Italy is one of the longest-living countries in the world, but that statement risks being incomplete without a more clinical question alongside it: how many of the added years are lived in good health, with functional autonomy and without significant disability? The issue is not only demographic but health-related. Increases in survival, when accompanied by multimorbidity, frailty, and dependence on care, can turn longevity into a sustainability challenge for the National Health Service (SSN).
A recent position paper published in Aging proposes tackling this scenario through a gradual integration of longevity medicine into Italy’s National Health Service (SSN). The starting point is clear: in Italy adults aged 65 and older account for 24.1% of the population—the highest share in the European Union—and the median age is projected to reach 51 by 2050. At the same time, life expectancy at birth remains high, but the years lived in good health are markedly lower. In 2023, Italian women had a life expectancy of 85.4 years and 69.6 years lived in health; men, 81.4 and 68.5 years respectively. (1)
That gap between life expectancy and the functional quality of life is at the heart of the problem. Longevity medicine, if interpreted correctly, is not a new marketing label nor a separate specialty from clinical medicine. It is rather a translational framework that integrates geroscience, prevention, risk stratification, biomarkers, digital technologies, and lifestyle interventions with a measurable goal: to extend the portion of life lived with good physical and cognitive function.
From Lifespan to Healthspan: why change the metric
Life expectancy, or lifespan, measures how many years a population lives on average. It is a powerful indicator, but it tells us nothing about the quality of those years. Therefore, in public health, the concept of healthspan, i.e., the portion of life lived in relatively good health, with preserved physical and cognitive function and without major limitations in daily activities, becomes increasingly important.
There are several indicators to estimate this concept. The Healthy Life Years (HLY), used by Eurostat, estimate the years expected without long-lasting limitations in daily activities due to health problems. A related indicator is Healthy Life Expectancy (HALE), used by the World Health Organization (WHO), which weights the years lived according to the quality of health. (2,3)
These indicators should not be read as perfect measures for a single patient, but as system signals. If a population lives long but spends many years with disability, multimorbidity, and reduced autonomy, the health system cannot simply treat diseases when they become manifest. It must anticipate risk trajectories.
The Italian case: high longevity, rising frailty
The position paper highlights several determinants of the gap in Italy between lifespan and healthspan. The first is socio-economic and territorial: life expectancy varies between the North and the South, reflecting inequalities in education, income, access to prevention, and quality of care. The second is behavioral: high adherence to the Mediterranean diet is not as widespread as often assumed, and more than 40% of Italians over 65 are sedentary, with higher rates above 75 years. (1,4,5)
Other determinants are environmental and social. Exposure to fine particulate matter with a diameter of 2.5 micrometers or less (PM2.5) remains a public health issue, especially in certain areas of the country. Social isolation and loneliness are linked to higher mortality and worse health trajectories, becoming particularly relevant in a population where many older adults live alone. (6)
The pharmacologic burden is another clinical knot. Polypharmacy is common among older adults, rises with age, and is associated with frailty, adverse events, and mortality. (7) In a healthy longevity framework, regular medication review, deprescribing when appropriate, and attention to sex and gender differences in prescribing safety are not geriatrics niceties: they are preventive interventions.
The limits of a reactive healthcare model
The Italian National Health Service (SSN) is universal, but largely organized around treating disease that has already been diagnosed. This model has been extraordinarily effective for many acute conditions and for the specialist management of chronic diseases, but shows growing limits in an aging, multimorbid, and territory-differentiated society.
The paper highlights several critical points: regional fragmentation, hospital-centered organization, incomplete interoperability of health data, home care that is uneven and often of low intensity, and financing still predominantly reactive. Reimbursement mechanisms based on diagnosis-related groups (DRGs), i.e., homogeneous groupings of diagnoses, tend to value procedures and admissions more than prevention, monitoring, and maintenance of function. (1,8)
A longevity medicine integrated into the SSN should operate under a different logic, closer to the P4 model: predictive, preventive, personalized, and participatory. (9) Predictive, because it uses clinical and functional data to identify risk trajectories. Preventive, because it intervenes before the irreversible accumulation of deficits. Personalized, because it tailors intensity and type of intervention to the patient’s phenotype. Participatory, because it requires adherence, health literacy, and shared responsibility.
Longevity medicine: what it is and what it is not
The main risk when talking about longevity is confusing the scientific field with the anti-aging market. Longevity medicine should not promise rejuvenation, nor convert exploratory biomarkers into clinical diagnoses. Its value lies elsewhere: bringing to medical practice a heightened focus on function, biological resilience, and the prevention of decline trajectories.
Geroscience studies the biological processes that contribute to aging and age-related diseases: genomic instability, cellular senescence, epigenetic alterations, mitochondrial dysfunction, disruption of nutrient-sensing pathways, chronic inflammation, and loss of proteostasis. These hallmarks of aging provide a useful conceptual map, but they are not yet validated diagnostic tools to guide therapies in an individual patient. (10)
The same goes for biological clocks and measures of biological age. Clocks based on DNA methylation, proteomics, metabolomics, or other multi-omics levels are promising research tools. Some predict mortality, multimorbidity, or functional decline better than chronological age, but their clinical utility remains to be demonstrated. (11,12) For now, they should not guide reimbursement, therapeutic decisions, or deterministic communications to patients.
From biology to clinical practice: function as the endpoint
The big challenge is turning biological plausibility into clinical benefit. An intervention that modifies a surrogate biomarker is not automatically helpful unless it improves meaningful outcomes: physical function, cognitive function, independence, hospitalizations, incident multimorbidity, quality of life, and mortality.
This principle is central. Longevity medicine must be evaluated with the same rigor as traditional medicine. It is not enough to show that a treatment “lowers biological age” according to a commercial test. One must demonstrate reductions in events, disability, or functional decline, with an acceptable risk-benefit profile and sustainable costs.
Interventions with the strongest evidence remain, today as well, the least “futuristic”: a Mediterranean-style diet, regular physical activity, strength training, adequate sleep, management of cardiometabolic risk factors, smoking reduction, stress management, social health, and prevention of inappropriate polypharmacy. These interventions modulate aging-related pathways, but more importantly they yield robust clinical and public health outcomes. (1,13)
Geroprotective drugs, metformin framed as anti-aging, senolytics, and experimental strategies such as heterochronic plasma exchange remain exploratory fields. They can spur important research but should not be advanced into routine practice before solid data on safety, clinical endpoints, and target populations are available. (14,15)
The Italian challenge is not just living longer: it is living more years in good health. The gap between life expectancy and years lived without functional limitations demands rethinking prevention, geriatrics, community-based medicine, and digital innovation within a single health framework oriented toward healthspan.
Longevity medicine can offer this framework, but it must avoid two opposite errors: on one side reducing everything to anti-aging marketing, and on the other side an a priori rejection of innovative tools. The right path lies in-between and in a rigorous approach: using now what has strong evidence, such as diet, exercise, sleep, cardiometabolic prevention, pharmacologic review, social support, and gradually evaluating what is promising but not yet mature, like multi-omics biomarkers, biological clocks, predictive AI, and geroprotectors.
In public health, longevity cannot be a luxury of the individual. It must become the system’s ability to preserve function, autonomy, and resilience across the life course. The SSN, by virtue of its universal nature, could be the most suitable place to test this transition: not toward a medicine that promises to “stop aging,” but toward one that measures and protects what truly matters to patients, namely the ability to live well for longer.
What to measure in a healthspan-oriented assessment
Physical function
- Gait speed.
- Grip strength.
- Timed Up and Go (TUG) test, i.e., time to stand up, walk, return, and sit down.
- Short Physical Performance Battery (SPPB), a brief battery of physical performance tests.
- Fall history and fear of falling.
Metabolic function
- Blood pressure.
- Lipid profile.
- Hemoglobin A1c (HbA1c).
- Waist circumference.
- Fatty liver disease/MAFLD when indicated.
Cognitive and psychological function
- Cognitive screening in at-risk patients.
- Sleep quality.
- Depressive and anxious symptoms.
- Social isolation and social support.
Care burden and pharmacologic load
- Number of medications and inappropriate prescribing.
- Adverse events, falls, hypotension, sedation.
- Therapy adherence.
- Unplanned visits, emergency department visits, hospitalizations.
Practical note
The single biomarker is not enough. The healthspan trajectory is measured by integrating clinical, functional, behavioral, and social data.
Digital health and AI: real promise, risk of inequality
Digital technologies can support a smoother, more community-based longevity medicine: wearables, home sensors, telemonitoring, platforms for multimorbidity, digital reminders, and self-management tools. Their potential lies in monitoring early variations in sleep, physical activity, heart rate, falls, adherence, and independence.
However, the paper highlights a concrete limit: the digital divide. Among older adults, particularly in remote areas, low digital literacy and infrastructural barriers can reduce access—precisely for those who would most benefit from continuous care. Technology introduced without accompanying support can widen disparities rather than reduce them.
AI also requires caution. Predictive models based on clinical data, sensors, and biomarkers could help stratify risk, but they must be explainable, tested for bias, validated in real-world contexts, and assessed on clinical outcomes. International guidelines on trustworthy AI in health emphasize transparency, safety, equity, privacy, and documentation. (16)
In a public health system, the question isn’t whether a technology is innovative, but whether it improves decisions, outcomes, and access. An algorithm that predicts frailty but does not alter the care pathway is a technical exercise. A system that detects early functional decline and triggers physical therapy, medication review, and home support can become preventive medicine.
The five strategic priorities for the SSN
The position paper proposes five investment priorities. The first is to develop and validate clinically useful biomarkers of biological age, including sex, ethnicity, and socioeconomic context. The second is to create interoperable digital platforms capable of integrating data from electronic health records, wearables, and community-based care.
The third concerns Bayesian adaptive multimodal trial designs. Bayesian designs allow updating probabilities and allocation of treatments as data emerge, potentially making the evaluation of complex interventions—nutrition, physical activity, medications, cognitive support, and digital technologies—more efficient. (17)
The fourth priority is to develop risk-stratification tools based on explainable AI with privacy-preserving approaches. The fifth concerns literacy and training: longevity curricula for physicians and health professionals, but also public education for citizens. Without skills, longevity medicine risks remaining an elitist or commercial sector.
The most important note, however, is the caveat: these priorities are not validated solutions but a progressive assessment agenda. Their relevance will depend on the ability to produce measurable benefits on outcomes important to patients, with economic sustainability and equity of access.
The role of integrative medicine
Integrative medicine can contribute significantly to this transition, but only if it remains rigorous. Its value lies not in adding unvalidated supplements or tests, but in uniting dimensions that are often kept separate: metabolism, nutrition, movement, sleep, mental health, medications, environment, social relationships, and function.
In a middle-aged patient with visceral obesity, insomnia, inactivity, and a family history of cardiovascular disease, a healthspan-oriented approach does not merely aim to “prevent a heart attack.” It measures metabolic risk, strength, sleep quality, habits, stress, work context, and adherence. It then builds a progressive plan: a personalized Mediterranean diet, combined aerobic and strength training, reduced alcohol, sleep optimization, blood pressure and metabolic monitoring, and pharmacologic therapy when indicated.
In an older adult with polypharmacy, early frailty, and social isolation, the intervention cannot be solely biochemical. It requires functional assessment, medication review, fall prevention, supervised exercise, nutritional support, social networks, and integration with primary care. This is the point: clinical longevity is not about molecules alone, but about sustaining autonomy.
Stepwise protocol for healthspan-oriented care
Step 1 – Stratify
- Chronological age, but also physical, cognitive, and social function.
- Multimorbidity, medications, frailty, falls, isolation.
- Cardiometabolic risk and lifestyle.
Step 2 – Identify modifiable drivers
- Physical inactivity.
- Poor-quality diet or excessive energy intake.
- Insufficient sleep or obstructive sleep apnea.
- Smoking, alcohol, chronic stress.
- Polypharmacy and inappropriate prescribing.
- Reduced social support.
Step 3 – Intervene with priorities
- Combined physical activity: aerobic, strength, balance.
- Patient-tailored Mediterranean diet.
- Prevention and treatment of sarcopenia.
- Management of cardiometabolic factors.
- Periodic pharmacologic review.
- Interventions on sleep and mental health.
Step 4 – Monitor real-world outcomes
- Strength, gait, falls, independence.
- Blood pressure, HbA1c, lipids, waist circumference.
- Sleep quality, mood, quality of life.
- Unplanned health service visits and hospitalizations.
Step 5 – Avoid drift
- Do not use biological clocks as definitive clinical diagnoses.
- Do not equate surrogate biomarkers with patient benefit.
- Do not introduce technologies that widen inequities.
- Do not propose geroprotectors without adequate clinical evidence.
Study
Marino N, Fiore M, Stingi A, Cipriano A, Chadha A, Ricordi C, Della-Morte D, di Fagagna F, Demaria M, Quarta M, Sebastiano V, Ferrucci L, Tasciotti E. Towards integration of healthspan strategies into the Italian National Health Service. Aging (Albany NY). 2026; 18:854-860.
Abbonati a Karla Miller
