Key Takeaways

• Hong Kong's life expectancy is estimated at 87.8 years for females and 82 years for males by World Population Review, 83.61 years by the Central Intelligence Agency, and 85.5 years by United Nations.
• The average life expectancy in Japan is around 84.67 years based on World Population Review's data, 84.83 years as per the Central Intelligence Agency, 84.26 years as per the World Health Organization, 84.8 years as per United Nations, and 85 years as per Statista.
• The average life expectancy in Spain is 83.612 years as stated by the World Population Review, 83.22 years as reported by the World Health Organization, and 83 years, according to United Nations.
• According to an article published in the Journal of Internal Medicine, a meta-analysis of 29 studies found that stricter adherence to the Mediterranean diet was associated with a 10% decrease in mortality.

Introduction

Countries With the Highest Life Expectancy

• Although sources differ in their life expectancy estimations for different countries, Hong Kong, Japan, Switzerland, Singapore, and Spain are the most commonly listed in the top five across a variety of prominent sources. Brief summary of the available figures for the two countries that aren't included in the overview can be found below.
• Switzerland's life expectancy is estimated at 83.84 years by World Population Review, 83.45 years by the World Health Organization, 84 years by United Nations, and 83 years by Statista.
• Singapore's life expectancy is about 83.662 years as per World Population Review, 86.25 years as per the Central Intelligence Agency, 83.22 years as per the World Health Organization, 82.8 years as per United Nations, and 84 years as per Statista.

Overviews

1. Hong Kong

• Hong Kong's life expectancy is estimated at 87.8 years for females and 82 years for males by World Population Review, 83.61 years by the Central Intelligence Agency, and 85.5 years by United Nations.
• According to researchers, Hong Kong has a high life expectancy because of economic prosperity, lower overall disease rates than other nations, remarkably low levels of smoking (prevalence rate of 9.5% in 2021), low maternal and infant mortality rates, and universal health coverage.

 

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• The article published in The Lancet Public Health states, "Hong Kong's leading longevity is the result of fewer diseases of poverty while suppressing the diseases of affluence." The authors believe that the model could be replicated in other developed and developing countries.
• The leading causes of death in the country in 2021, excluding those directly related to aging, were pneumonia (132.6 deaths per 100,000 people), and external causes of morbidity and mortality (26.7 deaths per 100,000 people).
• The last available data on the leading external reasons is from 2020. In that year, 50% of such deaths were connected to intentional self-harm, with two other leading causes being falls and accidental poisoning. However, in 2022, suicides became an even bigger issue, due to social isolation caused by the pandemic and the unavailability of recreational facilities.
• Notably, despite rapid economic development and universal health coverage, overall, Hong Kong spends significantly less on social and health care expenditures as a share of its gross domestic product when compared to other nations (nearly 7% vs. 19.7% in the United States).

2. Japan

• The average life expectancy in Japan is around 84.67 years based on World Population Review's data, 84.83 years as per the Central Intelligence Agency, 84.26 years as per the World Health Organization, 84.8 years as per United Nations, and 85 years as per Statista.
• Primarily, Japan's high life expectancy is the result of "fewer deaths from ischemic heart disease", along with fewer deaths caused by various cancers, especially prostate cancer and breast cancer, as compared to other nations. According to Dr. Martin Juneau, the Japanese consume less red meat, while consuming considerable amounts of plant foods (e.g., soybeans, tea) and fish. As a result, it has a strikingly low obesity rate, which is just 3.7% for females and 4.8% for males.
• Below is a comparison of the volume of different food items consumed per capita between select countries in the year 2013.

 

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• Also, the government invests heavily in public health and has introduced universal health insurance. In addition, people in Japan are remarkably active, even older individuals.
• Two of the leading causes of death in the country that are not directly related to aging are lower respiratory infections (85 deaths per 100,000 people) and self-harm (15.40 deaths per 100,000 people). Suicide has been a major social issue in Japan throughout the years, with the top reason among males being economic struggles. It is also worth noting that the problem was often not sufficiently addressed due to social stigma, though in recent years, policies have been introduced to reduce the suicide rate.

3. Spain

• The average life expectancy in Spain is 83.612 years as stated by the World Population Review, 83.22 years as reported by the World Health Organization, and 83 years, according to United Nations.
• Spain has a high life expectancy due to the fact that many of its citizens follow a Mediterranean diet that "is rich in healthy fats", according to the World Population Review. This diet also involves the consumption of copious amounts of fish and vegetables.
• According to an article published in the Journal of Internal Medicine, a meta-analysis of 29 studies found that stricter adherence to the Mediterranean diet was associated with a 10% decrease in mortality.
• Furthermore, citizens in Spain have access to a universal healthcare system and 13,122 primary care facilities.
• Two other potential reasons for a longer average lifespan in Spain are a sociable lifestyle and getting plenty of sunshine.
• Among the leading causes of death, only lower respiratory infections (29 deaths per 100,000 people) are not directly related to aging.
• However, suicide has been a growing issue in the country, with suicidal ideations nearly doubling between 2020 and 2021. In 2020, the number of suicides was 3,900, the highest ever in Spain's history. The growth can be attributed to a range of factors, including economic struggles, the pandemic, loneliness, and exposure to violence through technology, among others.

Research Strategy

Key Takeaways

• Blue Zones are basically areas of the world with the most number of centenarians or the world's oldest people and "in which people live exceptionally long lives."
• There are three criteria for identifying blue zones. They are based on the demographics of a given country, as well as the availability and reliability of the appropriate data/documentation.
• Dan Buettner and his team of medical researchers, anthropologists, demographers, and epidemiologists studied the population of all the identified blue zones. They wanted to understand what they were doing differently, and in particular, their lifestyle and habits.
• They identified nine evidence-based common denominators among the longest-lived people across the blue zones and dubbed it "the Blue Zones Power 9." They are related to outlook on life, diet, physical movement, and personal connections.

Introduction

Overview of Blue Zones

Definition of Blue Zones

• Blue zones were borne from the demographic idea, concept, or work developed by Gianni Pes and Michel Poulain, where both researchers sought to identify the areas of the world with the most concentrations of men who are 100 years of age.
• Starting with Sardinia in Italy, they identified these areas or regions, drew concentric blue circles on the map to highlight them, and then began to refer to these circled areas as the blue zones.
• Dan Buettner, Blue Zones founder, further identified other areas of longevity based on the work of Pes and Poulain and also called them 'blue zones.'
• Based on this, blue zones are basically areas of the world with the most number of centenarians or the world's oldest people and "in which people live exceptionally long lives."
• According to a journal published by Aging Clinical and Experimental Research, "the researchers defined blue zones as limited geographical spots characterized by the highest prevalence of centenarians, where a very traditional lifestyle is conducted and where inhabitants primarily consume local products that usually are cultivated or raised by consumers."

List of the Five Current Blue Zones

• Gianni Pes and Michel Poulain identified the first blue zone in Sardinia in Italy, among others. However, Dan Buettner and his team of demographers and researchers completed the identification and curated a list of all blue zones. They include:
•  Sardinia, Italy: "The Barbagia region of Sardinia is a mountainous highland of inner Sardinia with the world’s highest concentration of male centenarians."
•  Okinawa, Japan: "In Okinawa, females over 70 are the longest-lived population in the world."
•  Nicoya, Costa Rica: "The Nicoya Peninsula has the world’s  lowest rates of middle-aged mortality and the second highest concentration of male centenarians."
•  Ikaria, Greece: "The Aegean Island has one of the world’s lowest rates of middle age mortality and the lowest rates of dementia."
•  Loma Linda, California. "Loma Linda (the Seventh Day Adventist) has the highest concentration of centenarians, who generally live 10 years longer than their North American counterparts."

 

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Criteria for Identifying Blue Zones

• There are three criteria for identifying blue zones. They are based on the demographics of a given country, as well as the availability and reliability of the appropriate data/documentation.

• Criteria 1: The reliability of how long individuals in a given area live, including the ages of the oldest persons - dead or alive, must be comprehensively proven and ensured based on the required documentation, like birth and death records and continuous population registration systems.
• Criteria 2: "The longevity of the population at a national level should be among the highest-ranked at the world level based on demographic indicators, including life expectancy (computed both by period and cohort), population age, and sex structure as observed in censuses."
• Criteria 3: If Criteria 1 and 2 above are met, the area may be then be certified as a 'Blue Zone' within the country as a spatial or geographic collection of the local administrative entities where higher longevity of the population is statistically observed compared to the rest of the country. Statistical observations are based on various demographic indicators each for males and females, such as the life expectancy at birth and the probability to survive from 50 to 80, among others, as available.

Shared Characteristics of the Blue Zones

• Dan Buettner and his team of medical researchers, anthropologists, demographers, and epidemiologists studied the population of all the identified blue zones. They wanted to understand what they were doing differently, and in particular, their lifestyle and habits.
• They identified nine evidence-based common denominators among the longest-lived people across the blue zones and dubbed it "the Blue Zones Power 9." The infographic below shows a summary of this Blue Zones Power 9.

 

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• The Blue Zones Power 9 is categorized into four buckets: Move, Right Outlook, Eat Wisely, and Connect.
• Move: The world’s longest-lived people move naturally rather than run marathons or go to the gym.
• Right Outlook: People in blue zones know and understand their sense of purpose in life. They also have dedicated time and routines to unwind or shed stress - for example, by taking a nap and praying.
• Eat Wisely: These people implement the 80% rule, which dictates that they "stop eating when their stomachs are 80% full, as the 20% gap between not being hungry and feeling full could be the difference between losing weight or gaining it." Their diets are mostly beans, and soy, among other similar legumes or proteins, while their average pork consumption is 5 times monthly. They drink alcohol moderately and regularly, drinking 1-2 glasses per day.
• Connect: The world's longest-lived people belong to faith-based communities and social circles that support healthy behaviors, and they put their families first.

Blues Zones Growth Expectations

• Based on publicly available information, it's not explicitly clear if blue zones are expected to grow in other areas of the world or if existing ones may shrink. Additionally, Blue Zone, as the pioneer and leading private organization of the initiative, has not updated the list or simply may not be interested in doing so at this time, as there are no announcements or published plans in that regard.
• However, Accuweather published a list of places with the greatest number of people over 100 years. The list featured the blue zones and additional regions, including Georgia in Eurasia, Bama County in China, and Hunza in Pakistan.
• They also published a list of five countries where people tend to live longer based on population and life expectancy. The list includes Monaco, Japan, Singapore, San Marino, and Iceland. These suggest that there may be more blue zones coming up.

 

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• Lastly, more blue zones may be identified over time in the future, as "Dan and Blue Zones are now committed to creating healthy communities across the United States based on their Power 9 findings. The first effort, in Albert Lea, Minnesota, was a “stunning” success, and formed the blueprint for the Blue Zones Projects" - as per Blue Zones.
• The Blue Zones Projects, based on the insights gathered from the original blue zones, "are helping people live longer and better through community transformation programs that lower healthcare costs, improve productivity, and boost national recognition as great places to live, work, and play."
• The projects focused on improving street and park designs, public policy, and social involvement so that people can easily make healthy choices. "Other areas of focus include the optimization of city streets (smoking policies, bike lanes, sidewalks), public spaces (parks, lakes, walking paths), schools (cafeterias, safe walking paths to school), restaurants, grocery stores, employers, faith-based organizations, and community involvement.

 

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• Lastly, the successes recorded in the three communities where the initiative was implemented, such as significant reductions in smoking, obesity, and overweight, among others, suggest the proliferation of the blue zones concept. However, it is unclear whether and when it could translate into actually forming new blue zones.

Research Strategy

Key Takeaways

• The most mentioned risks of consuming unprocessed and ultra-processed food included obesity and overweight, as higher consumption levels of ultra-processed foods correspond to and account for higher percentages of calories from added sugars and carbohydrates while fiber, protein, and vitamins remain at lower levels.
• Ultra-processed food now contributes the majority (about 58%) of all energy equivalent in the average US diet. However, diet, or rather, poor diet, which ultra-processed food is known for, is a major modifiable risk factor for heart disease.
• Studies conducted by researchers on the contributions of ultra-processed foods to CVDs, such as heart attacks, coronary diseases/death, and stroke, showed that "participants with the highest intakes of ultra-processed foods had higher incident rates of CVDs compared to those consuming the least amount of ultra-processed foods."
• Studies have linked the consumption of processed and ultra-processed food to colorectal cancer in men and women, as one particular study that examined the diet of over 200,000 Americans found such an association, where all types of ultra-processed foods had marginal contributions.

Introduction

Impact of the American Diet on Overall Health

#1: Obesity and Overweight

• There has been a significant shift in the diet of Americans, as studies and reports reveal that "the consumption of ultra-processed foods has increased over the past two decades across nearly all segments of the US population" — children and youths inclusive.
• These shifts have raised health concerns on how the trend may lead to chronic diseases, such as an obesity epidemic, as it's widely studied, reported, and known that such types of industrially manufactured food include chemical additives and are directly associated with obesity, weight gain, and overweight.
• The most mentioned risks of consuming unprocessed and ultra-processed food included obesity and overweight, as higher consumption levels of ultra-processed foods correspond to and account for higher percentages of calories from added sugars and carbohydrates while fiber, protein, and vitamins remain at lower levels. Hence, they gain more weight.
• A study conducted by researchers at the National Institute of Diabetes (NIH) and Digestive and Kidney Diseases (NIDDK) examined two groups of Americans that ate either ultra-processed food or minimally processed food. They found that "people ate about 500 calories more per day on the ultra-processed diet (from carbohydrates and fat) than they did on the minimally processed diet. They also ate faster on the ultra-processed diet and gained 2 pounds on average. However, when they were on a minimally processed diet, they lost about the same amount of weight."

 

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• Overweight and obesity increase the risk for many other health problems, such as cardiovascular diseases like high blood pressure, heart disease, and stroke; some types of cancer; and joint problems; among other conditions.

• According to the Lancet, the US has the highest chronic disease burden and an obesity rate of 40%, which is two times higher than the OECD average (OECD — the Organization for Economic Co-operation and Development is an intergovernmental organization with 38 member countries).

 

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• Italy reportedly has the lowest percent energy intake from ultra-processed food (10%), even relative to most OECD countries, including the US. While only about 1 in 10 people have obesity in Italy, more than 2 in 5 people (42.4%) have obesity in the US.

#2: Cardiovascular Diseases (CVDs)

• Ultra-processed food now contributes the majority (about 58%) of all energy equivalent in the average US diet. However, diet, or rather, poor diet, which ultra-processed food is known for, is a major modifiable risk factor for heart disease.
• "Cardiovascular diseases (CVDs) are the leading cause of death for men, women, and people of most racial and ethnic groups in America," as the CDC reports that one person dies every 34 seconds.

 

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• With processed and ultra-processed food, the physical food structure and beneficial nutrients, which are mostly naturally occurring, are usually lost while non-beneficial nutrients and food additives are usually added during processing. Consuming these food items can cause adverse health/cardiovascular outcomes, such as high blood pressure and metabolic syndrome, among others.
• Studies conducted by researchers on the contributions of ultra-processed foods to CVDs, such as heart attacks, coronary diseases/death, and stroke, showed that "participants with the highest intakes of ultra-processed foods had higher incident rates of CVDs compared to those consuming the least amount of ultra-processed foods."
• Additionally, they found that "each daily serving of ultra-processed food was associated with a 7% increase in the risk of hard CVDs (sudden and non-sudden coronary death, heart attack, and fatal/non-fatal stroke), a 9% increase in the risk of hard coronary heart diseases (sudden and non-sudden coronary death and heart attack), a 5% increase in overall CVD, and a 9% increased risk in cardiovascular disease deaths."

 

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• Consumption of ultra-processed food subgroups, such as bread, was linked to an increased risk of hard CVDs, coronary heart diseases, and CVDs in general. Salty snack foods were linked to an increased risk of hard CVDs and coronary heart diseases, while low-calorie soft drinks were linked to an increased risk of CVDs.

• Another research on dietary fats, blood pressure, and artery health suggests that industry seed oils that contain linoleic acids may be linked to an increase in blood pressure and cardiovascular disease/mortality.
• Spain is reported as one of the countries with lower energy intake from ultra-processed food than the US.
• "CVD was the leading cause of death in Spain in 2018, accounting for 28.3% of all deaths registered (crude mortality rate, 258.6 deaths/100,000 population)," according to a study published in Revista Española de Cardiología.
• In the US, about  697,000 people died of heart diseases, which accounted for 1 in every 5 deaths. The mortality rate is 211.5 per 100,000 population.

#3: Colorectal Cancer

• Colorectal cancer is the cancer of the colon or rectum — depending on where the cancerous cells originate from. It is the third-most diagnosed type of cancer and the third leading cause of death from cancer in men and women in the US in 2022, as per estimates released by the American Cancer Society.
• Studies have linked the consumption of processed and ultra-processed food to colorectal cancer in men and women, as one particular study that examined the diet of over 200,000 Americans found such an association, where all types of ultra-processed foods had marginal contributions.

 

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• The researchers found that men who fall under the top 20% of ultra-processed food consumers had a 29% higher risk of developing colorectal cancer than those in the lowest 20%.

 

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• Furthermore, they found that the association remained despite having adjusted for each participant's body mass index or dietary quality, which translates that body mass index or dietary quality doesn't impact the risk of colorectal cancer for consumers of ultra-processed food.
• "American women were only found to have a higher risk for colorectal cancer if they consumed more a subgroup of ultra-processed food, which included ready-to-eat-or-heat dishes, such as pizza, which may relatively be less frequent in real terms compared to men, who were found to be more likely to have a higher risk of bowel cancer if they ate a lot of meat, poultry, or seafood-based ready-to-eat products and sugar-sweetened beverages," according to CNN.

• The Netherlands is another country with one of the lowest percent energy intake from ultra-processed food, lower than the US.

• However, while the incidence of colorectal cancer in the US is 36 per 100,000 persons, as per the CDC Cancer Visualization database (with Cancer Type filter set to 'Colon and Rectum'), it is higher in the Netherlands (41 per 100,000 men and women).

Research Strategy