Susan Friedman, MD, MPH

Krupa Shah, MD, MPH

University of Rochester Division of Aging
10th Annual Caring For Elders Program
Burgundy Basin Inn
April 27, 2016
 The aging of America – opportunities and
challenges
• Demographics; what does “extreme aging” look like?
• Changes in health / chronic disease
• Presence / role of geriatricians
 The Blue Zone approach
• Principles
• Replication
 Behavioral change
 Practical ideas to “Blue Zone” your life
 Na ta ekatostisis (may you live to be 100). (Greek)
 May you live to be 100 years, with one extra year to
repent. (Irish)
 May you live to be 120. (Jewish)
 May you die in bed at 95, shot by a jealous spouse. (Irish)
 May you live to be 100 and may the last voice you hear be
mine. (Frank Sinatra)
 Sto lat, sto lat, niech zyje zyje nam (Good luck, good
cheer, may you live a hundred years). (Polish)
 6% married
 17% live in poverty
 Dementia – 37% of those age 90+

 Functional status
◦ Over 80% with some activity of daily living impairment
 Independence
◦ 15% live alone
◦ 48% live in nursing homes
Centenarians in the US. US Census Bureau, 1999
Kincel B, The Centenarian Population 2007-2011, US Census
Bureau, 2014.
Neuroepidemiology. 2007 November; 29(1-2): 125–132
 Lived 1875 - 1997

 Father lived to almost 100, mother

86, brother 97

 Outlived her husband, daughter and

grandson

 Met Vincent Van Gogh when she was

13

 Saw Eiffel Tower being built

 Took up fencing at 85

 Lived on her own to 110

 Oldest person ever in a movie (114)

 Ascribed longevity to olive oil, port

wine and chocolate
Year Life
expectancy
1800 26
1900 47.3 (US)
2013 78.8 (US)
 Of all the people who
have lived to be 65 or
older, half are currently
alive.
700

600

500

400

Thousands
300

200

100

0
2015 2020 2030 2040 2050 2060

US Census Bureau, 2014 National

Population Projections
 NEJM 1980; 303: 130-5.

OR

“The failure of success” - Ernest Gruenberg

Milbank Q. 2005 Dec; 83(4): 779–800.
Hippocrates
460 BCE
 Never smoker
 BMI < 30
 Physical activity ≥ 3.5 hours per week
 High intake fruits/veg/whole grain, low meat

Ford et al., Arch Intern Med 2009;169(15):1355-62

 Physician’s health
study
 2,357 men
 Ave age 72
 5 risk factors:
◦ Smoking
◦ DM
◦ HTN
◦ Obesity
◦ Sedentary lifestyle

Arch Intern Med. 2008;168(3):284-290.

 Released 2010  4 health behaviors
 2020 Impact Goal ◦ Non-smoking
 Control risk / ◦ BMI < 25
◦ Physical activity at goal
promote health
◦ DASH diet
 Aim:
 3 ideal health factors
◦ ↑ cardiovascular
health by 20% ◦ Total chol < 200
◦ ↓ CVD and stroke ◦ Untreated BP < 120/80
deaths by 20% ◦ Untreated FPG < 100
 “Primordial
prevention”
Lloyd-Jones et al. Circulation. 2010;121:586-613.
 Obesity Trends Among U.S. Adults
Behavioral Risk Factor Surveillance System , 1990, 2000, 2010

1990 2000

2010

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

CDC, 2015
60%

50%

40%

30% 1988-1994
2009-2010
20%

10%

0%
Women Men
Data from NHANES survey
Ladabaum et al, Am J Med, 2014; 127(8):717-727.
 Healthy people 2010 target Fruit

 75% consuming
◦ 2 or more servings of fruit
 50% consuming
◦ 3 or more servings of
vegetables Vegetables
 Heart SCORE study  1 person had all 7
 1933 participants components
 Mean age 59  Ave of 2.3
 Community dwelling  5.3% with 5 or more
 Allegheny Cty, PA  Less with
 66% women ◦ Age
◦ Lower income
 44% African
◦ African American
American

Bambs et al. Circulation. 2011; 123(8): 850–857.

20%
18%
16%
14%
12%
1998
10%
2004
8%
2008
6%
4%
2%
0%
No chronic disease 4+ chronic diseases

Hung et al. BMC Geriatrics 2011;11:47-58.

80%

60%

1998
40%
2004
2008
20%

0%
HTN Diabetes Cancer COPD Arthritis
Hung et al. BMC Geriatrics 2011;11:47-58.
 Changes in mobility disability
60 60

50 50

40 40

30 1998 30 1998
2006 2006
20 20

10 10

0 0
50-59 60-69 70-79 80+ 50-59 60-69 70-79 80+
Men Women

Crimmins et al. J Gerontology Soc Sci 2011; 66B: 75-86.

 Over age 85
 Dependent in activities of daily living
 Complex biomedical problems
◦ Multimorbidity
◦ Polypharmacy
 Complex psycho-medical situations
◦ Dementia
◦ Depression
 Frail
 Geriatric syndromes
Warshaw et al. J Am Geriatr Soc 2008;56:1796-1801.
 Certificates
8000
7000
6000
5000
4000
Certificates
3000
2000
1000
0
2004 2014
 200
198 201 201 204 200
186
178
Active Certificates (per 1

162 154
million beneficiaries)

150 175
135

100

50

0
20042005200620072008200920102011201220132014

Year
* Aged 65 and over
 Rapidly increasing older adult population
 Increasing prevalence of chronic disease
 Evidence of increases in disability
 Limited number of geriatricians and PCPs

 How do we address this?

 Interest in health and physical fitness
 Active in their own medical care
 Information age
 Pro-active
 Self-motivated
 Areas of highest
longevity
 Live “better” as well as
longer
 Named for
demographers’ maps
 Personal interviews
 Looked for
commonalities
Icaria, Greece
• Highest % of 90 year olds on the planet
• Almost 1 in 3 reach 90
• 20% less cancer, 50% less heart disease, almost no dementia
 Move naturally
 Hara hachi bu
 Plant slant

 Drink alcohol, especially red wine, in moderation

 Ikigai or plan de vida - purpose
 Reduce stress
 Belong to a spiritual community
 Keep family first
 Surround yourself with people who have similar blue zone
values
The “3-legged stool”
Ikaria Rochester
Albert Lea, MN

• Town of 18,500
• 7 lakes
• History as meatpacking
town
• 60-65% overweight or
obese
• AARP / United Health
Foundation
 Town meetings
 Personal pledge
 Community gardens
 Walking and bike paths
 Changes in
◦ Restaurants
◦ Schools
◦ Grocery stores
◦ Workplace
 “Purpose” workshops
 Walking moais
 Walking school bus
 Community participation
◦ 60% of the city’s restaurants
◦ 51% of employers
◦ 100% of its schools
◦ 27% of citizens
◦ 150 “ambassadors”
• Ave life expectancy increased 3.1 years
• Ave wt loss of 2.8 lbs. each
• 21% drop in absenteeism
• 49% decrease in health care costs in city employees

Buettner, The Blue Zones Solution, 2015.

 California Beach cities
◦ Manhattan Beach
◦ Hermosa Beach
◦ Redondo Beach
 15 cities and towns in Iowa
 Naples, FL
 Hawaii
 Oregon
 Texas
 Behavior change in older persons present
special challenges:
◦ multiple comorbidities
◦ sensory impairments
◦ reduced mobility
◦ psychosocial factors (loneliness, depression, loss of
identity)
◦ dependency
 Health behaviors influenced by social network
◦ Smoking
◦ Obesity
◦ Happiness
 Influence extends to 3 degrees of separation

Christakis and Fowler, N Engl J Med 2007;357:370-9.

N Engl J Med 2008;358:2249-58.
British Medical Journal 337 (337): a2338 42
 Movement from South Asia to Europe
 Complex changes
 Primary trends
◦ Increase in energy and fat intake
◦ Reduction in carbohydrates
◦ Switch from whole grains to more refined sources
◦ Decrease in fiber
◦ More meat and dairy
 Higher incidence of
◦ DM2
◦ Obesity
◦ CVD
Holmboe-Ottesen et al, Food and Nutrition Research
2012, 56:18891.
To get moving in your Blue Zone, try some of
these tips.
 Inconvenience yourself
 Have fun. Keep moving.
 Walk
 Make a date
 Plant a garden
 Enroll in a yoga class
 Ergonomic work station
 Activity ≠ exercise
To follow 80 % rule in your Blue Zone, try the
following tips
 Serve and store
 Make food look bigger
 Use small vessels
 Make snacking a hassle
 Give yourself a daily reminder
 Buy smaller packages
To follow 80 % rule in your Blue Zone, try the
following tips

 Eat more slowly

 Focus on food
 Have a seat
 Eat early
Try these tips to incorporate more plants in
your diet
 Eat four to six vegetable servings daily
 Limit intake of meat
 Showcase fruits and vegetables
 Lead with beans
 Eat nuts every day
 Stock up
Introduce a glass of wine into a daily routine

 Buy a case of high-quality red wine.

 Treat yourself to a “Happy Hour”
 Take it easy
To realize your purpose, try the following tips

 Craft a personal mission statement

 Find a partner
 Learn something new
Use these tips to find a quiet space to slow
down in your Blue Zone

 Reduce the noise

 Be early
 Meditate
 Sleep
 De-clutter
To strengthen the spiritual dimension of your
Blue Zone, try these tactics

 Spiritual does not have to mean religious

 Be more involved
 Explore a new tradition
 Just go
These tips can help you create your family’s
Blue Zone.

 Get closer
 Establish routines
◦ Meals
◦ Holidays
 Put family first
Try these tips to build up the inner circle of
your Blue Zone

 Identify your inner circle.

 Don’t be a grump!
 Create time together
 Create a moai
 Timing – we are seeing changes in
 Demographics
 Health trends
 Healthcare reform
 Changes in lifestyle make a big difference!
 The Blue Zones focus on
 Activity
 Nutrition
 Connectedness