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Association between dietary diversity and healthy aging: a systematic review

BMC Nutrition volume 11, Article number: 102 (2025) Cite this article

Abstract

Objective

The proportion of older people has been enhanced in the past half-century around the world, consequently leading to the increasing overall prevalence of age-related health conditions. The present study aims to summarize the current evidence regarding the association between dietary diversity (DD) and the components of healthy aging.

Methods

The databases, including Scopus, PubMed, Web of Science, and Google Scholar, were searched using relevant keywords and without date restrictions up to November 2023. All original articles written in English evaluating the association between DD and healthy aging components were eligible for this systematic review.

Results

Totally, 2728 records were obtained in electronic search databases after removing duplicates and irrelevant studies based on the title and abstract; the full text of the 64 articles was critically screened, and 32 cross-sectional studies and 17 cohort studies were included in this review. Except for two cases, all of these studies (95.9%) reported that high DD was associated with lower cognitive and physical frailties, low sleep disturbance and mental disorders, and good nutritional status among the elderly population.

Conclusion

Findings suggest higher DD may contribute to healthy aging through improved nutrient intake and reduced risk of age-related diseases, but heterogeneity in study designs limits conclusive evidence. Enhancing healthy dietary behaviors for older people is suggested to increase their awareness and consequently DD. Further research is needed to confirm these results and the causal relationship.

Peer Review reports

Introduction

Older people have been enhanced in the past half-century around the world because of reduced fertility and enhanced life expectancy [1, 2]. On the other hand, the number of individuals over 65 has grown, from 461 million in 2004 to a projected 2 billion by 2050 [3]. Increasing population aging consequently leads to enhancing age-related health disorders, including dementia and cognitive impairments. Compared to life expectancy, healthy life expectancy increases more slowly [4, 5]. Previously, the lack of disability and disease was defined as healthy aging, where individuals were classified into healthy and diseased [6, 7]. Young et al. suggested that actual healthy aging is the coexistence of chronic diseases and healthy aging [8, 9]. Healthy aging is a multidimensional phenotype that encompasses not only the absence of clinical disease but also freedom from physical disability and preserved cognitive, affective, and social functioning [10].

Nutrition is one of the key factors influencing health and well-being throughout the lifecycle [11]. Among the elderly, a healthy diet and other healthful lifestyle behaviors are connected with lowering more than 50% of the early death rate [12]. The relationship between age-related degenerative disorders and dietary patterns, including the Mediterranean diet and the quality index of diet, has been investigated in some previous studies [13]. A recent review study reported that combining a healthy and high-quality diet with other lifestyle factors could extend disease-free life expectancies by 8–10 years [14]. Higher dietary diversity (DD) has been recognized as a main indicator of a high-quality diet [15, 16]. Dietary diversity score (DDS) is an index described as the number of various food groups consumed over a specific period [17]. Increasing intake from different food groups enhances the likelihood of obtaining the required micronutrients [18]. Adherence to a diet with high DD is recommended in the dietary guidelines and by the World Health Organization (WHO) [19]. Higher DD could promote human health in various dimensions; high DD and adequate nutrient intake were probably associated with improved cognitive function [20], better memory status [21], and healthy aging in adults [22]. Prospective studies also have reported that low DD was associated with higher all-cause mortality [23, 24].

Several investigations have studied the relationship between DD with cognitive and physical performance and healthy aging [20,21,22, 25]. While previous studies suggest a role for DD in aging, there is a lack of systematic evaluation summarizing existing evidence. Therefore, the current systematic review aimed to summarize the findings regarding the association between DD with the components of healthy aging.

Methods

Tabriz University of Medical Sciences, Tabriz, Iran’s Research Vice Chancellor registered and approved the current study’s protocol (Grant number: 73155).

Search strategy

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was taken into consideration during the conduct and reporting of this systematic review (Supplementary Table 1) by focusing on the association between DD and the healthy aging components. A systematic literature search was conducted using Web of Science, PubMed, Scopus, and Google Scholar databases until November 2023, without date restrictions. The search was performed using the MeSH terms and other related keywords ((“diet diversity” OR “dietary diversity” OR “dietary variety” OR “diet variety” OR “food diversity” OR “food variety”) AND (“aging” OR “elderly” OR “cognitive” OR “cognition” OR “dementia” OR “older adult” OR aging [MeSH] OR elderly [MeSH] OR cognition [MeSH])). Supplementary Table 2 shows the search strategy. The articles were downloaded to the EndNote software (Version X9) to better manage citations.

Eligibility criteria

All original articles evaluating the relationship between DD and healthy aging components that were written in English were eligible for this review. The PICOS (Population (elderly subjects), Intervention (dietary diversity), Comparison, Outcome (healthy aging components), and Study Design (cross-sectional and cohort studies)) criteria were used for the definition of research questions and eligibility criteria (Table 1). Review articles, book chapters, theses, letters, posters, conference publications, editorials, and commentary were not included. Studies that evaluated household DD or farm diversity were excluded from this study. Studies with unavailable full-text were also excluded.

Table 1 PICOS criteria for inclusion of studies
Full size table

Selection of the studies

Duplicate articles were removed, and the remaining articles were independently screened by two authors according to the inclusion and exclusion criteria. First, the titles and abstracts of the included studies were evaluated following the eligibility criteria. Then, the full text of eligible articles was assessed, and studies that could meet the predefined criteria and had required information were included in this review. Disagreements between the authors were resolved through discussion with a third reviewer. The calculated kappa for the inter-rater reliability between the two authors was 0.81 (93%) for the data screening and selection process, indicating almost perfect agreement.

Data extraction

Two independent authors also extracted the required data. The obtained data of the included studies were the authors’ name, publication year, study design and location, sample size, age of participants, duration and method for food intake assessment, DD criteria, the cut-off point of DD, considered food groups, adjusted covariates, and findings concerning the relationship between DD and anemia.

Assessing risk of bias and certainly of the evidence

The risk of bias was assessed by two independent authors using the Newcastle-Ottawa scale modified for cross-sectional and cohort studies. The criteria for assessing cross-sectional studies were adequate sample size, representativeness of the sample, exposure ascertainment, non-respondents, comparability of the subjects in outcome groups, outcome assessment, controlling the confounding factors, and long enough follow-up for outcomes to occur. Its score for cross-sectional studies has a maximum of 10 points, and a study with an overall score between 7 and 8 points has a good quality [26, 27]. The Newcastle-Ottawa scale criteria for cohort studies include three sections: selection of participants and outcomes, comparability based on the design, and outcome evaluation. Its score has a maximum of 9 points for cohort studies, and one study with an overall score of 6–9 points was of good quality [26, 27].

The overall strength and quality of the evidence were evaluated by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale [28].

Results

Selection of studies

In the initial search, 2728 records were retrieved from electronic databases including Scopus (n = 385), PubMed (n = 494), Web of Sciences (n = 1775), and Google Scholar (n = 74). By removing duplicate articles, 2083 studies remained further screened. The title and abstract of the studies were screened in the first stage, and 2019, irrelevant articles were excluded. In the second stage, the full text of 64 articles was critically reviewed of which 15 studies were excluded because were letters to the editor (n = 3), other languages (n = 4), studied DD only (n = 2) [29, 30], studied the association between shopping difficulty with DD and other factors (n = 1) [31], studied the effects of food aid on DD and food variety (n = 1) [32], studies the association of the natural teeth number with DD (n = 2) [33, 34], studied the association between food expenditure with DD and food security (n = 1) [35], and studied the association between eating alone with depression and food diversity (n = 1) [36]. Finally, 49 studies, including 32 cross-sectional and 17 cohorts, were reviewed in this study (Table 2). A PRISMA-compliant selection process is presented in Fig. 1.

Table 2 Characteristics of the studies that examined the relationship between DD with healthy aging
Full size table
Fig. 1
figure 1

The process of study selection for this systematic review (PRISMA diagram)

Full size image

Characteristics of the included studies

The extracted data from the studies are presented in Table 2. The included studies were published from 2002 to 2023. The range of sample sizes of the studies involved in the review was from 18 to 39,574, and a total of 254,955 older adults were involved in this study. The age of participants was > 60 years in 39 studies, > 70 years in six studies, and > 45 years in four studies. Except for two cases, all of the studies included both genders of elderly subjects; the mean percentage of females was 53.71%. In 80% (38 cases) of included studies, the food frequency questionnaire (FFQ) was applied for participants’ dietary assessment. Moreover, five studies used 24-hour dietary recall, and four others used 7-day dietary recall, 3-day dietary recall, and 3-day food record. In most of the studies, dietary diversity score (DDS) ranged from 0 to 10 points, and the considered food groups were meat, eggs, fish/shellfish, soybean products, milk, fruit, potatoes, green/yellow vegetables, seaweed, and fats/oils. The location of the studies was as follows: 19 cases in Japan, 17 cases in China, four cases in Taiwan, and one case in each of the United States, the UK, Spain, Australia, India, Korea, and Saudi Arabia. Above 60% of the studies were carried out in high-income countries, and others were in middle-income countries. In this review, the multivariate analysis results of the relationship of DD with the components of healthy aging were considered. Except for one case, all of the included studies adjusted major covariates such as age, sex, etc.

Risk of bias and quality of the evidence assessment

As shown in Supplementary Tables 3 and 4, the overall quality score ranged from 7 to 10 of a maximum of 10 scores and from 7 to 9 of a maximum of 9 scores for cross-sectional and cohort studies, respectively. Most of the included studies had a satisfactory score, particularly, sample size, use of validated measurement tools, and outcome assessment were appropriate. The majority of our studies generally involved a large sample size that was more representative of the community, however, most of them did not use of random sampling method. Moreover, the response rate of participants was not reported in the majority of the cross-sectional studies.

Using the GRADE system, the quality and strength of the obtained evidence were rated as moderate (Supplementary Table 5).

Relationship between DD and components of healthy aging

As shown in Table 2, except in two cases [37, 38], all the included studies demonstrated that high DD was associated with healthy aging. Based on the included studies’ findings, the participants with high DDS compared with the low DDS group, exhibited lower cognitive (n = 2) [39, 40] and physical frailty (n = 11) [41,42,43,44,45,46,47,48,49,50,51], cognitive impairment (n = 5) [20, 52,53,54,55], sleep disturbance (n = 3) [56,57,58], disabling dementia (n = 2) [59, 60], functional impairment (n = 2) [61, 62], and depression symptoms (n = 2) [63, 64]. They also demonstrated that high DD was connected with better cognitive function (n = 1) [65], lower medical service utilization (n = 1) [66], higher quality of life scores (n = 1) [67], and high intrinsic capacity (n = 1) [68], and had protective effects in maintaining physical performance (n = 2) [69, 70] and healthy aging score (n = 2) [22, 25]. Moreover, DD was significantly associated with older adults’ nutrient and energy intake [71, 72], body mass index (BMI) [72], and nutritional status [73, 74] (n = 4). Poor DD was associated with developing sarcopenia and severe sarcopenia (n = 3) [75,76,77], low psychological resilience (n = 1) [78], decline in intellectual activity (n = 1) [79], and malnutrition (n = 1) [80].

In two cases of included studies, DDS was not associated with muscle strength, health-related quality of life [37], and incident functional disability [38]. However, in one case, the interaction between DDS and eating status was associated with functional disability [38] (Table 2).

Discussion

The current systematic review aimed to comprehensively summarize the findings of the previous studies regarding the association between DD and healthy aging-related factors among older adults. The majority of the included studies (95.65%) reported that older adults’ higher DD was associated with healthy aging components, including lower cognitive and physical frailty, sleep disturbance, and mental disorders. They also reported that a high DD was associated with better cognitive function, lower medical service utilization, higher quality of life scores, and better physical performance. Moreover, DDS in older adults was significantly associated with their nutrient and energy intake, BMI, and nutritional status.

Diet-based approaches are potential preventive methods against cognitive decline [81,82,83]. DD as an indicator of nutrient adequacy can benefit several dimensions of human health, for example, by minimizing the foods’ adverse effects on health and enhancing biodiversity [18, 84, 85]. Previous evidence suggested that DD can indicate the nutritional and health status of the elderly population [30]. Healthy aging is not only the absence of clinical disease but also freedom from physical disability and cognitive decline, and preserved social functioning [10]. Nutrient adequacy and good nutrition status were possibly associated with better cognitive performance [86]. The findings of the recent study by Duan et al. indicated that participants with a lower risk of frailty had higher DD compared with the low DDS group [14]. Low DD may indicate malnutrition, which is characterized by a reduced energy store, poor nutrient intake, and an increased risk of some disorders, such as infectious diseases, impaired immunity, and multi-morbidities. Malnutrition might predict a decline in cognitive function [30, 87]. Numerous nutrients’ actions are dependent on the other nutrients present from different food groups, and nutrient balance can be reached only in the context of higher DD, which impacts the prevention of diseases [84]. Thus, the nutrients that are beneficial for cognitive functioning could not work as intended. Moreover, insufficient DD and poor nutritional status are linked to increased oxidative stress levels [88, 89], which would enhance the risk of cognitive impairment [90]. Because of the lower antioxidant storage, higher levels of oxidative stress, and reduced stress resistance [91,92,93], as well as the decreased adaptive capacity [94], the ability to maintain the normal function of the brain declined in the elderly. Hence, they are probably adversely affected by their poor DD. The physiological function of chewing, ingestion, secretion of salivation, and absorption will decline with aging, which influences nutrient intake [95]. The elderly will be more vulnerable as their DD and nutritional intake capabilities decline. On the other hand, healthier older adults may have more diverse diets because they can meet their requirements. Zhu et al. in the recent study indicated that the elderly who were in a healthy state had better DD, and the younger group was more active and benefited more than the older group in acquiring relatively adequate nutrition [96]. This may be becaouse of that the younger elderly more participate in activities both at home and in society including preparing food and acquiring nutrients compared with the older elderly. Moreover, the younger elderly have better function of chewing, salivation secretion, ingestion and absorption, which influence the nutrition intake. Digestive system declines with aging and disease that makes the elderly more vulnerable and sensitive to poor DD [97].

In addition to micronutrient adequacy, higher DD was linked with more protein intake [19]. Since the aging process is along with muscle mass and strength loss [98], frailty [99], and enhancing the functional impairment [100], adequate protein intake is important for preserving older adults’ muscle function [101, 102]. One of the main pathologies thought to cause frailty is a decline in muscle mass and strength [103]. According to earlier research, older adults with weak handgrip strength consumed fewer specific nutrients, such as essential amino acids, proteins, calcium, vitamin D, and antioxidants [104]. A significant association was observed between a high intake of protein and a decreased sarcopenia prevalence, as well as low dietary protein intake was associated with the risk of having low muscle mass in older adults [105, 106]. Moreover, a deficiency of energy and nutrients might affect the function of mitochondria and cause muscle-related symptoms such as frailty [106]. Older adults with malnutrition had a high frailty prevalence [107]. A high DDS of subjects was associated with being well-nourished [37, 73]. Additionally, the individuals with a good DD had adequate intake of vitamins, protein, and antioxidant nutrients [108], all of which have been shown to the prevention of frailty [41]. A high DDS was associated with reduced oxidative stress and inflammation [109], both of which accelerate bone mass and muscle loss and the deterioration of the function of the central nervous system [110,111,112], leading to frailty. As mentioned above, the various nutrients of different food groups present can influence the effects of many nutrients, and only a high DD can be nutritionally balanced, and the prevention of diseases can be achieved [84]. For example, fruits and vegetables as vitamin and mineral sources are crucial for the synthesis of muscle protein in addition to the foods of protein sources [51]. Evidence has suggested that a high intake of protein and fat and a low intake of carbohydrates have negative effects on mental health [113, 114]. Nutrients that contribute to frailty prevention are ineffective in a diet that lacks diversity. The balance and interactions of nutrients are critical in health and healthy aging compared to the nutrients alone [115]. Additionally, eating a variety of foods requires health awareness in meal planning, cooking, and shopping. These activities may help older adults in preserving physical performance [69] and functional ability [79]. Moreover, a diverse diet can lead to a healthier gut microbiota [116], which plays a role in improving the anabolic resistance of skeletal muscle to dietary proteins [117, 118] and can contribute to the prevention of frailty. On the other hand, gut dysbiosis could cause the initiation of an immune response and persistent low-grade inflammation [100], which can lead to various age-related degenerative diseases. Older persons who eat various food groups have more diverse gut microbiota [98].

Some of the included studies reported that maintaining a high DD during the long term had a better impact on older adults’ health status than in the short term [22, 41, 52]. Consistently high DD and increasing total dietary intake can reduce the frailty risk and help maintain good physical function among older adults.

The findings of this study may provide a useful strategy (diverse diet) for promoting healthy aging. Based on the findings, higher DD is important for better cognitive function, high physical performance, and good nutritional status in the elderly, which has important implications for public health policy. Enhancing healthy dietary behaviors for older people is suggested to increase their awareness and consequently DD. Healthcare providers could educate the elderly population to improve their dietary patterns by selecting diverse food groups. Moreover, the community should provide diverse food supplies for the elderly population to meet their needs of a high DD.

Strengths and limitations of the study

The strengths of this review were that it was a comprehensive systematic search, and two independent authors conducted all the steps, presenting reliable evidence. Moreover, the large sample sizes of the included studies, using a similar and valid method for the assessment of dietary intake, and the relatively similar criteria for DD assessment, which make results comparable, were other strengths of this study. However, most of the included studies had cross-sectional designs, and there was heterogeneity among the populations and settings of the included studies. Different food groups in DD measurements across the studies were another limitation of this review. In addition, because of assessing different components of healthy aging across the studies, we couldn’t conduct a meta-analysis. A framework for a standardized definition of healthy aging is proposed for future studies.

Conclusions

The majority of the included studies (95.9%) reported that higher DD was generally associated with better health outcomes relevant to aging, including lower cognitive and physical frailty, sleep disturbance, and mental disorders, although causality remains uncertain. The high DD was associated with better cognitive function, lower medical service utilization, higher quality of life scores, and better physical performance. Moreover, there was an association between DD and older adults’ nutrient and energy intake, BMI, and nutritional status. Our findings suggest a potential association between DD and aging outcomes, though further research is needed to confirm these results. The promotion of older adults’ nutritional educational interventions is required to enhance DD and consequently improve their health status.

Data availability

The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request [alipourb@tbzmed.ac.ir].

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Funding

We gratefully acknowledge the Vice-Chancellor for Research of Tabriz University of Medical Sciences, Tabriz, Iran, for financial support (Grant number: 73155).

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Authors and Affiliations

  1. Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran

    Roghayeh Molani-Gol

  2. Nutrition Research Center, Department of Community Nutrition, Faculty of Nutrition and Food Science, Tabriz University of Medical Sciences, Tabriz, Iran

    Roghayeh Molani-Gol & Maryam Rafraf

  3. Department of Community Nutrition, Faculty of Nutrition and Food Sciences, Tabriz University of Medical Sciences, Tabriz, Iran

    Beitullah Alipour

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  1. Roghayeh Molani-Gol
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Contributions

B.A. R.M-G. contributed to the conception and design of the study. R.M-G. collected the data, performed statistical analysis, and drafted the manuscript. B.A. and M.R. revised the manuscript. All the authors approved the final version of the manuscript.

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Correspondence to Beitullah Alipour.

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Moreover, this research protocol was approved by the Ethics Committee of Tabriz University of Medical Sciences, Tabriz, Iran (Ethical Code: IR.TBZMED.VCR.REC.1402.307). All participants signed written informed consent before completing the questionnaire.

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Molani-Gol, R., Rafraf, M. & Alipour, B. Association between dietary diversity and healthy aging: a systematic review. BMC Nutr 11, 102 (2025). https://doi.org/10.1186/s40795-025-01085-3

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Keywords

BMC Nutrition

ISSN: 2055-0928

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