Aging Clinical and Experimental Research (2024) 36:32

https://doi.org/10.1007/s40520-023-02684-5

REVIEW

The link between spirituality and longevity

Ligia J. Dominguez1 · Nicola Veronese2 · Mario Barbagallo2

Received: 7 October 2023 / Accepted: 21 November 2023

© The Author(s) 2024

Abstract
We are facing an inverted demographic pyramid with continuously growing aged populations around the world. However, the
advances that prolong physical life not always contemplate its psychological and social dimensions. Longevity is a complex
outcome influenced by a wide range of factors, including genetics, lifestyle choices, access to healthcare, socio-economic
conditions, and other environmental factors. These factors have been generally considered in the compelling research that
seeks the determinants of longevity, particularly those concerning personal lifestyle choices, socioeconomic conditions, and
molecular mechanisms proposed to mediate these effects. Nonetheless, fundamental aspects that can affect health and well-
being, such as spirituality and religiosity, have been somehow left aside despite numerous epidemiological studies showing
that higher levels of spirituality/religiosity are associated with lower risk of mortality, even after adjusting for relevant con-
founders. Because spirituality/religiosity are dimensions of great value for patients, overlooking them can leave them with
feelings of neglect and lack of connection with the health system and with the clinicians in charge of their care. Integrating
spirituality and religiosity assessment and intervention programs into clinical care can help each person obtain better and
complete well-being and also allowing clinicians to achieve the highest standards of health with holistic, person-centered
care. The present narrative review aims to explore the available evidence of a relationship between spirituality/religiosity
and longevity and discusses the possible mechanisms that can help explain such relationship.

Keywords Spirituality · Longevity · Aging · Religiosity · Religion · Mortality · Well-being

Introduction physical life not always contemplate its psychological and

social dimensions.
Old age is a season of life that has always questioned Spirituality and longevity are concepts that have been
humans, entailing a complex phenomenon, made up of vari- explored in numerous studies and discussions in relation to
ous elements and dimensions: biological, genetic, physical, aging. While there is no definitive scientific evidence linking
psychological, and also cultural, social, and environmental. directly spirituality and longevity [3], some research sug-
Because all of these elements find a different combination gests that spiritual practices and beliefs may have indirect
in each of us, getting old is a very personal fact, which does effects on physical and mental health, which could poten-
not allow easy generalizations. Times and ways of getting tially contribute to longer life spans. For example, there are
old have changed today: we are facing an inverted demo- meta-analyses indicating that some factors connected to
graphic pyramid with continuously growing aged popula- spirituality such as purpose in life and life satisfaction are
tions around the world [1]. Improved living conditions and associated with 17% and 12% reduced mortality risk, respec-
modern medicine have contributed to the global increase tively [4, 5]. Contrariwise, social isolation and loneliness
in life expectancy [2]. However, the advances that prolong have been associated with 29% and 26% increased mortality
risk, respectively [6]. Religious service attendance was also
associated with a lower risk of death from despair (related
* Mario Barbagallo to drugs, alcohol, and suicide) among health care profes-
[email protected]
sionals [7]. Attending a religious service more than once
1
School of Medicine, Kore University of Enna, 94100 Enna, per week was associated with 33% lower all-cause mortal-
Italy ity in women compared with those who had never attended
2
Geriatric Unit, Department of Medicine, University religious services [8].
of Palermo, 90127 Palermo, Italy

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Longevity, as well as aging, is a complex outcome influ- contribute to the heterogeneity of the approaches and results
enced by a wide range of factors, including genetics, lifestyle of studies dedicated to this area [3]. While the term S/R is
choices, access to healthcare, socio-economic conditions, useful when discussing generalities regarding the associa-
and other environmental factors [1]. In general, these fac- tions with health outcomes, S/R encompasses various dis-
tors have been taken into account in the compelling research similar dimensions. Moreover, each of these dimensions may
that seeks the determinants of longevity, particularly those exert specific and unique effects on health. Hence, under-
concerning personal lifestyle choices [9] and socioeconomic standing the results of specific studies depends to a great
conditions [10]; various molecular mechanisms proposed to extent on the particular dimension(s) of S/R studied.
mediate these effects have been studied [11, 12]. However, One of the authors with large experience in research on
fundamental aspects that can affect health and well-being, this topic is Harold G. Koenig, who has defined religion and
such as spirituality and religiosity, have been somehow left spirituality as follows:
aside. This may be due, at least in part, to the methodologi- “[Religion] Involves beliefs, practices, and rituals related
cal difficulties of performing this type of research related to the transcendent, where the transcendent is God, Allah,
to the heterogeneity of definitions and evaluation tools of HaShem, or a Higher Power in Western religious traditions,
these dimensions and the even more difficult transferring of or to Brahman, manifestations of Brahman, Buddha, Dao,
the results into practical applications [3]. In addition, while or ultimate truth/reality in Eastern traditions. This often
some evidence suggests that certain spiritual practices and involves the mystical or supernatural. Religions usually have
beliefs may indirectly contribute to better health and well- specific beliefs about life after death and rules about con-
being, it is essential to acknowledge that causation is chal- duct within a social group. Religion is a multidimensional
lenging to establish in this context. It is also crucial to keep construct that includes beliefs, behaviors, rituals, and cer-
in mind that the relationship between spirituality and longev- emonies that may be held or practiced in private or public
ity is complex and multifaceted, and individual experiences settings, but are in some way derived from established tradi-
may largely and significantly vary. tions that developed over time within a community. Religion
The present narrative review aims to explore the available is also an organized system of beliefs, practices, and sym-
evidence of a relationship between spirituality/religiosity bols designed (a) to facilitate closeness to the transcendent,
and longevity and discusses the possible mechanisms that and (b) to foster an understanding of one’s relationship and
can help explain such relationship. responsibility to others in living together in a community”
[14].
“Spirituality is distinguished from all other things—
Spirituality and Religiosity: similarities humanism, values, morals, and mental health—by its con-
and differences nection to that which is sacred, the transcendent. The trans-
cendent is that which is outside of the self, and yet also
What do we mean by the spiritual dimension of life? The within the self—and in Western traditions is called God,
term “spiritual” risks being understood in a partial or pre- Allah, HaShem, or a Higher Power, and in Eastern traditions
judicial way. The pre-understanding that accompanies this may be called Brahman, manifestations of Brahman, Bud-
word may lead to relegate it to religious, confessional con- dha, Dao, or ultimate truth/reality. Spirituality is intimately
texts: it is thought that the spiritual dimension is specific to connected to the supernatural, the mystical, and to organized
those who have an explicit faith and live a religious practice. religion, although also extends beyond organized religion
Conversely, to bring this dimension to its broader meaning (and begins before it). Spirituality includes both a search
and recognize that spirituality belongs to every human being for the transcendent and the discovery of the transcendent
we may say that spirituality is a dimension of life and as and so involves traveling along the path that leads from non-
such it must be recognized when considering human health. consideration to questioning to either staunch nonbelief or
There is much controversy and disagreement regard- belief, and if belief, then ultimately to devotion and finally,
ing definitions of spirituality and religiosity. While some surrender. Thus, our definition of spirituality is very similar
research refers to the concepts of spirituality/religiosity to religion and there is clearly overlap” [14].
(S/R) interchangeably there are differences between the two Thus, according to Koenig [15], on one hand, religion
concepts. Much of the confusion stems from the fact that is a system of beliefs and practices observed by a group
spirituality and religiosity are often, but not always, related, of people that are based on rituals or a set of Scriptures
leading to considering diverse concepts such as God, mean- and teachings “that recognize, worship, commune with the
ing, mystical, the sacred, transcendence, and faith overlap- Sacred, the Divine, God”. On the other hand, spirituality
ping [13]. Many researchers adopt the option of combining is a quality of the nature of the spirit, a factor pertinent to
these concepts in S/R (or R/S) to refer to these intertwined every human being. For Puchalski [16], one of the pioneers
constructs, but the divergence in the use of these notions of the movement to integrate spirituality into health care,
Aging Clinical and Experimental Research (2024) 36:32 Page 3 of 11 32

spirituality is each person's inherent search for the ultimate Table 1  The 7 × 7 dimensions of spiritual assessment developed by
meaning and purpose of life. This meaning can be found George Fitchett et al. [20]
in religion, but can often be broader than that, including Holistic assessment Spiritual assessment components
a relationship with a divine figure or with transcendence,
Medical Belief and Meaning
relationships with others, as well as the spirituality found in
Psychological Vocation and obligations
nature, art and rational thinking. Pargament et al. [17] define
Family systems Experience and emotions
spirituality as the search for meaning, the belief in a higher
Psychosocial Courage and growth
power, and finding happiness and joy in everyday life.
Ethnic, racial or cultural Ritual and practice
Thus, spirituality is a domain (inside or outside a reli-
Social issues Community
gion) that can be present in any human experience—such
Spiritual Authority and guidance
as in its values, morals, ethics, love, compassion, art, con-
nection, inner peace, hope, energy, joy, strength, support,
friendship, solidarity, humanism, comfort—and, especially,
in the meaning and purpose of life. All of these aspects can Mortality
influence how patients and healthcare professionals perceive
health and disease and how they interact with each other. One of the outcomes with the greatest number of investiga-
In this context, spirituality is one of the indicators of the tions in relation to S/R is mortality, both total and cause-
notion of health. specific. In an extensive review [15], Koenig indicated that
until 2010 at least 121 studies examined this relationship,
most of them were prospective cohort studies controlling
for multiple confounders. Of those studies, 68% found that
Evidence of the association greater S/R significantly predicted greater longevity, while
between spirituality/religiosity 5% reported the opposite. Considering 63 studies with the
and longevity most rigorous methodology, 75% reported that S/R predicted
greater longevity, while, again, 5% reported the contrary.
Tyler VanderWeele, a renowned author on spirituality and Two meta-analyses [26, 27] and a systematic review [28]
religiosity in relation to health outcomes, argues that the confirmed these results with effects particularly strong for
regular search for causes of mortality and morbidity or risk frequency of religious services attendance. Survival among
factors such as smoking, obesity or drug overdose is valuable frequent attendees of religious services was increased on
but incomplete because do not consider important concerns average by 30%, 37% and 43%, respectively [26–28], which
that are important for people’s daily lives. He emphasizes is surprising because these results are similar to or better
that in the definition of health given over 70 years ago by the than many medical interventions.
World Health Organization as “a state of complete physical, More recently, analyses of data from the Nurses’ Health
mental and social well-being and not merely the absence of Study (n = 74,534; followed from 1992 to 2012) reported
disease and infirmity” also other components of well-being that after multivariable adjustments for relevant factors,
besides physical health are embraced [18, 19]. attending a religious service ≥ once/week was associated
Other fields investigating determinants of human well- with 33% lower all-cause mortality, 27% lower cardiovas-
being including psychology, economics and sociology gen- cular mortality, and 21% lower cancer mortality compared
erally exclude physical health as a fundamental parameter of to women who had never attended religious services. [8].
well-being. What current explorations seek is to contemplate Thus, S/R may be an underappreciated resource that physi-
all the dimensions that can ultimately contribute holistically cians could explore with their patients. Other studies indi-
to health including S/R variables [13, 19]. For the purpose cate that psychological well-being domains closely linked
of these investigations, different related dimensions and to spirituality may contribute to shape physical health. For
variables have been taken into account (Table 1) and some example, two meta-analyses have shown that purpose in life
evaluation tools have been developed (Table 2). [4] and life satisfaction [5] were associated with reduced
In recent years, evidence has accumulated on the impact mortality risk. Contrariwise, social isolation and loneliness
of spirituality and religiosity on various health outcomes were related with increased mortality risk [6]. A recent pro-
that are related to longevity; this includes associations with spective study examined the association of religious service
decreased risk of mortality [4–8, 15, 26–28], cardiovascular attendance and deaths from despair (related to drugs, alco-
disease (CVD) [29–33], cancer [34–36], suicide [37], and hol, and suicide) reporting that health professionals who
also cognitive decline [38] and healthy aging that leads to attended religious services ≥ once/week had a 68% lower
healthy longevity. risk of death from despair compared with those who never
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Table 2  Examples of assessment tools to evaluate S/R dimensions

Assessment tool Components References

FICA spiritual assessment Faith or beliefs Puchalski CM, 2014 [21]

Importance & influence
Community
Address or application
HOPE Sources of Hope Snyder CR, Lopez SJ, 2009 [22]
Organized religion Anandarajah G, Hight E, 2001 [23]
Personal spirituality and practices
Effects on medical care issues and end of life issues
SPIRITual history Spiritual belief system Maugans TA, 1996 [24]
Personal spirituality
Integration with spiritual community
Ritualized practices and restrictions
Implications for medical care
Terminal events planning
Flourishing measures and questions Happiness VanderWeele TJ, 2017 [18]
Mental and physical health
Meaning and purpose
Character and virtue
Close social relationships
Financial stability
Spiritual distress assessment tool Meaning • Monod SM, et al. 2010 [25]
Transcendence
Values
Psychosocial Identity

attended religious services, in the fully adjusted statistical Hypertension

models [7].
According to Koenig’s review [15], 57% of the 63 studies
Cardiovascular disease examining the association between S/R and BP reported
lower values in those most adherent to S/R while 11%
Koenig found that among 19 studies examining the associa- reported significant higher BP levels, with similar results
tion between S/R and coronary heart disease (CHD), 63% when considering only high-quality studies [15]. To help
reported a significant inverse relationship, and one study explain the results reporting higher levels of BP in those
reported a direct association [15]. Considering only 13 stud- more adherent to S/R practices, Koenig argued that most of
ies with most rigorous methodology, 69% found a significant the population included were African–Americans, who are
inverse association between S/R and CHD. the most religious ethnic group in the society and also more
A recent cross-sectional study [29] among 2967 partici- likely to have high BP values. There are other factors that
pants of the Jackson Heart Study analyzed the association of can be confusing when evaluating parameters dependent on
S/R (religious attendance, private prayer, religious coping) multiple determinants as BP in dissimilar populations. To
with the American Heart Association (AHA) Life’s Sim- overcome the fact that most of the studies showing protec-
ple 7 indicators (LS7) (not smoking, healthy weight, eating tion of S/R with respect to hypertension (HTN) have been
healthy, being physically active, blood pressure [BP], choles- conducted in white populations with limited S/R measures
terol and blood sugar), The results showed that higher reli- (i.e., religious service attendance), a recent cross-sectional
gious attendance was associated with increased likelihood of study [30] evaluated four racial/ethnic groups and diverse
achieving intermediate/ideal levels of physical activity, diet, S/R variables, including individual prayer, group prayer,
smoking, BP, and LS7 composite score. Private prayer was nontheistic daily spiritual experiences, yoga, gratitude, posi-
associated with increased odds of achieving intermediate/ tive and negative religious coping. This study found different
ideal levels for diet and smoking. Religious coping was asso- patterns of associations depending on gender and ethnicity.
ciated with increased odds of achieving intermediate/ideal Among women: (1) religious attendance was associated with
levels of physical activity, diet, smoking, and LS7 composite lower HTN among Black and white women; (2) gratitude
score. These results reinforce the notion that S/R effects on was linked to lower HTN among Hispanic/Latino, South
lifestyle interventions may help decrease overall CVD risk Asian, and white women; (3) individual prayer was associ-
among African–Americans. ated with higher HTN prevalence among Hispanic/Latino
Aging Clinical and Experimental Research (2024) 36:32 Page 5 of 11 32

and white women; (4) yoga was associated with higher HTN overlook the benefits of enabling S/R practices among reli-
among South Asian women; and (5) negative religious cop- gious adults in the prevention of cognitive decline.
ing was linked to higher HTN among Black women. Among
men: significant results were only found among Hispanic/ Cancer
Latino men. Religious attendance and individual prayer were
associated with higher HTN, while group prayer and nega- From 29 studies evaluating the association of S/R and inci-
tive religious coping were associated with lower HTN. These dent cancer or outcomes in patients with cancer, including
results reflect the multifaceted nature of the S/R construct mortality, 55% found that those with more S/R practices had
with diverse manifestations by race/ethnicity and gender, a lower risk of developing cancer or a better prognosis when
which encourages the avoidance of considering a single already diagnosed with it vs. 7% reporting association with
approach to these complex outcomes and dimensions. worse prognosis [15]. The favorable results may be partially
explained by healthier behaviors (e.g., less smoking, alcohol
Heart failure abuse, more adherence to therapies) and/or a lower stress
level and higher social support. Similarly, several investiga-
Heart failure (HF) is currently among the most prevalent tions have correlated measures of S/R with better QoL and/
chronic diseases with estimates in the US of over 6.5 million or psychosocial functioning in the context of various types
people living with HF [39]. Clinical manifestations of HF of cancer [34], particularly in patients with advanced cancer.
comprise disturbing symptoms, instability in fluid manage- There is growing interest on the role of S/R practices in
ment and sodium intake, and need of frequent monitoring cancer prevention. A recent systematic review [35] evaluated
and hospitalizations [39], which worsen quality of life and is the influence of religious denominations, the importance of
frequently associated with depressive symptoms [40]. There religion in one’s life, and religious practices such as church
is evidence that factors related to S/R may be relevant in attendance, on the utilization of cancer screenings. Most of
patients with HF [31], especially when the disease exacer- the 27 studies included reported a positive association of
bates over time [32]. We have recently reported the results religious attendance with cancer screening utilization and
of a systematic review of available literature aiming to evalu- mixed evidence concerning religious denomination and
ate the importance of S/R in patients with HF [33]. Among religiosity. Some available meta-analyses on the study of
810 non-duplicate records, we screened the full texts of 25 S/R and health among cancer patients affirm that S/R is sig-
works. After relevant exclusions, 7 studies (3 observational nificantly though modestly associated with patient-reported
and 4 interventional) comprising 1234 HF patients followed- mental, physical, and social health with some favorable but
up for a median of 3 months were reviewed. Despite the also sometimes poorer outcomes [36]. Nevertheless, the
extreme heterogeneity of the populations included, of the available data should encourage clinicians to considered S/R
definitions of S/R, and of the interventions in the few stud- for the holistic patient-centered care.
ies that included them, all the studies reported some posi-
tive associations with S/R. The intervention studies showed Healthy aging
improvements in quality-of-life (QoL), in some cardiovas-
cular outcomes, or decreased mortality. Regrettably, S/R are With the increasing aging populations, interest has grown
aspects that are not generally considered in the usual clini- globally in identifying factors that may contribute to
cal practice and can potentially contribute to improving the healthy aging and longevity. Key aspects on the role that
conditions of chronically ill patients such as those with HF. S/R may play on the promotion of healthy aging include
the increased social support [41], the associations with
Cognitive decline improved QoL [42], decreased mortality and reduction of
some chronic conditions discussed above, psychological
By reducing stress and depression through enhanced effec- and mental health and resilience [43, 44], purpose in life
tive coping, S/R may favor positive effects on cognitive [45], improved cognitive function [38], and better man-
performance. Among 21 studies published before 2010 agement of end-of-life and death issues [46]. Yet, it is
examining the associations between S/R aspects and cogni- essential to bear in mind that there are significant differ-
tive function in healthy persons and in dementia patients, ences in terms of sex, ethnicity, cultural background, and
48% reported significant associations with better cognitive characteristics of family nuclei and communities regarding
performance and 14% found the opposite [15]. In a recent the interpretation of the role that S/R can play in healthy
systematic review [38] including 17 eligible studies, 82% aging. This may generate profound difficulties in the appli-
reported positive associations between S/R and cognitive cation of S/R interventions that can help in the promotion
performance. Thus, public health practitioners should not of healthy longevity.
 32 Page 6 of 11 Aging Clinical and Experimental Research (2024) 36:32

Potential mechanism to explain Stress reduction

the association between spirituality/
religiosity and longevity Engaging in spiritual practices, such as meditation, prayer,
or mindfulness, may help reduce stress and promote relaxa-
Several mechanisms and pathways are suggested to help tion. Chronic stress has been linked to various health issues,
explain how S/R may exert beneficial effects on longevity including CVD, HTN, and weakened immune function
and well-being shown in Figs. 1 and 2 as will be discussed through several pathways [47]. Persons with S/R regular
below. practices have shown better abilities handling emotion in
stressful situations [48]. By managing stress and finding
effective stress-reducing techniques people may improve
their overall health and potentially influence their life
expectancy.
Some studies have reported that a meditation program
is able not only to improve sleeping quality, but also to
increase brain plasticity, strengthening the ability to process
and store data [49, 50]. Meditation techniques have been
shown to inhibit sympathetic system activity and activate the
parasympathetic system [51], which may explain the reduc-
tion of stress. Stimulation of the parasympathetic system
inhibits inflammation, a mechanism associated with many
age-associated chronic diseases. The release of acetylcholine
from the vagus nerve suppresses gene expression and the
secretion of inflammatory proteins by binding to specific
inhibitory receptors on macrophages [52]. Achievement of
introspection skills via meditation has been associated with
lower levels of anxiety, and depression, as well as higher lev-
els of self-esteem and satisfaction [53]. People who meditate
on a regular basis as an S/R practice tend to obtain a greater
capacity for introspection, self-awareness, self-control, and
management of emotions, which reflect the optimal integra-
Fig. 1  Main mechanisms helping to explain the association between tion of autonomic, affective and cognitive processes.
S/R practices and longevity

Fig. 2  Suggested pathways to

explain the association between
S/R practices and longevity
Aging Clinical and Experimental Research (2024) 36:32 Page 7 of 11 32

Social support a significant positive relationship between optimism and S/R

[15]. Positive perception and optimism have been associ-
Spiritual practices often involve being part of a commu- ated with physical health [60, 61] and are frequently related
nity or religious group, which can provide a strong social with higher levels of S/R [62]. Religions explicitly promote
support network. Epidemiological studies have shown that positive emotions such as gratitude, compassion, and hope,
social relationships are crucial determinants of health and all of which have been proposed to lead to greater physical
longevity [54]. Socially isolated people are physically and and psychological well-being [18, 19]. People frequently
psychologically less healthy, and have a higher mortality turn to religion in their coping efforts. Pargament et al. have
risk compared with persons with regular social contacts. For extensively studied religious coping types, classifying them
example, unmarried people have a higher mortality rate than as positive and negative [63]. Positive religious coping com-
married counterparts and the risk of death doubles in men prises making benevolent religious reassessments, using a
and triples in women within the first month after the part- collaborative approach with God in facing problems, seek-
ner's death [55]. Recent analyses of data from the Health and ing spiritual support, and seeking support from members of
Retirement Study reported that both loneliness and social one’s religious community. Persons with high S/R practices
isolation were independently associated with several physi- are more inclined to use religious coping, which is often
cal health outcomes and behaviors after adjusting for a wide related to better psychological adjustments [17, 64].
range of covariates [41]. Hence, loneliness and social iso-
lation constitute distinct targets for interventions aimed at Health behaviors
improving population health and well-being. Participation
in an S/R community not only provides supportive social Some spirituals beliefs and practices promote healthier
connections and opportunities for altruism (through vol- behaviors (i.e., less alcohol and drug use, less cigarette
unteering or other faith-based altruistic activities), but also smoking, more physical activity and exercise, better diet,
increases the flow of health information that may improve and safer sexual practices). These lifestyle choices can con-
disease screening and promote health maintenance. Analyses tribute to better health and potentially lead to increased life
from the Nurses' Health Study reported that women who expectancy.
were more socially integrated were more likely to be healthy Several studies confirm the relationship of S/R practices
agers (no history of major chronic disease diagnosis, no self- and healthy behaviors, for example, the recent study men-
reported impairment in memory, and no major impairments tioned above in which African–Americans with greater reli-
in physical function or mental health) [56]. gious attendance were more likely to achieving intermediate/
The social support networks of those who belong to a ideal levels of physical activity, diet, smoking, BP, and LS7
religious community are larger than those who do not attend composite AHA score [29]. Interestingly, the association of
religious services regularly, and may be qualitatively differ- religiosity and healthy or unhealthy behaviors may depend
ent from other non-religious social support [57]. However, on the type of spiritual beliefs. For example, a positive belief
religious social interactions are not always positive or related (e.g., that the person works in partnership with God to stay
to better health. A longitudinal study of a national sample healthy) was associated with a higher fruit consumption
of African–Americans reported that positive religious social while a passive spiritual believe (e.g., that a higher power
support was associated with higher consumption of fruits controls the person’s health with no need of engaging in
and vegetables, and lower depressive symptoms and heavy healthy behaviors) was associated with lower vegetable con-
drinking over time, but negative religious social interactions sumption and higher alcohol drinking [58]. Epidemiological
predicted more alcohol consumption, increased depressive evidence has reported that healthy behaviors partially medi-
symptoms, and decreased emotional functioning [58, 59]. ate the effects of religious service attendance on physical
health and mortality [65]. The influence of particular reli-
Positive coping mechanisms gions, or denominations, on health behavior and outcomes
has been studied, but rarely as a primary focus [66].
Spiritual beliefs and practices can offer a framework Some religious communities and traditions clearly
for finding meaning and purpose in life, which may help endorse health behaviors or vetoes that may influence health,
understanding life's difficulties and cope with challenging such as prohibiting alcohol and other toxic substances or
situations. These positive coping mechanisms may help advising a vegetarian diet and banning sexual activity out-
individuals deal with stress, trauma, or loss, which could, side of marriage [67]. Other aspects of S/R have been linked
in turn, have a positive impact on their health and well- to health behaviors. For example, in a large sample of Afri-
being. S/R may be related to health through optimism, or can–Americans with diabetes, S/R beliefs and religious
the degree to which one has positive expectations for the social support were associated with adhering to a healthier
future. Over 80% of studies published prior to 2010 reported diet and better adherence to foot care [68].
 32 Page 8 of 11 Aging Clinical and Experimental Research (2024) 36:32

However, religion may not only exert positive effects on role of age using data from the 2012 Canadian Community
healthy behavior but the opposite has also been observed. Health Survey-Mental Health (CCHS-MH). Although S/R
A study conducted in a large randomly selected community was associated with positive mental health among all par-
sample found that the Religious Involvement Index (church ticipants, the association was stronger for older adults. These
attendance, importance of religion, and religion as a source findings highlight the importance of S/R in positive mental
of comfort) had a small but positive correlation with higher health across the adult lifespan.
obesity rate and more chronic disease and a weak corre-
lation with both healthy and unhealthy eating behaviors
[69]. Likewise, in a study of African–Americans, despite Improved immunological and endocrine
having more education, those from religious communities functioning
were more obese and had more diabetes and hyperlipidemia
compared with non-religious African–Americans. However, By promoting overall mental well-being, S/R practices may
participants from religious communities had higher rates of directly influence several biological systems, including the
treatment and control of most cardiovascular risk factors sympathetic nervous, endocrine, and immune systems [72].
(i.e., treated hyperlipidemia, controlled diabetes, controlled Acute and chronic dysregulation of the stress system at dif-
HTN, more physical activity, and less smoking) [70]. These ferent levels has been implicated as a major pathway and
results support the notion that the relationship between S/R link to numerous behavioral (e.g., anxiety, depression, eat-
and healthy behaviors is complex. ing disorders, post-traumatic stress disorder, sleep disorders,
etc.) and somatic disorders (e.g., chronic pain and fatigue
Psychological well‑being syndromes, obesity, metabolic syndrome, chronic inflam-
mation, type 2 diabetes, HTN, atherosclerosis, and CVD)
Spirituality can be a source of comfort, hope, and inner [47]. A recent cross-sectional study analyzed data from
peace, fostering a positive outlook on life that may lead to 4,734 community-dwelling participants of the US Health
improved emotional and psychological well-being. Main- and Retirement Study regarding the relationship between
taining good mental health and a positive mindset have chronic stress, inflammation, and religiosity (organizational,
been linked to improved overall health and may indirectly non-organizational, and intrinsic religiosity), controlling for
influence longevity. In fact, S/R, by enabling coping and relevant covariates. This study found that intrinsic religios-
negative events overcoming with meaning and purpose, has ity moderated the relationship between chronic stress and
been associated with better mental health (lower rates of inflammation suggesting that persons with stronger religious
depression, less anxiety, less stress, greater well-being and commitment/motivation may better cope with stress [73].
positive emotions). A study aiming to develop empirically Before 2010, Koenig et al. identified 27 studies evaluating
based S/R typologies and their relationship with health and the relationships between S/R and immune functions and
well-being analyzed data from 1431 adults. Typologies of found that 56% reported positive relationships or positive
S/R were derived based on religious service attendance, effects in response to an S/R intervention, and only one study
prayer, positive religious coping, and daily spiritual experi- (4%) found a negative effect. Considering only 14 studies
ences. In multivariate statistical analyses, four clusters were with the highest quality ratings, 71% reported significant
identified: highly religious, moderately religious, somewhat positive associations or increased immune functions in
religious, and minimally religious or non-religious. The response to an S/R intervention [15].
highly religious class was most likely to be happy and sat- A continuously growing area of interest and application
isfied with finances and least likely to be psychologically in medicine is that related to mindfulness-based programs
distressed [64]. (MBP). Following the first studies by Kavat-Zinn et al.
A recent review [43] examined the scientific evidence on involving small groups and reporting the effectiveness of
the relationship between S/R and both physical and men- MBP in reducing symptoms of anxiety and panic disorders
tal health. The authors found solid evidence for reduced [53], various investigations have shown associations between
depression, suicidality, and substance use, but mixed or mindfulness and various indicators of psychological health,
scarce results on other diagnoses, such as post-traumatic including increased subjective well-being, reduced psycho-
stress disorder, psychosis, and anxiety. They suggest that logical symptoms and emotional reactivity, and improved
S/R effects on mental health are likely bidirectional, and behavioral regulation [74]. There are also studies showing
the manner in which religious beliefs are used to cope with the positive effects of meditation on objective measurements
distress (i.e., negative and positive), may affect mental health such as reduction of blood cortisol levels in the short and
outcomes. A recent study [71] examined the relationship long term, as reported in a recent meta-analysis [75] includ-
between S/R and positive mental health and mental illness ing any type of meditation intervention but mostly concern-
(i.e., psychological distress) and the potential moderating ing mindfulness. In 10 randomized controlled trials among
Aging Clinical and Experimental Research (2024) 36:32 Page 9 of 11 32

395 participants there was a significant, medium-sized effect While there might be some correlations between S/R and
of meditation intervention on changes in blood cortisol lev- health outcomes, they do not necessarily imply causation
els. Because there is an explosion of studies that use MBP and not all spiritual beliefs or practices are beneficial for
interventions in different health outcomes, it is important to everyone: there is no “one-size-fits-all” approach to spiritu-
be aware that “mindfulness” is a generic concept and that ality. Ultimately, the decision to embrace spirituality should
more detailed elucidations on what is and what is not an be driven by personal beliefs, values, and experiences rather
MBP are necessary to delineate more rigorous investigations than an expectation of prolonging life.
in the future [76].

Author contributions LJD, NV, and MB: Conceptualization, Investiga-

tion, Writing-original draft, Writing-review and editing. All authors
Conclusions read and approved the submitted version.

With the continuous growth of population aging, multi- Funding Open access funding provided by Università degli Studi
di Palermo within the CRUI-CARE Agreement. No funding was
disciplinary and multidimensional strategies that can help received for conducting the present review and for the preparation of
to manage the complex situations of these populations are this manuscript.
needed. Interventions for this purpose should consider the
promotion of the physical, psychological, behavioral, and Declarations
social health of older adults who are in great need on all
Coflict of interest The authors have no competing interests to declare
these fronts. S/R comprise areas that have attracted and that are relevant to the content of this article.
continue to raise interest in health research. Numerous epi-
demiological studies have shown how higher levels of S/R Ethical approval Not applicable.
in its different expressions are associated with a lower mor-
tality rate, even after adjustments for relevant confounders. Open Access This article is licensed under a Creative Commons Attri-
Other positive results have been reported in cardiovascular bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
health and in well-being of cancer and psychiatric patients, as you give appropriate credit to the original author(s) and the source,
but there are also negative and neutral results. Factors that provide a link to the Creative Commons licence, and indicate if changes
may help explain the heterogeneity of the results and that were made. The images or other third party material in this article are
can be challenging are the diverse conceptualization of S/R included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
(from membership in organized religions and participation the article’s Creative Commons licence and your intended use is not
in their activities to individual practices, such as prayer, permitted by statutory regulation or exceeds the permitted use, you will
meditation or considering oneself a religious person) and need to obtain permission directly from the copyright holder. To view a
the dissimilar methods used for S/R assessment. In addition, copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
the difficulty of implementing programs in which there is
convincing transferring of the results in effective spiritual
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