The Role of Energy Balance in Successful Aging Among Elderly Individuals

Abstract

Objective: The determinants that promote living beyond life expectancy and successful aging still remain unknown. The aim of the present work was to evaluate the role of energy balance in successful aging, in a random sample of older adults living in the Mediterranean basin. Method: During 2005 to 2011, 2,663 older (aged 65-100 years) adults from 21 Mediterranean islands and the rural Mani region (Peloponnesus) of Greece were voluntarily enrolled in the study. Dietary habits, energy intake, expenditure, and energy balance were derived throughout standard procedures. A successful aging index (range = 0-10) was used. Results: After adjusting for several confounders, high energy intake (i.e., >1,700 kcal/day), b-coefficient [95% CI] = −0.21[−0.37, −0.05], as well as positive energy balance, b-coefficient [95% CI] = −0.21 [−0.37, −0.05], were inversely associated with successful aging. Conclusion: A diet with excessive energy intake and a positive energy balance seems to be associated with lower quality of life, as measured through successful aging.

Keywords

successful aging Mediterranean diet energy balance older adults

Introduction

Demographic changes have shown that the global population is aging (World Health Organization [WHO], 2002). Specifically, there is evidence indicating that people live a long and active life even after the seventh or eighth decade of life. According to the U.S. National Institute on Aging, the odds of being a person centenarian have risen from almost 1 in 20 million to 1 in 50 for females in some low-mortality populations (U.S. National Institute of Aging, 2007). Clearly, the process of living longer is quite complex and is associated with a variety of factors. A wider picture of the aforementioned complexity is represented throughout the healthy or successful aging concept, which has been associated with lower mortality rates (Schoenfeld, Malmrose, Blazer, Gold, & Seeman, 1994). In particular, successful aging is considered as low probability of disease and disability, high cognitive and physical capacity, and active participation through social activities (i.e., social relations, productive activities, education, etc.; Bowling & Dieppe, 2005; Rowe & Kahn, 1997).

Factors that promote successful aging still remain not well-understood and appreciated. Energy intake and expenditure have been characterized, among other lifestyle and biological factors, as important determinants of health status (Trepanowski, Canale, Marshall, Kabir, & Bloomer, 2011). Some studies have also revealed that energy balance is associated with lower risk for chronic diseases (Maraki & Sidossis, 2010). Energy intake, and specifically calorie restriction, has been related to a variety of biomarkers that through specific pathways may beneficially affect healthy long-living (Weiss & Fontana, 2011). A healthy dietary pattern, such as a high ratio of monounsaturated-to-saturated fatty acids, antioxidants, and polyphenols, may also enhance the process of healthy and successful aging (Keys et al., 1984; Mathers, 2013). In particular, it has been reported that the process of inflammation, oxidative stress, and aging are strongly related biological pathways that are partially mediated by the older individual’s dietary status (Willcox, Willcox, Todoriki, & Suzuki, 2009).

Given the rapid increase of the oldest old adults, the complexity of the aging pathway and the lack of data among Mediterranean populations, the aim of the present work was to evaluate the role of energy balance in successful aging, in a random sample of older adults living on Mediterranean basin and participated in the MEDiterranean Islands (MEDIS) study. The MEDIS study’s sample encompasses two of the already reported high life expectancy areas in the World (i.e., the islands of Ikaria and Sardinia). In addition, the selected older Mediterranean population has rarely been studied in the last four decades, a fact that makes this survey of major importance, as it was in two of the enrolled islands (i.e., Corfu and Crete) that Ancel Keys and his colleagues from the Seven Countries Study first observed the benefits of the Mediterranean diet and restricted energy intake on health status (Keys et al., 1984).

Method

The MEDIS Study Sample

During 2005 to 2011, a population-based, multinational, convenience sampling was performed to voluntarily enroll older people from 21 Mediterranean islands: Republic of Cyprus (n = 300), Malta (n = 250), Sardinia (n = 60), Sicily (n = 50), Mallorca and Menorca (n = 111), and the Greek islands of Lesvos (n = 142), Samothrace (n = 100), Cephalonia (n = 115), Crete (n = 131), Corfu (n = 149), Limnos (n = 150), Ikaria (n = 76), Syros (n = 151), Naxos (n = 145), Zakynthos (n = 103), Salamina (n = 147), Kassos (n = 52), Rhodes and Karpathos (n = 149), Tinos (n = 129), as well as from the rural region of Mani (n = 153; a southern Greek peninsula). According to the study’s protocol, individuals were not eligible for inclusion if they resided in assisted-living centers, had a clinical history of cardiovascular disease (CVD) or cancer, or had lived away from the island for a considerable period of time during their lives (i.e., >5 years); these exclusion criteria were applied because the study aimed to assess lifestyle habits that were not subject to modifications due to existing chronic health conditions or by environmental factors, other than living milieu. A group of health scientists (physicians, dietitians, and nurses) with experience in field investigation collected all the required information using a quantitative questionnaire and standard procedures.

The study followed the ethical considerations provided by the World Medical Association (52nd WMA General Assembly, Edinburgh, Scotland, October 2000). The Institutional Ethics Board of Harokopio University approved the design and procedures of the study (Reference No. 16/19-12-2006). Participants were informed about the aims and procedures of the study and gave their consent prior to being interviewed.

Evaluation of Clinical Characteristics

All the measurements taken in the different study centers were standardized, and the questionnaires were translated in all the cohorts’ languages following the WHO translation guidelines for tools assessment (WHO, 2014b). Weight, height, and waist circumference were measured using a standard protocol; body mass index (BMI) was calculated as the ratio of weight by height squared (kg/m²). Overweight was defined as BMI between 25 and 29.9 kg/m², and obesity was defined as BMI > 29.9 kg/m². Diabetes mellitus (type 2) was determined by fasting plasma glucose tests and was analyzed in accordance with the American Diabetes Association diagnostic criteria (glycated hemoglobin A1C ≥ 6.5 or fasting blood glucose levels greater than 125 mg/dl or 2-h plasma glucose > 200 mg/dl during an oral glucose tolerance test [OGTT] or a random plasma glucose > 200 mg/dl, or by a prior diagnosis of diabetes). Participants who had blood pressure levels ≥ 140/90 mmHg or used antihypertensive medications were classified as hypertensive. Fasting blood lipid levels (HDL-, LDL-cholesterol, and triglycerides) were also recorded, and hypercholesterolemia was defined as total serum cholesterol levels > 200 mg/dl or the use of lipid-lowering agents according to the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATPIII) guidelines (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001).

Evaluation of Dietary Habits, Socio-Demographic and Other Lifestyle Characteristics of the Participants

Dietary habits were assessed through a semi-quantitative, validated, and reproducible food-frequency questionnaire (Tyrovolas et al., 2010). To evaluate the level of adherence to the Mediterranean diet, the MedDiet score (theoretical range = 0-55) was used (Panagiotakos, Pitsavos, & Stefanadis, 2006). Higher values for this diet score indicate greater adherence to the Mediterranean diet. Energy intake was evaluated through the quantification of the portions of foods and beverages consumed, using food composition tables (Greek Food Composition Tables, 2001; U.S. Department of Agriculture Agricultural Research Service, USDA Nutrient Data Laboratory, 2009). Moreover, the tertiles of the participant’s energy intake, that is, <1,300 kcal, 1,300 to 1,700 kcal, and >1,700 kcal, were computed, for the classification as low, adequate, and high energy consumers, respectively. Total daily energy expenditure (TEE) was estimated using the Schofield prediction equations, adopted by the 2004 FAO/WHO/UNU report (FAO/WHO/UNU, 2004), using age, weight, and self-reported physical activity level (PAL) information (i.e., frequency and kind of physical activities as well as the duration of the activity). Moreover, the energy balance was calculated throughout the equation: Energy Balance = Energy Intake − Total Energy expenditure. If energy balance was <0, then the categorization was negative energy balance; if it was >0, then the categorization was positive energy balance (Leibel, Rosenbaum, & Hirsch, 2009).Basic socio-demographic characteristics, such as age, gender, years of school, financial status, and lifestyle characteristics, such as smoking habits and physical activity status, were recorded. Regarding financial status, the participants were asked to report their mean income during the previous 3 years using a 4-point scale (low, inadequate to cover daily expenses = 1; medium, trying hard to cover daily expenses = 2; good, adequate to cover daily expenses = 3; very good, very adequate to cover daily expenses = 4); this scale was decided on because of the variety of the populations studied, as well as the common difficulty of accessing exact financial data. The participants who were in the upper category were classified as participants with high financial status while all the others were classified as low and medium financial status (high- vs. low-medium financial status). Current smokers were defined as smokers at the time of the interview. Former smokers were defined as those who had previously smoked, but had not done so for a year or more. The remaining participants were defined as occasional or non-current smokers. Physical activity was evaluated in Metabolic Equivalent of Task (MET) -minutes per week, using the shortened, translated in all the cohort’s languages and validated in Greek version of the self-reported International Physical Activity Questionnaire (IPAQ; Papathanasiou et al., 2009). As minimally active or “health-enhancing physical activity (HEPA) active” were classified individuals who reported at least 3 MET-minutes per week. Furthermore, the weekly frequency of physical activity was recorded. Symptoms of depression during the previous month were assessed using the validated Greek version (also translated in all the cohort’s languages) of the shortened, self-report Geriatric Depression Scale (GDS; range = 0-20; Fountoulakis et al., 1999). Moreover, to evaluate the older adult’s social participation, the weekly frequency of their social activities with their family, their friends as well as their yearly frequency of excursions were recorded.

Further details about the MEDIS study protocol may be found elsewhere (Tourlouki et al., 2010; Tyrovolas et al., 2009).

Evaluated Outcomes

Following the multidimensional approach of successful aging already reported by several experts (Bowling & Dieppe, 2005; Parslow, Lewis, & Nay, 2011), 10 components (i.e., education as measured in years if school, financial status, physical activity status as classified using the IPAQ, BMI, psychological level as measured using the GDS score, participation in social activities with friends, with family, yearly excursions, burden of CVD risk factors, and dietary habits as evaluated using the MedDiet score) were incorporated for the measurement of successful aging. The composed successful aging index was represented as the cumulative score of the 10 components (theoretical range = 0-10); specifically, individual ratings (from 0 to 1) in each of the 10 components were assigned, according to their positive or negative (i.e., reverse scoring) influence on successful aging, according to the current literature (Searle, Mitnitski, Gahbauer, Gill, & Rockwood, 2008; Wilkie, Tajar, & McBeth, 2013). Specifically, for 3-scale components (normal weight/overweight/underweight or obese, no/mild/severe depression [GDS score], low/moderate/high adherence to the Mediterranean diet [MedDiet score]), the value of 0.5 was used to code the intermediate level (i.e., overweight, mild depression, moderate adherence to the Mediterranean diet). Similarly, for the 4-scale components (i.e., 0-2 years/3-6 years/7-12 years/>13 years of education, none/1-2 times/3-5 times/>5 times weekly physical activity, and low/moderate/good/very good financial status), the score 0 was used if the individual was in the lowest level; scores 0.33, 0.66, and 1 were given for each higher level. In addition, for the 5-scale components (i.e., none/1 time/2 times/3-5 times/>5 times of weekly social activities with friends, and with family, none/1 time/2 times/3-5 times/>5 times of yearly excursions, none/1 factor/2 factors/3 factors/4 factors of CVD risk), a response level was coded using the additional values of 0, 0.25, 0.5, 0.75, and 1 if the person ranged from the lowest level to the highest, respectively (Tyrovolas et al., 2014). The score was reversed for the CVD risk score, the BMI levels, and the GDS score.

The older adults with actual age greater than the gender (male, female) and country-specific (Greece, Cyprus Republic, Malta Republic, Italy and Spain) average population life expectancy (WHO, 2014) were classified in the group of the “oldest old”; otherwise, they were classified in the group of the “younger older adults.”

Statistical Analysis

Continuous variables are presented as mean ± standard deviation (SD) and categorical variables as frequencies. Comparisons of continuous variables between groups were performed using the independent samples t test (for normal distribution) and the Mann–Whitney U test (for skewed distribution). Associations between categorical variables were tested using the chi-square test. Linear regression models were applied to evaluate the association between various socio-demographic, bio-clinical, and nutritional factors (independent variables) and the level of successful aging (dependent outcome). Collinearity was tested using the Variance Inflation Factor criterion (VIF; values >4 suggested collinearity between independent variables and one of them was excluded from the model). The assumption of homoskedasticity was tested by plotting the scatter plot of standardized residuals over the predicted score values. Results from linear regression models are presented as b-coefficients and their 95% CIs. All reported p values were based on two-sided tests. SPSS software (Version 20) was used for all calculations (IBM Statistics, Greece).

Results

The proportion of the oldest old (living beyond the average population’s life expectancy) was 20% for the entire cohort. Comparing participants living in rural and urban areas, there was significant difference among the proportion of the oldest old (25% vs. 17%, p < .001). However, when the seven geographical areas of the participants were taken into account (West Mediterranean, Ionian, Aegean, Saronikos islands, Crete island, Mani, and Cyprus republic), the higher proportion of the oldest old were in the area of Cyprus (30%), while the area of West Mediterranean (Sardinia, Sicily, and Malta islands) and Saronikos area had the lowest proportion (13%; p < .001). When analysis by island was applied, the higher proportion of the oldest old were in the island of Ikaria (43%), while the island of Limnos had the lowest proportion (4.5%; p < .001). Demographic, behavioral, clinical, and lifestyle characteristics of the sample, by population’s life expectancy categorization (younger older adults vs. oldest old), are summarized in Table 1. Compared with younger older adults, the oldest old were rural residents (p < .001), less physically active (p = .009), and smokers (p = .003), and had lower prevalence of hypercholesterolemia (p < .001), lower rates of positive energy balance (p < .001), lower BMI levels (p < .001), education status (p < .001), adherence to the Mediterranean diet (p < .001), coffee consumption (p = .01), energy intake (p < .001), while they had higher depression levels (p < .001). Moreover, no differences were observed between both groups of older adults (younger older adults vs. oldest old) with regard to financial status, living alone, tea consumption, TEE, prevalence of hypertension and diabetes, and the level of successful aging.

Table 1.

Demographic, Behavioral, and Lifestyle Characteristics of the Multinational MEDIS Sample, by Population’s Life Expectancy Categorization.

	Younger older adults^a (n = 1,983)	Oldest old^a (n = 506)	p
Urban residence (%)	63	52	<.001
BMI (kg/m²)	28.7 ± 4.8	27.1 ± 4.0	<.001
Education (years of school)	7.0 ± 4.0	6.0 ± 4.7	<.001
High financial status (%)	20	17	.25
Living alone (%)	25	28	.16
Current smoking (%)	17	11	.003
Physical activity (%)	44	37	.009
MedDiet score (0-55)	32 ± 4.8	30 ± 5.1	<.001
Energy intake (kcal/day)	1,601 ± 509	1,477 ± 472	<.001
Energy expenditure (kcal/day)	1,948 ± 319	1,949 ± 323	.93
Energy balance (% of positive)	26	14	<.001
Alcohol consumption (%)	48	52	.07
Coffee consumption (%)	83	78	.01
Tea consumption (%)	42	43	.53
GDS score (0-15)	3.5 ± 3.5	4.5 ± 3.6	<.001
Hypertension (%)	63	63	.98
Diabetes mellitus (%)	23	21	.49
Hypercholesterolemia (%)	52	35	<.001
Successful aging (0-10)	2.5 ± 1.3	2.6 ± 1.2	.28

Note. MEDIS = MEDiterranean ISlands; BMI = body mass index; GDS = Geriatric Depression Scale.

The group of “oldest old” included the older adults with actual age greater than the gender and country-specific average population life expectancy; otherwise, the individuals were classified in the group of the “younger older adults.”

After adjusting for age, gender, urban residence, waist circumference, smoking habits, alcohol, tea, coffee consumption, it was found that higher energy intake (i.e., >1,700 kcal/day) was inversely associated with the successful aging score, b-coefficient [95% CI] = −0.21 [−0.37, −0.05], compared with adequate and lower energy intake. Waist circumference, −0.03 [−0.04, −0.025], and coffee consumption, −0.24 [−0.41, −0.08], were also inversely associated with the level of successful aging (data are shown only in text).

However, the aforementioned role of energy intake may better be explained through the energy balance, by taking into account the role of energy expenditure (Table 2). After adjusting for various aforementioned confounders, positive energy balance was inversely associated with the successful aging score, b-coefficient [95% CI] = −0.21 [−0.37, −0.05], compared with the negative one. Coffee consumption (p = .012) and increased waist circumference (p < .001) were also inversely associated with successful aging, while alcohol (p < .001) and tea consumption (p = .013) were positively associated with successful aging.

Table 2.

Results From Linear Regression Performed to Evaluate the Association of Various Socio, Bio-Clinical, Lifestyle Characteristics, and Energy Balance (Positive vs. Negative) in Relation to the Level of Successful Aging.

	Model
	b-coefficient	[95% CI]
Age (per 1 year)	−0.01	[−0.02, −0.002]
Sex (males vs. females)	0.17	[0.016, 0.33]
Urban residence (yes vs. no)	−0.04	[−0.18, 0.11]
Waist circumference (per cm)	−0.025	[−0.03, −0.02]
Current smoking habits (yes vs. no)	0.02	[−0.21, 0.25]
Alcohol consumption (yes vs. no)	0.49	[0.34, 0.64]
Tea consumption (yes vs. no)	0.18	[0.004, 0.31]
Coffee consumption (yes vs. no)	−0.24	[−0.42, −0.05]
Energy balance (positive vs. negative)	−0.21	[−0.37, −0.05]

Note. CI = Confidence interval.

When the analysis was stratified by gender, in males, positive energy balance was inversely associated with the successful aging score (p = .001) compared with the negative one. However in females, there was no association between the energy balance and the successful level of successful aging (p = .10; data are shown only in text).

Discussion

The present work revealed an inverse association between high energy intake and successful aging; particularly, multi-adjusted analysis revealed that high energy intake was inversely associated with the levels of successful aging, irrespective of the age, gender, urban residence, smoking habits, and alcohol, tea, and coffee consumption. In addition, a positive energy balance was inversely associated with the levels of successful aging, a concept that has been associated with lowered risk of various health outcomes (i.e., physical, mental functioning, biomarkers, and mortality; Bowling & Dieppe, 2005; Rowe & Kahn, 1997; Schoenfeld et al., 1994). The aforementioned relationships, especially among older adults of the Mediterranean basin, have rarely been studied.

According to the 2011 National Institute of Aging report, the proportion of the global population aged above 60 years is expected to reach 1.5 billion in 2050 (U.S. National Institute on Aging, 2011). Until now, the majority of the studies made an effort to evaluate population’s aging with the use of chronological age. However, a variety of characteristics relevant to population aging are changing over time and place. According to the literature (Warren & Scherbov, 2005), an individual’s age should not be defined according to the number of years lived since birth but according to the remaining years that this person is expected to live. Following the aforementioned approach, the proportion of the oldest adults (over the average population life expectancy) was 20%, among the multinational MEDIS study (i.e., countries: Italy, Spain, Malta Republic, Cyprus Republic, and Greece). Recent literature data report that, the population ≥80 years old represents almost only 1% of the global population. According to geographical regions, Northern America as well as Europe have the higher proportion of the oldest old (almost 3%), followed by Asia, Caribbean, and Latin America (>0.9%), and Africa (>0.4%; United Nations, 2001). Moreover, in the MEDIS study of the oldest old, lower physical activity and smoking habits, lower prevalence of hypercholesterolemia, BMI levels, adherence to the Mediterranean diet, coffee consumption, energy intake, and positive energy balance were observed, while the depression levels were higher, compared with the group of the younger older adults. It is well known that high adherence to the Mediterranean diet, physical activity, and low depression levels are determinants of good health (Tourlouki et al., 2010; Tyrovolas et al., 2009; Panagiotakos et al., 2011). In the applied analysis, the aforementioned factors were in lower rates in the group of the oldest old. This could be attributed to the high prevalence of disability and mobility problems among the older adults (Tyrovolas et al., 2015), the nutritional transition (i.e., following “Westernized type” diets) in this age group (Tyrovolas et al., 2009), and the high rates of living alone (Tourlouki et al., 2010). Similar to the abovementioned analysis, results have also been reported, among other Mediterranean live-longer populations, in other studies in the recent past (Panagiotakos et al., 2011; Tourlouki et al., 2010). All the aforementioned are in accordance with well-conducted studies that have showed reductions in morbidity and mortality at older ages (Manton, Gu, & Lowrimore, 2008).

It has been suggested that the living longer process reflects complex interrelations among multidimensional factors (Dupre, Liu, & Gu, 2008). A wider picture of the aforementioned complexity is represented throughout the healthy or successful aging concept, which has been associated with lower mortality rates and better health outcomes (Bowling & Dieppe, 2005; Parslow et al., 2011; Rowe & Kahn, 1997; Schoenfeld et al., 1994; Wilkie et al., 2013). Data analysis revealed that high energy intake was inversely associated with successful aging. However, the role of healthy nutrition in aging is well known (Keys et al., 1984; Mathers, 2013; Willcox et al., 2009), and well-conducted studies have shown that regular activity and healthy eating were associated with reduced overall mortality (Keys et al., 1984). Well-known findings of the Seven countries studies indicate that restricted energy intake through the adherence of Mediterranean diet was beneficially associated with a person living longer and with lower morbidity (Keys et al., 1984). More recent results revealed that the excessive energy intake was inversely associated with a variety of adverse health outcomes (Weiss & Fontana, 2011). These associations are supported not only from large epidemiologic studies (Weiss & Fontana, 2011) but also through pathophysiology (Osler & Schroll, 1997). More specifically, the restricted energy consumption is related with higher mitochondrial biogenesis, autophage, stress resistance, and genome integrity, factors that lower metabolic, cardiovascular, and neurological diseases, and beneficially affect the process of longevity and healthy aging (North & Sinclair, 2012).

A prerequisite of a healthy diet is the balanced energy intake (Keys et al., 1984; Trepanowski et al., 2011). Energy intake and expenditure represent independent potential risk factors for various health outcomes (Maraki & Sidossis, 2010; Trepanowski et al., 2011). According to the literature, there is a clear association between energy intake, energy expenditure, and aging. Both energy intake and expenditure decline with age, but not proportionally (Poehlman, 1992). This is the main reason of energy imbalances in the older adults characterized by obesity or excessive underweight (Trepanowski et al., 2011). However, both energy intake and expenditure are components of the energy balance (Poehlman, 1992). Despite the sound evidence supporting the beneficial effect of energy intake and expenditure on health and long-living (Ritz, 2001; Willcox et al., 2009), the information about their role in the successful aging is sparse. To further explore this lack of evidence, a linear regression analysis was applied between successful aging and energy balance, after adjusting for several confounders. Throughout the applied analysis, it was obvious that a positive energy balance was associated with lower levels of the successful aging. The maintenance of energy balance is very important as well as a complex procedure in the older adults and especially in the oldest old (Ritz, 2001). As age increases, the TEE decreases due to the equivalence reduction in the resting metabolic rate and energy expenditure related to physical activities (Elia, Ritz, & Stubbs, 2000). The aforementioned, in accordance with high prevalence of morbidity, chewing and meal preparation difficulties, living alone, and low income, likely explain the difficulties of the older adults to maintain a balanced energy intake. Energy imbalance leads to overweight and obesity or malnutrition, which, together with high physical inactivity, further contributes to higher presence of functional and physiological disabilities and the development of age-associated chronic diseases (Elia et al., 2000; Ritz, 2001).

Moreover, throughout the linear regression analysis, an inverse association between coffee consumption and a positive one between tea, alcohol intake, and successful aging was revealed. Because of their antioxidant constituents (i.e., polyphenols), tea and alcohol consumption may be positively associated with the healthy aging status (Holahan et al., 2012; Zaveri, 2006). While the beneficial effects of tea and alcohol consumption in health is quite consistent, the role of coffee intake is conflicting (Grobbee et al., 1990). However, the possible beneficial mechanism of coffee consumption could be attributed throughout the patho-biological mechanism of inflammation (Zampelas, Panagiotakos, Pitsavos, Chrysohoou, & Stefanadis, 2004). All the aforementioned support the proposed relationships between successful aging and various nutrition-related risk factors. Due to the complexity of aging, it is of major importance to assess possible nutrition-related determinants that will allow to better identify health risks among older adults for the enhancement of public health planning.

Strengths and Limitations

The present study has several strengths. It is one of the few that evaluated the effect of energy balance in the successful aging of a large sample of “healthy,” free-living older people in the Mediterranean basin. The limitation of the study is mainly caused by its cross-sectional design, and therefore there is lack of causal relationships. Moreover, our findings share the limitations of results from epidemiological studies that rely on self-reported measures of energy intake and expenditure. Also, the cumulative successful aging index that was developed here by simply adding the presence of the common determinants of the individuals may not accurately estimate the successful aging status. This methodology, however, was based on a standard procedure described in the literature and previously used in other aging-associated definitions (i.e., frailty, healthy aging; Bowling & Dieppe, 2005; Parslow et al., 2011; Rowe & Kahn, 1997; Wilkie et al., 2013).

Conclusion

The present work investigated the various determinants of the oldest old and successful agers from the multinational MEDIS study. It is of major interest nowadays to study the characteristics of people living above the expected life span, and to understand the dynamics and the transforming nature of aging. Impressively, in the present study, the agers above the average population life expectancy were roughly 20%. Data analysis of the MEDIS study also revealed that major modifiable nutrition-related risk factors, like the energy balance, alcohol, coffee, and tea consumption, might depict some of the major determinants of the successful agers. However, further exploration is needed to understand how these factors interrelated and which are the most important in the process of successful aging. Moreover, promoting dietary and lifestyle modifications that impede the development of chronic disorders may provide an opportunity to the public health authorities to facilitate a goal of the WHO (WHO, 2002), healthy and successful aging.

Footnotes

Acknowledgements

We are, particularly, grateful to the men and women from the islands of Malta, Sardinia, Sicily, Mallorca, Menorca, Cyprus, Lesvos, Samothraki, Crete, Corfu, Lemnos, Zakynthos, Cephalonia, Naxos, Syros, Ikaria, Salamina, Kassos, Rhodes, Karpathos, Tinos, and the rural area of Mani, who participated in this research. We also express our gratitude to M. Tornaritis, A. Polystipioti, M. Economou, (field investigators from Cyprus), K. Gelastopoulou, I. Vlachou (field investigator from Lesvos), I. Tsiligianni, M. Antonopoulou, N. Tsakountakis, K. Makri (field investigators from Crete), E. Niforatou, V. Alpentzou, M. Voutsadaki, M. Galiatsatos (field investigators from Cephalonia), K. Voutsa, E. Lioliou, M. Miheli (field investigator from Corfu), Tyrovolas S, G. Pounis, A. Katsarou, E. Papavenetiou, E. Apostolidou, G. Papavassiliou, P. Stravopodis (field investigators from Zakynthos), E. Tourloukis, V. Bountziouka, A. Aggelopoulou, K. Kaldaridou, E. Qira, (field investigators from Syros and Naxos), D. Tyrovola (field investigators from Kassos), I. Protopappa (field investigator from Ikaria), C. Prekas, O. Blaserou, K. D. Balafouti (field investigators from Salamina), S. Ioakeimidi (field investigators from Rhodes and Karpathos), A. Mariolis (field investigators from Mani), S. Piscopo (field investigators from Malta), J. A. Tur (field investigators from Mallorca and Menorca), and G. Valacchi B. Nanou (field investigators from Sardinia and Sicily) for their substantial assistance in the enrollment of the participants.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed the receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by research grants from the Hellenic Heart Foundation, and therefore we thank Professor Pavlos Toutouzas, Director of the Foundation. Stefano Tyrovolas received a scholarship from the Foundation for Education and European Culture (IPEP) to undertake his post-doctoral research, of which this work is part. Josep A. Tur was funded by Grants PI11/01791, CIBERobn, CB12/03/30038, and CAIB/EU 35/2001.

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