Heather Bedard, C.H.E.
Next on our list, we’ll take a look at Okinawa, Japan. Okinawa is the fifth largest island of Japan and boasts the highest ratio of centenarians worldwide. It also claims the title of home of the world’s longest-lived women.[1] At the time these centenarians were born, the life expectancy in Japan averaged 39 years. Despite the fact that by the time they hit their 100th birthday, the life expectancy had gone up to 82 years - these amazing people were outliving their mainland Japanese counterparts by 20 years.[2] What was their secret? Let’s start by looking at their diet.
One of the most noteworthy features of the Okinawan diet is that it is extremely low in calories but incredibly nutrient dense. This allows them to eat less but maintain a highly active and healthy lifestyle. One of the mottos of the elderly is “eat only until 80% full”. While minimal studies have been done showing long-term caloric restriction and mortality in humans, a study in 2007 investigated decades of population data in Okinawa and found evidence to support the idea that calorie restriction over the long term results in life-long low BMI and a lower chance of dying from an age-related disease.[3] Rather than develop malnutrition from a lack of calories, eating nutrient rich foods and staying physically active affords the Okinawan elderly the ability to enjoy an active lifestyle and independence well into their 90’s. Okinawans traditionally eat lots of vegetables and fruit, soy based products, colorful sweet potatoes and minimal meats. When they do eat meat, it usually consists of fish and pork. Rather than use salt for seasoning, herbs and spices are used. All of these components together create an extremely low fat and high carbohydrate diet with plenty of phytonutrients and antioxidants.[4],[5] Research has shown that a high carbohydrate diet consisting of plant-based fats and protein, rather than animal fat and protein, has a lower mortality rate than a low carbohydrate diet.[6] Like their fellow Greek centenarians, the food they eat provides not only nutrients but also acts as medicine. Many Okinawan gardens contain Mugwort, which is used for its anti-parasitic effects and the treatment of gastrointestinal problems. And lastly turmeric, which helps with arthritis, anxiety and inflammation.[7],[8],[9]
The independent and active lifestyle of the elderly Okinawan has created a robust community where people work longer and retain their sense of vitality and purpose. This, in addition to consistent social contact, contributes to their mental and physical health. This meta-analysis of 148 studies, including over 308,000 people, showed a 50% increased likelihood of survival with active social engagement.[10] In addition to the communal network aspect of health and longevity, the elderly Okinawan women play a big role in how the community functions. Perhaps this is part of the reason that Okinawa has the longest-lived women in the world. The elderly women have strong-knit social groups who care for one another and also participate in activities, such as a style of weaving known as Basho-fu. The women receive compensation for their labor, empowering them to be a contributing member of society, giving them a sense of value and purpose.[11],[12] In addition, older women play an important leadership role in religious activities. This engagement in religion could be contributing factor to the low levels of depression seen in this demographic. Research has shown that 60% of people in over 444 studies report a reduction in depression in response to religious activities.[13] One last observation with regard to lifestyle, would be that elderly Okinawan’s take daily afternoon naps. A simple comparative study noticed that elderly individuals that took naps in suburban Okinawa and had daily activity, experienced better sleep than those of their urban neighbors. Healthy sleep patterns can be associated with low mortality, as shown in the systematic review and meta-analysis of sleep duration and all-cause mortality studies.[14],[15]
The Okinawans have a rich history of tight knit communities and a laid-back lifestyle accentuated by simple eating habits and unprocessed foods. This combination together appears to give them a leg-up on living long, active lives full of purpose.
Sardinia, Italy
While Okinawa, Japan boasts the world’s longest-living women, the beautiful island of Sardinia, Italy is the home of the world’s longest-living men. A possible contributing factor could be that many men in this region are shepherds and live a more active lifestyle. They do this while engaging in moderate food intake practices. This is comprised mostly of fruits, vegetables and minimal meats. The men and those in pastoral regions have been less exposed to the nutritional transition happening in the more urban areas. This transition involved eating differing fruits and higher fat and protein foods than were readily available up until then. These more modern diets began to emerge around the end of WWII as the area was exposed to western influence. This means that their diet and the diet of the general community in the area consisted simply of cereals, legumes, potatoes, and dairy products at least up until the 1950’s. Fruits were less common in the early years of these centenarians, but they did partake of wild fruit like cactus pear and figs.[16] Similar to the previous countries described here, Sardinians grow their own herbs and use them medicinally.[17] Considering that many of those in the longest-living group are shepherds, the majority of the meat that is eaten is from sheep and pork and the dairy that is consumed is from sheep or goats. While cow, sheep and goat milk are all high in fat and could contribute to cardiovascular problems, sheep and goat milk does not contain the A1 beta casein that most forms of cow milk have.[18] This, along with the small size of the fat globules, makes it much easier to digest and less inflammatory to the digestive system. Furthermore, in vitro studies of goat and sheep fermented products, such as cheese and yogurt, report anti-thrombotic properties and protection against cardiovascular disease despite their high fat content.[19],[20],[21] While the dairy consumption from sheep and goat is high, the intake of meat is not. Although eating red, white or processed meats has been shown to increase mortality and cancer mortality, the minimal consumption of pork or sheep doesn’t seem to affect the elderly Sardinians.[22] Meat of any kind is relegated to the weekends or special occasions and even then, moderation is always practiced. Moreover, the meat is locally produced, eliminating the need for toxic preservatives or chemical additives and typically seasoned simply with salt and pepper. Although it is an island, fish consumption is lower than one would assume, particularly inland, possibly due to a lack of refrigeration and difficulty in accessing the beaches from the mountain areas. Finally, while the Sardinians eat a diet high in proinflammatory cereals (wheat and barley), when it comes to turning that into bread, the Sardinians have found a secret. They make their bread from a microbial starter containing Lactobacilli, which a study has found can improve postprandial glucose and insula plasma levels. This could contribute to further protection from diabetes and obesity when paired with their extremely active lifestyle. What’s more, according to a study of 21 mildly hypercholesterolemic men, diets containing barley may help to lower blood cholesterol.[23],[24]
True to the stereotype, the Sardinian Italians love their wine and a unique local wine called Cannonau is bottled here. Cannonau grapes are not sprayed with phytochemicals and are free from many of the preservatives commonly found in mainstream wines.[25] Elderly Sardinians generally enjoy 2-3 glasses a day. While the alcohol component of wine is not generally advised, it appears that particular production practices in Sardinia promote procyanidins as the principal polyphenol in their wine and those have been shown to give vascular health benefits.[26]
From a lifestyle perspective, 85% of the elderly men in Sardinia reported being former smokers, while 97% of the women never smoked. This disparity may be a cultural one. As one might expect, as of 2012, mortality rates for lung cancer were the highest of all other cancers and yet these people still manage to live decades longer than their counterparts in other more modernized countries. Perhaps this is due to the cardiovascular strength the mountainous people exhibit in walking miles through rough terrain with their flocks, the high flavanol content of their local wines, laid back lifestyle, and farm-fresh, vitamin and mineral rich produce.[27]
Loma Linda, California
Our quest leads us next to Loma Linda, California. Loma Linda is located in southern California and is home to over 18,000 Seventh-day Adventists. Seventh-day Adventists are typically very religious in their adherence to the beliefs and convictions of their community. Followers are encouraged to follow a vegan diet consisting of fruits, vegetables, grains, and nuts and strictly prohibit alcohol and coffee. Not everyone in this tight-knit community follows the guidelines and may include small amounts of fish and dairy or the occasional alcoholic beverage. However, this is extremely uncommon. The effects of this healthy lifestyle are clearly observable as the majority of this group of people are active well into their 90’s and beyond. The mostly vegan/vegetarian diet of the Seventh-day Adventist does hold some legitimacy as the American Dietetic Association has made their position on veganism and vegetarianism clear. They state that, “Well-planned vegetarian diets are appropriate for individuals during all stages of the life cycle” and also that, “Vegetarians also appear to have lower low-density lipoprotein cholesterol levels, lower blood pressure, and lower rates of hypertension and type 2 diabetes than nonvegetarians”.[28] The clean Adventist diet, virtually void of high fats and processed foods, could be a contributing factor to their longevity. The Adventists have conducted many studies on their community’s diet such as Adventist Health Study 1 and Adventist Health Study 2 and have found many associations that seem to support the association between vegetarian and vegan diets and the lack of many chronic diseases.[29],[30] Other studies done within this pool of people have shown links between vegetarians, vegans and low rates of diabetes and obesity.[31]
A laid-back and physically active lifestyle is important to the Seventh-day Adventists and they continue this into their 90’s! Interestingly, a study on the effects of walking on mortality among nonsmoking retired men found that regular walking is associated with a lower mortality rate.[32] Furthermore, the religion calls for the observance of a 24hr sabbath once a week. This time is set aside for God and the community and it is important to them that they abstain from anything that could be seen as work. This type of priority placed on rest and community give people a sense of pride and purpose. Although the exact mechanism of longevity may not be entirely known, a meta-analysis of ten prospective studies showed that having a high sense of purpose contributed to low mortality rates over 126,275 participants.[33]
While the Seventh-day Adventists in Loma Linda are surrounded by temptations to eat the standard American diet and don’t have the benefit of being isolated off the mainland, they have managed to live longer, healthier, and more active lives than their fellow Americans through strict adherence to their religious philosophy.
Nicoya Peninsula, Costa Rica
Our fifth stop lands us on the Nicoya Peninsula in Costa Rica. These exceptional people have the 2nd highest life expectancy in the Americas and spend one tenth of what the United States does per person for healthcare. The tropical forests and bountiful pastures account for the significant production of bananas, plantains, pejibaje, beans, squash, and yams. While the main portion of the Nicoyan diet consists of fresh produce, they do consume a significant amount of beef, fish, pork, sodas, and light cheese. Surprisingly, however, they do not consume much cow milk and drink much less than their surrounding Costa Rican neighbors. An interesting dietary note is that although the Nicoyans have a much simpler diet of primarily rice and beans than their Costa Rican neighbors, they still consume the same amounts of sweets, potato chips, eggs, and pastries.
Like the other people groups we have studied, Nicoyans love their coffee. Around 85% of the men drink coffee and research shows that coffee can help prevent chronic diseases like type 2 diabetes and liver disease.[34]
The Nicoyan population is a study in contradictions. They do eat a lot of animal proteins and fats but have a low level of cardiovascular risk. They also have low levels of functional disabilities and cognitive decline, but extremely high levels of geriatric depression particularly in females. Pastries, sweets, and fats are a staple, however, Nicoyans have low diagnoses of diabetes. Over 87% of the men report smoking and yet mortality from lung cancer is 4 times less than in the United States.[35] When considering their diet, it is important to look at the entirety of the diet as many factors play a complex part of how and why they live so long including a low-stress lifestyle.
In an article written by Alexander Villegas, he focuses on the sense of purpose that Nicoyan elderly and centenarians have. He writes, “As residents age, many have a heightened sense of purpose – they find their motivation in providing for their families and teaching them the skills they’ve learned so they can keep the Nicoyan way of life going for generations to come.”[36] This theme is reiterated by Dan Buettner who studied longevity and coined the term, the Blue Zones. Life on the Nicoyan Peninsula is considerably more laid-back than other parts of Costa Rica with less stress and higher levels of physical activity than many other parts of the world as well. Perhaps, for these beautiful people, a healthy lifestyle and perspective give their bodies the added edge they need to live longer.
Seventh Day Adventists (outside of Loma Linda)
One final group we will look at on our health quest is the Seventh-day Adventists that live outside of Loma Linda, California. This group follows the same dietary guidelines as their Loma Linda counterparts but are often a little less strict. The typical diet of a Seventh-day Adventist consists of fruits, vegetables, nuts, seeds, legumes, and grains. Eggs, low-fat dairy, and “clean” meats are eaten in moderation. Clean meats are those considered “clean” in the Bible such as fish, some poultry and red meat other than pork. Those that choose to follow the diet abstain from caffeinated beverages such as coffee, drinking alcohol and using drugs or tobacco as well.
In an assessment of the consumption of lifetime dietary patterns in the Adventist population, authors found that as the Adventists ages, any trend toward the consumption of animal products is lowered and they adopt more of a vegetarian pattern of eating.[37] Further studies of Adventist cohorts shows that vegetarian diets provide protection against cardiovascular diseases, some cancer and total mortality. Vegan diets also offer protection against obesity and diabetes amongst other health concerns.[38] Although studies on diet are intrinsically hard to do, the vast majority seem to show that plant-based diets can reduce the risk of all-cause mortality.[39]
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[12] Buettner D, Skemp S. Blue Zones: Lessons From the World's Longest Lived. Am J Lifestyle Med. 2016;10(5):318-321. Published 2016 Jul 7. doi:10.1177/1559827616637066
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[16] Pes, G., Tolu, F., Dore, M. et al. Male longevity in Sardinia, a review of historical sources supporting a causal link with dietary factors. Eur J Clin Nutr 69, 411–418 (2015). https://doi.org/10.1038/ejcn.2014.230
[17] https://www.sciencedirect.com/science/article/abs/pii/S0367326X04000474
[18] Jianqin S, Leiming X, Lu X, Yelland GW, Ni J, Clarke AJ. Effects of milk containing only A2 beta casein versus milk containing both A1 and A2 beta casein proteins on gastrointestinal physiology, symptoms of discomfort, and cognitive behavior of people with self-reported intolerance to traditional cows' milk [published correction appears in Nutr J. 2016;15(1):45]. Nutr J. 2016;15:35. Published 2016 Apr 2. doi:10.1186/s12937-016-0147-z
[19] Megalemou K, Sioriki E, Lordan R, Dermiki M, Nasopoulou C, Zabetakis I. Evaluation of sensory and in vitro anti-thrombotic properties of traditional Greek yogurts derived from different types of milk. Heliyon. 2017;3(1):e00227. Published 2017 Jan 9. doi:10.1016/j.heliyon.2016.e00227
[20] Sofi F, Buccioni A, Cesari F, et al. Effects of a dairy product (pecorino cheese) naturally rich in cis-9, trans-11 conjugated linoleic acid on lipid, inflammatory and haemorheological variables: a dietary intervention study. Nutr Metab Cardiovasc Dis. 2010;20(2):117-124. doi:10.1016/j.numecd.2009.03.004
[21] http://www.dieteticai.ufba.br/temas/leitederivados/cabra%20e%20ovelha.pdf
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[23] Maioli M, Pes GM, Sanna M, et al. Sourdough-leavened bread improves postprandial glucose and insulin plasma levels in subjects with impaired glucose tolerance. Acta Diabetol. 2008;45(2):91-96. doi:10.1007/s00592-008-0029-8
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[25] Mezzasalma V, Sandionigi A, Bruni I, et al. Grape microbiome as a reliable and persistent signature of field origin and environmental conditions in Cannonau wine production. PLoS One. 2017;12(9):e0184615. Published 2017 Sep 11. doi:10.1371/journal.pone.0184615
[26] Corder R, Mullen W, Khan NQ, et al. Oenology: red wine procyanidins and vascular health. Nature. 2006;444(7119):566. doi:10.1038/444566a
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[29] Jacobsen BK, Knutsen SF, Oda K, Fraser GE. Parity and total, ischemic heart disease and stroke mortality. The Adventist Health Study, 1976-1988. Eur J Epidemiol. 2011;26(9):711-718. doi:10.1007/s10654-011-9598-x
[30] Terry L Butler, Gary E Fraser, W Lawrence Beeson, Synnøve F Knutsen, R Patti Herring, Jacqueline Chan, Joan Sabaté, Susanne Montgomery, Ella Haddad, Susan Preston-Martin, Hannelore Bennett, Karen Jaceldo-Siegl, Cohort Profile: The Adventist Health Study-2 (AHS-2), International Journal of Epidemiology, Volume 37, Issue 2, April 2008, Pages 260–265, https://doi.org/10.1093/ije/dym165
[31] Tonstad S, Butler T, Yan R, Fraser GE. Type of vegetarian diet, body weight, and prevalence of type 2 diabetes. Diabetes Care. 2009;32(5):791-796. doi:10.2337/dc08-1886
[32] Hakim AA, Petrovitch H, Burchfiel CM, et al. Effects of walking on mortality among nonsmoking retired men. N Engl J Med. 1998;338(2):94-99. doi:10.1056/NEJM199801083380204
[33] Cohen R, Bavishi C, Rozanski A. Purpose in Life and Its Relationship to All-Cause Mortality and Cardiovascular Events: A Meta-Analysis. Psychosom Med. 2016;78(2):122-133. doi:10.1097/PSY.0000000000000274
[34] Nieber K. The Impact of Coffee on Health. Planta Med. 2017;83(16):1256-1263. doi:10.1055/s-0043-115007
[35] Costa Rica and US life expectancy,Luis Rosero-Bixby, William H. Dow, Proceedings of the National Academy of Sciences Feb 2016, 113 (5) 1130-1137; DOI: 10.1073/pnas.1521917112
[36] https://www.bbc.com/worklife/article/20200429-nicoya-the-costa-rican-peninsula-where-centenarians-thrive
[37] Martins MCT, Jaceldo-Siegl K, Orlich M, Fan J, Mashchak A, Fraser GE. A New Approach to Assess Lifetime Dietary Patterns Finds Lower Consumption of Animal Foods with Aging in a Longitudinal Analysis of a Health-Oriented Adventist Population. Nutrients. 2017;9(10):1118. Published 2017 Oct 13. doi:10.3390/nu9101118
[38] Le LT, Sabaté J. Beyond meatless, the health effects of vegan diets: findings from the Adventist cohorts. Nutrients. 2014;6(6):2131-2147. Published 2014 May 27. doi:10.3390/nu6062131
[39] Kim H, Caulfield LE, Rebholz CM. Healthy Plant-Based Diets Are Associated with Lower Risk of All-Cause Mortality in US Adults. J Nutr. 2018;148(4):624-631. doi:10.1093/jn/nxy019