Open Access | COMMENTARY
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Successful aging through integrative nutrition: a four-pillar framework for deprescribing and resilience
* Corresponding author: Mikhail Kogan
Mailing address: Geriatrics and Palliative Medicine, The George
Washington University School of Medicine and Health Sciences,
Washington, DC, USA.
Email: mkogan@gwcim.com
Received: 21 January 2026 / Accepted: 02 February 2026 / Published: 31 March 2026
DOI: 10.31491/APT.2025.12.192
Abstract
Polypharmacy, micronutrient deficiencies, and gut dysbiosis frequently intersect in older adults to drive frailty, falls, cognitive decline, and loss of independence in late life. Using a representative case of an 81-year-old woman with recurrent falls and chronic polypharmacy, this commentary synthesizes some current evidence on integrative geriatric nutrition. We propose a four-pillar, nutrition-centered framework for guiding deprescribing and restoring resilience: food-based therapeutics for mild, self-limiting conditions that can safely substitute or reduce medications; nutrient density and targeted micronutrients including choline, creatine, C15:0, and vitamin D; the food matrix and anti-inflammatory dietary patterns to optimize nutrient bioavailability, metabolic signaling, and mitigation of cellular senescence; and gut microbiome–centered strategies that leverage fiber diversity, fermented foods, and synbiotics to support muscle, mood, cognition, and immune function. This framework incorporates evidence ranging from well-established interventions to emerging areas such as C15:0; therefore, findings should be applied with consideration of differing evidence maturity. Applied to the index case, this framework informs structured deprescribing, micronutrient repletion, diet-pattern shifts, and microbiome rehabilitation as low-risk pathways to reverse functional decline. Integrative geriatric nutrition, operationalized through these four pillars, offers clinicians a practical, scalable model to reduce medication burden while enhancing function, resilience, and quality of life in aging populations.
Keywords
Integrative geriatric nutrition, polypharmacy, deprescribing, gut microbiome, successful aging, frailty
Introduction
In today’s healthcare landscape, older adults frequently
navigate a complex web of multiple medications, a.k.a.polypharmacy. This overreliance on pharmaceuticals amplifies risks such as adverse drug interactions, reduced
mobility, cognitive decline, and rising healthcare costs [1].
By contrast, nutrition offers a more foundational, integrative strategy—one that enhances resilience while curbing
unnecessary medication use.
Dr. Kogan, along with his co-authors Julie Wendt and
Colleen Considine, explore this paradigm in Integrative
Geriatric Nutrition: A Practitioner’s Guide to Dietary Approaches for Older Adults [2]. Building on this work and
incorporating emerging evidence, the present commentary
proposes a nutrition-centered framework for deprescribing in older adults. Specifically, we organize integrative
geriatric nutrition around four interconnected pillars that provide clinicians with a practical approach to reducing
medication burden, restoring function, resilience, and
quality of life.
Case study
An 81-year-old woman presents to a comprehensive
integrative medicine clinic with progressively worsening symptoms: fatigue, generalized muscle weakness,
and increasing forgetfulness. Though she has maintained
relatively good health until recently, the onset of a series
of falls has instilled a growing fear of walking. This functional decline is compounded by profound grief as her
husband of over 50 years passed away approximately one
year ago.
Her current medication regimen includes omeprazole for
chronic gastroesophageal reflux disease, hydrochlorothiazide for hypertension, atorvastatin for hypercholesterolemia, nightly low-dose lorazepam for sleep and anxiety,
and sertraline to address ongoing low mood. Laboratory
investigations reveal hyponatremia, hypomagnesemia,
and deficiencies in 25-hydroxyvitamin D and vitamin
B12, along with elevated homocysteine levels. Other parameters are within normal limits.
This case exemplifies a common and complex clinical
scenario in older adults—polypharmacy, compounded nutritional deficiencies, sarcopenia, increased fall risk, mood
disturbance, and functional decline—intersecting to foster
a trajectory toward frailty, deconditioning, and possibly
irreversible morbidity and mortality [1, 3].
The four-pillar framework
Food-based therapeutics for mild, self-limiting conditions
This first pillar focuses on accessible, food-based interventions that older adults can use to manage everyday
symptoms without escalating medication reliance. When
faced with mild, self-resolving symptoms—such as a
common cold or mild reflux—older adults can often rely
on the healing power of foods instead of immediately
turning to medications. For instance, in gastroesophageal
reflux disease (GERD), the current mainstay treatments
are PPIs and histamine-2 receptor antagonists.
Chronic omeprazole use in older adults carries risks such
as hypomagnesemia and increased fracture risk [4]. When
there is no ongoing indication for proton pump inhibitor
(PPI) therapy, a structured deprescribing approach is recommended [5]. Complementary integrative measures—
such as elevating the head of the bed by 6–8 inches,
avoiding reflux-triggering foods (spicy, acidic, or fatty
meals), limiting caffeine and late-night eating, and incorporating stress-reduction techniques like gentle yoga or
breathing exercises—can further support symptom control
[2, 5]. Herbal and supplement options, including aloe vera
juice (1/4 cup diluted, 1–3 times daily), deglycyrrhizinated licorice (DGL) chewables before meals, and ginger tea, may soothe the gastric lining and ease reflux discomfort [2]. Monitoring should include vigilance for acid
rebound—where short-term antacid use can be helpful—
as well as periodic checks of serum magnesium and B12
if deficiency is suspected, with GI symptoms reassessed
after 4–6 weeks [5].
Nutrient density & targeted micronutrients
Beyond symptom-focused applications, integrative geriatric nutrition also emphasizes targeted micronutrients that address underlying physiological vulnerabilities in aging.
Choline
Choline is a widely under-consumed essential nutrient
that plays a vital role in human health. Its biological functions are vast. It serves as a precursor to acetylcholine,
a fundamental neurotransmitter for cognition, muscle
activation, and autonomic nervous system regulation [6].
Despite its physiological importance, the mean choline intake for both men and women remains significantly below
the Adequate Intake set by the Institute of Medicine [6].
The Adequate Intake for adult men is 550 mg/day and 425
mg/day for adult women [6]. Choline deficiency is also
associated with several liver pathologies, such as nonalcoholic fatty liver disease (NAFLD), cirrhosis, and liver
carcinoma, reflecting choline’s essential role in maintaining liver health [6].
A study investigating the cognitive effects of choline
found that a 12-week supplementation of 500 mg per day
of citicoline (CDP-choline) improved episodic memory
and composite memory scores in participants aged 50–85
compared to placebo [7].
Creatine
Creatine is an emerging supplement with antioxidant properties that is being used to help prevent sarcopenia in older adults. A randomized control trial combining creatine with resistance training in older adults showed a significant increase in glutathione peroxidase compared to older adults who only did resistance training and compared to older adults in the control group [8]. Glutathione peroxidase is an enzyme involved in the antioxidation of reactive oxygen species (ROS). Increased levels of this enzyme with creatine supplementation provide hopeful mechanisms to not only combat age-related sarcopenia from increased ROS but also to prevent other diseases linked to oxidative stress, including cancer and cardiovascular disease [8].
C15:0
C15:0 is an odd-chain saturated fatty acid that is emerging
as a key nutrient involved in human longevity, cardiometabolic, immune, and liver health. C15:0 directly targets
multiple hallmarks of aging (mitochondrial dysfunction,
cellular senescence, impaired cellular signaling, inflammaging), playing a direct role in cellular pathways with
demonstrated anti-inflammatory, antifibrotic, and anticancer activities (activation: AMPK, PPAR-α/δ; inhibition:
mTOR, JAK-STAT, HDAC-6) [9].
Increasing dietary C15:0 effectively raises RBC memIncreasing dietary C15:0 effectively raises RBC mem
Vitamin D
Vitamin D plays an essential role in musculoskeletal integrity, neuromuscular function, immune regulation, and
mood stability—domains that are particularly vulnerable
in older adults [11-14]. Despite its importance, vitamin
D insufficiency is highly prevalent in aging populations,
driven by reduced dermal synthesis, limited outdoor exposure, renal conversion decline, and medication-induced
disruptions (including PPIs, glucocorticoids, and certain
anticonvulsants).
Active vitamin D (1,25-dihydroxyvitamin D) modulates
adaptive and innate immunity by enhancing antimicrobial
peptide production to improve mucosal defense against
infections, suppressing pro-inflammatory, and promoting
T-regulatory cell populations to maintain immune tolerance and reduce auto-inflammatory activity [13].
Vitamin D deficiency contributes to muscle weakness,
impaired balance, falls, fractures, and secondary hyperparathyroidism. Observational evidence also links low
vitamin D with cognitive decline and depressed mood, underscoring its broader neuromodulatory influence [11, 12,
14]. Importantly, serum concentrations adequate for bone
health may not fully support immune function. While ≥ 30
ng/mL is typically associated with musculoskeletal benefits, studies suggest that immunomodulatory effects likely
require concentrations closer to 40–60 ng/mL [13, 15].
Cholecalciferol (vitamin D3) remains the preferred form
for repletion, which should be taken daily with a meal
containing some form of fat to maximize absorption and
in tandem with magnesium repletion [15, 16].
The food matrix & dietary patterns
Dietary patterns & anti-inflammatory eating
Almost half of all deaths in the United States in 2022 were
due to heart disease and cancer (21.4%, 18.5%) [17]. Nutrition is essential to prevent disease-related morbidity and
mortality. Inflammatory processes drive chronic disease;
thus, dietary interventions should mitigate inflammation.
Foods rich in antioxidants and phytonutrients may help
reverse the oxidative damage associated with aging. In
addition to eating foods high in vitamins and minerals, it
is also important to consider how nutrient-dense foods are
broken down. Previously, the diet-health relationship was
viewed in terms of the number of nutrients in a food, but
more recent research shows that a more holistic approach
that considers the complexity of the food matrix is a better
measure of a healthy diet [18].
A food matrix is made up of the composition of nutrients,
bioactive constituents, other compounds, and how they
are packaged and compartmentalized. An example of how
form and structure play a role in the food matrix: healthy
participants were fed test meals with intact, disrupted, or
fiber-free apples. Postprandial plasma glucose increased to similar concentrations in all three treatments, but serum
insulin rose the least in the intact apples [18].
Nutrient density and senescence
Senescence is characterized by a gradual decline in physiological reserve and increased vulnerability to cellular
stressors, a process that can be exacerbated by nutrient
insufficiency and metabolic dysregulation. Nutrient density—the concentration of essential vitamins, minerals,
amino acids, and bioactive compounds per calorie—is
critically important, as energy intake often declines. Diets
low in processed foods and rich in nutrient‐dense whole
foods provide the micronutrients necessary for physiological and cellular maintenance.
For example, organ meats (liver, heart, and kidney) are
among the most nutrient-dense foods, delivering bioavailable B vitamins, heme iron, zinc, selenium, vitamin A,
choline, and other cofactors that support cellular resilience
in aging. By minimizing processing and prioritizing nutrient density, the diet may more effectively counteract cellular senescence. Literature increasingly points to the role
of nutritional inputs in modulating pathways of cellular
senescence and aging. For instance, a review outlines how
micronutrients, antioxidants, and bioactives may influence
senescence‐associated phenotypes, enhancing mitochondrial health, reducing reactive oxygen species, and modulating inflammatory signaling [19].
The gut microbiome as a central integrator
The gut microbiome is a dynamic, metabolically active ecosystem that plays a central role in health across the lifespan. In aging, disruptions to this ecosystem have been associated with sarcopenia, frailty, neurocognitive decline, mood disorders, metabolic dysfunction, and heightened inflammatory burden [20-22]. Polypharmacy further compounds these effects. Medications commonly prescribed to older adults have been shown to reduce microbial diversity and alter the abundance of key functional taxa [23].
Dysbiosis as a driver of inflammaging, frailty, and cognitive decline
The gut microbiome is a primary regulator of the microbiota-gut-brain-immune axis, influencing cognitive resilience, neuroinflammation, and emotional health through production of neuromodulatory short-chain fatty acids (SCFAs) and other metabolites [23]. SCFA depletion has been associated with diminished hippocampal function, worse executive function scores, and increased risk of mild cognitive impairment and Alzheimer’s disease [21, 23]. Dysbiosis also promotes increased intestinal permeability, enabling lipopolysaccharide (LPS) translocation into systemic circulation—a recognized mechanism of neuroinflammation and mood disturbance [22].
Nutrition, microbial diversity, and healthy longevity
Diet remains the strongest modifiable determinant of gut microbiome composition [23, 24]. For our 81-year-old patient, low dietary variety, low magnesium status, and chronic PPI use may jointly inhibit microbial resilience and nutrient bioavailability. Foundational food-as-medi-cine strategies include high-diversity dietary fiber, prebiotic fibers, fermented foods, and Polyphenol-rich foods. These food-based strategies align closely with deprescribing goals by reducing reflux symptoms, improving bowel regularity, and enhancing mood and cognition.
Precision supplementation to restore microbial function
Targeted supplementation may be warranted in older
adults experiencing dysbiosis or malabsorption, especially
when medication regimens can further impair nutrient uptake. Clinical options include:
• Multispecies probiotics: prioritizing strains with geriatric evidence shown to reduce constipation, improve mood,
and support immune responses to vaccines [22, 25].
• Postbiotics and microbial metabolites: including SCFAenhancing substrates, gaining attention for restoring epithelial barrier integrity and reducing inflammaging [25].
• Synbiotics: combinations of prebiotic and probiotic
components (and their metabolites) designed to confer
microbiome-mediated health benefits, with growing interest in their potential role in supporting resilience in older
adults [25].
Emerging microbiome-supportive nutrients discussed
elsewhere in this paper (C15:0, creatine, choline) may
exert synergistic benefits through mitochondrial health,
methylation support, and inflammatory modulation.
Clinical integration: a gut-centered approach to deprescribing
An integrative model places gut health at the center of deprescribing strategies. As PPIs are tapered appropriately, nutritional support helps prevent symptom rebound while rebuilding microbial and mucosal resilience. Regular monitoring for constipation, unintentional weight loss, and mood changes ensures early detection of microbiomelinked frailty trajectories. Gut microbiome optimization in older adults is not merely a digestive intervention. It is foundational to preserving muscle, memory, mood, mobility, and meaning—the five essential domains of successful aging.
Conclusions
In the case of this 81-year-old woman, low 25-hydroxyvitamin D status likely contributes to her muscle weakness,
balance impairment, falls, depressed mood, and increased
infection vulnerability. Chronic PPI therapy further reduces vitamin D and magnesium absorption, worsening neuromuscular function and bone health. Correcting her deficiency to 30+ ng/mL for musculoskeletal benefits (ideally
40–60 ng/mL to support immune modulation) would be a
high-yield intervention that strengthens mobility, restores
confidence in ambulation, and may reduce healthcare
encounters associated with fall-related injuries and preventable infections. Ensuring adequate magnesium intake
and repletion concurrently would support both vitamin D
metabolism and improved physical performance, accelerating the reversal of her functional decline. Food-based
therapeutics, such as aloe vera, DGL licorice, ginger tea, and honey-based remedies, offer safe alternatives to medications she is currently over-relying on, particularly PPIs
and sedating agents that exacerbate fatigue, micronutrient
depletion, and fall risk. Targeted micronutrient repletion
(choline for elevated homocysteine and cognitive symptoms, creatine to counter sarcopenia and improve muscle
strength, C15:0 for cellular resilience) provides low-risk
options for restoring physiological reserve. Transitioning
from processed, low-fiber foods toward nutrient-dense,
matrix-intact whole foods can improve satiety, stabilize
glucose responses, and enhance micronutrient absorption–
essential in older adults with reduced appetite and functional limitations. Finally, her chronic PPI use, benzodiazepine exposure, low dietary diversity, and micronutrient
deficiencies suggest significant gut dysbiosis, which may
perpetuate systemic inflammation, mood disturbances,
and frailty. Introducing fermented foods, prebiotic fibers,
polyphenol-rich plants, and, when appropriate, geriatricfocused probiotics/synbiotics can help restore microbial
diversity and SCFA production. Applying all four pillars
described provides a comprehensive, low-risk pathway to
reduce polypharmacy, improve functional capacity, and
rebuild the resilience necessary for successful aging. Nutrition, when used as medicine, not only adds years to life
but life to years.
By integrating food-based therapeutics for mild conditions, targeted micronutrient repletion, dietary patterns
that honor the food matrix, and microbiome-centered
strategies, providers can shift care from reactive disease
management to proactive restoration of resilience. Applied thoughtfully, these tools not only reduce medication
burden but also reestablish the physiological, cognitive,
and emotional foundations that allow older adults to thrive
rather than merely survive.
Declarations
Authors’ contributions
Mikhail Kogan led the conceptualization of the manuscript, provided the overarching framework for content inclusion, and critically reviewed and edited all sections. Mehrshad Fahim Devin performed manuscript refinement, developed and articulated the four-pillar framework, and coordinated drafting, revisions, and submission among co-authors. Leigh A. Frame contributed subject-matter expertise and authored major sections on vitamin D and the gut microbiome, in addition to substantially editing and refining the integrative nutrition framework. Lindsey Gordon, Zeynep Celikkol, and Ruhsen Ozcaglayan each contributed to writing specific sections, literature review, and critical revision of the manuscript for important intellectual content. All authors reviewed and approved the final version of the manuscript.
Financial support and sponsorship
None.
Conflicts of interests
All authors declared that there are no conflicts of interest.
Ethical approval and consent to participate
Not applicable.
Copyright
Authors retain copyright of their works through a Creative Commons Attribution 4.0 International License that clearly states how readers can copy, distribute, and use their attributed research, free of charge.
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