Aging, longevity, and healthy agingthe public health approach

Vincenza Gianfredi, Daniele Nucci, Flavia Pennisi, Stefania Maggi, Nicola Veronese et al. (+1)•View original

OverviewBalancedalloy voice

Let’s talk about one of the most profound demographic shifts of our time: populations everywhere are growing older. But here’s the crucial twist the paper by Gianfredi and colleagues brings into focus—aging is simultaneously a public health triumph and a systems-level challenge. Longer lives are the payoff from sanitation, vaccines, antibiotics, better maternal and child health, and sustained socioeconomic development. Yet the very success of extended longevity brings with it multimorbidity, functional decline, and rising demand for long-term care. So how should health policy evolve in light of these trends? The authors set the stage by grounding their discussion in the World Health Organization’s framing. Aging isn’t just biological wear and tear; it’s also a gradual reduction in physical and mental capacities that increases disease risk and, ultimately, mortality. Healthy aging, in turn, is defined not as the absence of disease but as maintaining the functional abilities—what the WHO calls intrinsic capacity—that allow people to live well in older age. That redefinition matters, because it pushes policy beyond treating illnesses to supporting capability and independence across the life course. Now, how fast is the world aging? The numbers here are striking. Global life expectancy at birth climbed from 46 years in 1950 to over 70 years in 2023. By 2050, more than 2.1 billion people will be 60 or older—over 21% of humanity. While high-income countries such as Japan, Italy, and Switzerland already exceed 80 years of average life expectancy, many low-income countries remain under 60—but every region is aging in absolute and relative terms. Why? A sustained decline in fertility, major health system gains in prevention, diagnosis, and treatment, and a dramatic shift in the disease landscape from infectious epidemics to chronic, non-communicable diseases. This epidemiological transition is central to policy. Non-communicable diseases now account for 41 million deaths each year—74% of all global deaths. Within that total, cardiovascular disease leads with 17.9 million deaths annually, followed by cancers at 9.3 million, chronic respiratory diseases at 4.1 million, and diabetes at 2.0 million, including diabetes-related kidney disease. These conditions cluster with age and often coexist. Multimorbidity—the presence of two or more chronic conditions—becomes the rule rather than the exception in later life, complicating care, inflating costs, and increasing the need for coordinated, long-term support. And disability is widespread: the WHO estimates 1.3 billion people—16% of the world’s population—live with significant disability, which intersects powerfully with aging. The figure on page 3 of the paper—titled “Achievements and challenges of aging: key factors and social implications”—is a helpful mental map. Imagine a two-sided schematic. On the “achievement” side sit the drivers of longevity: socio-political stability, economic growth, sanitation and clean water, education, and advances in medical technology and care delivery. On the “challenge” side, the consequences: higher burdens of chronic disease and multimorbidity, workforce shortages in health and social care, stress on pension systems as worker-to-retiree ratios shrink, and a growing need for long-term and home-based care. The policy task, the authors argue, is to hold both sides together—continue to invest in the conditions that lengthen life, while redesigning systems to preserve function and independence in those added years. Here’s an important nuance for decision-makers. It’s easy to assume that aging alone will explode health spending. The evidence in this review suggests a more complex picture. Countries with very high life expectancy, such as Spain and Italy, don’t necessarily incur higher health expenditures simply because of longevity. Rather, spending is more tightly linked to morbidity—the burden of disease—and, above all, to end-of-life care. Multiple analyses cited here show that health care costs concentrate in the last years of life during periods of severe illness, not evenly across the extra healthy years that longevity adds. That insight should steer budgets: prioritize prevention and functional maintenance to delay morbidity, and plan deliberately for the intensive needs of end-of-life care. A companion metric in the paper will be familiar to many of you but underused in policy debates: disability-free life expectancy, or DFLE. According to WHO data summarized here, in most high-income countries there is roughly a 10-year gap between total life expectancy and DFLE—and the gap is even larger in low- and middle-income regions. In other words, many people spend a decade or more of late life with notable disability or chronic illness. That’s a call to action. DFLE should be used to anticipate demand for medical services, social support, assistive technologies, and long-term care, and to evaluate whether interventions are actually compressing morbidity—shifting the experience of disability later and shortening its duration. Let’s turn to labor markets and pensions, because health policy does not operate in a vacuum. As the proportion of older adults rises, pay-as-you-go pension systems come under strain, and governments often respond by raising retirement ages or encouraging longer workforce participation. But the health literature the authors review reminds us to proceed carefully. First, there’s the “healthy worker effect”: those who remain employed longer are, on average, healthier than peers who retire earlier due to illness or disability. In Italian data comparing employed people to recent retirees aged 60–64, retirees showed higher prevalence of functional limitations, heart disease, stroke, and COPD—suggesting selection effects rather than gains or harms from work per se. Second, mental health is nuanced. A meta-analysis cited here reports that retirement reduces the risk of depression by about 20% compared to those over 60 who keep working—yet the broader literature is mixed, with some evidence of a short-term uptick in depression risk during the transition that diminishes over time. The policy implication? Pension reforms should build in flexibility and protections for those in poor health or with strenuous job histories, and complement workforce participation goals with strong occupational health, mental health support during transitions, and equitable pathways for earlier retirement when warranted. So what does a future-ready health policy look like? The authors point to the WHO’s Decade of Healthy Aging (2021–2030) and, concretely, to tools like ICOPE—Integrated Care for Older People. This is a person-centered framework for assessing and supporting intrinsic capacity across domains such as mobility, cognition, vitality, and sensory function. Notably, the ICOPE manual was updated in January 2025 to include conditions like urinary incontinence that were previously underemphasized—an example of policy instruments evolving with evidence. And here’s some encouraging news: cohort analyses from England and China suggest intrinsic capacity is improving, particularly in cognitive, locomotor, and vitality domains, likely reflecting broader social changes and medical progress. That tells policymakers that investments in prevention, education, and care quality can move the needle at population scale. The paper’s second schematic—the figure on page 6 titled “Determinants of healthy aging: biological, behavioral, environmental, and healthcare system factors”—is essentially a policy blueprint. Think of concentric or interacting domains. Biological factors set the baseline; behaviors like nutrition and physical activity modify risk; environments—housing, transport, social networks—enable or constrain function; and health systems—through screening, integrated primary care, and rehabilitation—either coordinate support or allow fragmentation. If policy touches only one layer, the returns are limited; align all four and you create compounding benefits for DFLE, independence, and quality of life. What does that look like in practice? The review offers both programmatic and lifestyle levers. On the systems side, integrated community-based models reduce hospitalizations and support autonomy. Japan’s “Comprehensive Community Care System” bundles healthcare, social, and housing services locally; Denmark’s co-housing communities for older adults combat isolation and strengthen mental well-being. Those examples show how design choices—service integration and social architecture—translate into health outcomes and lower institutional care reliance. On prevention and self-management, the guidance is concrete. Nutrition matters, and not only for weight. Diets patterned on the Mediterranean diet—rich in fruits, vegetables, whole grains, fish, legumes, and olive oil—are associated, in the evidence summarized here, with reduced risks of cardiovascular disease, type 2 diabetes, certain cancers, and neurodegenerative conditions such as dementia and Alzheimer’s disease. There’s also an association with lower depression risk—an important dimension of well-being in late life. Protein requirements rise with age: the Italian LARN recommendations, cited in the review, suggest at least 1.1–1.2 grams of protein per kilogram of body weight per day for older adults, higher still when protein is primarily plant-based. Add adequate calcium and vitamin D to protect bone health and prevent fractures. These aren’t just clinical niceties—they’re policy-relevant for meal standards in long-term care, primary care counseling, and food assistance programs. Physical activity is a pillar. Even moderate activity, like regular walking, is linked to reductions in dementia risk and broad improvements across cardiovascular, metabolic, and mental health domains. A rounded program should include resistance training to preserve muscle, aerobic activity to support cardiopulmonary fitness, and balance exercises to prevent falls—one of the leading causes of morbidity in older adults. Policies that fund community exercise programs, safe walking environments, and referral pathways from primary care to activity programs will pay off in functional capacity and DFLE. Then there’s the clinical scaffolding that holds prevention together: timely access to preventive services and chronic disease management. Regular screening for hypertension, diabetes, and cardiovascular risk; early diagnosis; and continuous monitoring with adherence support are highlighted here as core strategies to reduce complications and maintain quality of life. The review calls for expanding public coverage of preventive services—an economic and equity lever that aligns incentives, lowers out-of-pocket barriers, and shifts care upstream. Of course, implementing all this requires people—trained, coordinated teams capable of managing multimorbidity. The authors emphasize workforce planning and the need to recruit and retain healthcare professionals with geriatric and multidisciplinary skills. This extends to dementia, where the paper argues for elevating primary prevention within healthy aging policies: support accessible screening for cognitive risk factors, scale physical and cognitive activity programs tailored for older adults, run public awareness campaigns on modifiable lifestyle factors that bolster cognitive reserve, and fund longitudinal research to strengthen the evidence base. Pair that with teams trained in both general gerontology and dementia care, and you’re set up to manage complexity rather than react to crises. Let me pause on equity and environment, because the paper does. Social inequalities—lower socioeconomic status, educational disparities, limited access to care—are linked to worse outcomes in older adults. Policy that ignores these gradients risks widening the DFLE gap. The solution is multisectoral: age-friendly cities, safe public spaces, transportation that connects older adults to services and social life, and supports for caregivers who shoulder a large share of long-term care. The review reminds us that a significant portion of the economic burden is borne by families and informal caregivers—so respite care, training, and financial supports are not luxuries; they’re essential infrastructure. What about limitations and open questions? The authors present a broad synthesis rather than a single-country cost model or a randomized policy trial, so translation will vary by context. DFLE estimates differ by region and income, and many middle- and low-income countries face a compressed timeline of aging and system development—meaning policies must be sequenced and tailored carefully. Evidence around retirement and mental health, while suggestive, is mixed and sensitive to individual, occupational, and social factors; policy should favor flexibility rather than one-size-fits-all mandates. And as tools like ICOPE evolve—for example, the 2025 update adding urinary incontinence—health systems will need iterative training and evaluation to ensure uptake translates into outcomes. So where does this leave health policy? Three practical takeaways emerge from the paper. First, measure what matters—track not only life expectancy but DFLE and intrinsic capacity, and use those metrics to budget for long-term care, rehabilitation, and assistive technologies. Second, invest early and broadly—fund preventive services, nutrition and activity programs, and age-friendly environments, because they compress morbidity and reduce high-cost utilization concentrated at the end of life. Third, build integrated capacity—multidisciplinary teams trained for multimorbidity and dementia, with community-based service models that keep older adults independent and connected. The promise here is real. As the authors conclude, with integrated health policies and multidisciplinary care models, longer lives can be paired with better lives—more years lived with autonomy, purpose, and social participation. The demographic wave is coming either way. The question for policy is whether we surf it with systems designed for function and dignity… or let it break against services built for a different century. The evidence in this review points clearly toward the former—and invites us to start now.

Yet the very success of extended longevity brings with it multimorbidity, functional decline, and rising demand for long-term care. So how should health policy evolve in light of these trends?

The authors set the stage by grounding their discussion in the World Health Organization’s framing. Aging isn’t just biological wear and tear; it’s also a gradual reduction in physical and mental capacities that increases disease risk and, ultimately, mortality. Healthy aging, in turn, is defined not as the absence of disease but as maintaining the functional abilities—what the WHO calls intrinsic capacity—that allow people to live well in older age.

That redefinition matters, because it pushes policy beyond treating illnesses to supporting capability and independence across the life course.

Now, how fast is the world aging? The numbers here are striking. Global life expectancy at birth climbed from 46 years in 1950 to over 70 years in 2023.

By 2050, more than 2.1 billion people will be 60 or older—over 21% of humanity. While high-income countries such as Japan, Italy, and Switzerland already exceed 80 years of average life expectancy, many low-income countries remain under 60—but every region is aging in absolute and relative terms. Why?

A sustained decline in fertility, major health system gains in prevention, diagnosis, and treatment, and a dramatic shift in the disease landscape from infectious epidemics to chronic, non-communicable diseases.

This epidemiological transition is central to policy. Non-communicable diseases now account for 41 million deaths each year—74% of all global deaths. Within that total, cardiovascular disease leads with 17.9 million deaths annually, followed by cancers at 9.3 million, chronic respiratory diseases at 4.1 million, and diabetes at 2.0 million, including diabetes-related kidney disease.

These conditions cluster with age and often coexist. Multimorbidity—the presence of two or more chronic conditions—becomes the rule rather than the exception in later life, complicating care, inflating costs, and increasing the need for coordinated, long-term support. And disability is widespread: the WHO estimates 1.3 billion people—16% of the world’s population—live with significant disability, which intersects powerfully with aging.

The figure on page 3 of the paper—titled “Achievements and challenges of aging: key factors and social implications”—is a helpful mental map. Imagine a two-sided schematic. On the “achievement” side sit the drivers of longevity: socio-political stability, economic growth, sanitation and clean water, education, and advances in medical technology and care delivery.

On the “challenge” side, the consequences: higher burdens of chronic disease and multimorbidity, workforce shortages in health and social care, stress on pension systems as worker-to-retiree ratios shrink, and a growing need for long-term and home-based care. The policy task, the authors argue, is to hold both sides together—continue to invest in the conditions that lengthen life, while redesigning systems to preserve function and independence in those added years.

Here’s an important nuance for decision-makers. It’s easy to assume that aging alone will explode health spending. The evidence in this review suggests a more complex picture.

Countries with very high life expectancy, such as Spain and Italy, don’t necessarily incur higher health expenditures simply because of longevity. Rather, spending is more tightly linked to morbidity—the burden of disease—and, above all, to end-of-life care. Multiple analyses cited here show that health care costs concentrate in the last years of life during periods of severe illness, not evenly across the extra healthy years that longevity adds.

That insight should steer budgets: prioritize prevention and functional maintenance to delay morbidity, and plan deliberately for the intensive needs of end-of-life care.

A companion metric in the paper will be familiar to many of you but underused in policy debates: disability-free life expectancy, or DFLE. According to WHO data summarized here, in most high-income countries there is roughly a 10-year gap between total life expectancy and DFLE—and the gap is even larger in low- and middle-income regions. In other words, many people spend a decade or more of late life with notable disability or chronic illness.

That’s a call to action. DFLE should be used to anticipate demand for medical services, social support, assistive technologies, and long-term care, and to evaluate whether interventions are actually compressing morbidity—shifting the experience of disability later and shortening its duration.

Let’s turn to labor markets and pensions, because health policy does not operate in a vacuum. As the proportion of older adults rises, pay-as-you-go pension systems come under strain, and governments often respond by raising retirement ages or encouraging longer workforce participation. But the health literature the authors review reminds us to proceed carefully.

First, there’s the “healthy worker effect”: those who remain employed longer are, on average, healthier than peers who retire earlier due to illness or disability. In Italian data comparing employed people to recent retirees aged 60–64, retirees showed higher prevalence of functional limitations, heart disease, stroke, and COPD—suggesting selection effects rather than gains or harms from work per se. Second, mental health is nuanced.

A meta-analysis cited here reports that retirement reduces the risk of depression by about 20% compared to those over 60 who keep working—yet the broader literature is mixed, with some evidence of a short-term uptick in depression risk during the transition that diminishes over time. The policy implication? Pension reforms should build in flexibility and protections for those in poor health or with strenuous job histories, and complement workforce participation goals with strong occupational health, mental health support during transitions, and equitable pathways for earlier retirement when warranted.

So what does a future-ready health policy look like? The authors point to the WHO’s Decade of Healthy Aging (2021–2030) and, concretely, to tools like ICOPE—Integrated Care for Older People. This is a person-centered framework for assessing and supporting intrinsic capacity across domains such as mobility, cognition, vitality, and sensory function.

Notably, the ICOPE manual was updated in January 2025 to include conditions like urinary incontinence that were previously underemphasized—an example of policy instruments evolving with evidence. And here’s some encouraging news: cohort analyses from England and China suggest intrinsic capacity is improving, particularly in cognitive, locomotor, and vitality domains, likely reflecting broader social changes and medical progress. That tells policymakers that investments in prevention, education, and care quality can move the needle at population scale.

The paper’s second schematic—the figure on page 6 titled “Determinants of healthy aging: biological, behavioral, environmental, and healthcare system factors”—is essentially a policy blueprint. Think of concentric or interacting domains. Biological factors set the baseline; behaviors like nutrition and physical activity modify risk; environments—housing, transport, social networks—enable or constrain function; and health systems—through screening, integrated primary care, and rehabilitation—either coordinate support or allow fragmentation.

If policy touches only one layer, the returns are limited; align all four and you create compounding benefits for DFLE, independence, and quality of life.

What does that look like in practice? The review offers both programmatic and lifestyle levers. On the systems side, integrated community-based models reduce hospitalizations and support autonomy.

Japan’s “Comprehensive Community Care System” bundles healthcare, social, and housing services locally; Denmark’s co-housing communities for older adults combat isolation and strengthen mental well-being. Those examples show how design choices—service integration and social architecture—translate into health outcomes and lower institutional care reliance.

On prevention and self-management, the guidance is concrete. Nutrition matters, and not only for weight. Diets patterned on the Mediterranean diet—rich in fruits, vegetables, whole grains, fish, legumes, and olive oil—are associated, in the evidence summarized here, with reduced risks of cardiovascular disease, type 2 diabetes, certain cancers, and neurodegenerative conditions such as dementia and Alzheimer’s disease.

There’s also an association with lower depression risk—an important dimension of well-being in late life. Protein requirements rise with age: the Italian LARN recommendations, cited in the review, suggest at least 1.1–1.2 grams of protein per kilogram of body weight per day for older adults, higher still when protein is primarily plant-based. Add adequate calcium and vitamin D to protect bone health and prevent fractures.

These aren’t just clinical niceties—they’re policy-relevant for meal standards in long-term care, primary care counseling, and food assistance programs.

Physical activity is a pillar. Even moderate activity, like regular walking, is linked to reductions in dementia risk and broad improvements across cardiovascular, metabolic, and mental health domains. A rounded program should include resistance training to preserve muscle, aerobic activity to support cardiopulmonary fitness, and balance exercises to prevent falls—one of the leading causes of morbidity in older adults.

Policies that fund community exercise programs, safe walking environments, and referral pathways from primary care to activity programs will pay off in functional capacity and DFLE.

Then there’s the clinical scaffolding that holds prevention together: timely access to preventive services and chronic disease management. Regular screening for hypertension, diabetes, and cardiovascular risk; early diagnosis; and continuous monitoring with adherence support are highlighted here as core strategies to reduce complications and maintain quality of life. The review calls for expanding public coverage of preventive services—an economic and equity lever that aligns incentives, lowers out-of-pocket barriers, and shifts care upstream.

Of course, implementing all this requires people—trained, coordinated teams capable of managing multimorbidity. The authors emphasize workforce planning and the need to recruit and retain healthcare professionals with geriatric and multidisciplinary skills. This extends to dementia, where the paper argues for elevating primary prevention within healthy aging policies: support accessible screening for cognitive risk factors, scale physical and cognitive activity programs tailored for older adults, run public awareness campaigns on modifiable lifestyle factors that bolster cognitive reserve, and fund longitudinal research to strengthen the evidence base.

Pair that with teams trained in both general gerontology and dementia care, and you’re set up to manage complexity rather than react to crises.

Let me pause on equity and environment, because the paper does. Social inequalities—lower socioeconomic status, educational disparities, limited access to care—are linked to worse outcomes in older adults. Policy that ignores these gradients risks widening the DFLE gap.

The solution is multisectoral: age-friendly cities, safe public spaces, transportation that connects older adults to services and social life, and supports for caregivers who shoulder a large share of long-term care. The review reminds us that a significant portion of the economic burden is borne by families and informal caregivers—so respite care, training, and financial supports are not luxuries; they’re essential infrastructure.

What about limitations and open questions? The authors present a broad synthesis rather than a single-country cost model or a randomized policy trial, so translation will vary by context. DFLE estimates differ by region and income, and many middle- and low-income countries face a compressed timeline of aging and system development—meaning policies must be sequenced and tailored carefully.

Evidence around retirement and mental health, while suggestive, is mixed and sensitive to individual, occupational, and social factors; policy should favor flexibility rather than one-size-fits-all mandates. And as tools like ICOPE evolve—for example, the 2025 update adding urinary incontinence—health systems will need iterative training and evaluation to ensure uptake translates into outcomes.

So where does this leave health policy? Three practical takeaways emerge from the paper. First, measure what matters—track not only life expectancy but DFLE and intrinsic capacity, and use those metrics to budget for long-term care, rehabilitation, and assistive technologies.

Second, invest early and broadly—fund preventive services, nutrition and activity programs, and age-friendly environments, because they compress morbidity and reduce high-cost utilization concentrated at the end of life. Third, build integrated capacity—multidisciplinary teams trained for multimorbidity and dementia, with community-based service models that keep older adults independent and connected.

The promise here is real. As the authors conclude, with integrated health policies and multidisciplinary care models, longer lives can be paired with better lives—more years lived with autonomy, purpose, and social participation. The demographic wave is coming either way.

The question for policy is whether we surf it with systems designed for function and dignity… or let it break against services built for a different century. The evidence in this review points clearly toward the former—and invites us to start now.