Leocadio Rodríguez-Mañas
Robert Murray2- 1Service of Geriatrics, Getafe University Hospital and CIBER on Frailty and Healthy Aging (CIBERFES), Getafe, Spain
- 2Department of Pediatrics, Emeritus, The Ohio State University College of Medicine, Columbus, OH, United States
- 3Abbott Laboratories Ltd., Maidenhead, United Kingdom
- 4Abbott Laboratories, Abbott Park, IL, United States
Ensuring healthy lives and promoting wellbeing across the age spectrum are essential to sustainable development. Nutrition is at the heart of the World Health Organization (WHO) Sustainable Development Goals, particularly for Sustainable Development Goal 2/Subgoal 2, which is to End all forms of malnutrition by 2030. This subgoal addresses people of all ages, including targeted groups like young children and older adults. In recent decades, there have been marked advances in the tools and methods used to screen for risk of malnutrition and to conduct nutritional assessments. There have also been innovations in nutritional interventions and outcome measures related to malnutrition. What has been less common is research on how nutritional interventions can impact healthy aging. Our Perspective article thus takes a life-course approach to consider what is needed to address risk of malnutrition and why, and to examine how good nutrition across the lifespan can contribute to healthy aging. We discuss broad-ranging yet interdependent ways to improve nutritional status worldwide—development of nutritional programs and policies, incorporation of the best nutrition-care tools and methods into practice, provision of professional training for quality nutritional care, and monitoring health and economic benefits of such changes. Taken together, our Perspective aims to (i) identify current challenges to meeting these ideals of nutritional care, and to (ii) discover enabling strategies for the improvement of nutrition care across the lifespan. In harmony with the WHO goal of sustainable development, we underscore roles of nutrition to foster healthy human development and healthy aging worldwide.
1. Background
As the world population grows and longevity increases in the 21st century, the need for sustainable development challenges us to ensure health and wellbeing across the age spectrum. In 2015, the United Nations (UN) established 17 Sustainable Development Goals (SDG), which were adopted by all Member States. With a target of achievement by 2030, the UN seeks a better future for all people (1). Two SDG are fundamental and interrelated: Zero Hunger (SDG #2) and Good Health and Wellbeing (SDG #3) (1). The World Health Organization (WHO) has a complementary initiative on healthy aging, with 2020–2030 being recognized as the Decade for Healthy Aging (2–4). Aging well includes components of physical, mental, social, and emotional wellbeing—all of which can affect or be affected by dietary intake and nutritional status (1, 5–8). Indeed, nutrition is at the heart of sustainable development; meeting nutritional needs from infancy through old age builds a framework for health and wellbeing throughout life.
A specific subgoal for SDG #2 (subgoal 2) is to end all forms of malnutrition by 2030, particularly among targeted groups like young children and older adults. In recent decades, we have seen advances in the tools and methods to screen for risk of malnutrition and to assess nutritional status. As well, we have seen improvements in nutritional intervention strategies, treatment products, and methods for measuring treatment outcomes. Nevertheless, research is lacking on how nutritional interventions impact healthy aging. This Perspective article thus takes a life-course approach to define what is needed to address malnutrition and why, and to examine how good nutrition across the lifespan contributes to healthy aging. We posit that improvement of global nutrition requires broad-ranging approaches—developing nutrition programs and policies, incorporating the best nutrition-care tools and methods into practice, training professionals for quality nutritional care, and monitoring the health and economic benefits of such changes. Here we discuss the following strategies, which are summarized in Supplementary Box 1:
• A focus on updating nutritional policies can help move food systems toward healthy and sustainable food production by leading the way to recognizing healthy and sustainable diets (9). For population health, policies can build food sufficiency for people of all ages worldwide. For individuals, policies can promote intake of healthy foods (e.g., fruits and vegetables, whole grains, legumes, nuts, virgin olive oil (10), and seeds) and reduced consumption of unhealthy foods (e.g., processed red meats, sugary snacks) (11).
• It is important to identify and incorporate best measures of nutritional status into clinical practice—tools for screening, assessment, and outcome measures of nutrition-related growth and health (12). Such methods can flag healthy and unhealthy aging (13, 14). Various measures identify individuals who need nutritional intervention, and they reflect post-intervention health outcomes for individuals and populations.
• To integrate new methods and tools, an early practical challenge is to achieve consensus among health professionals on use of age-specific tools, methods, and indicators of nutritional status for all segments of the population (15–22). Based on such evidence, healthcare professionals then need to develop expert guidelines on use of these tools and measures, and to identify age- and population-specific cutoffs for measures of nutritional and functional status. Further, health professionals need clinical education and training programs on best-practice nutritional care for people of all ages (23–26).
• As new nutritional policies, programs, and methods are incorporated into practice, it is essential to monitor effectiveness of such changes in achieving sufficient and healthy dietary intake in cost-effective ways (27–30). We ask the question, “What is the value of nutrition?”
This Perspective aims to (i) identify current challenges to end malnutrition and deliver high quality nutritional care, and to (ii) discover enabling strategies that can enhance nutritional care and can support sustained health and wellbeing across the lifespan.
2. Nutrition matters across the lifespan
In the WHO model, healthy aging is viewed as a life-course progression (31, 32). Healthy nutrition is foundational for supporting physical growth and mental development in infants, young children, and adolescents; in young adulthood and midlife, nutrition and lifestyle patterns influence accumulation and maintenance of muscle, thus supporting aspects of health and physical function (Figure 1). In early life, nutrition helps build reserves for mental and physical function (31–34). In later adulthood, age-related decline is expected, but individuals with healthier growth at the beginning of life build biological reserves that prevent or delay age-related disabilities later (14, 35). In older age, good nutrition, including supplemental nutrition when needed, can be used to prevent functional decline and to restore health following acute or chronic diseases, injury, or surgery (36). Together, achieving good nutrition from youth through mid-adulthood is particularly relevant to muscle strength and functionality in older age; goals are to build peak muscle in youth, maintain muscle strength and function in midlife, and sustain muscle function or minimize loss in older age (Supplementary Figure 1) (32, 37).
Figure 1. Nutrition across the lifespan is foundational for health and wellbeing in older age.
2.1. Grow well to age well: Infancy, childhood, and adolescence
Optimal nutrition is critical from infancy through adolescence and puberty to support growth and to achieve important motor, language, and social milestones (34, 38). Nutritional requirements for children in the first years of life support rapid linear growth and weight gain for increased bone length and muscle mass and for growth and development of the gastrointestinal tract, cardiorespiratory system, kidneys, and immune and central nervous systems (39). Brain development is especially rapid in the first 24 months, thus requiring adequate macro- and micronutrients (38, 39). Without good early nutrition, a child may experience diminished cognitive performance throughout life (39). In middle childhood (5–9 years) and early adolescence (10–14 years), healthy children experience steady linear growth and development, which are supported by adequate nutrition relative to body size (34). During puberty, adolescents (15–19 years) grow and develop rapidly, which requires higher amounts of energy, protein, and micronutrients (34). For lifelong functionality, wellbeing, and achievement, adequate intake of energy, protein, and micronutrients in youth is thus key to physical growth, along with motor, language, and socioemotional development (34, 38–40).
2.2. To age well, stay well: Early adulthood and midlife
Staying well in early adulthood and midlife further builds a foundation for healthy aging. Yet some chronic diseases are now increasingly common among younger-aged adults and adolescents, often because of poor nutrition, lack of physical activity, and smoking (41). The WHO estimates that the elimination of these behaviors would decrease the risk of cardiovascular disease, stroke, and type 2 diabetes by 80% in older adults (41). Focus on nutrition, weight management, and physical activity in the middle years can facilitate longer and healthier lives.
In terms of nutrition, healthy aging is based on cumulative effects during the early and middle years of adult life (33). Food insecurity and unhealthy diets are problems that can affect low-, middle-, and high-income countries, although underlying causes differ as demographic, political, or economic conditions vary (11). Notably, middle-aged adults in the United States (US) consume less than the recommended daily requirements for most essential micronutrients leading to deficiencies that increase risk for certain chronic conditions (33). The prevention of osteoporosis in later life, for example, depends on the intake of calcium during childhood and young adulthood to achieve peak bone mineral density by age 30 years (33). Other examples include evidence supporting long-term use of dietary flavanol intake for reducing risk of later Alzheimer’s disease and dementia (42) and long-term adherence to the Mediterranean diet, which can lead to significant reductions in frailty, cardiovascular complications, and macular degeneration in older adults (33). Taking dietary supplements such as vitamin D, calcium, B12, and other micronutrients during the middle years, along with a healthy diet, can help prevent age-associated deficiencies and adverse health consequences (33, 43).
2.2.1. The importance of weight management
Weight management for maintenance of a healthy body mass index (between 18.5 and 24.9 kg/m2) (44) plays a key role in midlife and helps decrease risk of developing age-related conditions. The WHO recently reported that 1.9 billion adults worldwide are overweight or obese, while 462 million are underweight (45). Undernutrition and underweight in adulthood, often associated with poverty or illness, lead to conditions such as frailty, osteoarthritis, and impaired mobility, while overweight and obesity increase risk of sleep apnea and urinary incontinence, as well as type 2 diabetes, cardiovascular disease, and cancer (33). Thus, sufficient and healthy dietary intake (fruits, vegetables, whole grains, legumes, nuts, seeds, seafood, healthy oils, and moderate amounts of carbohydrates) is important to achieving weight goals and long-term health benefits (10, 33, 43).
2.2.2. Healthy nutrition and physical activity
A lifestyle of healthy nutrition and physical activity in early adulthood and midlife is key to aging well. Healthcare professionals can incorporate routine nutrition screening into clinical and office-based care for all adults. While there is currently not a well-validated nutritional screening tool for free-living adults in midlife, tools for hospitalized patients can be adapted for community use (33). In addition, the new Remote Malnutrition APP test (R-MAPP) tool was recently introduced for remote screening of adults for nutritional risk and for loss of muscle mass and function when healthcare access was limited during the COVID-19 pandemic; R-MAPP identifies risk for malnutrition and sarcopenia by combining Malnutrition Universal Screening (MUST) and Strength, Assistance in walking, Rise from a chair, Climb stairs, and Falls (SARC-F) tools (18, 22). Advice on maintaining physical activity during midlife and into older age further supports healthy aging, preserves musculoskeletal function, and helps lessen effects of decreased energy intake with aging (33, 46).
2.3. To age well, eat well: Older people
The global population of older people (≥ 60 years) is predicted to double over the next three decades—reaching 2.1 billion by 2050 (2). Strategies and systems are thus needed to ensure aging well in this latter phase of life to improve their quality of life and to limit potentially outsized increases in healthcare burdens and costs (2). To this end, health professionals propose a shift from disease-centered care to function-centered care for older people (47, 48). In fact, older people themselves want to maintain function (both physical and mental) (5), an aim reflected in the WHO’s goals for facilitating healthy aging (2–4, 49, 50). WHO now frames this concept as intrinsic capacity, which refers to the combination of physical and mental abilities (3). Thus, healthy aging refers to sustained intrinsic capacity, while lowered intrinsic capacity reflects functional decline. There is agreement that intrinsic capacity has multiple dimensions—including locomotion, vitality, sensory, cognition, and psychological domains. However, the methods for assessing each of these five dimensions presently differ across studies (51).
Among older people, proper nutrition is a key strategy to prevent or delay onset of chronic disease and functional decline, and to support quality of life—that is, to support aging well (52, 53). Conversely, malnutrition (deficient or excess intake of macronutrients or deficient intake of specific micronutrients) can lead to loss of intrinsic capacity with declining physical and mental health (54–57). In fact, there is substantial evidence that poor nutrition is a mediator of adverse outcomes in older people, e.g., lower physical function (58), poorer quality of life (59), greater risk for development of sarcopenia and frailty (53, 60, 61), cognitive decline (57), and shorter survival (62, 63).
2.3.1. What strategies can healthcare professionals use to identify and treat malnutrition and its risk in older people?
Healthcare experts worldwide have developed nutritional guidelines for general health and for muscle health in older people (14, 43, 64, 65). Guidance from the United States of America (USA) advises older adults to improve dietary intake by increasing consumption of fruit, vegetables, whole grains, and dairy, while ensuring that protein intake meets recommendations (43). European protein-intake recommendations have been set higher for older adults compared to those for younger ages, as there is evidence that older adults’ protein requirements are increased to maintain functionality (66, 67). Limited intake of added sugars, saturated fat, and sodium is also recommended for older adults to help manage or avoid chronic conditions (43). A recent study in Spain identified nutrient deficiencies in frail older adults, specifically protein, ω-3 fatty acids, retinol, ascorbic acid, niacin equivalents, folic acid, magnesium, and potassium (68). Other studies have implicated adequate intake of antioxidant and anti-inflammatory micronutrients (vitamins of the B group and vitamins A, C, D, and E) as important to maintaining cognitive health (57). Asian guidelines highlight additional practices to reduce risk of malnutrition and sarcopenia, i.e., (i) offering older adults nutritional counseling on good dietary patterns, and (ii) providing oral nutritional supplements (ONS) when indicated (14).
For clinical and public health professionals, steps to improved nutrition in older people are like those for younger people—screen routinely for nutritional risk, assess patients at risk to diagnose malnutrition severity, and intervene with nutritional care when needed based on a personalized nutrition plan (69). Continued monitoring is important to determine whether the selected nutritional intervention plan is effective. Numerous nutritional screening and assessment tools can be used for older people who are hospitalized (70, 71) or living in the community (15, 72).
Tools have been developed and validated specifically for screening older people and have been shown to predict morbidity and mortality (8, 16, 73). For use in the community, there are several nutritional screening, assessment, and diagnosis tools that can be used; Mini Nutritional Assessment short form (MNA-SF; a validated 6-question tool to rapidly assess geriatric patients for malnutrition or its risk) and Global Leadership Initiative on Malnutrition (GLIM; a tool that assesses three phenotypic [weight loss, low body mass index, and low skeletal muscle mass] and two etiologic [low food intake and presence of disease with systemic inflammation] criteria, with diagnosis confirmed by any combination of one phenotypic and one etiologic criterion fulfilled) criteria are commonly used (73–75).
Patients recognized as malnourished or at malnutrition risk need a more detailed nutritional assessment to identify and quantify specific nutritional problems. Such an assessment includes subjective and objective parameters—medical history, current and past dietary intake (including energy and protein balance), physical examination and anthropometric measurements, functional and mental assessment, quality of life, medications, and laboratory values (69).
When a patient’s nutritional assessment shows evidence of nutritional risk, malnutrition, sarcopenia, or frailty, a diagnosis can be made, and a healthcare professional must develop a personalized nutritional care plan. Implementation of nutritional intervention is particularly urgent for those who are already malnourished or have muscle impairment (41, 76, 77). A Canadian initiative proved effective for avoiding development of frailty (78), while results of a recent European study demonstrated that nutritional care could prevent loss of mobility (79).
2.3.2. How can healthcare professionals monitor the effectiveness of interventional strategies?
The WHO’s Integrated Care for Older People (ICOPE) recommendations advise (i) measuring dimensions of intrinsic capacity to quantify the severity of malnutrition-associated functional decline, and (ii) monitoring these dimensions during and after nutritional interventions (3). Recommendations for managing declines in functionality/intrinsic capacity include dietary advice and use of oral nutritional supplementation. For individuals’ physical health, measures of physical function, ability to perform daily life activities, and strength are used (3). For their mental health, perceived quality of life, cognition, and psychological wellness can be measured (3). In addition to nutritional care, individuals can benefit from exercise or physical activity programs, cognitive care, and encouragement of social connections (79–82). For healthcare systems, nutritional interventions for care of older people can also be measured in terms of resource use, cost savings, and cost-effectiveness. Supplementary Figure 2 provides a summary of strategies to quantify nutrition-related health outcomes in older adults.
2.3.3. What does the recent evidence show about nutritional interventions and health outcomes for older people?
People in the older population, including those living in the community, are among the most vulnerable to malnutrition. Poor nutrition in older people commonly leads to declining physical function, along with social and economic burdens (58, 83–88). However, these problems have often gone unrecognized until very recently. Here we present a detailed summary of recent reports from studies of older people around the world. We summarize up-to-date information and evidence on nutrition screening and assessment, nutritional intervention and outcomes, and implications for nutritional care in clinical practice (Table 1), thus providing evidence-based rationale for incorporating nutritional care into public health policies and clinical practice. Search criteria included articles published in English within the last 4 years and pertaining to older adults.
Table 1. Recent studies on nutritional interventions to support healthy aging in older adults.
3. Health economic studies show “value” in nutritional care
Beyond tolls to health and wellbeing, poor nutritional status increases use of healthcare resources with concordant rises in costs for healthcare in children (89, 90) and in young and older adults (Table 1). The field of Health Economics and Outcomes Research (HEOR) has emerged over the past decade to measure the link between treatments and actual outcomes, including cost outcomes. HEOR thus provides evidence-based guidance on how to improve care. In HEOR terms, the “value” of a care strategy is determined by outcomes relative to costs; the numerator of a value equation is outcome, while the denominator is cost (91). Nutritional care is advantageous when it improves outcomes. The “value” of nutritional care is recognized when patients’ health outcomes improve at reasonable incremental costs for nutritional care and with reduced overall costs of care (91).
There are many studies to illustrate the “value” of nutritional care. A recent cost-modeling study was conducted among older, community-living adults in Colombia (92). Following a nutrition-focused intervention with ONS use, total healthcare resource needs over a 90-day interval were reduced by more than 40% (hospitalizations ↓80%, emergency department visits ↓60%, and outpatient clinical visits ↓40%; P < 0.001). Based on economic modeling, per-patient cost savings of $210 over 90 days was attributed to this nutritional care. Total cost savings was consistent with nearly twice the initial investment for Quality Improvement Program (QIP) intervention; that is, the per-dollar return on investment was $1.82 (92). In a cost study from the USA, use of an advanced enteral nutritional formula in hospitalized patients with sepsis was estimated to save at least $52 million annually (93). Another study of older patients in home healthcare programs showed that rates of hospitalization and healthcare resource use were significantly reduced by prescribing ONS for adults at-risk/malnourished; cost-savings from 90-day healthcare resource utilization was approximately $1500 per patient treated (94). Numerous other studies and reviews underscore cost savings/cost effectiveness of nutritional interventions, especially ONS (95–101).
4. Conclusion
Our Perspective documents clear links between nutritional sufficiency in early life and better chances of good health, sustained functionality, and maintained wellbeing in older age. We now call on healthcare clinicians and public health professionals to act against poor nutrition in infants, children, and adults. We propose the following specific nutrition-related actions to meet UN and WHO goals of Zero Malnutrition and Good Health and Wellbeing across the lifespan.
• Build programs worldwide for professional training on nutritional awareness and care.
• Gain consensus among health professionals on the best tools for measurements of nutritional risk and outcomes.
• In some situations, it may be necessary to develop new nutritional screening and assessment tools. It is important to seek tools that result in easy and actionable steps for both the healthcare provider and the patient.
• Train professionals on use of best-practice tools.
• Use outcome studies to inform best-practice nutritional care across the lifespan.
• Create policies to emphasize nutritional care in communities, hospitals, and long-term care facilities worldwide.
Data availability statement
The data presented in this study are included in this article/Supplementary material, further inquiries can be directed to the corresponding author.
Author contributions
SS conceived the manuscript concept. SS and CG participated actively in the manuscript drafting. LR-M and RM served as expert consultants/editors on content for the geriatric and pediatric sections, respectively. All authors reviewed, edited, and approved the final version of the manuscript.
Funding
Abbott Laboratories (Abbott Park, IL, USA) provided funding to support publication of this Perspective article in Frontiers in Nutrition.
Acknowledgments
We thank Cecilia Hofmann, Ph.D. and Kathryn Hennessy, MS, RN, FASPEN (C Hofmann & Associates, Western Springs, IL, USA) for their skillful editorial assistance.
Conflict of interest
CG and SS were employees of Abbott Laboratories; they receive salaries for their work, and they are stockholders. LR-M and RM had received speaking honoraria from Abbott Laboratories but received no payment for their work on this manuscript, a perspective article based on current scientific evidence.
Publisher’s note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fnut.2022.1113060/full#supplementary-material
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Keywords: nutrition, malnutrition, lifespan, healthy aging, wellbeing
Citation: Rodríguez-Mañas L, Murray R, Glencorse C and Sulo S (2023) Good nutrition across the lifespan is foundational for healthy aging and sustainable development. Front. Nutr. 9:1113060. doi: 10.3389/fnut.2022.1113060
Received: 01 December 2022; Accepted: 23 December 2022;
Published: 24 January 2023.
Edited by:
Juan E. Andrade Laborde, University of Florida, United StatesReviewed by:
Michał Czapla, Wrocław Medical University, PolandCopyright © 2023 Rodríguez-Mañas, Murray, Glencorse and Sulo. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Leocadio Rodríguez-Mañas, 
leocadio.rodriguez@salud.madrid.org