Healthy ageing: the natural consequences of good nutrition—a conference report

Advances in science and medicine have led to increased life expectancy in high-income countries. By 2050, more than one-third of the population in high-income countries is expected to be of age 60 or older [144]. As a leading risk factor for chronic disease, ageing is also associated with reduced productivity and rising healthcare costs; age-related public spending is expected to double by 2050 in many countries [158]. This combination of disease and healthcare burden has piqued societies’ interest in the topic of ageing in recent years and led to research and medical initiatives aimed at slowing, delaying or even reversing the ageing process. To cope with these changes, the goal for societies should be to optimize intrinsic capacity and functional ability of individuals and populations as healthy ageing does not require people to be disease-free [154].

Nevertheless, understanding the phenomenon of ageing is critical to ameliorating its impact on both individuals and society. Ageing has been described as “…a decline or loss (a “de-tuning”) of adaptation with increasing age, caused by a time-progressive decline of Hamilton’s forces of natural selection…” [131]. However, ageing is considered more like the sum of its parts—a non-linear multifaceted phenomenon, that can be defined at the molecular, cellular, physiologic, functional levels, and by disease state (Fig. 1).

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At the molecular level, ageing is perhaps most well defined by telomere attrition, which is believed to determine cellular lifespan. Other molecular factors linked to ageing include genomic instability and epigenetic alterations. These, in turn, can result in declining cellular function in the form of altered intercellular communication, organelle dysfunction and cellular senescence [93]. These changes manifest themselves at the physiologic level resulting in chronic inflammation, or “inflammageing”, alterations in body composition, energy metabolism and neuronal function [162]. Ageing also results in changes in sensory functions, including changes in taste, smell and diminished appetite [160]; and changes in visual and auditory function [78]. Sarcopenia is a rapid age-associated decline in skeletal muscle mass and physical function resulting from a convergence of chronic inflammation, hormonal changes, cellular dysfunction, poor diet and lack of physical activity [161]. Age-related cognitive changes can also serve as precursors to dementia and Alzheimer’s disease [128]. In addition to cognitive disease, ageing also results in an increased risk for a variety of other chronic diseases, including heart disease, diabetes and cancer. According to data from the US Centers for Disease Control, compared to adults 45–64 years of age, those 65 and older have more than twice the prevalence of heart disease, diabetes and cancer [41].

Researchers have recently assessed age-associated changes in the microbiome. The population and diversity of gut microorganisms evolves with age from birth to death. Initially, there is a rapid rise in number and diversity of organisms from infancy to adulthood, followed by a precipitous decline in diversity through the elderly years [83]. The cause for this decline is uncertain and likely multifactorial. Further, it remains to be elucidated what role, if any, the change in microbial diversity has with the cellular, physiologic and functional changes that define the ageing process.

The interest in ageing has progressed from understanding its origins, mechanisms and processes, to studying how to reduce, delay or reverse its effects, and importantly, policy responses that addresses older adults’ needs and rights. This has led to an entire new field of research, new public health initiatives and health and wellness consumer products collectively under the category of “healthy ageing”. Although once thought of as merely the absence of disability and chronic disease with longevity, the term healthy ageing has evolved to mean much more. Today, the term is meant to encompass social well-being and quality of life as well [84]. Despite widespread interest in healthy ageing, there are differing definitions and interpretations of the term, e.g., “successful ageing” or “ageing gracefully”. Irrespective of the term or terms used, healthy ageing has evolved to include the intersection between avoiding and managing disease and disability, optimizing cognitive and physical functions and engagement with life throughout the ageing years [133] (Fig. 2).

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Researchers have developed indices that can be used to predict factors, behaviors and traits that best contribute to healthy ageing. For example, Tyrovolas et al. developed a ten-point healthy ageing index, scoring attributes such as education, participation in social activities, number of yearly excursions, adherence to a healthful ‘Mediterranean diet’, frequency of physical activity and BMI. Elderly subjects who scored the highest on the healthy ageing index also reported using less healthcare services [143]. Other strong associations with healthy ageing include non-smoking status, the number of social contacts, better self-perceived health, independent living, life satisfaction and absence of depression [35, 64].

While substantial progress has been made identifying predictors of healthy ageing, assessing the impact of particular interventions has proven more challenging. This is due, in part, to the cost and difficulty of studying the long latency of disability and disease, and the subjective nature of some healthy ageing predictors. Moreover, heterogeneity in the ageing processes reflects peoples’ accumulated opportunities and vulnerabilities, as well as their choices and personal values. Identifying inequalities and identifying social, economic and other policies that can reduce unfair processes within and across countries are key to improving everyone’s chances to optimize healthy ageing. Nonetheless, measuring healthy ageing and the impact of lifestyle interventions remains an area of research focus. Metabolomics and transcriptomics have led to the emergence of biomarkers that may be used to assess the impact of various interventions on the process of healthy ageing [16, 109, 119].

Clearly the role of diet and nutrition is central to the sustaining of life. However, little is known about specific nutritional interventions that most effectively promote healthy ageing. At a recent workshop organized by the National Academy of Science, Engineering and Medicine, only caloric restriction was identified as a well-established dietary intervention that promotes healthy ageing (specifically longevity) [112]. With a rapidly ageing global population and the accompanying increase in comorbidities, mortalities and associated social costs, there is an urgent need to identify solutions including nutritional and dietary interventions that could promote healthy ageing. And despite this broad need, the ability to measure the impact of these interventions remains a major research challenge.

Society’s response to population ageing requires a vision to harness extra years of life, ensure that these years are spent in good health, and that these can be used to do what people value through-out the life course. A fundamental transformation in policies and institutions is required to enable a cohesive response that celebrates diversity yet narrows health inequities, within and across countries.

The World Health Organization (WHO) published its first World Report on Ageing and Health in September 2015 [154], and all Member States endorsed its first Global Strategy and Action Plan on Ageing and Health (GSAP) in May 2016 [155]. The Strategy represents a commitment from Member States and mandate for the WHO to establish partnerships to implement five strategic areas and reach agreed upon goals, including setting up a Decade for Healthy Ageing 2021–2030 aligned to Agenda 2030. One strategic area is to “Improve measurement, monitoring and research” with a sub-objective to agree on ways to describe, measure, analyze and monitor healthy ageing and document a baseline across countries by 2020.

The WHO Report and GSAP promote healthy ageing as a person-centered concept, based on life course and capability-based perspectives that can be applied to all people in all settings. Rather than a focus on morbidity or disease, healthy ageing is defined as “the process of developing and maintaining the functional ability that enables well-being in older age, with functional ability determined by the intrinsic capacity of the individual, the environments they inhabit and the interaction between them.” [153].

Functional ability (FA) comprises the health-related attributes that enable people to be and to do what they have reason to value. It is determined by the intrinsic capacity of the individual (i.e., the combination of all the individual’s physical and mental—including psychosocial—capacities). Moreover, ageing is not a disease.

Intrinsic capacity (IC) at any point in time is determined by many factors, including underlying physiological and psychological changes, health-related behaviors and the presence or absence of disease. These in turn are strongly influenced by the environments in which people have lived throughout their lives. Environments comprise all the factors in the extrinsic world (understood in the broadest sense and including physical, social and policy environments) that form the context of an individual’s life. Healthy ageing is inclusive of all older adults, in contrast to “successful ageing” or “anti-ageing” discourses that focus on elimination of disease or ageing processes [107]. Moreover, broader determinants of health and intermediary determinants [135], such as need met by health and long-term care services, are recognized as responsible for a large part of the heterogeneity observed in older age.

Using these concepts, the World Report proposed a public health framework for action addressing healthy ageing [9]. Figure 3 illustrates conceptually that when considering the population as a whole, IC and FA can vary across the second half of the life course. Trajectories reflect a continuous phenomenon, and can be divided into three common periods: a period of relatively high and stable capacity, a period of declining capacity, and a period of significant loss of capacity. These periods are not defined by chronological age and trajectories are not necessarily monotonic (that is, continually decreasing). Distinguishing between IC and FA is necessary to understand if levels, distributions and trajectories of functioning are due to changes in the individual or the environments they inhabit or both. It is also necessary to document what can be done to improve IC and FA for individuals, groups or populations, involving different policies, sectors and interventions. To agree on ways to describe, measure, analyze and monitor IC and FA, each concept requires further clarification, including a description of what are its components, pathways to optimize each across the life course, measurement approaches, and useful metrics to monitor and communicate progress.

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WHO is pursuing a collaborative process to develop and test a standardized approach to measure IC and FA that is person centered. The WHO International Classification of Functioning, Disability and Health (ICF) [152] offers an international reference and normative framework for describing, understanding and studying health and health-related states, outcomes and determinants, that are etiology-neutral and applicable to individuals and populations. This can inform the approach to agree on multi-domain profiles of IC and FA, drawing on the ICF’s universal and standard dimensions of “body functions and body structures”, “activities”, “participation” and “contextual” factors. For each domain, what should be measured needs to meet criteria, such as whether this will convey useful information on a person’s or population’s current IC and FA status, whether this reflects a pre-condition or critical stage to optimize IC or FA in the future, or whether this is sensitive to predict potential declines or improvements. How each of these are actually measured—and their feasibility in clinical or community settings—could be achieved through a range of biomarkers, other measured or performance tests, self-reported questionnaires, or observations. Finally, each domain may be assessed using several measures, then combined for each “domain score” for a multi-domain profile of IC and FA, and then be aggregated across domains, to obtain a composite score for IC and FA, respectively.

Monitoring and eventual evaluation should respond to at least three questions:

As there is no existing single generic instrument for assessing IC and FA, three approaches drawing on existing data mapped to IC and FA, provide preliminary insights to the first question.

Re-analyses of data collected through the WHO Study on Global Ageing and Adult Health (SAGE) [134], Wave 1 (2007–2010), offer an initial attempt to measure IC in nationally representative cross-sectional samples from all six participating countries (China, Ghana, India, Mexico, Russia, South Africa). IC is described through eight domains (mobility, self-care, pain and discomfort, cognition, interpersonal activities, sleep and energy, affect, and vision), and assessed by tests and self-reported questionnaires.

For people 50 years and over, Fig. 4 provides population representative distributions (histograms), of the composite IC score from 0 to 100 combining information across each domain, with a higher score representing better IC. Another example is reanalysis of longitudinal data drawn from the English Longitudinal Study on Ageing (ELSA) [32]. One analysis describes IC in five domains (vitality, sensory, locomotor, cognitive, psychosocial), through commonly collected biomarkers and self-reported measures over time; another identifies distinct trajectories of IC over time. Finally, the WHO Model Disability Survey [27], conducted in nationally representative samples in Chile and Sri Lanka, provides the only preliminary approach to quantifying FA in light of hindering or facilitating aspects of the general environment, such as family and social support; attitudes of others, accessibility to information, regular use of medication, personal assistance, assistive products for self-care, mobility, seeing, hearing, work and education, facilitators at home, school, work and community.

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Additionally, systematic efforts are needed, including reanalysis of other existing data, such as from the vast network of health and retirement studies, and new research on ways to collect data and develop a generic instrument specifically constructed to monitor IC and FA. To conclude, WHO launched the International Consortium on Healthy Ageing Metrics and Research in March 2017 and it has identified work packages to build up standards on healthy ageing data, measures, and metrics by 2020. Members include academic institutions, other UN and international bodies, non-government organizations, as well as other collaborative networks, e.g., the UN City group on age and age-disaggregated data. Measuring the change, we collectively want to see is part of the fundamental transformation needed across societies to enable healthy ageing.

Given the vast literature, evidence and recommendations on nutrition and older adults, three discussion questions to consider:

Key references: [151, 152, 153].

Definitions of healthy ageing continue to evolve. The WHO recently conceptualized a public-health framework for healthy ageing that considers physical health, mental health, environment, and environmental support [154]. Priorities for action that can help achieve healthy ageing under this framework include aligning health systems to the older population they now serve, developing systems of long-term care, creating age-friendly environments, and improving measurement, monitoring and understanding. This framework can also be used to support the rapidly growing population of the very old, such as centenarians who are aged 100 and older [140]. This presentation elaborated on WHO’s framework in two ways among centenarians: (1) nutrition as an environmental support to healthy ageing and (2) examination of cross-cultural differences and similarities between centenarians residing in Tokyo, Japan and Georgia, USA, in subjective measures of well-being, physical health, and social health.

Interventions to extend healthy lifespan or “healthspan” are needed. Accumulating evidence suggests molecular changes that occur with ageing are among the root causes of age-related disease and disability [80, 93]. Experiments with animals show that these molecular changes can be slowed or reversed, producing increases in healthy lifespan [39, 75]. Translation of these therapies, called “geroprotectors” [110], to extend human healthspan is increasingly plausible [92, 113, 114]. A barrier to translation is the challenge of measuring changes in the rate of human ageing.

Unlike worms, flies, and mice, humans live too long to observe complete lifespans within individual studies. Age-related disease and disability typically develop over the second half of the human life course, a period spanning decades. Interventions that modify biological processes of ageing to prevent age-related disease are, therefore, needed relatively early in life, before age-related disease becomes established [49, 108]. True tests of the effectiveness of such interventions will require decades of follow-up. To establish proof of concept for such long-term studies, measurements are needed that allow tests of a candidate therapy’s potential to slow the rate of human ageing over shorter intervals [12, 73].

Measurements to quantify biological processes of ageing could be implemented to test putative geroprotective effects of interventions over the short term. Measurements taken before, during, and at the conclusion of an intervention could be used to estimate how that intervention might change the rate of age-dependent deterioration in system integrity, providing a simple test of whether the intervention showed promise to extend healthspan. Measurements to quantify biological processes of ageing are now being developed. The most promising combine multiple sources of information, e.g., from clinical parameters or gene expression and DNA methylation measurements [74]. Initial epidemiologic studies of these algorithm-based biomarkers of ageing indicate promise [74]. For example, so-called “epigenetic clocks” composed of dozens or hundreds of methylation marks have been shown to predict mortality in multiple studies [24]. Research is needed to test if these new ageing biomarkers can inform evaluations of candidate therapies to slow ageing and extend healthspan [13].

Work by Belsky et al. [10, 11, 12, 13] has focused primarily on measures of biological ageing derived from indices of organ system functioning, including blood chemistries, blood counts, and organ system tests such as blood pressure, lung function, and cardiorespiratory fitness measurements. This work has yielded four main findings. First, consistent with theories of biological ageing, organ systems throughout the body show age-dependent declines in integrity even among young healthy people in their 20s and 30s. Moreover, the rate of this decline is correlated across different organ systems and is variable between individuals. Thus, measurement of the rate of biological ageing in relatively young people as the average rate of decline in integrity across organ systems is possible [11]. Second, young people whose bodies exhibit a faster rate of biological ageing measured in this way have worse physical functioning, as measured by tests of strength, balance, and motor coordination, and show evidence of early cognitive decline, as measured from changes in cognitive test performance between childhood and midlife. They also report being in worse health and are rated as looking older by others [11]. Third, people with early-life characteristics associated with shorter healthy lifespan, including exposure to childhood poverty and child maltreatment, poor health in childhood, and low childhood cognitive function and deficits in self-control evidence a faster rate of biological ageing [10]. Fourth, the rate of biological ageing measured from decline in the integrity of multiple organ systems is slowed by caloric restriction, an intervention established to extend healthy lifespan in animals [12]. This last study observed changes in the rate of biological ageing over the relatively short term of a 2-year intervention trial.

Critically, Belsky et al. [10, 11, 12, 13] observed consistent findings for multiple approaches to quantify biological ageing from organ system function data using their own longitudinal-change “Pace of Ageing” approach and cross-sectional methods that compare research participants to reference populations to quantify their biological age [82, 90] or their homeostatic dysregulation [29]. These methods, which can be implemented using standard blood chemistry panels and other data routinely collected in clinical studies, suggest new possibilities for studies to evaluate interventions that may affect the rate of ageing. In theory, these measures of biological ageing may be more sensitive than individual disease-endpoint measures, which focus on more extreme outcomes. Instead, biological ageing measures are designed to capture subtle, organism-wide shifts in physiological integrity. They may thus provide an interesting avenue for studies of nutritional interventions.

To study healthy ageing, data-driven tools and models can be used to quantify nutrition and health in a population. The value of good data can be stressed as it plays a key role in today’s data age, including the use of secondary data sources. To assess intakes at a population and subpopulation level, the data collected need to be of high quality, while keeping in mind time, cost, participant burden and other factors. The opportunity to analyze specific demographics, including vulnerable groups from a nutritional standpoint, is of great importance when trying to address healthy ageing. Food consumption surveys provide extensive information. They enable the assessment and monitoring of health and nutritional status of specific demographics, to inform healthy eating guidelines and to reduce diet-related chronic diseases, which all have a part to play in healthy ageing.

Food consumption surveys are also used to evaluate the benefits and safety of potential supplementation and fortification strategies, as well as to inform businesses on consumer intakes, dietary impact of products and ingredients, as well as research and development decisions. In addition, the data are used for monitoring food safety via food exposure assessments to additives, pesticides and contaminants. When analyzing and modelling those specific topics, it is of importance to have access to individual food diaries, detailed and quality food composition or chemical data, demographic, anthropometric and biomarker data. Methodologies for assessment of food and supplement intake vary widely, however, there is a view to harmonizing them within the European Union (EU) [2].

Even though the acceleration in data generation presents opportunities, gaps in availability or access, unfit-for-purpose data, lack of specific information and out-of-date data remain an outstanding challenge for public health nutrition research. To overcome such problems, data sources including market research data, online tools and platforms to gather data more efficiently, as well as the construction of new models combining complementary data from various sources of origin can be promising alternatives.

Models such as the Compiled European Food Consumption Database [116] and the Global Expanded Nutrient Supply (GENuS) Model [138] extrapolate consumption using existing databases. The Compiled European Food Consumption Database estimates the consumption of the European population using European Food Safety Authority (EFSA) comprehensive summarized intake statistics [98] and simulating 29 days of intake distributions for 40,000 individuals using 36 clusters of age groups and gender having similar diets. A limitation is that the database contains no estimates of nutrient intakes and no breakdown by country. Also due to the applied methodology, some outliers may be over- or underestimated. The GENuS model uses Food and Agricultural Organization (FAO) food balance sheets, production and trade data combined with nutrient composition tables to calculate the nutrient supply across 175 nations, 26 demographic groups and 225 food categories. The database, however, does not assess consumption of foods at the individual level and nutrient availability is overestimated. Examples of ongoing efforts to gather up-to-date and more harmonized data on food consumption are the EU menu [2] and the International Dietary Data Expansion (INDDEX) project [28], but whether the databases will be accessible and how they can be used remain to be seen.

The use of large datasets and mathematical models to assess and define optimal dietary changes in specific populations can generate valuable insights and opportunities for public health nutrition strategies and food product development.

Consumption of bioactive compounds can have beneficial and/or adverse health effects; however, intakes of those compounds are not routinely assessed in populations. As part of the European Commission (EC)-funded BACCHUS, ‘Beneficial effects of bioactive compounds in humans’ project, national food consumption data were linked to bioactive composition data. To estimate intake distributions and to account for variability of bioactive concentrations, a probabilistic intake modelling approach was applied [5, 124].

In the EC-funded ODIN project on vitamin D entitled Food-based solutions for optimal vitamin D nutrition and health through the life cycle; EC Contract 613977 [117], national food consumption surveys and a standardized vitamin D database were combined to assess vitamin D nutrition. Incremental food fortification scenarios, such as enrichment of animal food sources (meats, eggs, fish and dairy products) were then applied to ensure the safe increase of vitamin D intakes across the population distribution and prevent deficiency. In addition, safety across European countries was assessed using available data on consumption [98] and a worst-case scenario approach due to the lack of individual data [123].

Another example examined new food products and their impact on health outcomes, such as blood pressure and cardiovascular events, by assessing individual data on food consumption combined with intake models. This study by Dainelli et al. [31] looked at the shift in intakes of potassium-fortified milk powder and consecutively the health impact via replacing milk consumption with the fortified product in adults above the age of 45.

As part of the overall Healthy Ireland initiative [53], the Irish food industry is proactively contributing to healthier choices and product reformulation, but progress is not assessed regularly when looking at consumption. To quantify the impact of voluntary food reformulation efforts on Irish consumers, probabilistic intake assessments were performed using Irish national food consumption surveys (IUNA) in combination with industry data on reformulated product composition and market share data [60, 61, 62, 63, 122].

Combining databases and probabilistic intake models represents a great opportunity for informing public health strategies, including healthy ageing. The impact of dietary changes via using and modelling databases can provide powerful information for government and industry; however, available and fit-for-purpose databases, as well as the tools and expertise to exploit such data remain a challenge.

Since January 1, 2011, every day for the next 20 years, roughly 10,000 Americans will celebrate their 65th birthday. The US Census Bureau projects that between 2005 and 2025, the number of US individuals > 65 will increase by 50% [150]. Globally, currently 686 million people (12%) are over 60. By 2050, it is predicted that there will be nearly as many people aged > 60 as children under 15. In many countries, life expectancy of age 60 is now at least a third more than what it was in the mid-twentieth century [55]. Interestingly, the over-80 group is projected to be the fastest growing subset in this over-65 trend, which was 14% in 2012, and is predicted to be at 20% in 2050 [150]. This represents a major demographic shift with significant public health and socio-economic impact. Advances in science have greatly increased lifespan; however, at the same time, new and developing challenges, such as sarcopenia, cardiovascular disease, obesity, diabetes, dementia, macular degeneration, cataracts, and emerging infections, as well as the costs associated with these conditions are on the rise, impacting the health and functional lifespan of older adults while diminishing their ability to be fully contributing members of their communities.

Accumulating evidence, however, indicates that poor health in late life is not inevitable. Contrary to the previously held belief that increased risk of diseases and disability with advancing age results from inevitable, as well as genetically determined intrinsic ageing processes, more recent studies indicate that many of the usual ageing characteristics are due to lifestyle and other modifiable factors and are not unavoidable consequences of ageing itself [42, 51, 66]. Thus, developing strategies to increase “health span” or the years of “successfully ageing” for older adults becomes critical—socially, and economically.

Studies across species show that ageing is associated with dysregulated immune and inflammatory responses, which may contribute to many age-related diseases including cancer, infection, cardiovascular diseases, diabetes, Alzheimer’s disease and osteoporosis. The immune system is comprised of different cell types that engage in a complex series of interactions to defend the host against invading pathogens. These interactions, under normal conditions, are well-orchestrated so that a temporary upregulation in inflammatory responses needed to eliminate the pathogen is subsequently diminished and controlled. With ageing, the normal “checks and balances” of the immune response is impaired, creating a state of chronic inflammation (hyperactivity of parts of the immune system involved in innate immune response) on one hand, and hypoactivity of the cell-mediated immunity, particularly T cells, on the other (Fig. 5).

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This dichotomy presents a challenge in devising effective interventions to prevent/treat age-related changes of the immune response. Recent evidence, however, suggests that both the hyper- and hypo-activity of immune response associated with ageing might be governed by some of the same molecular/biochemical aberrations that might be responsive to nutritional intervention.

A significant portion of the global older population have nutritional problems exhibited as both under-nutrition (e.g., micronutrient deficiencies such as B vitamins, vitamin C, E, D, Se, Zn, Ca, and Fe) and over-nutrition (i.e., obesity); often existing together [81]. These age-associated nutritional problems provide opportunities and challenges in developing interventions that could reduce inflammation while improving host defense against infection. Strategies include single nutrient interventions, e.g., vitamin E [20, 46, 48, 52, 56, 99, 103, 105], vitamin B6 [106], zinc [6, 7, 8, 43, 100, 126], fish oils [102, 104, 159], or whole food such as wolfberry [38, 127, 145, 146] and pre-and probiotics [40, 87]. In addition, calorie restriction in both animal and humans has been shown to reduce inflammation and improve immune response [3, 101, 115, 149]. These studies provide strong evidence that appropriate nutritional intervention could optimize the immune and inflammatory responses in older adults leading to improved resistance to chronic and infectious diseases. These interventions, particularly started earlier in life, could have significant public health implications for older adults. However, success has been curbed due to the lack of adequate information on specific nutritional needs of older people. As a result, older people of a wide age range from 60 to 100 and with varied genetic and socio-economic backgrounds are included in studies without appreciation for heterogeneity of their nutritional status, which in turn, reduces the effectiveness of any given intervention. Addressing this gap, would expedite development of efficient and cost-effective nutritional strategies to improve quality of life in older adults.

Despite the obvious connection existing among ageing, nutrition and quality of life (QoL) in older adults, a systematic investigation in the field is lacking [37]. This is particularly the case when the focus is moved from clinical-based studies, where QoL is a traditional outcome of clinical or nutritional intervention, to the broader context of public health. Public health implications of nutrition and QoL in the older stages of life are of paramount importance, being interconnected to all of the most prominent issues, from (1) multi-comorbidities enhanced by poor diet and nutrient deficiencies, (2) polypharmacy as a consequence of the former situation and as a sign of improper approaches to healthy lifestyles, to (3) social aspects such as meal sharing with friends or families and (4) economic aspects, such as food insecurity.

Not only has better diet in older adults been shown to be associated with significantly higher physical and emotional QoL scores [147] and with better functional status [45], but the whole life satisfaction in older adults is impacted by nutritional adequacy [79]. The definition of healthy ageing itself includes diet quality and eating habits as essential components [121], with immediate consequences on hard outcomes, such as overall and disease-specific mortality [89]. Diet quality, which is mainly defined in terms of proper nutrient variety and adequate caloric intake, is, however, rarely met in older adults, mostly because of the aforementioned issues. In particular, intake of fruits and vegetables, which provide a wide variety of different micronutrients and bioactive compounds, are sub-optimally consumed by older people, with no improvement over the past decade. Supplementation has been advocated as a valid remedy to ameliorate diet quality challenges in older adults, most often in a very cost-effective way. In a recent review (unpublished)² on the impact of reported use of the active administration of any dietary supplement (vitamins, minerals, herb or botanical compounds, amino acids, dietary substances, concentrates, metabolites, constituents or extracts), the analysis of 83,350 subjects showed reported supplement use was associated with a significant reduction in mortality risk for cancer (pooled estimated HR 0.93, 95% CI 0.88–0.99) and stroke (pooled estimated HR 0.97, 95% CI 0.95–0.99). A marked impact on stroke mortality was noted for Ginkgo biloba-containing supplements (HR 0.59, 95% CI 0.37–0.93), Selenium + Coenzyme Q10-containing supplements (HR 0.46, 95% CI 0.33–0.64) and vitamin B (HR 0.75, 95% CI 0.62–0.91). Alternatively to a single-component analysis of the effects of supplementation on health, a recent review on fruit and vegetables concentrates and their potential impact on risk reduction for major health events [47] showed a strong inverse relationship between reported consumption and major chronic disease, in particular coronary heart disease and stroke (unpublished)³ (Fig. 6). Thus, the potential gain in terms of events avoided due to a better nutrition, via supplementation, in older adults, suggests a potential reduction of public health expenditure.

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The same simulation scenario as in the previous case shows indeed that a significant number of cases were avoided (approximately 9,965,819 (95% CI 643,567–25,202,911)), attributable to nutrient supplementation (in people aged 65 years or more) (Table 1). In this scenario, fostering vitamin consumption via fruits and vegetables or by supplementation is an essential component for promoting healthy ageing. Supplementation could thus be seen as a cost-effective solution to overcome behavioral obstacles typical of older age yet ensuring proper intake of most relevant nutrients.

Micronutrient deficiencies are common in older adults around the globe [157]. Numerous factors can limit the ability of elders to access and consume nutrient-dense foods, such as declining income, impaired mobility, poor oral health, altered taste and smell, loss of appetite, lack of food variety, changes in cognition and diminished vision. The greatest burden of chronic disease is borne by older adults, which by their very nature can lead to a disruption of the immune system, changes in metabolism, and impact inflammatory mediators, which can increase the body’s need for specific micronutrients. Medications used to treat chronic disease can be nutrient wasting, causing significant declines in the status of micronutrients vital for well-being and health.

While frank nutrient deficiency states are well-known (e.g., rickets, scurvy, pellagra), there is a growing body of evidence showing that less than optimal biochemical levels are associated with impaired cognitive function, cardiovascular disease, cancer, poor bone health, eye disease and other conditions that are common in older populations [22]. The focus of this presentation was to examine the prevalence, impact and risk factors for several key micronutrients in the ageing population.