Good nutrition across the lifespan is foundational for healthy aging and sustainable development
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
References
2. WHO Global Strategy on Ageing and Health. Decade of healthy ageing 2020-2030 proposal. World Health Organization: Geneva, CH: (2020).
3. World Health Organization [WHO]. Integrated care for older people (ICOPE). Guidance on person-centred assessment and pathways in primary care. Geneva, CH: World Health Organization (2019).
4. World Health Organization [WHO]. Decade of healthy ageing: baseline report. Geneva, CH: World Health Organization (2020).
5. Halaweh H, Dahlin-Ivanoff S, Svantesson U, Willen C. Perspectives of older adults on aging well: a focus group study. J Aging Res. (2018) 2018:9858252. doi: 10.1155/2018/9858252
6. Centers for Disease Control and Prevention [CDCP]. Well-being concepts: U.S. Washington, DC: Department of Health & Human Services (2018).
7. Ahmed N, Choe Y, Mustad V, Chakraborty S, Goates S, Luo M, et al. Impact of malnutrition on survival and healthcare utilization in medicare beneficiaries with diabetes: a retrospective cohort analysis. BMJ Open Diabetes Res Care. (2018) 6:e000471. doi: 10.1136/bmjdrc-2017-000471
8. Ahmed T, Haboubi N. Assessment and management of nutrition in older people and its importance to health. Clin Interv Aging. (2010) 5:207–16. doi: 10.2147/CIA.S9664
9. Development Initiatives [DI]. 2021 Global nutrition report: the state of global nutrition Bristol, UK. (2021). Available online at: https://globalnutritionreport.org/reports/2021-global-nutrition-report/. (accessed September 2, 2022).
10. Donat-Vargas C, Dominguez L, Sandoval-Insausti H, Moreno-Franco B, Rey-Garcia J, Banegas J, et al. Olive oil consumption is associated with lower frailty risk: a prospective cohort study of community-dwelling older adults. Age Ageing. (2022) 51:afab198. doi: 10.1093/ageing/afab198
11. Food and Agriculture Organization [FAO], International Fund for Agricultural Development [IFAD], UNICEF, World Food Programme [WFP], World Health Organization [WHO]. The state of food security and nutrition in the world 2022. Repurposing food and agricultural policies to make healthy diets more affordable. Rome: Food and Agriculture Organization (2022). doi: 10.4060/cc0639en
12. de van der Schueren M, Jager-Wittenaar H. Malnutrition risk screening: new insights in a new era. Clin Nutr. (2022) 41:2163–8. doi: 10.1016/j.clnu.2022.08.007
13. Arosio B, Cesari M. Nutrition and muscle health. Nutrients. (2021) 13:797. doi: 10.3390/nu13030797
14. Chen L, Arai H, Assantachai P, Akishita M, Chew S, Dumlao L, et al. Roles of nutrition in muscle health of community-dwelling older adults: evidence-based expert consensus from Asian working group for sarcopenia. J Cachexia Sarcopenia Muscle. (2022) 13:1653–72. doi: 10.1002/jcsm.12981
15. Hamirudin A, Charlton K, Walton K. Outcomes related to nutrition screening in community living older adults: a systematic literature review. Arch Gerontol Geriatr. (2016) 62:9–25. doi: 10.1016/j.archger.2015.09.007
16. Isautier J, Bosnic M, Yeung S, Trappenburg M, Meskers C, Whittaker A, et al. Validity of nutritional screening tools for community-dwelling older adults: a systematic review and meta-analysis. J Am Med Dir Assoc. (2019) 20:e13–25. doi: 10.1016/j.jamda.2019.06.024
17. Kruizenga H, van Keeken S, Weijs P, Bastiaanse L, Beijer S, Huisman-de Waal G, et al. Undernutrition screening survey in 564,063 patients: patients with a positive undernutrition screening score stay in hospital 1.4 d longer. Am J Clin Nutr. (2016) 103:1026–32. doi: 10.3945/ajcn.115.126615
18. Krznaric Z, Bender D, Laviano A, Cuerda C, Landi F, Monteiro R, et al. A simple remote nutritional screening tool and practical guidance for nutritional care in primary practice during the COVID-19 pandemic. Clin Nutr. (2020) 39:1983–7. doi: 10.1016/j.clnu.2020.05.006
19. Marino L, Collaco N, Ashton J, Cader S, Cooke M, Cooke L, et al. Pedi-R-MAPP: the development of a nutritional awareness tool for use in remote paediatric consultations using a modified delphi consensus. Clin Nutr. (2022) 41:661–72. doi: 10.1016/j.clnu.2022.01.009
20. Murray R, Kerr K, Brunton C, Williams J, DeWitt T, Wulf K. A first step towards eliminating malnutrition: a proposal for universal nutrition screening in pediatric practice. Nutr and Diet Suppl. (2021) 13:17–24. doi: 10.2147/NDS.S287981
21. Sherry C, Sauer A, Thrush K. Assessment of the nutrition care process in US hospitals using a web-based tool demonstrates the need for quality improvement in malnutrition diagnosis and discharge care. Curr Dev Nutr. (2017) 1:e001297. doi: 10.3945/cdn.117.001297
22. Salmeron Rios S, Plaza Carmona L, Estrella Cazalla J, Navarro Olivera J, Gomez Diaz de la Rosa F, Alonso Lucas M, et al. [Risk of sarcopenia and malnutrition related to COVID-19 in an institutionalized population of castilla-la mancha (Spain): determined by R-MAPP.]. Rev Esp Salud Publica. (2022) 96:e202209075.
23. Blunt S, Kafatos A. Clinical nutrition education of doctors and medical students: solving the catch 22. Adv Nutr. (2019) 10:345–50. doi: 10.1093/advances/nmy082
24. DiMaria-Ghalili R, Mirtallo J, Tobin B, Hark L, Van Horn L, Palmer C. Challenges and opportunities for nutrition education and training in the health care professions: intraprofessional and interprofessional call to action. Am J Clin Nutr. (2014) 99(Suppl. 5):1184S–93S. doi: 10.3945/ajcn.113.073536
25. Lenders C, Twillman G. Update on nutrition, metabolism, and lifestyle curricula for medical education, research, and practice: USA. Nestle Nutr Inst Workshop Ser. (2019) 92:151–60. doi: 10.1159/000499558
26. Van Horn L, Lenders C, Pratt C, Beech B, Carney P, Dietz W, et al. Advancing nutrition education, training, and research for medical students, residents, fellows, attending physicians, and other clinicians: building competencies and interdisciplinary coordination. Adv Nutr. (2019) 10:1181–200. doi: 10.1093/advances/nmz083
27. Blankenship J, Blancato R, Kelly R. Quality improvement as the foundation for halth care advancement. J Acad Nutr Diet. (2019) 119:S15–7. doi: 10.1016/j.jand.2019.05.026
28. McCauley S, Mitchell K, Heap A. The malnutrition quality improvement initiative: a multiyear partnership transforms care. J Acad Nutr Diet. (2019) 119:S18–24. doi: 10.1016/j.jand.2019.05.025
29. Phillips W, Becker P, Wong Vega M, Smith E, Konek S, Bailer J, et al. comprehensive application of the malnutrition quality improvement initiative (MQII) toolkit to pediatric malnutrition care. J Acad Nutr Diet. (2021) 121:1021–34. doi: 10.1016/j.jand.2020.08.091
30. Valladares A, Kilgore K, Partridge J, Sulo S, Kerr K, McCauley S. How a malnutrition quality improvement initiative furthers malnutrition measurement and care: results from a hospital learning collaborative. JPEN J Parenter Enteral Nutr. (2021) 45:366–71. doi: 10.1002/jpen.1833
31. Kuruvilla S, Sadana R, Montesinos E, Beard J, Vasdeki J, Araujo de Carvalho I, et al. A life-course approach to health: synergy with sustainable development goals. Bull World Health Organ. (2018) 96:42–50. doi: 10.2471/BLT.17.198358
32. Cesari M, Vanacore N, Agostoni C. The two extremes meet: pediatricians, geriatricians and the life-course approach. Pediatr Res. (2019) 86:432–5. doi: 10.1038/s41390-019-0479-4
33. Roberts S, Silver R, Das S, Fielding R, Gilhooly C, Jacques P, et al. Healthy aging-nutrition matters: start early and screen often. Adv Nutr. (2021) 12:1438–48. doi: 10.1093/advances/nmab032
34. United Nations Children’s Fund [UNICEF]. Programming guidance: nutrition in middle childhood and adolescence. New York, NY: United Nations Children’s Fund (2021).
35. Chao Y, Fang W, Chen W, Peng T, Yang W, Kao T. Exploring muscle health deterioration and its determinants among community-dwelling older adults. Front Nutr. (2022) 9:817044. doi: 10.3389/fnut.2022.817044
36. Struijk E, Hagan K, Fung T, Hu F, Rodriguez-Artalejo F, Lopez-Garcia E. Diet quality and risk of frailty among older women in the nurses’ health study. Am J Clin Nutr. (2020) 111:877–83. doi: 10.1093/ajcn/nqaa028
37. Cruz-Jentoft A, Bahat G, Bauer J, Boirie Y, Bruyere O, Cederholm T, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. (2019) 48:16–31. doi: 10.1093/ageing/afy169
38. Reverri E, Arensberg M, Murray R, Kerr K, Wulf K. Young child nutrition: knowledge and surveillance gaps across the spectrum of feeding. Nutrients. (2022) 14:3093. doi: 10.3390/nu14153093
39. Murray R. Assessing nutritional risk among infants and toddlers in primary care practice. Pediatr Ann. (2018) 47:e465–9. doi: 10.3928/19382359-20181016-01
40. Murray R. Starting strong: dietary, behavioral, and environmental factors that promote “strength” from conception to age 2 years. Appl Physiol Nutr Metab. (2020) 45:1066–70. doi: 10.1139/apnm-2020-0073
41. Shlisky J, Bloom D, Beaudreault A, Tucker K, Keller H, Freund-Levi Y, et al. Nutritional considerations for healthy aging and reduction in age-related chronic disease. Adv Nutr. (2017) 8:17–26. doi: 10.3945/an.116.013474
42. Shishtar E, Rogers G, Blumberg J, Au R, Jacques P. Long-term dietary flavonoid intake and risk of Alzheimer disease and related dementias in the framingham offspring cohort. Am J Clin Nutr. (2020) 112:343–53. doi: 10.1093/ajcn/nqaa079
43. United States Department of Agriculture [USDA], United States Department of Health and Human Services [HHS]. Dietary guidelines for Americans, 2020 - 2025. Washington, DC: USDA (2020).
44. Centers for Disease Control [CDC]. Healthy weight, nutrition, and physical activity: assessing your weight. Atlanta, GA: Centers for Disease Control (2022).
45. World Health Organization [WHO]. Malnutrition key facts geneva: world health organization. (2021). Available online at: https://www.who.int/news-room/fact-sheets/detail/malnutrition (accessed September 6, 2022).
46. Daskalopoulou C, Stubbs B, Kralj C, Koukounari A, Prince M, Prina A. Physical activity and healthy ageing: a systematic review and meta-analysis of longitudinal cohort studies. Ageing Res Rev. (2017) 38:6–17. doi: 10.1016/j.arr.2017.06.003
48. Rodriguez-Manas L, Rodriguez-Artalejo F, Sinclair A. The third transition: the clinical evolution oriented to the contemporary older patient. J Am Med Dir Assoc. (2017) 18:8–9. doi: 10.1016/j.jamda.2016.10.005
49. World Health Organization [WHO]. World report on ageing and health. Geneva, CH: World Health Organization (2015).
50. World Health Organization [WHO]. Evidence profile: malnutrition. Geneva, CH: World Health Organization (2017).
51. Lopez-Ortiz S, Lista S, Penin-Grandes S, Pinto-Fraga J, Valenzuela P, Nistico R, et al. Defining and assessing intrinsic capacity in older people: a systematic review and a proposed scoring system. Ageing Res Rev. (2022) 79:101640. doi: 10.1016/j.arr.2022.101640
52. Lorenzo-Lopez L, Maseda A, de Labra C, Regueiro-Folgueira L, Rodriguez-Villamil J, Millan-Calenti J. Nutritional determinants of frailty in older adults: a systematic review. BMC Geriatr. (2017) 17:108. doi: 10.1186/s12877-017-0496-2
53. Rodriguez-Manas L, Rodriguez-Sanchez B, Carnicero J, Rueda R, Garcia-Garcia F, Pereira S, et al. Impact of nutritional status according to GLIM criteria on the risk of incident frailty and mortality in community-dwelling older adults. Clin Nutr. (2021) 40:1192–8. doi: 10.1016/j.clnu.2020.07.032
54. Black M, Bowman M. Nutrition and healthy aging. Clin Geriatr Med. (2020) 36:655–69. doi: 10.1016/j.cger.2020.06.008
55. Prado C, Landi F, Chew S, Atherton P, Molinger J, Ruck T, et al. Advances in muscle health and nutrition: a toolkit for healthcare professionals. Clin Nutr. (2022) 41:2244–63. doi: 10.1016/j.clnu.2022.07.041
56. Rasheed S, Woods R. Malnutrition and quality of life in older people: a systematic review and meta-analysis. Ageing Res Rev. (2013) 12:561–6. doi: 10.1016/j.arr.2012.11.003
57. Melzer T, Manosso L, Yau S, Gil-Mohapel J, Brocardo P. In pursuit of healthy aging: effects of nutrition on brain function. Int J Mol Sci. (2021) 22:5026. doi: 10.3390/ijms22095026
58. Villafane J, Pirali C, Dughi S, Testa A, Manno S, Bishop M, et al. Association between malnutrition and barthel index in a cohort of hospitalized older adults. J Phys Ther Sci. (2016) 28:607–12. doi: 10.1589/jpts.28.607
59. Marshall S, Bauer J, Isenring E. The consequences of malnutrition following discharge from rehabilitation to the community: a systematic review of current evidence in older adults. J Hum Nutr Diet. (2014) 27:133–41. doi: 10.1111/jhn.12167
60. Prado C, Anker S, Coats A, Laviano A, von Haehling S. Nutrition in the spotlight in cachexia, sarcopenia and muscle: avoiding the wildfire. J Cachexia Sarcopenia Muscle. (2021) 12:3–8. doi: 10.1002/jcsm.12673
61. Demirdag F, Kolbasi E, Aykut G, Guler K, Murat S, Ozturk G, et al. Nutritional status as a mediator between the age-related muscle loss and frailty in community-dwelling older adults. Arch Gerontol Geriatr. (2022) 98:104569. doi: 10.1016/j.archger.2021.104569
62. Prado C, Purcell S, Alish C, Pereira S, Deutz N, Heyland D, et al. Implications of low muscle mass across the continuum of care: a narrative review. Ann Med. (2018) 50:675–93. doi: 10.1080/07853890.2018.1511918
63. Shakersain B, Santoni G, Faxen-Irving G, Rizzuto D, Fratiglioni L, Xu W. Nutritional status and survival among old adults: an 11-year population-based longitudinal study. Eur J Clin Nutr. (2016) 70:320–5. doi: 10.1038/ejcn.2015.109
64. Volkert D, Beck A, Cederholm T, Cruz-Jentoft A, Goisser S, Hooper L, et al. ESPEN guideline on clinical nutrition and hydration in geriatrics. Clin Nutr. (2019) 38:10–47. doi: 10.1016/j.clnu.2018.05.024
65. Volkert D, Beck A, Cederholm T, Cruz-Jentoft A, Hooper L, Kiesswetter E, et al. ESPEN practical guideline: clinical nutrition and hydration in geriatrics. Clin Nutr. (2022) 41:958–89. doi: 10.1016/j.clnu.2022.01.024
66. Bauer J, Biolo G, Cederholm T, Cesari M, Cruz-Jentoft A, Morley J, et al. Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE study group. J Am Med Dir Assoc. (2013) 14:542–59. doi: 10.1016/j.jamda.2013.05.021
67. Deutz N, Bauer J, Barazzoni R, Biolo G, Boirie Y, Bosy-Westphal A, et al. Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN expert group. Clin Nutr. (2014) 33:929–36. doi: 10.1016/j.clnu.2014.04.007
68. Moradell A, Fernandez-Garcia A, Navarrete-Villanueva D, Sagarra-Romero L, Gesteiro E, Perez-Gomez J, et al. Functional frailty, dietary intake, and risk of malnutrition. Are nutrients involved in muscle synthesis the key for frailty prevention? Nutrients. (2021) 13:1231. doi: 10.3390/nu13041231
69. Reber E, Gomes F, Vasiloglou M, Schuetz P, Stanga Z. Nutritional risk screening and assessment. J Clin Med. (2019) 8:1065. doi: 10.3390/jcm8071065
70. Holyday M, Daniells S, Bare M, Caplan G, Petocz P, Bolin T. Malnutrition screening and early nutrition intervention in hospitalised patients in acute aged care: a randomised controlled trial. J Nutr Health Aging. (2012) 16:562–8. doi: 10.1007/s12603-012-0022-3
71. Neelemaat F, Meijers J, Kruizenga H, van Ballegooijen H, van Bokhorst-de van der Schueren M. Comparison of five malnutrition screening tools in one hospital inpatient sample. J Clin Nurs. (2011) 20:2144–52. doi: 10.1111/j.1365-2702.2010.03667.x
72. Bloom I, Zhang J, Parsons C, Bevilacqua G, Dennison E, Cooper C, et al. Nutritional risk and its relationship with physical function in community-dwelling older adults. Aging Clin Exp Res. (2022) 34:2031–9. doi: 10.1007/s40520-022-02171-3
73. Kaiser M, Bauer J, Ramsch C, Uter W, Guigoz Y, Cederholm T, et al. Validation of the mini nutritional assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging. (2009) 13:782–8. doi: 10.1007/s12603-009-0214-7
74. Cederholm T, Jensen G, Correia M, Gonzalez M, Fukushima R, Higashiguchi T, et al. GLIM criteria for the diagnosis of malnutrition - A consensus report from the global clinical nutrition community. Clin Nutr. (2019) 38:1–9. doi: 10.1016/j.clnu.2019.02.033
75. Barazzoni R, Jensen G, Correia M, Gonzalez M, Higashiguchi T, Shi H, et al. Guidance for assessment of the muscle mass phenotypic criterion for the global leadership initiative on malnutrition (GLIM) diagnosis of malnutrition. Clin Nutr. (2022) 41:1425–33. doi: 10.1016/j.clnu.2022.02.001
76. Tamura Y, Omura T, Toyoshima K, Araki A. Nutrition management in older adults with diabetes: a review on the importance of shifting prevention strategies from metabolic syndrome to frailty. Nutrients. (2020) 12:3367. doi: 10.3390/nu12113367
77. Ng T, Feng L, Nyunt M, Feng L, Niti M, Tan B, et al. Nutritional, physical, cognitive, and combination interventions and frailty reversal among older adults: a randomized controlled trial. Am J Med. (2015) 128:1225–36.e1. doi: 10.1016/j.amjmed.2015.06.017
78. Rasiah J, Prorok J, Adekpedjou R, Barrie C, Basualdo C, Burns R, et al. Enabling healthy aging to AVOID frailty in community dwelling older Canadians. Can Geriatr J. (2022) 25:202–11. doi: 10.5770/cgj.25.536
79. Bernabei R, Landi F, Calvani R, Cesari M, Del Signore S, Anker S, et al. Multicomponent intervention to prevent mobility disability in frail older adults: randomised controlled trial (SPRINTT project). BMJ. (2022) 377:e068788. doi: 10.1136/bmj-2021-068788
80. Wang H. Wisdom in healthy aging research: starting from measurement. Int Psychogeriatr. (2022) 34:593–6. doi: 10.1017/S1041610222000540
81. Wang S, Zhao M, Shi Y, Zhang M, Ying J, Li H, et al. Associations of frailty, loneliness and the quality of life of empty nesters: a cross-sectional study in rural areas. Int J Nurs Pract. (2021) 28:e12947. doi: 10.1111/ijn.12947
82. Cesari M, Azzolino D, Arosio B, Canevelli M. Nutritional interventions for early dementia. J Nutr Health Aging. (2021) 25:688–91. doi: 10.1007/s12603-021-1616-4
83. Tey S, Huynh D, Berde Y, Baggs G, How C, Low Y, et al. Prevalence of low muscle mass and associated factors in community-dwelling older adults in Singapore. Sci Rep. (2021) 11:23071. doi: 10.1038/s41598-021-02274-3
84. Vandewoude M, Alish C, Sauer A, Hegazi R. Malnutrition-sarcopenia syndrome: is this the future of nutrition screening and assessment for older adults? J Aging Res. (2012) 2012:651570. doi: 10.1155/2012/651570
85. Verlaan S, Ligthart-Melis G, Wijers S, Cederholm T, Maier A, de van der Schueren M. High prevalence of physical frailty among community-dwelling malnourished older adults-a systematic review and meta-analysis. J Am Med Dir Assoc. (2017) 18:374–82. doi: 10.1016/j.jamda.2016.12.074
86. Wolters M, Volkert D, Streicher M, Kiesswetter E, Torbahn G, O’Connor E, et al. Prevalence of malnutrition using harmonized definitions in older adults from different settings - A MaNuEL study. Clin Nutr. (2019) 38:2389–98. doi: 10.1016/j.clnu.2018.10.020
87. Gomez G, Botero-Rodriguez F, Misas J, Garcia-Cifuentes E, Sulo S, Brunton C, et al. A nutritionally focused program for community-living older adults resulted in improved health and well-being. Clin Nutr. (2022) 41:1549–56. doi: 10.1016/j.clnu.2022.05.003
88. O’Keeffe M, Kelly M, O’Herlihy E, O’Toole P, Kearney P, Timmons S, et al. Potentially modifiable determinants of malnutrition in older adults: a systematic review. Clin Nutr. (2019) 38:2477–98. doi: 10.1016/j.clnu.2018.12.007
89. Freijer K, van Puffelen E, Joosten K, Hulst J, Koopmanschap M. The costs of disease related malnutrition in hospitalized children. Clin Nutr ESPEN. (2018) 23:228–33. doi: 10.1016/j.clnesp.2017.09.009
90. Gambra-Arzoz M, Alonso-Cadenas J, Jimenez-Legido M, Lopez-Gimenez M, Martin-Rivada A, de Los Angeles Martinez-Ibeas M, et al. Nutrition risk in hospitalized pediatric patients: higher complication rate and higher costs related to malnutrition. Nutr Clin Pract. (2020) 35:157–63. doi: 10.1002/ncp.10316
91. Sulo S, Gramlich L, Benjamin J, McCauley S, Powers J, Sriram K, et al. Nutrition interventions deliver value in healthcare: real-world evidence. Nutr Dietary Suppl. (2020) 12:139–46. doi: 10.2147/NDS.S262364
92. Sulo S, Schwander B, Brunton C, Gomez G, Misas J, Gracia D, et al. Nutrition-focused care for community-living adults: healthcare utilization and economic benefits. Value Health Reg Issues. (2022) 32:70–7. doi: 10.1016/j.vhri.2022.08.005
93. Tyler R, Barrocas A, Guenter P, Araujo Torres K, Bechtold M, Chan L, et al. Value of nutrition support therapy: impact on clinical and economic outcomes in the United States. JPEN J Parenter Enteral Nutr. (2020) 44:395–406. doi: 10.1002/jpen.1768
94. Riley K, Sulo S, Dabbous F, Partridge J, Kozmic S, Landow W, et al. Reducing hospitalizations and costs: a home health nutrition-focused quality improvement program. JPEN J Parenter Enteral Nutr. (2020) 44:58–68. doi: 10.1002/jpen.1606
95. Hong K, Sulo S, Wang W, Kim S, Huettner L, Taroyan R, et al. Nutrition care for poorly nourished outpatients reduces resource use and lowers costs. J Prim Care Community Health. (2021) 12:21501327211017014. doi: 10.1177/21501327211017014
96. Freijer K, Nuijten M, Schols J. The budget impact of oral nutritional supplements for disease related malnutrition in elderly in the community setting. Front Pharmacol. (2012) 3:78. doi: 10.3389/fphar.2012.00078
97. Abizanda P, Sinclair A, Barcons N, Lizan L, Rodriguez-Manas L. Costs of malnutrition in institutionalized and community-dwelling older adults: a systematic review. J Am Med Dir Assoc. (2016) 17:17–23. doi: 10.1016/j.jamda.2015.07.005
98. Elia M, Normand C, Norman K, Laviano A. A systematic review of the cost and cost effectiveness of using standard oral nutritional supplements in the hospital setting. Clin Nutr. (2016) 35:370–80. doi: 10.1016/j.clnu.2015.05.010
99. Freijer K, Bours M, Nuijten M, Poley M, Meijers J, Halfens R, et al. The economic value of enteral medical nutrition in the management of disease-related malnutrition: a systematic review. J Am Med Dir Assoc. (2014) 15:17–29. doi: 10.1016/j.jamda.2013.09.005
100. Schuetz P, Sulo S, Walzer S, Vollmer L, Brunton C, Kaegi-Braun N, et al. Cost savings associated with nutritional support in medical inpatients: an economic model based on data from a systematic review of randomised trials. BMJ Open. (2021) 11:e046402. doi: 10.1136/bmjopen-2020-046402
101. Schuetz P, Sulo S, Walzer S, Vollmer L, Stanga Z, Gomes F, et al. Economic evaluation of individualized nutritional support in medical inpatients: secondary analysis of the EFFORT trial. Clin Nutr. (2020) 39:3361–8. doi: 10.1016/j.clnu.2020.02.023
102. Cheong M, Chew S, Oliver J, Baggs G, Low Y, How C, et al. Nutritional biomarkers and associated factors in community-dwelling older adults: findings from the SHIELD study. Nutrients. (2020) 12:3329. doi: 10.3390/nu12113329
103. McKeever L, Farrar I, Sulo S, Partridge J, Sheean P, Fitzgibbon M. Nutritional adequacy and oral nutritional supplementation in older community-dwelling adults. J Aging Res Clin Practice. (2019) 8:7–14. doi: 10.14283/jarcp.2019.2
104. Chavarro-Carvajal D, Ayala A, Venegas-Sanabria L, Gomez G, Sulo S, Misas J, et al. Use of a nutrition-focused quality improvement program for community-living older adults at malnutrition risk is associated with better nutritional outcomes. Clin Nutr ESPEN. (2022) 48:291–7. doi: 10.1016/j.clnesp.2022.01.032
105. Chew S, Tan N, Cheong M, Oliver J, Baggs G, Choe Y, et al. Impact of specialized oral nutritional supplement on clinical, nutritional, and functional outcomes: a randomized, placebo-controlled trial in community-dwelling older adults at risk of malnutrition. Clin Nutr. (2021) 40:1879–92. doi: 10.1016/j.clnu.2020.10.015
106. Smith T, Cawood A, Walters E, Guildford N, Stratton R. Ready-made oral nutritional supplements improve nutritional outcomes and reduce health care use-a randomised trial in older malnourished people in primary care. Nutrients. (2020) 12:517. doi: 10.3390/nu12020517
107. Smith M, Bergeron C, Lachenmayr S, Eagle L, Simon JRA. Brief intervention for malnutrition among older adults: stepping up your nutrition. Int J Environ Res Public Health. (2020) 17:3590. doi: 10.3390/ijerph17103590
108. Hong K, Sulo S, Wang W, Kim S, Huettner L, Taroyan R, et al. Patient and healthcare provider satisfaction with a nutrition care program implemented in community clinics. Qual Prim Care. (2022) 30:41791.
109. Rodriguez-Sanchez B, Sulo S, Carnicero J, Rueda R, Rodriguez-Manas L. Malnutrition prevalence and burden on healthcare resource use among Spanish community-living older adults: results of a longitudinal analysis. Clinicoecon Outcomes Res. (2020) 12:355–67. doi: 10.2147/CEOR.S256671
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