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J.H. Park, Y.J. Park


NutriEpigenomics Laboratory, Department of Nutritional Science and Food Management, College of Science and Industry Convergence, Ewha Womans University, Seoul, Republic of Korea

Corresponding Author: Yoon Jung Park, NutriEpigenomic Laboratory, Department of Nutritional Science and Food Management, Ewha Womans University, 52 Ewhayeodae-gil, Seodaemoon-gu, Seoul 03760, Korea, Rep. of. Telephone: 82-2-3277-6533, FAX: 82-2-3277-2862 E-mail: park.yoonjung@ewha.ac.kr

J Aging Res Clin Practice 2018;7:3-8
Published online February 15, 2018, http://dx.doi.org/10.14283/jarcp.2018.2



An increasing number of researches on gerontology has emphasized an aging process without impairments of physical and/or cognitive function, alongside with an increase of life expectancy. However, studies to date on a healthy aging have suggested limited information on normal and usual aging in an inconsistent manner. Here, we review characteristics to define a healthy aging and, moreover, suggest effective elements to achieve the healthy aging through systematic review. Based on two databases including RISS and PUPMED, we collected original articles showing links between health-related traits and associated factors in Korean population aged 65 years or older. After screening the titles and abstracts, full texts of 186 articles were reviewed, and the remaining 109 papers meeting the inclusion criteria were analyzed to extract aging characteristics and factors of healthy aging. Here, we focus on two themes: 1) definition of a healthy aging and 2) effective determinants influencing the healthy aging. Our results suggest that a healthy aging is a multidisciplinary concept involving objective, subjective and comprehensive definitions. We classify the healthy aging-associated factors into physical, emotional, mental, social and economic domains, and identify that dietary patterns and nutrients among the multi-layer elements become good modifiable factor to achieve the healthy aging..

Keywords: Healthy aging, successful aging, midlife factors, Korean elderly.



The progressive increase of life expectancy is a major epidemiologic issue we are facing. By the early 20th century, major causes of illness and death were infectious and parasitic diseases and, thus, a short life expectancy was accompanied by a low survival rate of children and the elderly who are easily infected from virus and bacteria (1). However, a dramatic increase of global life expectancy is being driven by the remarkable improvements of hygiene, nutrition and accessibility to medical care during the last century. According to the report of the World Health Organization, the global population of older adults aged 65 or older would be expected to increase from an estimated 524 million in 2010 to nearly 1.5 billion in 2050 (1). Alongside with the rapid aging, a transition of illness causing the world population to suffer has occurred from infectious diseases to non-communicable diseases such as obesity, diabetes, cardiovascular diseases and cancer. The high prevalence of chronic diseases raises the question whether the present population lives longer with maintaining their well-being status. A concept of well-being encompasses positive status of physical and emotional health, economic condition, social activity and life satisfaction (2). Thus, it is important to understand and strengthen well-being to provide a way for diseases prevention as well as comprehensive health promotion. However, the concept of well-being has a limitation to apply to the elderly specifically, due to the wide coverage of population. Thus, it becomes critical how to define a healthy aging in terms of well-controlled physical, mental and socioeconomic systems without illness in the elderly. To date, a term of successful aging has been widely used to define a healthy aging in a usual population. A model for the successful aging was proposed by Rowe and Kahn, for the first time, and this involves multidimensional domains which are similar elements of well-being (3). However, many studies have still offered inconsistent criteria to define an effective successful aging with diverse terminologies. Therefore, we aim to explore coherent characteristics organizing healthy and successful aging via a systematic review of clinical researches, particularly in Korean elderly. In addition, we investigate effective determinants contributing to the healthy aging at an individual level as well as social and national levels.



Search strategy

We searched articles on the Korean Research Information Service System (RISS) and the PubMed databases. We used search terms “elderly”, “aging”, “health” and “Korean” and searched articles published from 1995 to 2017. The search is processed by RISS as: “Korean” [All Fields] AND “elderly” [All Fields] AND “health” [All Fields] AND “aging” [All Fields]) and by PubMed as: (“Korean” [Title/Abstract] AND “elderly” [Title/Abstract] AND “Health” [Title/Abstract] AND “aging” [Title/Abstract]). In RISS database, domestic scientific journals and international journals were included and thesis, books and research reports were excluded. In PubMed database, every journal searched was included. Searching articles were conducted between January 5 and 17, 2017.

Figure 1 Flow of the selection process

Figure 1
Flow of the selection process



Study selection

Peer-reviewed journals conducted in the Korean elderly population aged 65 years or older were included. First, the titles and abstracts of the articles were screened according to inclusion and exclusion criteria as shown in Figure 1. Firstly, we excluded articles that were non-original articles, including review articles and conference publications, and were overlapped. Secondly, we excluded articles which did not match the research topic for healthy aging and the appropriate subjects such as participants who were non-Korean through reviewing titles and abstracts. Considering that the chronological age of 65 year is used to define elderly in Korea national reports such as Korea National Health and Nutrition Examination Survey and Dietary Reference Intakes for Koreans, we also excluded articles on the population under 65 years of age. After the screening, we reviewed the full-texts and extracted the finalized articles.

Data extraction

We extracted the following information from the included articles: (1) first author, (2) title, (3) published journal and year, (4) study design; (5) number of participants; (6) age of participants; (7) characteristics of aging outcomes; (8) and effective determinant influencing healthy aging (9). The extracted information was reviewed and categorized according to organizing criteria. Components of aging characteristics and factors affecting health status of the elderly from the included articles were categorized. Information regarding the Korean-specific aging was described with example articles in the text and discussion.




Results of the literature search

Figure 1 shows the flow of article selection for systematic review. We searched initially four hundred fourteen articles in RISS (n = 307) and PUBMED (n = 107). The remained articles (n = 376) after removing duplicates (n = 38) were screened at titles and abstract levels. Full-texts of 186 articles were reviewed and 109 articles were included to extract data. The 109 articles comprised cross-sectional studies (n = 95), case-control studies (n = 0), nested case-control studies (n = 1), cohort (n = 12) and randomized control trials (n = 1). All the included researches were conducted in south Korea and every participant was the Korean elderly with age of 65 years or older.

Outcome characteristics to define aging in the Korean elderly

Few studies assess intervention or randomized control trial and, instead, cross-sectional and cohort. One study determined that the effect of exercise program on the improvement of health of the elderly through a randomized control. A variety of health characteristics to define aging were identified in the reviewed articles. The characteristics of health status of the elderly could be divided into objective and subjective criteria: the objective terms are defined by diagnosable characteristics such as mental and physical disorders and related-diseases, and the subjective characteristics are defined by self-reported ones such as perceived health and life satisfaction. The objective criteria could be classified into six subtypes; mortality, emotional disorders, mental functions, physical disorder, physical functions and molecular marker. Eighteen out of the 109 studies investigated emotional disorders including depression, suicide ideation or attempt, perceived stress and death anxiety. Ten studies investigated mental functions and related disorders including cognitive function, dementia, and Alzhimer’s disease. In relation to physical health, twenty-eight studies investigated physical diseases and the majority of the studies focused on metabolic diseases including obesity, sarcopenic obesity, glucose dysregulation and cardiovascular related-diseases as well as other physiological diseases including renal and pulmonary dysfunction, osteoarthritis, immune disorder and restless legs syndrome. Physical functions were investigated in sixteen studies in which six studies measured activities of daily living (ADL) and instrumental ADL (IADL), three studies assessed grip strength to evaluate functional ability of the elderly, and others investigated falls, frailty, hearing loss and oral health status to define physical functions. With regards to subjective criteria, self-reported characteristics were assessed by twenty studies. Eight studies evaluated self-rated health status which reflects simply an individual’s perception of general health status. Also, social participation activities and nutrient intakes were assessed through self-reporting scales by two and one studies, respectively.

Table 1 Classification of outcomes of aging reported in the included articles

Table 1
Classification of outcomes of aging reported in the included articles


In addition to the single elements in terms of objective and subjective criteria, twelves studies used comprehensive terms including ‘successful aging’, ‘health-related quality of life’ and ‘general health status’. Seven cross-sectional studies used the term ‘successful aging’ but the definitions could be divided into two concepts. A first concept of successful aging means psychological and social state by evaluating self-esteem, self-control, relationship with spouse and life satisfaction through success of children, which is suggested and defined by Kim and Shin (4). The other concept is based on the theory of human aging suggested by Rowe and Kahn, which encompasses diseases status, physical and mental functions and social activity (3). A term of ‘health-related quality of life’ contains physical function, mental health, emotional state and social participation were used in four cross-sectional literatures. A super-ordinate concept of ‘general health status’ embracing health-related quality of life and illness, geriatric depression, physical function was used in one article. These concepts are similar to the one of successful aging based on the Rowe and Kahn’s model.

Effective factors influencing healthy aging

Table 2 shows that healthy aging-associated factors are categorized into five; biological, mental, behavioral, nutritional and socioeconomic factors. Biological factors encompass physiological and biochemical factors. More specifically, physiological factors involve body composition, physical disabilities, pain, dental health including the number of missing teeth and denture wearing, dysphagia, auditory and visual impairments, renal function and anemia. These physiological factors are implicated to impact on comprehensive health status in the elderly as well as mortality (5-11). Biochemical factors are measurable in the blood and these consist of adiponectin, retinol binding protein (RBP) 4, vitamin D, thyroid-stimulating hormone (TSH), insulin-like growth factor (IGF) 1, insulin, lipids and serum anion gaps. The biochemical elements would be predictive factors of aging-related physical diseases. For instance, serum adiponectin, RBP4 and vitamin D levels are associated with prevalence of metabolic diseases (12-14). Serum TSH and cholesterol-related lipoprotein levels are risk factors of cognitive function (15) and sarcopenic obesity (16), respectively. Serum anion gap is a predictive factor of all-cause mortality (17). Factors categorized into mental health are stress, depression, sleep patterns, self-esteem, life satisfaction and cognitive function. These are associated with not only mental outcomes mentioned in the aging characteristics such as suicide ideation and memory capacity (18, 19) but also physical characteristics such as falls, frailty and urinary function (20-23). Behavioral factors reflecting individual life styles included physical activity, exercise, gait speed, alcohol consumption, smoking and polypharmacy, and were reported to be associated with the aging characteristics, mainly the prevalence of non-communicable diseases, physical function and emotional disorders and mortality (18, 24-28).

Table 2 Effective factors influencing healthy aging

Table 2
Effective factors influencing healthy aging


Associations between nutritional factors and healthy aging

In relation to nutritional factors, three cross-sectional studies provided that dietary intake and patterns, mainly affecting ratio of macro-nutrients, are associated with body composition and metabolic diseases in the aging characteristics. No, 2012, reported characteristics of healthy behaviors, particularly in dietary patterns of the Korean elderly by analyzing 2010 Korea National Health and Nutrition Examination Survey (KNHANES) (29). The Korean elderly highly consume carbohydrate and lower consumption of fat and vitamin C relative to the amount of daily nutritional allowance. When the population is classified into non-obese without metabolic syndrome (normal group), non-obese with metabolic syndrome, obese without metabolic syndrome and obese with metabolic syndrome, the obese groups exhibit a higher consumption of vitamin A, retinol and carotene, relative to the non-obese groups (29).
In addition, Oh et al. identified that dietary patterns in Korean elderly are differently associated with body composition changes, possibly affecting progression of non-communicable diseases (25). The elderly groups are classified into three groups according to their dietary patterns based on the consuming food groups; traditional Korean diet, meat and alcohol diet, and westernized Korean diet. Characteristics of the Korean traditional diet are high consumption of white rice and low consumption of meat, milk and dairy products, which may lead to low protein and calcium intakes. The meat and alcohol, and the westernized Korean groups fulfill their carbohydrate needs from other grains and flour-based foods such as noodle, dumpling and bread instead of white rice. The meat and alcohol diet group highly consumes meat and alcohol relative to other two groups and, thus, their intakes of protein and iron are also higher relative to other groups. Others excluding the traditional Korean diet group and the meat and alcohol group are assigned to the westernized Korean diet group. When comparing body compositions between the groups, the meat and alcohol group shows an increase of BMI and the westernized group shows an increase of Appendicular skeletal muscle / bodyweight (ASM/Wt). In other words, the Korean traditional diet has a lower ratio of muscle mass to bodyweight, relative to the westernized Korean diet. This probably leads to high risks against decline of physical function such as frailty, falls, ADL and instrumental ADL and, furthermore, age-related muscle wasting such as sarcopenia and sarcopenic obesity.
Regarding sarcopenic obesity, a cross-sectional study which was excluded due to the participants aged 60 or older reports that the prevalence of sarcopenic obesity is associated with consumption of energy and micronutrients in the Korean elderly (30). High intakes of carbohydrate in men and potassium in women decrease the likelihood of sarcopenic obesity in a gender-specific manner. Also, enough serum vitamin D levels decrease the prevalence of sarcopenic obesity both in men and women, but whether intake levels of vitamin D are also changed is unknown. This negative association between serum vitamin D levels and an onset of aging-related diseases was reported in another article showing links between deficiency of serum 25-hydroxyvitamin D (25-OHD) and stenosed coronary artery (31).



This review suggests a comprehensive summary of evidence for the categorization of aging characteristics and probable factors in the Korean elderly. In our review of the 109 articles, characteristics to define an individual aging could be classified into objective traits such as diseases and functional declines and into subjective traits such as perceived health and life satisfaction. Only 9 studies provide multidimensional concepts to define healthy aging and, of the 9 studies, 4 articles use a concept of successful aging proposed by Rowe and Kahn, consisting of avoidance of diseases, maintenance of physical and cognitive function, and active social engagements (3). Moreover, the majority of studies conducted the survey through cross-sectional design while the studies based on the randomized control trial and cohorts were relatively scarce. Thus, multidisciplinary and prospective approaches to investigate causal relations between effective factors and healthy aging in Korean population more need to be considered in further studies.
Our findings provide classification of aging outcomes based on the domains of measurements into biological, mental, behavioral, nutritional and socioeconomic factors. Several determinants mutually influence in the included articles so that what was identified as a factor in some articles was assigned as an outcome in other researches. In many cases, physical elements such as functional disability and mental determinants such as geriatric depression and cognitive function affect each other (11, 21). Through the review regarding determinants to define a successful aging, we found the successful aging is significantly affected by gender and age in the Korean elderly (32). The female elderly has a lower probability to achieve successful aging, relative to male elderly, and the elderly older than 75 has a lower achievement than the elderly aged between 65 and 74. Given that South Korea shows the most rapid increase of aged population in the world, the negative effect of age on successful aging would be far greater in the following generation living in an aging society (1). Thus, we are facing an urgent need for a nation-wide effort to accomplish healthy aging through improving other modifiable determinants such as behavioral and socioeconomic supports. In this review, we suggest several nutritional determinants as modifiable elements influencing physical health such as body composition and onset of sarcopenic obesity. Therefore, based on this evidence, dietary intervention trials considering an excessive carbohydrate rate and/or a deficient vitamin D may improve the healthy aging in the Korean elderly.
In conclusion, we provide a step toward exploring a healthy aging in the Korean elderly. The healthy aging is a multidimensional concept embracing physical, mental and social domains. Physical function, social support, and behaviors including smoking and alcohol, and diet might contribute to the achievement of healthy aging. Further systematic review and meta-analysis in various populations following different ethnic as well as life styles and dietary patterns are needed to validate consistency of our findings and, moreover, further research on the prevention and/or intervention may help improve healthy aging in global population.


Funding: This study was supported by ILSI Korea.

Conflict of interest: Authors have no conflict of interest to disclose.



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S. Puri1, M. Shaheen2, D.H. Pai Panandiker3, R. Sinha4


1. Associate Professor; 2. Research Fellow, Department of Food & Nutrition, Institute of Home Economics, University of Delhi; 3. Chairman, ILSI-India;
4 . Executive Director, ILSI-India

Corresponding Author:  Seema Puri, Department of Food & Nutrition, Institute of Home Economics, University of Delhi, dr.seemapuri@gmail.com

J Aging Res Clin Practice 2017;6:246-251
Published online November 30, 2017, http://dx.doi.org/10.14283/jarcp.2017.33



 Increasing number of oldest old worldwide has made human longevity a major area of scientific research. It is a well-established fact that the health of an individual and the population in general are the result of interactions between genetics and a number of environmental factors; nutrition and physical activity being of major importance. The Asian Indian phenotype predisposes Indians to NCDs, more so at an earlier age. Indian diets are in a state of transition with increasing amounts of refined carbohydrates and fats being consumed. Physical activity levels are markedly low. Concomitantly, a sharp rise in the prevalence of non-communicable diseases (NCDs) like diabetes, hypertension, cardiovascular diseases and cancers has been observed. Although some of the physiological changes experienced by older adults occur primarily as a result of the biological process of aging, lifestyle factors – such as diet and physical activity – are important modulators of the risk factors associated with chronic disease and even age related decline.

Keywords: Elderly, aging, midlife factors, NCDs.



The physiological aging process starts once one reaches adulthood and continues throughout the middle age. While every individual ages at a different rate, the exposure to various environmental factors during this period can contribute not only to accelerating the aging process but may also influence the onset of chronic degenerative diseases which when superimposed on the aging process lead to further deterioration in the quality of life of the elderly. India is currently undergoing a rapid transition in its demographics as well as socioeconomic milieu. With better access to nutrition and health care and an increase in life expectancy to over 65 years, more Indians are living to an older age, often with chronic ailments. All those diseases which were characteristic of westernized societies in the past are now emerging as major health problems in developing and middle-income countries like India.
It is well established that at any Body Mass Index (BMI) and age, Asian Indians have higher body fat, visceral fat and waist circumference; lower skeletal muscle mass; thinner hips; short legs; profoundly higher rates of insulin resistance, metabolic syndrome, diabetes, dyslipidemia, hypoadiponectinemia, and increased cardiovascular risk than Europeans (1) which correlates with insulin resistance and adiponectin levels (2). These unique clinical and biochemical characteristics among Asian Indians in particular and South Asians in general are collectively referred to as the “Asian Indian Phenotype” or thin–fat phenotype. Hence, not only is the prevalence of NCDs greater among Indians but also the onset is at a much younger age. Moreover, the relationship of poor foetal growth with the development of NCDs in early adulthood is well known. There is evidence that low birth weight as well as ‘‘catch-up growth’’ are associated with an increased risk of hypertension, insulin resistance, Type 2 Diabetes Mellitus, and Coronary Heart Disease (CHD) in adults (3, 4).


Nutrition transition

India is presently undergoing a nutrition transition in three stages. In stage 1, consumers moved away from traditional staple items to food products more prevalent in ‘‘westernized’’ diets. In stage 2, the influences of globalization were much more marked and the consumers have access to a variety of convenience foods often high in salt, fat, sugar, preservatives etc. In stage 3, some people (especially those belonging to the high socioeconomic stratum) tend to realize adverse eating habits and try to adapt a healthy lifestyle.  Most Indians are currently in the second stage of nutrition transition (5). This transition over the past 30 years (1973–2004), has resulted in a 7% decrease in energy derived from carbohydrates and a 6% increase in energy derived from fats. A decreasing intake of coarse cereals, pulses, fruits and vegetables, an increasing intake of meat products and salt, coupled with declining levels of physical activity due to rapid urbanization have resulted in escalating levels of obesity, atherogenic dyslipidemia, subclinical inflammation, metabolic syndrome, type 2 diabetes mellitus, and coronary heart disease in Indians (5).


Dietary factors that influence aging in India

High carbohydrate consumption

Energy intake from carbohydrates (particularly cereals) is higher in Asian Indians as compared to other ethnic groups (6). Cereals are the staple diet in India, and carbohydrate consumption constitutes the bulk of the total calorie intake. The decreasing consumption of cereals in the past two decades (7) may indicate a shift towards (more) energy-dense ‘‘fast’’ foods (highly processed, deep-fried, unhealthy foods, devoid of adequate nutrients) as a source of energy in the diets but it still contributes approximately 73% of the energy intake in rural areas and 68% in urban areas. It is known that a high intake of carbohydrate (>55% of energy), even with a low fat intake, may lead to high serum triglyceride levels, hyperinsulinemia, and low levels of high density lipoprotein-cholesterol (HDL-C) (8). In addition, recent studies indicate that several dietary carbohydrates directly influence lifespan in various organisms through diverse signaling pathways (9, 10). It is seen that glucose consumption decreases the activity of AMP-activated protein kinase (AMPK), an energy sensor that regulates an organism’s lifespan.

High dietary fats

Indian diets are primarily vegetarian, and plant foods being low in ‘‘invisible’’ fat content, do not contribute significantly to total fat intake. The ‘‘visible fats’’ are derived from animal sources such as ghee (clarified butter having a high content of saturated fat), butter, and vegetable oils (11). ICMR has recommended a total fat intake between 20en% and 30en% for Indian adults (12).  Importantly, total fat intake has increased over the last three decades (1973–2005) in both rural (24– 35.5 g ⁄ day) and urban (36–47.5 g ⁄ day) populations in India (7, 13-15) due to an increase in the supply of fats and oils as well as an increase in the availability and consumption of energy-dense, high-fat diets (5). A recent report by NIN (2011) has shown the average intake of fats and oils among adult men to be 20g/day and among adult women 17 g/day (16). A high-fat diet (HFD) is generally associated with increased mortality and increased incidence of many metabolic diseases, including type 2 diabetes and cardiovascular problems (17). It is seen that dietary lipids may affect mammalian health and longevity by altering the compositions of body fat and cellular membranes (18).

Saturated fatty acids

In the Indian diets, saturated fatty acids (SFAs) are mostly derived from butter and ghee in north, middle, and west India, and coconut oil in south India. The SFA intake is increasing in the middle SES. Indian foods such as parantha (Indian bread prepared on a griddle using fat), bhatura (Indian bread prepared by deep frying), samosa (snack prepared by stuffing potato in refined wheat flour dough cones and deep frying), and suji halwa (dessert prepared using refined wheat flour [semolina] and fried in oil) are prime sources of SFAs in Indian diets, particularly when ghee or vanaspati (obtained from partially hydrogenated vegetable oil), are used in their preparation (19). Coconut fat accounts for 80% of the fat intake among Indians residing in south India. Kerala has not only the highest level of blood cholesterol, but also the highest rate of CHD in India (20).

Unsaturated fatty acids

Diets enriched in natural unsaturated fatty acids lower blood pressure, improve insulin sensitivity, and reduce the risks of cardiovascular and metabolic diseases (21).

Polyunsaturated fatty acids

Studies indicate that polyunsaturated fatty acids (PUFAs) prevent aging-associated diseases and promote longevity. For example, arachidonic acids, which are omega (Ω)-6 PUFAs, induce apoptosis of cancer cells (22). Saturated fatty acids and monounsaturated fatty acids are generally more resistant to oxidative damage than that of PUFAs with multiple double bonds (18). Thus, opposite from their potential role as dietary lipids, low levels of PUFAs in the membranes may be beneficial for longevity and health. Intake of n–3 PUFAs and long chain n–3 PUFAs is low in some South Asian populations, particularly among vegetarians (11). However, longitudinal cohort studies are needed in Indians to assess whether the ratio of n–6: n–3 or their absolute amounts play a role for the prevention and management of atherosclerosis (5).

Monounsaturated fatty acids

The MUFAs are present in the following oils: mustard, palm, olive, groundnut, rice bran, and soybean (all available in India), and some seeds (coriander, groundnut, sesame, and mustard) (23). Diets deficient in Monounsaturated fatty acid (MUFA) are reported to have detrimental effects on diastolic blood pressure (24) and lipid metabolism (25), particularly when the total fat intake is above the median (>37% of energy) (23). Data show that Indians belonging to low SES consume low amounts of MUFAs: males 4.7% and females 5.7% (26).  Rastogi et al (2004) compared persons consuming sunflower oil with those using mustard oil (the traditional cooking oil used in India, containing 70% MUFA, 10% ALNA and 12% LA) for cooking and frying and found that the latter had a significant lower risk for CVD after adjustment for age, sex, and smoking (27); however, dietary intervention to study the effects of MUFA-rich diets has not been attempted with Indians and needs investigation (5).

Trans-fatty acids

A high intake of trans-fatty acids (TFAs) has been associated with dyslipidemia and an increased risk of T2DM and CHD (28). Dietary trans-fats (unsaturated fatty acids with trans-isomers) trigger inflammatory responses, which increase the risks of developing cardiovascular and metabolic diseases (29). Indian diets as well as commercially fried, processed, baked, ready-to eat foods, and foods made by street vendors in India derive TFAs from partially hydrogenated vegetable oil, vanaspati due to its convenience of handling, low cost, and long shelf life (5). A TFA intake (percent energy) of 1.13 and 1.11 amongst adolescent and young adults in north India, respectively, has been reported by Misra et al (19).

Low protein intake

Protein intake among Indians is influenced by the vegetarian status of the majority of Indians whose protein is derived, apart from milk, from a combination of cereals and pulses, such as pulses and rice, and pulse and whole wheat unleavened bread (5). The NIN report (2011) revealed that the average intake of protein was around 60 g/day among 18-60 year old rural and urban men in India, while the average intake of protein was approximately 50 g/day among 18-60 year old women in rural and urban India (16). The consumption pattern of meat and related products is linked to the SES of the family in India. As Indians are becoming more affluent, animal foods are increasingly being consumed, both among rural and urban areas.  Interestingly, plant proteins contain considerably lower methionine than animal proteins (30), and this low methionine content may underlie the beneficial effects of dietary plant on longevity.

Dietary fibre, fruits and vegetables

The intake of coarse cereals and millets, such as whole wheat flour, pearl millet, barley, sorghum, and maize (corn), along with husked pulses, fruits and vegetables have been the most important contributors towards dietary fibre in Indian diets (5). A dose-dependent inverse association is seen between vegetable intake and CHD in the metropolitan Indian cities (27). Nationally representative surveys in India, however, indicate a very low per capita consumption of fruits and vegetables both among rural and urban adults (16).  In a study in south India, a higher intake of fruits and vegetables explained 48% of the protective effect against cardiovascular risk factors (31).

Indian spices and dietary salt

Spices have been an integral part of the Indian diets since ancient times. Some Indian spices have been reported to possess antioxidant and antimicrobial properties. In a natural mutant model of obese mice, turmeric (haldi) has been demonstrated to reduce the oxidation of LDL-C, lipid levels, blood glucose, and renal lesions (32); however, these beneficial effects of turmeric remain to be tested in human studies (5). Consumption of 25 g fenugreek seed powder in the daily diet has been shown to decrease blood glucose levels and has potential as an adjunctive therapy in the management of diabetes (33).  Garlic,  ginger, cloves  and mustard may also have some antioxidant, antimicrobial, anti-thrombotic, anti-inflammatory, and anti-cancer activities, as reported in (in vivo and in vitro) animal models in anecdotal studies (34).
Importantly, salt consumption has been found to be a significant predictor of hypertension in urban as well as in rural communities in north India (35). Population salt consumption, a strong determinant of high blood pressure and associated CVD, is very high across different regions with the average intake ranging between 8.5-9 grams/day (6, 36), with the intake being higher in urban compared to rural areas.

Nuts and oilseeds

Nuts and oilseeds are complex plant foods that are not only rich sources of unsaturated fat but also contain several non-fat constituents, such as protein, fibre, micronutrients (e.g. copper and magnesium), plant sterols, and phytochemicals (37). Long-term nut consumption has been associated with lower body weight and lower risk of obesity (38).  The frequency and quantity of nut consumption has been documented to be higher in vegetarian than in non-vegetarian populations.

Other Dietary Components

Kumar et al (39) found that low vitamin B12 levels is linked with higher incidence of CAD in this population recruited from a tertiary care centre in New Delhi, India. Another observational study by Chahal, Raina and Kaur (40) showed low mean serum Vitamin B12 levels in both study groups of employees as well as students. There is widespread prevalence of varying degrees (50- 90%) of Vitamin D deficiency with low dietary calcium intake in Indian population according to various studies published earlier (41, 42). Tuohimaa (43) showed that Calcidiol (pre-cursor of vitamin D), an active circulating hormone, is associated with an increased risk of aging-related chronic diseases more directly than calcitriol.
A study by Dherani et al (44) showed that the mean levels of serum vitamin C in a north Indian population was 0.22 mg/dl and that of vitamin E (α Tocopherol) is 0.23 mg/dl. Such low concentrations are said to cause age-related diseases in long-term (45).


Lifestyle factors that affect aging in India

When centenarians and other long-lived individuals are studied, their longevity is often attributed to a healthy lifestyle. Three characteristic behaviours are routinely reported; these include exercising regularly, maintaining a social network, and maintaining a positive mental attitude (46).

Physical Inactivity

The impact of physical activity on primary aging processes is difficult to study in humans because cellular aging processes and disease mechanisms are highly intertwined (47). Rather, regular physical activity increases average life expectancy through its influence on chronic disease development (via reduction of secondary aging effects) (48).
Few studies have estimated the physical activity levels in Indian population so far. In a study by Ramachandran et al (49) on temporal changes associated with pattern of life style (1989-2003) there had been a decline in levels of physical activity. Moreover, fewer subjects were engaged in manual work (22.8% in 2003 vs. 80% in 1989).  Rastogi et al (27) conducted a hospital-based case-control study and collected data from 350 cases of acute myocardial infarction and 700 controls matched on age, gender, and hospital in New Delhi and Bangalore. They observed a positive association between non-work sedentary activity and CHD risk; leisure-time exercise, as much as 35-40 minutes per day of brisk walking, was protective for CHD risk and sedentary lifestyles were positively associated with risk of CHD.

Tobacco Use

Tobacco use is also a leading risk factor for premature NCD associated death and disability  and accounts for more than two-third of all new cases of NCDs. Tobacco smoke has been linked to cause premature skin aging (50). A recent national data from the Global Adult Tobacco Survey (51) indicated the overall prevalence of tobacco use to be 35%, with increases noted in women compared to earlier surveys (48% in men and 20% in women). Nearly two in five (38%) adults in rural areas and one in four (25%) adults in urban areas use tobacco in some form (52). Furthermore, over half of all adults are being exposed to second-hand smoke (51).

Alcohol Consumption

Alcohol consumption has both health and social consequences via intoxication and alcohol dependence. Pattern of alcohol consumption varies with geographical location in the country. In India, the estimated numbers of alcohol users in 2005 was 62.5 million, with around 17% of them, which translates into 10.6 million, being dependant users (53). According to NFHS-3, 35% of ever married males report consumption of alcohol (54). Although moderate consumption of alcohol appears to be protective for heart attacks in western populations it appears to be either neutral or conferring higher risk among South Asians (55) possibly related to the binge drinking practices in India.


Diseases that affect aging in India


The causes of profound accumulation of adipose tissue in an organism are primarily a combination of excessive caloric intake and a lack of physical activity (56). Studies in humans show that high total and abdominal adiposity are directly related to decreased telomere length, suggesting that obesity may accelerate the aging process (57).
The NFHS-3 (54) reported that among men, 8% were overweight and 1% obese. The highest rates of overweight and obesity have been observed in the epidemiologically and nutritionally advanced states, which, incidentally, also have higher rates of NCD risk and disease burden (58). Misra et al (26) reported 25% prevalence of obesity in the slums of Delhi.


High serum lipid levels are major risk factors of coronary heart diseases that are influenced by lifestyle transition and urbanization. Limited information exists regarding the changing time-trends in lipid levels and the prevalence of dyslipidaemia in Indian subjects. ICMR study (59) reported 36.8% and 39.8% prevalence of hypercholesterolemia in the urban Delhi and rural Haryana respectively during 1991-94. Repeat cross- sectional surveys among urban subjects in Jaipur showed 37% vs. 43% prevalence among men and women during 2001 and 33% vs. 29% during 2002-03 (60, 61).

Frailty and Sarcopenia

There has been wide agreement amongst experts in the field that frailty is a distinct clinical entity, with a recent consensus statement defining frailty as (62): ‘….a medical syndrome with multiple causes and contributors that is characterised by diminished strength, endurance and reduced physiologic function that increases an individual’s vulnerability for developing increased dependency and/or death.’ Frailty has shown to predict the negative health outcomes that we associate with vulnerable older people such as disability, institutionalisation, hospitalisation, falls and death (63). Sarcopenia was first described by Rosenberg as the age-related loss of skeletal muscle mass (64). Regardless of the definition used, prevalence increases with age but women do not always have a higher prevalence than men (65). The prevalence of sarcopenia was found to be 17.5 % in a study by Tyrovolas et al (66). A multi-country study by WHO in community-dwelling older adults aged 50 years and above reported the incidence of frailty to be 55.5 % (67).

Non Communicable Diseases (NCDs)

Non-communicable diseases (NCDs) contribute to around 5.87 million deaths that account for 60 % of all deaths in India. India shares more than two-third of the total deaths due to NCDs in the South-East Asia Region (SEAR) of WHO. Major metabolic risk factors are obesity, raised blood pressure, raised blood glucose and raised blood total cholesterol levels. Besides being the leading cause of death globally, NCDs also cause impairments that, due to physical, environmental, social and/or attitudinal factors, can lead to disability. This reflects the accumulated effects of disease and injury during a person’s life, as well as declining physical strength in older age (68).



Adverse perinatal events due to maternal nutritional deprivation may cause low-birth weight infants, which, coupled with early childhood ‘‘catch-up growth’’, leads to obesity in early childhood, thus predisposing to NCDs later in life. The nutrition transition in India has resulted in a decreasing intake of coarse cereals, pulses, fruits and vegetables, an increasing intake of meat products and salt, coupled with declining levels of physical activity due to rapid urbanization. This has resulted in escalating levels of obesity, atherogenic dyslipidemia, subclinical inflammation, metabolic syndrome, type 2 diabetes mellitus, and coronary heart disease in Indians. The Asian Indian phenotype makes Indians not only highly susceptible to NCDs but also at a much younger age. Most NCDs have shared risk factors (tobacco use, unhealthy diet, physical inactivity, alcohol use) and integrated interventions targeting these risks from middle age will not only help to prevent and control NCDs, but also ensure a good quality of life in advancing years.


Conflicts of Interest: None. This review was supported by a grant from ILSI -India.



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