"Blue zones" have captivated health and longevity experts. But are they real or statistical grift?

Despite significant advances in medicine, living conditions and social safety nets over time, Americans continue to lag behind in terms of health and happiness. This comes in great contrast to certain regions of the world, where modern advances have largely been thwarted by enduring native practices – practices that may, in fact, lend insights toward living not only longer, but healthier and more fulfilling lives. Perhaps, therefore, it's time to reconsider the American approach to health and wellbeing by examining places known as blue zones.

Blue zones are pockets of the world where an unusually high number of people are reported to reach the age of 100 and beyond. These centenarians don't follow fad diets, take expensive supplements or keep up with the latest health trends — they stick to what's tried and true, largely living in the same manner (and often manor) as their ancestors centuries ago. 

These so-called blue zones are scattered across the globe, spanning different cultures, environments and histories – likely ruling out the source of this phenomenon being a sole line of exceptional genetics. The five recognized blue zones of the world are Okinawa, Japan; Sardinia, Italy; Nicoya, Costa Rica; Ikaria, Greece; and Loma Linda, California.

While there's ongoing debate over what factors allow inhabitants of blue zones to live longer, numerous investigations by researchers, demographers and medical experts have revealed common threads that provide a better understanding of aging and longevity. We can start by looking at some current pitfalls in America.

During the COVID-19 pandemic, as the world was forced to grapple with the ramifications of a global health crisis, a peculiar paradox revealed itself: The modern-day lifestyle of America, with all its comforts, securities and conveniences, has left us incredibly vulnerable and perhaps even less protected than in the past when it comes to public health emergencies.

Owing to our diet and sedentary ways, the U.S. was already suffering from an epidemic of obesity when the pandemic hit. According to a National Health and Nutrition Examination Survey, more than 2 in 5 adults (and nearly 1 in 5 children) are obese. Those with comorbidities, such as obesity, fared far worse during the pandemic.

What's more, just as an official end to the COVID pandemic was being declared, U.S. Surgeon General Dr. Vivek Murthy released an advisory warning of yet another public health crisis – an epidemic of loneliness, isolation and lack of connection in the country. This is a trend that, although is an expected consequence of certain American customs, was surely exacerbated by the pandemic.

Blue zones may offer an alternative approach to living that Americans can adopt. The concept comes from the work done by Gianni Mario Pes and Michel Poulain while they were studying longevity in Sardinia. The nomenclature is in reference to blue marks they drew on a map around villages home to high concentrations of centenarians and low instances of chronic diseases. Their 2004 paper identified "a geographic area characterized by extreme longevity." The proportion of centenarians in this region is roughly three times greater than the rest of Sardinia and Italy, according to their research.

I had the privilege of visiting this unique area this summer while traveling through Sardinia. It's a region called Ogliastra in the central-eastern part of the island, which encompasses six municipalities, one of which is Baunei – a small medieval commune built into the mountainside, where I stayed for two nights. I asked my local hotel clerk Franca how the old population of about 3,500 inhabitants handled COVID.

She told me that almost everyone in the village of Baunei caught COVID at some point. Mind you, this is anecdotal and unverified – but Franca said that, to the best of her knowledge, only one centenarian died from COVID in Baunei. I then asked what the village's secret was for staying so healthy and her response was simple but nonetheless reflective of a certain kind of lifestyle: "A glass of wine everyday from our very good grapes probably helps."

According to a 2020 study on the Ogliastra region of Sardinia, "behavioral and socio-cultural factors, such as nutrition, physical activity and family support" are likely more important than purely genetic factors in terms of explaining longevity in a blue zone. Mainly engaged in agricultural activities, locals lead relatively traditional lives, with the study finding that their plant-based diet, integrated with an adequate supply of animal proteins, may be the key to maintaining optimal health and high-quality of life throughout the aging process.

Sardinia has restaurants all over the island referred to as "agriturismo," which is where local farms offer up a dining experience typically entailing a set menu consisting of only ingredients from the property. I stopped at several, and it became clear that the quality of the ingredients, without the inclusion of additives and chemicals, exceeded that of standard American cuisine.

Talking to my bike tour operator, a Venetian who lived a majority of his life in Sardinia, I received a different opinion. He reasoned that, though diet and lifestyle play a part, longevity in Sardinia is mostly thanks to genetics: "This is a resilient and tough people, especially the current generation of centenarians, who lived through hard times."

However, some scientists refer to this "toughness" as epigenetics – which is to say that behaviors and environmental factors can cause changes that affect the way our genes work. According to Blue Zones, an organization that trademarked the name and is dedicated to promoting healthy living, Sardinia was not devastated by the pandemic like the rest of Italy: "Some of the reasons [blue zone] Sardinians are able to live vitally into their 80s, 90s, and 100s may be helping them stave off COVID-19 – and sustaining them during their country's lockdown."

Older residents of blue zones rarely live alone in nursing homes, which proved to be virus hotspots in the U.S. and elsewhere. In Sardinia, multi-generational families often live under the same roof and within walking distance of each other, and the children take care of their aging parents. Research is finding that strong family and community support networks and staying active into old age while remaining a valuable member of society might alter the expression of our genes, thereby extending longevity.

Many communities within the Ogliastra region had no measurable increase in mortality during COVID in 2020 despite its high-risk elderly population. Other blue zone populations like Okinawa, Japan, and Ikaria, Greece, were also relatively unaffected by the pandemic. It should be noted, however, that all of these blue zones are on islands, providing a degree of geographical isolation against the virus; in 2021, Sardinia did get hit by a delayed wave of COVID. 

The only inland blue zone is Loma Linda, California – one of the world's largest populations of Seventh-Day Adventists. While many there claim that it's their faith that promotes healthy living, studies show that they have similar plant-based diets and outdoor- and community-focused lifestyle regiments, possibly explaining their longevity and comparatively low death rates from COVID, despite being only 60 miles east of Los Angeles.

By intertwining the principles of blue zones with the lessons learned from the pandemic, a novel perspective emerges that could reshape American lifestyles and health for the better. Dr. Peter Attia, author of Outlive: The Science and Art of Longevity, has championed a distinction between "healthspan" and lifespan.

While life expectancy has been steadily climbing in the U.S. and around the world for centuries, our healthspan hasn't been keeping up. For some perspective: in 1900, life expectancy in America was age 47, whereas today it hovers between 77 and 80 (depending on different sources). However, U.S. life expectancy dropped for two years in a row from 2019 to 2021, according to the CDC's National Center for Health Statistics (NCHS). With nearly three years shaved off of average life expectancy over this period, it was the steepest two-year decline of the century, which brought U.S. life expectancy back down to its 1996 level.

Based on the NCHS's most recent data, this dramatic fall in life expectancy was primarily due to COVID-19 and drug overdoses. While other countries also saw a dip or stagnation in life expectancy during the pandemic years, it appears the U.S. took an exceptionally hard hit. Perhaps this should come as no surprise, given that the U.S. ranks only 47th in the world in life expectancy, behind places like Italy and Japan.

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Our lifespans are contingent on our healthspans – not the other way around, according to Attia. Obesity and loneliness will likely kill us faster than advances in medicine will help us. We shouldn't seek to just live longer; we should strive to live healthier – longevity will follow from there. But American elders don't go outside or stay active throughout their life and into old age like the centenarians of blue zones. We don't have a society that fosters a feeling of purpose within the elderly population. And many Americans don't grow old because they're in poor health from an early age.

The COVID-19 pandemic should be a wake-up call. High levels of stress, sedentary behavior and poor dietary habits – staples of the modern U.S. lifestyle, whether by choice or otherwise – have likely hindered our ability to fight infections and prevent severe illnesses. Thus, the ways of old could be the best bet for growing old.

However, some researchers disagree. Dr. Saul Newman of Australian National University and now Oxford University told The Sydney Morning Herald in 2021 that blue zones were "rife with fraud, error and logical inconsistency." He pointed to areas like Okinawa, which has higher levels of clinical depression, obesity and alcohol consumption than the rest of the country, according to Statistics Japan. 

Newman claims on his Oxford staff profile that blue zones can be "predicted by an absence of birth and death certificates, higher old-age poverty rates, and (remarkably) a lower probability of reaching old age." 

I reached out to Newman for more details on the five blue zones, asking whether he thinks there's any truth to the theory that the epigenetics (diet, culture, etc.) of these regions affect longevity. His response came in five parts in support of his opinion: "The 'Blue Zones' are a feel-good grift that cherry-picks other cultures to sell books. They have no empirical support and no basis in fact."

Regarding California's blue zone, he stated, "Loma Linda has an estimated life expectancy of only 77.6 years — lower than the life expectancy of around fifty countries, and lower than the California average." His statistics come from the Robert Wood Johnson Foundation and Centers for Disease Control and Prevention (CDC).

On Greece, referencing a 2012 Reuters article, Dr. Newman said, "Some 200,000 Greek pensions were fake, including at least 72% of centenarians that disappeared between the 2012 census and the 2013 investigations of pension fraud." It should be noted, however, this information is not specific to the blue zone region in question, Ikaria.

Turning to Nicoya, Costa Rica, Dr. Newman continued, "The Costa Rican blue zone is a non-standard statistical region with scant information available (and is therefore probably the most defensible, as there is not enough data to puncture the nonsense). But in the 1984 census, 50% of 80+ year olds had faked their age and in the 2000 censuses, 42% of 99+ year olds were discovered to be faking their ages." This information came from this 2019 study in the journal Demographic Research covering age exaggeration.

As for Sardinia, he indicated that "Eurostat, the statistical branch of the EU, ranks the Italian blue zone as only the 12th-longest-lived region of Italy … The official data from the EU offers absolutely no support for extreme longevity."

The region of greatest controversy seems to be Okinawa, Japan. According to Newman, "Seven years after Okinawa was designated a blue zone, 230,000 (82%) of the centenarians in the country were revealed to be undetected fakes. They were missing or dead." Again, it should be noted that these statistics pertain to Japan as a whole and not a specific region.

Based on Japanese Government data, which tabulates one of the largest nutritional surveys in the world, he went on to say, "Okinawa consistently has the least vegetarian and least healthy diet of any province … and that it also has the highest female BMI and second-highest male BMI in Japan.

Moreover, Dr. Newman pointed to the World Happiness Report, which placed Japan at 47th in the world for happiness, and rates of depression in old people in Okinawa. "They have about-average-happiness in a moderately unhappy country."

Blue Zones (the organization) refuted this data. Its founder Dan Buettner now has a new Netflix series out that highlights the benefits of blue zone practices. I caught up with Buettner, who's a National Geographic Fellow and bestselling author, while he was on assignment in Japan. I asked him to respond to Dr. Newman's criticisms.

For Okinawa, Buettner directed me to Dr. Craig and Bradley Willcox and Professor Makato Suzuki of the Okinawa Research Center for Longevity Science, as they provided the demographic work and did the record verification there. Buettner told me, "I just saw data from the Japanese government and in the age group of people over 90, Okinawa is still number one."

However, Buettner did agree that Okinawa should no longer be considered a blue zone, "But where [Dr. Newman] is wrong: In 1999, when I started there, Okinawa was producing the longest living humans in the history of the world. Since then, the influence of the U.S. naval base and the forest of fast food restaurants and the highways that now criss-cross Okinawa have brought the American way of living and with it comes chronic disease, and they're the least healthy prefecture in Japan right now."

I asked a spokesperson for the Okinawa Research Center for Longevity Science to comment on this and was told: "The number one reason Okinawa's longevity is decreasing is because of the lack of education, which cannot win against heavy Western influence … The older grandmothers and grandfathers are not teaching their children or grandchildren how to make traditional food recipes, what to eat, why they should eat it … The longevity lifestyle is still alive and well among older Okinawans — it is just not being promoted."

Buettner has written and spoken publicly about Okinawa's tragic decline, explaining, "Mortality is still really low among people over 90 in Okinawa because they don't change their habits, but middle-aged people are the worst. Okinawans are the unhealthiest people in all of Japan, and when they move through the next decades, you're going to see they're the ones that are dying the quickest, but that's because things have changed."

Buettner went on, "Saul has never been to a Blue Zone. He's never gone into a municipal hall to look at the birth records. Not only in Okinawa, but in the other blue zones, [Gianni Pes and I] also went to the churches and looked at the birth and baptismal certificates …  Pes has published papers on the painstaking work they did to verify ages in Sardinia."

The outlook for blue zones around the world is not promising, Buettner told me. "They're all eroding. I think they'll all be gone in a generation, quite honestly. As soon as the standard American diet comes in the front door, longevity goes out the back door … As soon as the cars come and the chips and the sodas and processed food replace the beans and tortillas in Nicoya or the tofu and the sweet potatoes in Okinawa or minestrone in Sardinia – and young people aren't eating that way for the most part – they'll end up looking like the rest of their country, longevity-wise."

I asked Buettner if he thought implementing blue zone practices in America would be feasible, which took the conversation in a more positive direction. "Singapore is the 2.0. I didn't rely on the old demographic work. I partnered with the IHME [Institute for Health Metrics and Evaluation] at the University of Washington, which is a consortium of about 1000 scientists worldwide. And they told me that Singapore produces the longest health adjusted life expectancy in the world. And this is a really interesting metric because it measures not only years of life but expected years of life in full health … Singapore has seen life expectancy go up by about 20 years in one lifetime. These other blue zones took centuries or millennia to evolve. But here's one lifetime and it's very clear that the reason they're living a long time is because Lee Kuan Yew and his government realized that their number one resource was human beings and they went about passing policies that favor the health and wellbeing of humans."

Buettner elaborated on how Singapore places a massive tax on cars, thus incentivizing a highly efficient public transit system. "Nobody's more than 300 meters away from a subway … and people are getting 7,000 or 8,000 steps a day without thinking about it. So it's no coincidence that their rate of obesity is 6%. They've had the courage to tax sugar, which America doesn't have, even though almost 75% of us are overweight."

"Singapore, it's a 2.0 that we ought to be paying attention to," he continued, "that's where the excitement is … The Saul Newmans of the world can find ways to poke holes, but it's not where I want to spend my time." 

Just as Singapore is a diverse city, Buettner explained how American cities could follow suit. "If we shifted our focus to setting up an environment where people don't get sick in the first place, it would have good impacts on America … My day job for the past dozen years has been working with cities and helping them lower their obesity rate, thereby their chronic disease."

Regarding policies, he said, "We have to look at it through the lens of prevention. It can't be the lens of behavioral change. I know of no place in the world where you can get an entire population to change its behavior." 

Buettner suggested that we need policies like those in Singapore "that create an environment where it's easy, cheaper and more delicious to eat that way [healthy]. And people will unconsciously do it. That's the big idea. The same goes for walkability." 

If we had cities where walking was easier and more commonplace, then Americans would get their steps in without thinking about it, he concluded. "Only about 24% of Americans get the minimum amount of physical activity, which is 20 minutes a day. It's ridiculous. So that means over 75% don't even get 20 minutes a day. What we're doing is not working." 

While the blue zone debate remains open-ended, using a blueprint based on blue zone best practices when designing cities and environments could promote active lifestyles, such as walkable neighborhoods, green spaces and communal areas – with certainly little downside to this. And by improving our diet, building a stronger sense of community and seamlessly exercising during daily routines, we would almost certainly advance physical and mental health in America.

A shift toward preventive health care, rather than the drug-fueled reactive healthcare system we currently have in the U.S., is imperative if we are to improve health and longevity – regardless of blue zone legitimacy. To fully realize this vision, policy changes and educational campaigns need to emphasize and incentivize nutrition and exercise. This blue zone paradigm, as it were, would likely mitigate the impact of future and ongoing health crises.