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 ◦ 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 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 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, 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 .