Paradigms and perspectives
Fasting, dietary restriction, and
immunosenescence
Valter D. Longo, PhD,a,b and Salvatore Cortellino, PhDb
Key words: Hematopoietic stem cell, exhausted T cell, inflamma-
tion, metabolism, dietary intervention
During aging, immune surveillance and the response to
vaccination are reduced, leading to increased susceptibility to
viral and bacterial infection, and consequently to an increased
incidence of cancer and age-related disease. This phenomenon,
called immunosenescence, affects both the innate and adaptive
arms of the immune system.
The adaptive immune system is the most affected by aging,
with the reduction in naive T cells depending on different factors:
(1) the thymus involution; (2) hematopoietic stem cell
(HSC)-skewed differentiation toward a myeloid lineage; (3)
expansion of late differentiated memory T cells and exhausted
T-cell population (programmed cell death protein 1 expression);
and (4) reduced accessibility and production of IL-7, essential for
survival and metabolic homeostasis of naive T cells, due to
architectural change and dysfunction in secondary lymphoid
organs.1
In older people (>_65 years), the accumulation of senescent
cells and the acquisition of senescence-associated secretory
phenotype, macrophage activation, oxidative stress, adiposity,
and gut dysbiosis promote the secretion of cytokines and create a
chronic inflammation that contributes to both immunosenescence
and persistent immune activation.
HSCs and T cells in the elderly exhibit global hypomethylation
of DNA, histone loss, and high heterogeneity in histone
acetylation and histone and DNA methylation, suggesting that
epigenetic changes could be responsible for part of the
age-dependent immune dysfunction. Such remodeling of
epigenetic markers could favor the repression of differentiation
genes expressed by immune cells as well as the activation of
autoimmune genes, favoring the differentiation of the HSCs
toward a myeloid line and of the naive cells toward effector
memory T cells.
From athe Longevity Institute, Davis School of Gerontology, University of Southern
California, Los Angeles; and bIFOM, FIRC Institute of Molecular Oncology, Milan.
This work was supported in part by the Associazione Italiana per la Ricerca sul Cancro
(grant no. IG#17605) and in part by Cariplo (grant no. 2018-054) and National
Institutes of Health (grant nos. AG034906 and AG20642).
Disclosure of potential conflict of interest: V. D. Longo has equity interest in L-Nutra, a
company developing and marketing medical food. S. Cortellino has no relevant
conflicts of interest.
Received for publication February 28, 2020; revised July 9, 2020; accepted for
publication July 15, 2020.
Available online August 24, 2020.
Corresponding author: Valter D. Longo, PhD, Longevity Institute, School of
Gerontology, Department of Biological Sciences, University of Southern California,
3715 McClintock Ave, Los Angeles, CA 90089. E-mail: vlongo@usc.edu; valter.
longo@ifom.eu.
J Allergy Clin Immunol 2020;146:1002-4.
0091-6749/$36.00
! 2020 American Academy of Allergy, Asthma & Immunology
https://doi.org/10.1016/j.jaci.2020.07.035
1002
Los Angeles, Calif, and Milan, Italy
The availability of different metabolites (methionine, iron,
ketoglutarate, nicotinamide adenine dinucleotide (NAD)1,
acetyl-CoA, s-adenosylmethionine) is one of the major factors
controlling the activity of different epigenetic enzymes and
therefore epigenetic changes. Notably, 1-carbon metabolism,
which contributes to epigenetic maintenance and redox defense
through the biosynthesis of nucleotides, lipids, nicotinamide
adenine dinucleotide phosphate (NADPH), and glutathione, is
altered in aged T cells and might impact epigenetic remodeling
and immunosenescence (Fig 1).
DIETARY INTERVENTIONS AND
IMMUNOSENESCENCE
A diet low in animal proteins (in particular red and cured meat)
and rich in fruits, vegetables, whole grains, legumes, and olive oil
has been implicated in the delay of immunosenescence, possibly
by reducing the inflammatory state oxidative stress and
preserving intestinal microbial eubiosis.2 Certain probiotics can
also reduce the inflammatory state by inhibiting the release of
TNF-a, IL-1b, and IL-6 and increasing the production of
anti-inflammatory cytokine IL-10.3 However, chronic dietary
changes are difficult to implement in the general population and
may have limited efficacy. New dietary interventions such as
calorie restriction, intermittent fasting, and fasting-mimicking
diet (FMD) are emerging as interventions potentially effective
in reducing inflammation and improving the immune response
in mice and possibly humans.4,5 However, these interventions
can have both positive and negative effects on immunity based
not only on their length and frequency but also on the composition
of the diet being tested.
In human subjects, reducing nutrient and caloric intake
modulates several signaling pathways promoting mammalian
target of rapamycin (mTOR), nuclear factor kappa B, and
mitogen-activated protein kinase pathway inhibition and AMP-
activated protein kinase (AMPK) activation in lymphocytes.
Inactivation of mTOR induces the metabolic transition from
glycolysis to oxidative phosphorylation and counteracts the
chronic activation of glycolysis in aged T cells. Nutrient scarcity
and energy deficiency also activate AMPK, which promotes
mitochondrial regeneration through the expression of nuclear
respiratory factor (NRF)-1 and peroxisome proliferator-activated
receptor g transcription factors. Caloric restriction and fasting
exert protective effects against oxidative stress by activating
antistress response pathways, in part via NRF-2 and forkhead box
O1 induction. Furthermore, energy deficiency increases NAD1/
NADH and results in Sirtuin 1 activation, epigenetic remodeling,
and a metabolic shift toward fatty acid oxidation and oxidative
phosphorylation.6
Such epigenetic, genetic, and metabolic changes induced by
calorie restriction are associated with reduced expression of
IL-1b, IL-6, and TNF-a, and the removal of dysfunctional
J ALLERGY CLIN IMMUNOL LONGO AND CORTELLINO 1003
VOLUME 146, NUMBER 5

FIG 1. Aging reshapes the immune system, both adaptive and innate, and generates low chronic
inflammation. Thymus involution, bone marrow dysfunction, and tissue senescence (SASP) lead to naive
T- and B-cell reduction, aberrant HSC differentiation to lymphoid lineage, and an increase in the memory T
cell, neutrophils, monocytes, and natural killer cells and enhance proinflammatory cytokines release, which
elicit the lymphocytes exhaustion, affecting the immune response against external agents and pathogens in
the elderly. diff., Differentiation; Lymph., lymphocyte; NK, Natural killer; SASP, senescence-associated
secreted phenotype.

immune cells.4 However, chronic calorie restriction may also
impair some immune functions possibly by inhibiting mTOR,
although this side effect of calorie restriction may be limited by
alternating calorie restriction cycles with a standard diet.7
In fact, either fasting (only water for 48 hours) or FMDs (low
protein and sugar and high-fat but low-calorie diet) lasting 2 to 5
days and alternated with longer periods on a standard diet can be
effective in reversing markers of immunosenescence in mice.
Multiple cycles of water-only fasting alternated with normal
feeding cause a temporary reduction in circulating white blood
cells and activation of HSCs, leading to an increase in stem and
progenitor cells and to an improved lymphoid myeloid ratio
and a reversal of low white blood cell count in response
to chemotherapy. These effects are mediated in part by
downregulation of insulin like growth factor 1, protein kinase A
signaling (Fig 2).4 Studies in mice indicate that the refeeding
period may be as important as the fasting period in promoting re-
generating effects in the hematopoietic system. In another study,
bimonthly cycles of an FMD started at middle age promote im-
provements in the immune cell profile in older mice, as well as
a major reduction and delay in tumor incidence and extension
of mean lifespan.5 Other forms of fasting have recently been
shown to not only reduce the load of circulating monocytes in
the blood but also change their metabolism. For example, in
mice, intermittent fasting improves chronic inflammatory and
autoimmune disorders without compromising tissue regeneration
nor immunity against pathogen invasion.8
In several studies focused on mouse models of autoimmune
diseases including multiple sclerosis and inflammatory bowel
disease, cycles of fasting/FMDs and normal feeding reduce
inflammation and promote an increase in stem cell number and
regenerative function, leading to an amelioration or reversal in
pathology.9,10 These studies indicate that the combination of
fasting and refeeding stages is essential to remove autoimmune
cells and replace them with functional ones, in part by relying
on the more functional stem cells. In a pilot randomized study
of patients with multiple sclerosis, a single weeklong FMD
caused a temporary decline in the white blood cell count and
improvements in quality of life, whereas in a randomized study
of 100 subjects, 3 FMD cycles once a month for 5 days caused a
reduction in C-reactive protein and in the associated
lymphocytosis.9,10
In summary, different forms of dietary restriction are emerging
as promising modulators of the immune system. Chronic calorie
restriction interventions may cause reduced numbers of immune
cells and can impair some immune responses, whereas a short
period of fasting or calorie restriction followed by longer periods
of normal feeding are emerging as interventions effective in
1004 LONGO AND CORTELLINO J ALLERGY CLIN IMMUNOL
NOVEMBER 2020

FIG 2. Fasting, immunosenescence, inflammation, and regeneration. In the elderly, accumulation of genetic
and epigenetic mutations promotes HSCs skewing toward the myeloid lineage population. The myeloid
population increase contributes to the establishment of inflammation caused by the release of
proinflammatory cytokines by senescent tissues and by dysfunctional immune cells. In mice, cycles of
fasting and refeeding increase hematopoietic cell number and activity in the bone marrow and determine a
redistribution of the lymphoid and myeloid population from peripheral blood to the bone marrow. Fasting/
refeeding cycles promote HSC rejuvenation, probably by removing damaged organelles, molecules, and
defective cells by autophagy or apoptosis and by optimizing memory T-cell function and improving the
immune effective responses, and induce a metabolic change in the monocytes, which elicits reduced
proinflammatory activity.8 The effect of fasting on senescent tissues is not clear; however, it is plausible that
it reduces inflammation by removing or regenerating senescent cells. Refeeding represents a key phase of
the regenerative process by promoting the proliferation and self-renewal of HSCs, which, differentiating in
lymphoid population, improve the lymphoid/myeloid ratio. SASP, Senescence-associated secreted
phenotype.

reducing inflammation and/or promoting stem cell–based
regeneration in mice and possibly humans. In mice, these
improvements of the immune cell profile are accompanied by
reduced cancer incidence and a lowering of symptoms associated
with autoimmunities. Investigations of the role of different
dietary interventions in altering the profile and function of
immune cells in humans are ongoing and are expected to
eventually identify nutritional strategies able to improve
immunity while minimizing side effects.
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