Thank you to Elizabeth Moxley, PhD, RN, BS, FAHA, FPCNA and Morgan Moxley for this article on implementing the successes of blue zones for cardiovascular health.

People reaching age 100 or older living in the world’s Blue Zones—Sardinia, Italy; the islands of Okinawa, Japan; the Nicoya Peninsula in Costa Rica; Ikaria, Greece; and Loma Linda, California—have the lowest incidence of cardiovascular disease (CVD),¹ obesity, cancer, osteoarthritis, and type 2 diabetes.² Considering the increased incidence of these global health problems, Blue Zone living has become a sort of coveted secret—the secret to longevity. Paradoxically, researchers have discovered that Blue Zone living is very simple.³ The benefits of Blue Zone living for cardiovascular health can be implemented just about anywhere to provide short- and long-term benefits.

Blue Zone Nine Power Traits for Healthy Living

National Geographic and the National Institute on Aging have partnered with US organizations to use the model of Blue Zones to promote healthy lifestyle changes, community investments, and access to nutritious foods.⁴ Since Blue Zones are located in diverse regions throughout the globe, they are home to residents with health advantages established by the nine common lifestyle characteristics referred to as the Power 9®. The Blue Zone® corporation has four major outcomes to benefit overall health included in the Power 9® campaign:

1. Move naturally. People who live in Blue Zones integrate activity into their daily lives. Instead of going to the gym or running marathons, they walk places and limit the use of transportation, and routinely garden and engage in labor-intensive house and yard work.
2. Have the right outlook on life. Blue Zone residents find meaning and worth in how they live their life, giving them an overall sense of purpose, yet at the same time they take time to relax. Depending on the zone, this behavior varies from remembering loved ones, praying, napping, or social time with friends during happy hour.
3. Eat wisely. Blue Zoners tend to stop eating before they actually feel full, a behavior that some attribute to the difference between a healthy weight and becoming overweight. Similarly, they consume most of their calories – the cornerstone of which is plant-based, especially legumes with limited meat consumption – earlier in the day, with the smallest meal consumed by early evening. Nearly all Blue Zone residents regularly consume 1-2 glasses of alcohol, primarily wine, on a daily basis.
4. Connect with family, loved ones and community. The vast majority of Blue Zoners have a high regard for family by either residing with aging family members or investing in children. Most have a life partner, involvement in a type of faith-based community, as well as a healthy social circle.

The Blue Zone Project has implemented Blue Zone living in several U.S. cities to improve the well-being index, including decreasing mortality risks from modifiable factors like smoking, exercise, daily stress, diet, and community access to healthcare and infrastructure.⁵ The Blue Zone is more than the geographical location; it includes lifestyle behaviors of engaging in adequate quantities of exercise, consuming produce from one’s own garden, working in the home, yard, and garden without the aid of modern technology, and fostering a sense of belonging and community pride.^4,5

Move Naturally: The Physically Active Blue Zone Lifestyle

In Blue Zones, residents engage in physical activity that is integrated into their lifestyle instead of scheduled workouts or exercise programs. Most physical activity in the Blue Zones consists of walking; Blue Zone living equates to at least 30 minutes of brisk walking 5 days/week, or 8,000 to 10,000 steps daily,² amounting to a quantity consistent with the US guidelines for recommended physical activity.⁶ Research demonstrating physical activity prevents CVD is well-established, with greater quantities attenuating weight gain in children, adolescents, and adults.^7,9

Walking in adults, at a specific cadence and duration, has been found to be extremely beneficial for overall health, with multi-faceted benefits: mitochondrial rejuvenation, increased nutrient sensing pathways, improved epigenetic regulation and stress resilience, and lowered oxidative stress and inflammation.²

Furthermore, regular physical activity in the Blue Zones has been theorized to improve overall health in the community, workplace, and at home. Habitual physical activity may increase intrinsic and extrinsic motivation in daily occupations, decrease healthcare costs, and contribute to satisfaction with the overall experience of living in the environment.

Have the Right Outlook on Life: Purpose and Downshift

Another Power 9® trait that exemplifies Blue Zone living is the sense of purpose: a reason to get up in the morning, termed “Ikigai” for the Okinawans, or “plan de vida” for Nicoyans.⁸ Blue Zone researchers believe a sense of purpose contributes to an added life expectancy of seven years.⁴

Similarly, diminishing stress or downshift, is another trait exercised by those in the Blue Zones. Examples include praying, remembering ancestors, taking a nap, or even happy hour, each contributing to maintaining a healthy outlook on life and subsequent longevity.⁸

Eat Wisely: The Blue Zone Diet for Overall Well-Being

Centenarians who reside in the Blue Zones consume a primarily Mediterranean diet, which is associated with improved cardiovascular health, and decreased risk for CVD, myocardial infarction, congestive heart failure, heart valve disease, and abnormal heart rhythms.^9,10

The Blue Zone diet is exempt from refined foods. Individuals consume whole grains and natural fiber sources, often harvesting produce from their own gardens. Along with fewer animal-based foods, the typical Blue Zone diet is comprised of a greater number of vegetables, berries that are high in fiber and antioxidants, leafy greens, eggplants, nuts, Greek yogurt, and extra virgin olive oil.¹

Other fiber-rich foods consumed by those who live in the Blue Zones include up to a cup per day of a legume—beans, peas, or lentils, depending on region. In Okinawa, Japan, individuals prefer soybeans; in Sardinia, Italy, fava beans are a favorite; for those in Nicoya, Costa Rica, black beans are the lentil of choice;¹¹ and in Ikaria, Greece, the giant bean is consumed.¹²

On average, individuals in Blue Zones also consume about a handful of nuts on a daily basis. Choices such as almonds, pistachios, walnuts, and cashews are all vitamin-, mineral-, and fiber-rich (Table 1). The cardio-protective benefit of nuts was demonstrated in a study involving 31,000 Seventh-day Adventists who consumed at least four servings each week.¹³ Compared to those who consumed only one serving a day of nuts, frequent consumption resulted in a 52% reduction in the likelihood of CVD-related death, and myocardial infarctions were 49 percent less likely.

Longevity Superfoods from the World’s Blue Zones Diets

Vegetables	Fruits	Beans (Legumes)	Grains	Nuts and Seeds	Lean Protein	Daiey	Beverages	Sweeteners and Seasonings
fennel	avocados	black beans	barley	almonds	salmon	feta cheese	coffee	garlic
kombu and wakame (seaweed)	bananas	black-eyed peas	whole grain bread	walnuts	soy milk	pecorino cheese	green tea	honey
wild greens	bitter melon	chickpeas	brown rice	pistachios	tofu		red wine	meriterranean herbs
potatoes	lemons	fave bens	maize nixtamal	cashews	lean protein		water	milk
shiitake mushrooms	papayas	soybeans	oatmeal	pecans				tumeric
squash	tomatoes	other cooked beans		macadamia nuts

The time of day that food is eaten also makes a difference. Centenarians also consume most of their calories early in the day, which is associated with short-term weight loss¹¹ and cardio-protective benefits.¹⁴ The body is more efficient at metabolizing meals in the morning and early afternoon than later in the day, a pattern that aligns with circadian rhythms.¹⁴

While research is ongoing on the impact of alcohol on cardiovascular health (14), most of those living in the Blue Zones, with the exception of Seventh Day Adventists, drink 1-2 glasses of alcohol per day (preferably wine).¹⁵

Connect with Others, Environment, and Self

Blue Zone residents live with a sense of purpose, a philosophy of life that is thought to add an additional seven years to life expectancy.¹¹ Similarly, attending faith-based services four times per month may increase life expectancy by up to 14 years.¹¹ In an interview with 263 centenarians who belonged to a faith-based community, researchers found that everyone valued a sense of belonging, irrespective of denomination.⁸ This sense of belonging extends from the high value placed on aging family and friends, which is another contributing factor to their improved morbidity and mortality. In Okinawa, a group of five friends—a moai—commit to each other for life, which prevents loneliness and shapes health in a favorable manner.¹⁶

Key Takeaways: Applying Blue Zone Living to Improve Cardiovascular Health and Longevity

Even in areas of the world that are not labeled as Blue Zones, individuals can successfully start programs to manage consumption patterns and achieve cardiovascular fitness goals.^8,11 The Blue Zone Project has created case studies to identify the main factors for lifestyle changes, starting with community well-being index and community-supported metrics.⁵ Cardiovascular fitness and reduced CVD risks are possible through simple impacts on individuals consistent with guidelines from the American Heart Association.¹⁷ The key to success is to begin, take the first step, and thrive in the Zone.

Given our current reliance on modern conveniences, it may be difficult to implement all aspects of a Blue Zone lifestyle, but incorporating at least some strategies is feasible and can help improve cardiovascular health:

1. Eat the rainbow: The American Heart Association recommends eating a variety of foods to obtain the necessary vitamins, minerals, and nutrients.¹⁷
2. Integrate physical activity into lifestyle:
   a. Plant a garden—working in the garden is a great opportunity for physical activity and exercise and provides ample quantities of free and accessible produce.
   b. Discover safe routes using a bicycle or walking instead of an automobile for running errands and measure the activity using an activity tracker to see how it adds up.
   c. Walking with a friend or family member to catch up and spend time together is a great say to increase a sense of community as well as mutual support.
3. Embrace the environment: Locate parks, sidewalks, walking routes, bike trails or even affordable gyms that are conducive to exercise, especially in inclement weather. Learn how to access supermarkets with affordable healthy food options to plan ahead and avoid eating out at fast food restaurants.
4. Address stress and emotional factors: Utilize healthy strategies to manage stress:
   a. Instead of emotional eating, consider physical activity, or meditation
   b. Build a sense of community by inviting friends to be physically active, do volunteer service, or even join in a healthy meal with you
5. Aim for the right amount of restful sleep: Adequate rest and quality sleep serve as essential fuels to maintain lifestyle habits as well as benefitting heart health.

Related Resources

• Heart Healthy Toolbox
• Plant-based Diets, Cardiovascular Disease, and Healthy Aging
• Physical Activity in the Key to Healthy Aging
• Behavior Change Mini Certificate

References

1. Gupta, Gupta & Gupta. An Evidence Base for Heart Disease Prevention Using a Mediterranean Diet Comprised Primarily of Vegetarian Food [published online ahead of print, 2023 Jul 25]. Recent Adv Food Nutr Agric. 2023;10.2174/2772574X14666230725094910. doi:10.2174/2772574X14666230725094910
2. Ungvari Z, Fazekas-Pongor V, Csiszar A, Kunutsor SK. The multifaceted benefits of walking for healthy aging: from Blue Zones to molecular mechanisms. Geroscience. 2023;45(6):3211-3239. doi:10.1007/s11357-023-00873-8
3. Poulain M, Pes GM, Grasland C, et al. Identification of a geographic area characterized by extreme longevity in the Sardinia island: the AKEA study. Exp Gerontol.     2004;39(9):1423-1429. doi:10.1016/j.exger.2004.06.016
4. Buettner, D., 2024. Power 9^®: Reverse engineering longevity. Blue Zones^®.
5. Blue Zones Project, 2023. Results from case studies: Beach Cities, California, Fort Worth,Texas, Albert Lea, Minnesota. Sharecare, Inc. Retrieved on 10 June, 2024.        
6. U.S. Department of Health and Human Services (USDHHS), 2023. Physical Activity Guidelines for Americans (2nd ed.). Office of Disease Prevention and Health Promotion. (PDF)
7. Poitras VJ, Gray CE, Borghese MM, et al. Systematic review of the relationships between objectively measured physical activity and health indicators in school-aged children and youth. Appl Physiol Nutr Metab. 2016;41(6 Suppl 3):S197-S239. doi:10.1139/apnm-\ 2015-0663
8. Blue Zones, 2024. Nicoya, Costa Rica, a Latin American Blue Zone. Original Blue Zones Explorations. Retrieved on 14 June, 2024.
9. Martinez-Gonzalez MA, Gea A, Ruiz-Canela M. The Mediterranean Diet and Cardiovascular Health. Circ Res. 2019;124(5):779-798. Doi:10.1161/CIRCRESAHA.118.313348
10. Abrignani V, Salvo A, Pacinella G, Tuttolomondo A. The Mediterranean Diet, Its Microbiome Connections, and Cardiovascular Health: A Narrative Review. Int J Mol Sci. 2024;25(9):4942. Published 2024 Apr 30. doi:10.3390/ijms25094942
11. Buettner, D., 2019. The Blue Zones Kitchen: 100 Recipes to Live to 100. National Geographic Society.
12. Pieroni A, Morini G, Piochi M, et al. Bitter Is Better: Wild Greens Used in the Blue Zone of Ikaria, Greece. Nutrients. 2023;15(14):3242. Published 2023 Jul 21. doi:10.3390/nu15143242
13. Fraser GE, Sabaté J, Beeson WL, Strahan TM. A possible protective effect of nut consumption on risk of coronary heart disease. The Adventist health study. Arch Intern Med. 1992;152(7):1416-1424.
14. Young IE, Poobalan A, Steinbeck K, O’Connor HT, Parker HM. Distribution of energy intake across the day and weight loss: A systematic review and meta-analysis. Obes Rev. 2023;24(3):e13537. doi:10.1111/obr.13537
15. Kassaw NA, Zhou A, Mulugeta A, Lee SH, Burgess S, Hyppönen E. Alcohol consumption and the risk of all-cause and cause-specific mortality-a linear and nonlinear Mendelian randomization study. Int J Epidemiol. 2024;53(2):dyae046. doi:10.1093/ije/dyae046
16. Kritz M, Thøgersen-Ntoumani C, Mullan B, Stathi A, Ntoumanis N. “It’s Better Together”: A Nested Longitudinal Study Examining the Benefits of Walking Regularly With Peers Versus Primarily Alone in Older Adults. J Aging Phys Act. 2021;29(3):455-465. doi:10.1123/japa.2020-0091
17. American Heart Association, 2024. Eat More Color. Accessed August, 17, 2023.