centers for Disease Control and Prevention. Arthritis-related statistics 2018;1(2):e180237.
[Internet]. 2018 [cited 15 Jan 2021]. Available from: https://www.cdc. 48. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity
gov/arthritis/data_statistics/arthritis-related-stats.htm#prevspecific among adults and youth: United States, 2015–2016. NCHS Data Brief
29. Shivappa N, Steck SE, Hurley TG, Hussey JR, Hébert JR. Designing 2017;(288):1–8.
and developing a literature-derived, population-based dietary 49. Asghari G, Mirmiran P, Yuzbashian E, Azizi F. A systematic review
inflammatory index. Public Health Nutr 2014;17(8):1689–96. of diet quality indices in relation to obesity. Br J Nutr 2017;117(8):
30. Hussain T, Tan B, Yin Y, Blachier F, Tossou MC, Rahu N. Oxidative 1055–65.
stress and inflammation: what polyphenols can do for us? Oxid Med 50. United States Government Accountability Office, Nutrition Assistance
Cell Longev 2016;2016:7432797. Programs. Agencies could do more to help address the nutritional
31. Blount BC, Mack MM, Wehr CM, MacGregor JT, Hiatt RA, Wang G, needs of older adults. Washington (DC): USGA Office; 2019. p. 1–64.
Wickramasinghe SN, Everson RB, Ames BN. Folate deficiency causes 51. National Institutes of Health, Office of Dietary Supplements. Nutrient
uracil misincorporation into human DNA and chromosome breakage: recommendations: dietary reference intakes (DRI). 2011 [cited August
implications for cancer and neuronal damage. Proc Natl Acad Sci USA 20, 2018] [Internet]. Available from: https://ods.od.nih.gov/Health_
1997;94(7):3290–5. Information/Dietary_Reference_Intakes.aspx
32. Ames BN. Low micronutrient intake may accelerate the degenerative 52. Baum JI, Kim I-Y, Wolfe RR. Protein consumption and the elderly:
diseases of aging through allocation of scarce micronutrients by triage. what is the optimal level of intake? Nutrients 2016;8(6):359.
Proc Natl Acad Sci USA 2006;103(47):17589–94. 53. Volpi E, Campbell WW, Dwyer JT, Johnson MA, Jensen GL, Morley JE,
33. Jin K. Modern biological theories of aging. Aging Dis 2010;1(2):72. Wolfe RR. Is the optimal level of protein intake for older adults greater
34. Gregor MF, Hotamisligil GS. Inflammatory mechanisms in obesity. than the recommended dietary allowance?J Gerontol A Biol Sci Med
Annu Rev Immunol 2011;29:415–45. Sci 2013;68(6):677–81.
35. Centers for Disease Control and Prevention. Trends in aging–United 54. Roberts SB, Rosenberg I. Nutrition and aging: changes in
States and worldwide. MMWR 2003;52(6):101. the regulation of energy metabolism with aging. Physiol Rev
36. Kennedy BK, Berger SL, Brunet A, Campisi J, Cuervo AM, Epel ES, 2006;86(2):651–67.
Franceschi C, Lithgow GJ, Morimoto RI, Pessin JE. Aging: a common 55. Bhasin S, Travison TG, Manini TM, Patel S, Pencina KM,
driver of chronic diseases and a target for novel interventions. Cell Fielding RA, Magaziner JM, Newman AB, Kiel DP, Cooper C.
2014;159(4):709–13. Sarcopenia definition: the position statements of the sarcopenia
37. Rehm CD, Peñalvo JL, Afshin A, Mozaffarian D. Dietary intake among definition and outcomes consortium. J Am Geriatr Soc 2020;68(7):
US adults, 1999–2012. JAMA 2016;315(23):2542–53. 1410–18.
38. Otten JJ, Hellwig JP, Meyers LD. Dietary reference intakes: the 56. Cawthon PM, Manini T, Patel SM, Newman A, Travison T, Kiel DP,
essential guide to nutrient requirements. Washington (DC): National Santanasto AJ, Ensrud KE, Xue QL, Shardell M. Putative cut-points
Academies Press; 2006. in sarcopenia components and incident adverse health outcomes: an
39. Berryman CE, Lieberman HR, Fulgoni VL, III, SM Pasiakos. Protein SDOC analysis. J Am Geriatr Soc 2020;68(7):1429–37.
intake trends and conformity with the Dietary Reference Intakes 57. Aversa Z, Zhang X, Fielding RA, Lanza I, LeBrasseur NK. The clinical
in the United States: analysis of the National Health and Nutrition impact and biological mechanisms of skeletal muscle aging. Bone
Examination Survey, 2001–2014. Am J Clin Nutr 2018;108(2): 2019;127:26–36.
405–13. 58. Rolland Y, Czerwinski S, Van Kan GA, Morley J, Cesari M, Onder G,
40. Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft AJ, Woo J, Baumgartner R, Pillard F, Boirie Y. Sarcopenia: its assessment,
Morley JE, Phillips S, Sieber C, Stehle P, Teta D. Evidence-based etiology, pathogenesis, consequences and future perspectives. J Nutr
recommendations for optimal dietary protein intake in older people: Health Aging 2008;12(7):433–50.
a position paper from the PROT-AGE Study Group. J Am Med Dir 59. Lichtenstein AH. Optimal nutrition for older adults. In: Rippe JM,
Assoc 2013;14(8):542–59. editor. Nutrition in Lifestyle Medicine. Cham: Humana Press; 2017.
41. Damanti S, Azzolino D, Roncaglione C, Arosio B, Rossi P, Cesari p. 355–66. https://doi.org/10.1007/978-3-319-43027-0_19.
M. Efficacy of nutritional interventions as stand-alone or synergistic 60. Morley JE. Nutrition and aging well. J Am Med Dir Assoc
treatments with exercise for the management of sarcopenia. Nutrients 2017;18(2):91–4.
2019;11(9):1991. 61. Kaushik S, Wang JJ, Flood V, Tan JSL, Barclay AW, Wong TY,
42. Bird JK, Murphy RA, Ciappio ED, McBurney MI. Risk of deficiency Brand-Miller J, Mitchell P. Dietary glycemic index and the risk
in multiple concurrent micronutrients in children and adults in the of age-related macular degeneration. Am J Clin Nutr 2008;88(4):
United States. Nutrients 2017;9(7):655. 1104–10.

Nutrition for broadly healthy aging 1445

 62. Payette H, Shatenstein B. Determinants of healthy eating 83. Shams-White MM, Chung M, Du M, Fu Z, Insogna KL, Karlsen
in community-dwelling elderly people. Can J Public Health MC, LeBoff MS, Shapses SA, Sackey J, Wallace TC. Dietary protein
2005;96(Suppl 3):S27–31. and bone health: a systematic review and meta-analysis from the
63. Little MO. Updates in nutrition and polypharmacy. Curr Opin Clin National Osteoporosis Foundation. Am J Clin Nutr 2017;105(6):
Nutr Metab Care 2018;21(1):4–9. 1528–43.
64. Whitcomb EA, Chiu C-J, Taylor A. Dietary glycemia as a determinant 84. Hanley DA, Cranney A, Jones G, Whiting SJ, Leslie WD, Cole
of health and longevity. Mol Aspects Med 2015;46:14–20. DE, Atkinson SA, Josse RG, Feldman S, Kline GA. Vitamin D
65. Ellis AC. Nutrition and healthy aging. In: Coll P. Healthy Aging. Cham: in adult health and disease: a review and guideline statement
Springer; 2019. p. 263–74. https://doi.org/10.1007/978-3-030-06200- from Osteoporosis Canada. Can Med Assoc J 2010;182(12):
2_22. E610–18.
66. Miller M. Hormonal aspects of fluid and sodium balance in the elderly. 85. Kanis J, Burlet N, Cooper C, Delmas P, Reginster J-Y, Borgstrom
Endocrinol Metab Clin North Am 1995;24(2):233–53. F, Rizzoli R. European guidance for the diagnosis and management
67. Phillips PA, Rolls BJ, Ledingham JG, Forsling ML, Morton JJ, Crowe of osteoporosis in postmenopausal women. Osteoporos Int
MJ, Wollner L. Reduced thirst after water deprivation in healthy elderly 2008;19(4):399–428.
men. N Engl J Med 1984;311(12):753–9. 86. Weaver C, Alexander D, Boushey C, Dawson-Hughes B, Lappe JM,
68. Lavizzo-Mourey RJ. Dehydration in the elderly: a short review. J Natl LeBoff M, Liu S, Looker A, Wallace T, Wang D. Calcium plus
Med Assoc 1987;79(10):1033–8. vitamin D supplementation and risk of fractures: an updated meta-
69. Shlisky J, Bloom DE, Beaudreault AR, Tucker KL, Keller HH, Freund- analysis from the National Osteoporosis Foundation. Osteoporos Int
Levi Y, Fielding RA, Cheng FW, Jensen GL, Wu D, et al. Nutritional 2016;27(1):367–76.
considerations for healthy aging and reduction in age-related chronic 87. Beydoun MA, Beydoun H, Wang Y. Obesity and central obesity as risk
disease. Adv Nutr 2017;8(1):17–26. factors for incident dementia and its subtypes: a systematic review and
70. Kuczmarski MF, Weddle DO, American Dietetic Association. Position meta-analysis. Obes Rev 2008;9(3):204–18.
paper of the American Dietetic Association: nutrition across the 88. Veronese N, Facchini S, Stubbs B, Luchini C, Solmi M, Manzato E,
spectrum of aging. J Am Diet Assoc 2005;105(4):616–33. Sergi G, Maggi S, Cosco T, Fontana L. Weight loss is associated with
71. Amiri S, Behnezhad S, Hasani J. Body mass index and risk of frailty improvements in cognitive function among overweight and obese
in older adults: a systematic review and meta-analysis. Obes Med people: a systematic review and meta-analysis. Neurosci Biobehav Rev
2020;18:100196. 2017;72:87–94.
72. Rashidi Pour Fard N, Amirabdollahian F, Haghighatdoost F. Dietary 89. Wu L, Sun D. Adherence to Mediterranean diet and risk of developing
patterns and frailty: a systematic review and meta-analysis. Nutr Rev cognitive disorders: an updated systematic review and meta-analysis
2019;77(7):498–513. of prospective cohort studies. Sci Rep 2017;7:1–9.
73. Silva R, Pizato N, Da Mata F, Figueiredo A, Ito M, Pereira M. 90. Petersson SD, Philippou E. Mediterranean diet, cognitive function,
Mediterranean diet and musculoskeletal-functional outcomes in and dementia: a systematic review of the evidence. Adv Nutr
community-dwelling older people: a systematic review and meta- 2016;7(5):889–904.
analysis. J Nutr Health Aging 2018;22(6):655–63. 91. van de Rest O, Berendsen AA, Haveman-Nies A, de Groot LC. Dietary
74. Park Y, Choi J-E, Hwang H-S. Protein supplementation improves patterns, cognitive decline, and dementia: a systematic review. Adv
muscle mass and physical performance in undernourished prefrail and Nutr 2015;6(2):154–68.
frail elderly subjects: a randomized, double-blind, placebo-controlled 92. Cao L, Tan L, Wang H-F, Jiang T, Zhu X-C, Lu H, Tan M-S,
trial. Am J Clin Nutr 2018;108(5):1026–33. Yu J-T. Dietary patterns and risk of dementia: a systematic review
75. Tieland M, Dirks ML, van der Zwaluw N, Verdijk LB, Van De Rest O, and meta-analysis of cohort studies. Mol Neurobiol 2016;53(9):
de Groot LC, Van Loon LJ. Protein supplementation increases muscle 6144–54.
mass gain during prolonged resistance-type exercise training in frail 93. Ruan Y, Tang J, Guo X, Li K, Li D. Dietary fat intake and risk of
elderly people: a randomized, double-blind, placebo-controlled trial. J Alzheimer’s disease and dementia: a meta-analysis of cohort studies.
Am Med Dir Assoc 2012;13(8):713–19. Curr Alzheimer Res 2018;15(9):869–76.
76. ten Haaf DS, Eijsvogels TM, Bongers CC, Horstman AM, Timmers S, 94. Chakravarthy U, Wong TY, Fletcher A, Piault E, Evans C, Zlateva G,
de Groot LC, Hopman MT. Protein supplementation improves lean Buggage R, Pleil A, Mitchell P. Clinical risk factors for age-related
body mass in physically active older adults: a randomized placebo- macular degeneration: a systematic review and meta-analysis. BMC
controlled trial. J Cachexia Sarcopenia Muscle 2019;10(2):298–310. Ophthalmol 2010;10(1):1–13.
77. Beasley JM, LaCroix AZ, Neuhouser ML, Huang Y, Tinker L, Woods 95. Chapman NA, Jacobs RJ, Braakhuis AJ. Role of diet and food intake
N, Michael Y, Curb JD, Prentice RL. Protein intake and incident frailty in age-related macular degeneration: a systematic review. Clin Exp
in the Women’s Health Initiative observational study. J Am Geriatr Soc Ophthalmol 2019;47(1):106–27.
2010;58(6):1063–71. 96. Age-Related Eye Disease Study 2 Research Group. Lutein + zeaxanthin
78. Coelho-Júnior HJ, Rodrigues B, Uchida M, Marzetti E. Low protein and omega-3 fatty acids for age-related macular degeneration: the
intake is associated with frailty in older adults: a systematic review and Age-Related Eye Disease Study 2 (AREDS2) randomized clinical trial.
meta-analysis of observational studies. Nutrients 2018;10(9):1334. JAMA 2013;309(19):2005–15.
79. Starr KNP, McDonald SR, Bales CW. Obesity and physical frailty in 97. Ye J, Lou L-X, He J-J, Xu Y-F. Body mass index and risk of age-
older adults: a scoping review of lifestyle intervention trials. J Am Med related cataract: a meta-analysis of prospective cohort studies. PLoS
Dir Assoc 2014;15(4):240–50. One 2014;9(2):e89923.
80. Silverwood V, Blagojevic-Bucknall M, Jinks C, Jordan J, Protheroe 98. Drinkwater JJ, Davis WA, Davis TM. A systematic review of risk
J, Jordan K. Current evidence on risk factors for knee osteoarthritis factors for cataract in type 2 diabetes. Diabetes Metab Res Rev
in older adults: a systematic review and meta-analysis. Osteoarthritis 2019;35(1):e3073.
Cartilage 2015;23(4):507–15. 99. Zhao L-Q, Li L-M, Zhu H. The effect of multivitamin/mineral
81. Nelson AE, Allen KD, Golightly YM, Goode AP, Jordan JM. supplements on age-related cataracts: a systematic review and meta-
A systematic review of recommendations and guidelines for the analysis. Nutrients 2014;6(3):931–49.
management of osteoarthritis: the chronic osteoarthritis management 100. Jiang H, Yin Y, Wu C-R, Liu Y, Guo F, Li M, Ma L. Dietary vitamin
initiative of the US bone and joint initiative. Semin Arthritis Rheum and carotenoid intake and risk of age-related cataract. Am J Clin Nutr
2014;43:701–12. 2019;109(1):43–54.
82. Heaney RP. Calcium, dairy products and osteoporosis. J Am Coll Nutr 101. Dhanda N, Taheri S. A narrative review of obesity and hearing loss. Int
2000;19(Suppl 2):83S–99S. J Obes 2017;41(7):1066–73.

1446 Roberts et al.

102. Puga A, Pajares M, Varela-Moreiras G, Partearroyo T. Interplay 120. Sofi F, Macchi C, Abbate R, Gensini GF, Casini A. Mediterranean
between nutrition and hearing loss: state of art. Nutrients diet and health status: an updated meta-analysis and a proposal
2018;11(1):35. for a literature-based adherence score. Public Health Nutr
103. Jung SY, Kim SH, Yeo SG. Association of nutritional factors with 2014;17(12):2769–82.
hearing loss. Nutrients 2019;11(2):307. 121. Siervo M, Lara J, Chowdhury S, Ashor A, Oggioni C, Mathers JC.
104. Durga J, Verhoef P, Anteunis LJ, Schouten E, Kok FJ. Effects of Effects of the Dietary Approach to Stop Hypertension (DASH) diet on
folic acid supplementation on hearing in older adults: a randomized, cardiovascular risk factors: a systematic review and meta-analysis. Br
controlled trial. Ann Intern Med 2007;146(1):1–9. J Nutr 2015;113(1):1–15.
105. Jensen MD, Ryan DH, Apovian CM, Ard JD, Comuzzie AG, 122. Mazidi M, Katsiki N, Mikhailidis DP, Sattar N, Banach M. Lower
Donato KA, Hu FB, Hubbard VS, Jakicic JM, Kushner RF, et al. carbohydrate diets and all-cause and cause-specific mortality: a
AHA/ACC/TOS guideline for the management of overweight population-based cohort study and pooling of prospective studies. Eur
and obesity in adults: a report of the American College of Heart J 2019;40(34):2870–9.
Cardiology/American Heart Association Task Force on Practice 123. Estruch R, Ros E, Salas-Salvadó J, Covas M-I, Corella D, Arós
Guidelines and the Obesity Society. Circulation 2014;129(25 Suppl F, Gómez-Gracia E, Ruiz-Gutiérrez V, Fiol M, Lapetra J. Primary
2):S102–38. prevention of cardiovascular disease with a Mediterranean diet
106. Yamaoka K, Nemoto A, Tango T. Comparison of the effectiveness of supplemented with extra-virgin olive oil or nuts. N Engl J Med
lifestyle modification with other treatments on the incidence of type 2018;378(25):e34.
2 diabetes in people at high risk: a network meta-analysis. Nutrients 124. Chiavaroli L, Viguiliouk E, Nishi SK, Blanco Mejia S, Rahelić D,
2019;11(6):1373. Kahleová H, Salas-Salvadó J, Kendall CW, Sievenpiper JL. DASH
107. Dinu M, Pagliai G, Casini A, Sofi F. Mediterranean diet and multiple dietary pattern and cardiometabolic outcomes: an umbrella review of
health outcomes: an umbrella review of meta-analyses of observational systematic reviews and meta-analyses. Nutrients 2019;11(2):338.
studies and randomised trials. Eur J Clin Nutr 2018;72(1):30–43. 125. Suárez AL. Burden of cancer attributable to obesity, type 2 diabetes and
108. Schwingshackl L, Missbach B, König J, Hoffmann G. Adherence to a associated risk factors. Metabolism 2019;92:136–46.
Mediterranean diet and risk of diabetes: a systematic review and meta- 126. World Cancer Research Fund International. Diet, nutrition, physical
analysis. Public Health Nutr 2015;18(7):1292–9. activity and cancer: a global perspective. The Third Expert Report
109. Schwingshackl L, Bogensberger B, Hoffmann G. Diet quality as [Internet]. 2019 [cited 15 Jan 2021]. Available from: https://www.wcrf.
assessed by the healthy eating index, alternate healthy eating index, org/dietandcancer
dietary approaches to stop hypertension score, and health outcomes: 127. Foscolou A, Koloverou E, Matalas A-L, Tyrovolas S, Chrysohoou
an updated systematic review and meta-analysis of cohort studies. J C, Sidossis L, Rallidis L, Panagiotakos DB. Decomposition of
Acad Nutr Diet 2018;118(1):74. Mediterranean dietary pattern on successful aging, among older
110. Satija A, Bhupathiraju SN, Rimm EB, Spiegelman D, Chiuve SE, Borgi adults: a combined analysis of two epidemiological studies. J Aging
L, Willett WC, Manson JE, Sun Q, Hu FB. Plant-based dietary patterns Health 2019;31(9):1549–67.
and incidence of type 2 diabetes in US men and women: results from 128. Fransen HP, Beulens JW, May AM, Struijk EA, Boer JM, de Wit
three prospective cohort studies. PLoS Med 2016;13(6):e1002039. GA, Onland-Moret NC, van der Schouw YT, Bueno-de-Mesquita HB,
111. Livesey G, Taylor R, Livesey HF, Buyken AE, Jenkins DJ, Augustin Hoekstra J, et al. Dietary patterns in relation to quality-adjusted life
LS, Sievenpiper JL, Barclay AW, Liu S, Wolever T. Dietary glycemic years in the EPIC-NL cohort. Prev Med 2015;77:119–24.
index and load and the risk of type 2 diabetes: a systematic review 129. Schwingshackl L, Hoffmann G. Adherence to Mediterranean
and updated meta-analyses of prospective cohort studies. Nutrients diet and risk of cancer: an updated systematic review and
2019;11(6):1280. meta-analysis of observational studies. Cancer Med 2015;4(12):
112. Lean ME, Leslie WS, Barnes AC, Brosnahan N, Thom G, McCombie 1933–47.
L, Peters C, Zhyzhneuskaya S, Al-Mrabeh A, Hollingsworth KG. 130. Dinu M, Abbate R, Gensini GF, Casini A, Sofi F. Vegetarian,
Primary care-led weight management for remission of type 2 vegan diets and multiple health outcomes: a systematic review with
diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet meta-analysis of observational studies. Crit Rev Food Sci Nutr
2018(391):541–51. 2017;57(17):3640–9.
113. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin 131. Huang T, Yang B, Zheng J, Li G, Wahlqvist ML, Li D. Cardiovascular
JM, Walker EA, Nathan DM. Reduction in the incidence of type disease mortality and cancer incidence in vegetarians: a meta-analysis
2 diabetes with lifestyle intervention or metformin. N Engl J Med and systematic review. Ann Nutr Metab 2012;60(4):233–40.
2002;346(6):393–403. 132. Mitchell LJ, Davidson ZE, Bonham M, O’Driscoll DM, Hamilton
114. Papamichou D, Panagiotakos D, Itsiopoulos C. Dietary patterns and GS, Truby H. Weight loss from lifestyle interventions and severity
management of type 2 diabetes: a systematic review of randomised of sleep apnoea: a systematic review and meta-analysis. Sleep Med
clinical trials. Nutr Metab Cardiovasc Dis 2019;29:531–43. 2014;15(10):1173–83.
115. Huo R, Du T, Xu Y, Xu W, Chen X, Sun K, Yu X. Effects 133. de Vries J, Miller PE, Verbeke K. Effects of cereal fiber on
of Mediterranean-style diet on glycemic control, weight loss and bowel function: a systematic review of intervention trials. World J
cardiovascular risk factors among type 2 diabetes individuals: a meta- Gastroenterol 2015;21(29):8952–63.
analysis. Eur J Clin Nutr 2015;69(11):1200. 134. Institute of Medicine. Dietary reference intakes: energy, carbohydrate,
116. McArdle P, Greenfield S, Rilstone S, Narendran P, Haque M, Gill P. fiber, fat, fatty acids, cholesterol, protein, and amino acids. Washington
Carbohydrate restriction for glycaemic control in type 2 diabetes: a (DC): The National Academies Press; 2005.
systematic review and meta-analysis. Diabet Med 2019;36(3):335–48. 135. McRorie JW, Jr, Fahey GC, Jr, Gibb RD, Chey WD. Laxative effects
117. Snorgaard O, Poulsen GM, Andersen HK, Astrup A. Systematic review of wheat bran and psyllium: resolving enduring misconceptions about
and meta-analysis of dietary carbohydrate restriction in patients with fiber in treatment guidelines for chronic idiopathic constipation. J Am
type 2 diabetes. BMJ Open Diab Res Care 2017;5(1):e000354. Assoc Nurse Pract 2020;32(1):15–23.
118. Trial Maruthur N, Wang N, Appel L. Lifestyle interventions reduce 136. Subak LL, Richter HE, Hunskaar S. Obesity and urinary incontinence:
coronary heart disease risk: results from the PREMIER. Circulation epidemiology and clinical research update. J Urol 2009;182(6S):S2–7.
2009;119(15):2026–31. 137. Willett WC, Sacks F, Trichopoulou A, Drescher G, Ferro-Luzzi A,
119. Kahleova H, Salas-Salvadó J, Rahelić D, Kendall CW, Rembert Helsing E, Trichopoulos D. Mediterranean diet pyramid: a cultural
E, Sievenpiper JL. Dietary patterns and cardiometabolic outcomes model for healthy eating. Am J Clin Nutr 1995;61:1402S–6S.
in diabetes: a summary of systematic reviews and meta-analyses. 138. United States Department of Health and Human Services. Dietary
Nutrients 2019;11(9):2209. guidelines for Americans, 5th ed. Washington (DC): USDA; 2000.

Nutrition for broadly healthy aging 1447

139. USDA Food and Nutrition Service. Healthy Eating Index (HEI) 156. GBD Obesity Collaborators. Health effects of overweight and obesity
[Internet]. 2019 [cited 15 Jan 2021]. Available from: https://www.fns. in 195 countries over 25 years. N Engl J Med 2017;377(1):13–27.
usda.gov/resource/healthy-eating-index-hei 157. Mozaffarian D, Hao T, Rimm EB, Willett WC, Hu FB. Changes in diet
140. Jankovic N, Geelen A, Streppel MT, de Groot LC, Orfanos P, van and lifestyle and long-term weight gain in women and men. N Engl J
den Hooven EH, Pikhart H, Boffetta P, Trichopoulou A, Bobak M, Med 2011;364(25):2392–404.
et al. Adherence to a healthy diet according to the World Health 158. Hu Y, Bhupathiraju SN, de Koning L, Hu FB. Duration of obesity and
Organization guidelines and all-cause mortality in elderly adults overweight and risk of type 2 diabetes among US women. Obesity
from Europe and the United States. Am J Epidemiol 2014;180(10): 2014;22(10):2267–73.
978–88. 159. Ortega FB, Lavie CJ, Blair SN. Obesity and cardiovascular disease. Circ
141. Morris MC, Tangney CC, Wang Y, Sacks FM, Bennett DA, Aggarwal Res 2016;118(11):1752–70.
NT. MIND diet associated with reduced incidence of Alzheimer’s 160. Arnold M, Freisling H, Stolzenberg-Solomon R, Kee F, O’Doherty MG,
disease. Alzheimers Dement (Amst) 2015;11(9):1007–14. Ordóñez-Mena JM, Wilsgaard T, May AM, Bueno-de-Mesquita HB,
142. Jenkins D, Wolever T, Collier GR, Ocana A, Rao AV, Buckley G, Lam Tjønneland A. Overweight duration in older adults and cancer risk:
Y, Mayer A, Thompson LU. Metabolic effects of a low-glycemic-index a study of cohorts in Europe and the United States. Eur J Epidemiol
diet. Am J Clin Nutr 1987;46(6):968–75. 2016;31(9):893–904.
143. Toledo E, Salas-Salvadó J, Donat-Vargas C, Buil-Cosiales P, Estruch 161. Mattison JA, Roth GS, Beasley TM, Tilmont EM, Handy AM, Herbert
R, Ros E, Corella D, Fitó M, Hu FB, Arós F. Mediterranean diet and RL, Longo DL, Allison DB, Young JE, Bryant M, et al. Impact of caloric
invasive breast cancer risk among women at high cardiovascular risk restriction on health and survival in rhesus monkeys from the NIA
in the PREDIMED trial: a randomized clinical trial. JAMA Intern Med study. Nature 2012;489(7415):318–21.
2015;175(11):1752–60. 162. Ravussin E, Redman LM, Rochon J, Das SK, Fontana L, Kraus WE,
144. Weaver CM. The role of nutrition on optimizing peak bone mass. Asia Romashkan S, Williamson DA, Meydani SN, Villareal DT, et al.
Pac J Clin Nutr 2008;17:135–7. A 2-year randomized controlled trial of human caloric restriction:
145. Shishtar E, Rogers GT, Blumberg JB, Au R, Jacques PF. Long-term feasibility and effects on predictors of health span and longevity. J
dietary flavonoid intake and risk of Alzheimer disease and related Gerontol A Biol Sci Med Sci 2015;70(9):1097–104.
dementias in the Framingham Offspring Cohort. Am J Clin Nutr 163. Das SK, Balasubramanian P, Weerasekara YK. Nutrition modulation
2020;112(112):343–53. of human aging: the calorie restriction paradigm. Mol Cell Endocrinol
146. Talegawkar SA, Bandinelli S, Bandeen-Roche K, Chen P, Milaneschi Y, 2017;455:148–57.
Tanaka T, Semba RD, Guralnik JM, Ferrucci L. A higher adherence to a 164. Kraus WE, Bhapkar M, Huffman KM, Pieper CF, Das SK, Redman
Mediterranean-style diet is inversely associated with the development LM, Villareal DT, Rochon J, Roberts SB, Ravussin E. 2 years of
of frailty in community-dwelling elderly men and women. J Nutr calorie restriction and cardiometabolic risk (CALERIE): exploratory
2012;142(12):2161–6. outcomes of a multicentre, phase 2, randomised controlled trial. Lancet
147. León-Muñoz LM, Guallar-Castillón P, López-García E, Rodríguez- Diabetes Endocrinol 2019;7(9):673–83.
Artalejo F. Mediterranean diet and risk of frailty in community- 165. World Health Organization. Global strategy on diet, physical
dwelling older adults. J Am Med Dir Assoc 2014;15(12):899–903. activity and health [Internet]. 2004 [cited 15 Jan 2021]. Available
148. Merle BM, Colijn JM, Cougnard-Grégoire A, de Koning-Backus from: https://www.who.int/dietphysicalactivity/strategy/eb11344/
AP, Delyfer M-N, Kiefte-de Jong JC, Meester-Smoor M, Féart C, strategy_english_web.pdf
Verzijden T, Samieri C. Mediterranean diet and incidence of advanced 166. Dietary Guidelines Advisory Committee. Dietary guidelines for
age-related macular degeneration: the EYE-RISK Consortium. Americans 2015–2020. Office of Disease Prevention and Health
Ophthalmology 2019;126(3):381–90. Promotion; 2015.
149. Bosland MC, Kato I, Zeleniuch-Jacquotte A, Schmoll J, Rueter EE, 167. Intergovernmental Panel on Climate Change. Climate change and land
Melamed J, Kong MX, Macias V, Kajdacsy-Balla A, Lumey L. Effect [Internet]. 2019 [cited 15 Jan 2021]. Available from: https://www.ipcc.
of soy protein isolate supplementation on biochemical recurrence of ch/report/srccl/
prostate cancer after radical prostatectomy: a randomized trial. JAMA 168. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United
2013;310(2):170–8. States and other high-income countries. JAMA 2018;319(10):1024–39.
150. Andreeva VA, Touvier M, Kesse-Guyot E, Julia C, Galan P, Hercberg S. 169. National Prevention Council. Healthy aging in action [Internet]. 2016
B vitamin and/or ω-3 fatty acid supplementation and cancer: ancillary [cited 15 Jan 2021]. Available from: https://www.cdc.gov/aging/pdf/
findings from the supplementation with folate, vitamins B6 and B12, healthy-aging-in-action508.pdf
and/or omega-3 fatty acids (SU.FOL.OM3) randomized trial. Arch 170. Kritchevsky SB. Nutrition and healthy aging. J Gerontol A Biol Sci Med
Intern Med 2012;172(7):540–7. Sci 2016;71(10):1303–5.
151. Bailey RL, Dodd KW, Goldman JA, Gahche JJ, Dwyer JT, Moshfegh 171. Morley JE. Nutrition and aging well. J Am Med Dir Assoc
AJ, Sempos CT, Picciano MF. Estimation of total usual calcium and 2017;18(2):91–4.
vitamin D intakes in the United States. J Nutr 2010;140(4):817–22. 172. Fleischhacker SE, Woteki CE, Coates PM, Hubbard VS, Flaherty
152. Krasinski SD, Russell RM, Samloff IM, Jacob RA, Dallal GE, McGandy GE, Glickman DR, Harkin TR, Kessler D, Li WW, Loscalzo J.
RB, Hartz SC. Fundic atrophic gastritis in an elderly population: effect Strengthening national nutrition research: rationale and options for a
on hemoglobin and several serum nutritional indicators. J Am Geriatr new coordinated federal research effort and authority. Am J Clin Nutr
Soc 1986;34(11):800–6. 2020;112(3):721–69.
153. Lam JR, Schneider JL, Zhao W, Corley DA. Proton pump inhibitor and 173. Johnson MA, Dwyer JT, Jensen GL, Miller JW, Speakman JR,
histamine 2 receptor antagonist use and vitamin B12 deficiency. JAMA Starke-Reed P, Volpi E. Challenges and new opportunities for
2013;310(22):2435–42. clinical nutrition interventions in the aged. J Nutr 2011;141(3):
154. Centers for Disease Control and Prevention. Adult obesity facts 535–41.
[Internet]. 2018 [cited 15 Jan 2021]. Available from: https://www.cdc. 174. Defeat Malnutrition Today. Homepage [Internet]. 2020 [cited 15 Jan
gov/obesity/data/adult.html 2021]. Available from: https://www.defeatmalnutrition.today/
155. Crow RS, Lohman MC, Titus AJ, Cook SB, Bruce ML, Mackenzie TA, 175. Dwyer JT, Gahche JJ, Weiler M, Arensberg MB. Screening community-
Bartels SJ, Batsis JA. Association of obesity and frailty in older adults: living older adults for protein energy malnutrition and frailty: update
NHANES 1999–2004. J Nutr Health Aging 2019;23(2):138–44. and next steps. J Community Health 2020;45(3):640–60.

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