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 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 to olive oil, port wine and chocolate Year 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 ◦ BMI < 25  Control risk / promote health ◦ Physical activity at goal ◦ 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 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 198 201 201 204 200 200 186

178 175 162 154 150 135

100

50

million beneficiaries)million 0 Active CertificatesActive(per1 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, • 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

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