Maya Adam:

Welcome to Health Compass. I'm your host, Maya Adam, director of Health Media Innovation at Stanford Medicine.

David Rehkopf:

Sometimes people think, oh, it's just about living to 100 or living to 105, but these folks are living well to those ages, which is something as I've studied aging. And one of the reasons I'm interested in aging is not just of course, how long you live, but really more importantly, the quality of life.

Maya Adam:

Today we're talking about something we all have to deal with, inevitably aging. As someone who's already starting to send kids off to college, I'm definitely entering a new phase of my own life. And healthy aging is something I think about a lot. I still feel young at heart and I still have big dreams for the future. So I've been wondering to what extent is aging something that's in our own hands? How do our behaviors and actions, even the people we surround ourselves with, how does that affect how we age? Today I'm joined by David Rehkopf, a social epidemiologist whose research specializes in aging and longevity. In particular, David's work focuses on places known as Blue Zones, areas in the world where people tend to live extraordinarily long lives. So what can we learn from these places? David, I'm so looking forward to digging into that question with you. Thanks so much for joining me.

David Rehkopf:

Ah, thanks for having me.

Maya Adam:

Before we start talking about Blue Zones, David, I'm wondering if you can tell me a bit about how you got into this line of work?

David Rehkopf:

Yeah, happy to. Yeah, I think most people, most kindergartners don't think they want to be a social epidemiologist when they grow up. 

Maya Adam:

So start by telling us what is a social epidemiologist?

David Rehkopf:

Yeah, sure. So a social epidemiologist is someone who studies how social and economic environments affect people's health, and they use the kind of quantitative mathematical tools of epidemiology to look at how those kind of exposures affect people's health.

Maya Adam:

And how did you get into this field?

David Rehkopf:

Yeah, so I grew up in Washington state and I spent a lot of time in rural areas. I did a lot of camping as a kid with my family and with Boy Scouts, and I just saw a lot of places around the state. And I think one of the things that hit me as a young kid was just how different those places were and how different people's lives were in different parts of the state. I think in particular, I spent a lot of time hiking near tribal lands on Native American reservations, the Quileute, the Quinalt, there's like 29 recognized tribes in Washington state. And I remember some of those places where I went seeing just amazing architecture, the longhouses amazing places, and really vital thriving communities. And then there were other places around the state, other Native American reservations where they weren't thriving and when there was really high poverty. And so I just saw those kind of differences and I think they were in the back of my mind as a kid. And so as I developed my academic interests and had a few other experiences, just sort of got interested in trying to understand why that was.

Maya Adam:

And David, so you've spent a lot of time in these blue zones. Can you tell us a little bit about these parts of the world and what makes them special and what are the real estate prices like there in case we all want to move there?

David Rehkopf:

Well, interestingly, the real estate prices are pretty low. They don't tend to be expensive areas or very developed areas. So there's a few things that are in common. They tend to be sort of more rural. They tend to not have a super high fast pace of life, and people tend to be very active. They have sort of close communities, and so they tend to be more isolated populations, either an island or somewhere up in the mountains. And so yeah, a few attributes like that they have in common.

Maya Adam:

So David, tell us a little bit more about what it's like to be there.

David Rehkopf:

So the one where I've done the most research on is the Blue Zone in Costa Rica in Nacoya. And I traveled around meeting with people who were in the areas that I study. So part of what I do is I just have data that we've collected that's sort of anonymous, but then I've also gone to visit there myself. And it definitely strikes you as a place where things slow down a little bit. There's a lot of places in the world that are like that, but definitely slower. And then again, there's kind of sweet spot where a lot of the western diet fast food things haven't come in yet. So there were no sort of convenience stores, no chain stores.

The other thing about them that was notable is that the way people moved around, so people walked, people moved naturally. Some of the things that just have stuck in my head was the number of folks who were older. And by older, I mean in their nineties or over a 100 who I saw out working in their garden, sweeping their porch out there all day long, being pretty active. So sometimes people think, oh, it's just about living to 100 or living to 105, but these folks are living well to those ages, which is something as I've studied aging. And one of the reasons I'm interested in aging is not just of course how long you live, but really more importantly, the quality of life.

Maya Adam:

That's interesting. It also makes me wonder about the value of being useful, whether there's almost a longevity promoting benefit of having a role to play in the household, like sweeping the porch or looking after the grandchildren.

David Rehkopf:

Yeah, I think that's very important. So that seems to be consistent across the blue zones. And then I'll also say in other research I did just in the US, just in the general population, having sort of a sense of purpose came up as one of the top 10 predictors of living longer and having a longer life expectancy. So it's something that compared to diet and exercise, we don't have as much data on, but there's information from the blue zones and then from a few studies and emerging information that is pretty important.

Maya Adam:

So David, what would a day in the life of someone in Nicoya look like? Let's say an older person,

David Rehkopf:

It's a pretty fantastic average day. They're spending time with friends, spending time with your family, doing some household chores, spending a lot of time cooking. What I saw was not buying a lot of prepared foods, having a few hours sometimes to cook, but cooking with family and friends, so having as a social activity and then walking places. So I met a lot of people that would, even if it was a few miles away or a mile away, maybe they didn't have a car but would walk over to their family's house or friend's house. And so we've also done some research about those kind of social connections and how people who lived in terms of telomere length, and we could talk about that later, but some of the biological changes that we saw, people didn't have those biological advantages or those positive changes if they were socially isolated. So to me, that tells me that something about how connected people are to other people in koya was really important.

Maya Adam:

So would you say, I know it's difficult to say, but would you say that the social connections, the social behaviors are kind of the secret sauce or is it the food intake or is it genetics or a combination of all of those?

David Rehkopf:

Yeah, I would say it's definitely a combination of all of those things that come together, but I think the social connections can be reinforcing of positive diet, positive physical activity, positive emotion. There's a lot of research, and this is just kind of common sense as well, that if you are in an environment that has a lot of negative influences on health, everyone around you is not eating well, everyone around you is really sedentary and you're connected with all those people, that might not be a good thing. But the fact that folks there have the positive diet, the physical activity, that people are more active and then are connected with each other, all of those things really kind of benefit each other and reinforce each other, I would say.

Maya Adam:

And David, if you took someone hypothetically, or maybe you have studied this as well, somebody who let's say lived or was born in one of these blue zones and then got a job in a corporate Manhattan type of setting, what happens to that kind of person?

David Rehkopf:

For the most part, people tend to sort of take on the health profile of the place where they move to. So you bring a little bit with you, maybe you're a little bit better off, but for the most part, people are pretty adaptable in good and bad ways to sort of new environments, and that's a positive thing. So if we make environments better and healthier for people, people can get healthier, but it also can go the other way that you mentioned.

Maya Adam:

That's interesting. So I wonder then about how much the culture is actually also contributing to this protective influence that we're seeing in these zones. Would you say that that's a big part of the equation?

David Rehkopf:

Yeah, yeah, it absolutely is. So all of those things come together and they come together in somewhat unique ways. I mean, there are differences between the blue zones or sort of high longevity areas, but there is something sort of overall in those places that kind of continues over time. There are some concerns about some of the blue zones that may be ending in terms of western diets coming in or that culture changing or modernization, that not all modernization is bad, but the type of modernization that's detrimental to health in particular, sort of in the type of food people eat and how active they are.

Maya Adam:

So David, I'm curious about what it was like to be welcomed into these blue zones as a foreigner to the area. Did you feel welcomed right from the beginning? What was that experience like?

David Rehkopf:

Yeah, I mean I did, I think the first blue zone that I went to was in Sardinia in Italy. And the folks there were very proud. They knew about the research. So a lot of the folks that we met with and knew about Dan Buttner's work, and they were really proud of what they had done and what they had there. And so they were proud of their culture or proud of their way of life. And so we're excited that scientists were finding that and not just doing a typical scientific study about risk factors and what harms you, but I think flipping it on the positive side and saying, what are the things that are beneficial? What are the things that we can learn from? So they were the folks that I met there were excited to share and excited that other people could learn from them.

Maya Adam:

It reminds me, I'm just thinking as you talk about extreme longevity. My late grandmother lived to be 107 years old, and she died just over a year ago. I remember in her nineties when I would ask her, even when she was in her late nineties, I would ask her, how are you doing? And she would say, so far, so good. And when she turned a hundred, I asked her what's the best part of being a hundred? And she said to me, there's no peer pressure. So she had this amazing sense of humor and I'm wondering how much a person's attitude, maybe a sense of humor or that sense of not taking oneself so seriously could be a contributor. Did you see that sort of mindset in these communities?

David Rehkopf:

Yeah, absolutely. I definitely saw that and the people that I talked with both in Sardinia and in Costa Rica. And I would say that's another thing that comes out from some of the other studies that I've done too. And we've used something called negative affect, which is sort of the opposite of that, which is anything that happens having negative framing around that, which we found detrimental to longevity. And so it makes sense that the opposite would be true. And then other literature and psychology, I think that would support that too.

Maya Adam:

Okay, let's do it. Let's dig into the biology a little bit and I will try and follow you. Can you tell us a bit about how these behaviors and this culture and this environment can actually affect the physiology of the residents of these blue zones?

David Rehkopf:

So the social environment gets translated into an economic environment, ways we behave our mental state, and that in turn can affect things in the body. And so it becomes sort of another way to tell the story rather than just, so I think it's super important to just ask people how they're doing. Do they overall feel good? There's a lot of quality of life measures, but that might not capture the full story. And there may be changes, good or bad within people in terms of their biology. And so it's not just people saying they're doing better, but also we see some sort of underlying patterns. And the one thing that we looked at a few times was telomere length. So there'd been a number of studies showing that telomeres, which are repeated sequences at the end of chromosomes, that they degrade faster and result in cell death among people who are very, very stressed.

And so folks have talked about it as sort of a biomarker of stress to sort of capture that. So in addition to what people report, so even if you thought you felt fine or were in denial about your level of stress, we can sort of capture it from looking at telomere length and just sort of the average across cells. And so we saw differences in the Nicoya region, the blue zone of Costa Rica as compared to the rest of Costa Rica. So Costa Rica already overall is a very healthy country with a really long life expectancy and for some age groups better than the US actually. But then in Nicoya it's even better, and we found sort of longer telomere length in Nicoya.

Maya Adam:

So if you had to summarize, given all the social things you've seen and the biological markers you've examined, if you had to summarize what this magic formula is for us, how would you summarize it?

David Rehkopf:

Yeah, I think the magic formula is being in a place that really supports you doing things that are good for your wellbeing and your health, if that makes sense. I think the people in Nicoya or other blue zones, and maybe your grandmother was like this, they're not trying real hard every day to be healthy. They're kind of being who they are and living their lives and they happen to live in a place that really supports that. And so I think it's a really important information and message for public health and medicine to think about how we create these places that just make it easy for people to be healthy and that you don't have to try and you don't have to think, I got to get to the gym in 10 minutes. I got to cook a healthy dinner. I got to rush around and end up more stressed than you would be otherwise. I think to answer your question, I think that the kind of exciting thing about Blue Zones and then the work I do in social epidemiology is thinking about how we create these places that help people be happier and healthier.

Maya Adam:

And David, just because I love talking about food, tell me about the average diet. I'd love to dig into this kind of healthier behaviors so that we can maybe sort of try and adopt some of these healthier behaviors ourselves.

David Rehkopf:

Yeah, so the things we see, the number one thing is not a lot of processed foods, definitely not fast foods, but definitely not a lot of processed foods. Well, a balance between a lot of vegetables, smaller amounts of meat. So generally, I'm not sort of a dietary researcher, so don't want to speculate too much about that, but at least that's what I've seen when I've been there.

Maya Adam:

Yeah, no, that's what I'm asking, what you saw when you were there.

David Rehkopf:

I love food too.

Maya Adam:

It sounds very healthy. It sounds very healthy, so excellent. So David, how have you changed the way you live your life after having visited these regions?

David Rehkopf:

Wow, that is a great question. I would say I was always a pretty active person, but I've kind of tried to build that more into my life. So for me, the version of that is instead of driving to work the 20 minutes riding my bike, the 30 minutes, it's like an extra 10 minutes, just bike commuting in. I mean, I did that a little bit before, but just sort of realized, yeah, that's something that's kind of automatically built into my day. Once I'm at work and I'm really tired and I need to get home, I still need to ride my bike home, so I'm going to do it automatically. So I'd say on the physical activity side, it's trying to build that in a little more naturally has been one of the lessons I've taken personally.

Maya Adam:

And what about stress management? Have you changed your ways to become more like a blue zone dweller?

David Rehkopf:

I wish I could say that. I think it's a great example of if you're in an environment that is asking a lot, expecting you to do a lot, has a lot of expectations, it's hard just kind of on your own to just change how stressed you are. At least for me,

I would say one of the things that I've tried to do in terms of for other people, in terms of the people that I work with here, the people in my lab of trying to create an environment that's less stressful for them, that we take time to talk about wellbeing and self care and that I try to give folks, students or trainees or staff to take a long view and say we're in it to do this work for many, many years. We want to stay healthy, we want to stay motivated. And so just staying up till 2:00 AM every night trying to get our work done is not going to be sustainable. So as sort of a supervisor or mentor, I'm trying to support that in my team. So that is a lesson that I've taken for sure.

Maya Adam:

So you're trying to create a micro blue zone for your

David Rehkopf:

Yeah. Yeah,

Maya Adam:

I love that. 

David Rehkopf:

That's good. You can interview them too and see if they think it's true.

Maya Adam:

So David, I hear that you've been doing some research also in another blue zone in Sardinia. Can you tell us a little bit about that work?

David Rehkopf:

Yeah, so some of the work we were doing there is looking at whether the sort of molecular impacts, the biological impacts were exactly the same in Sardinia and then also Aria in Greece with Costa Rica and Koya. So taking three blue zones and looking at the methylation patterns. And what we found is those methylation patterns were somewhat similar but kind of unique in each of those places, which meant that there were sort of not just one way to be a blue zone. One interpretation of that is there isn't just one way to be a blue zone, but there's a lot of different ways that things could come together. And so there are these differences between the blue zones, even though each of them has sort of achieved this kind of very interesting high longevity.

Maya Adam:

And were there between the different Blue Zones, are there striking certain striking similarities that you would say the one thing that these places all have in common is X?

David Rehkopf:

Yeah, so not on the molecular side, which is interesting. But on the sort of behavioral side, I think those connections, the generally a diet of non-processed, healthier foods and then people being active and moving naturally. And then as we talked about earlier, also that kind of sense of purpose, whatever that might be, and sort a reason to get up in the morning and just, yeah.

Maya Adam:

What would be, if you had to give our audience members a few key takeaways from what you've learned that maybe they could implement in their lives, what would you say to someone just living in a, let's say a bigger city maybe with the typical amount of stress? And you're right that it's typical to be the lone island that tries to do things differently when everybody around you is racing. So how can we do better?

David Rehkopf:

Yeah, I'll say there's two sides to that. The one side is things for you personally. So building in sort of movement and walking. If you take the train or take public transportation, you're probably going to have a walk to that station. Walk to the train that's going to build in those steps. I don't think you ever need to be obsessive about a step can or a step watch or anything, but if that helps you realize how active you are, how non-active you are, that can be helpful. I mean, I just have this as my watch anyway, but sometimes when I'm traveling for work and have a lot of conferences and meetings, I look down, I'm like, wow, this has been three days with 500 steps. I need to kind of get out and rebuild it. So thinking about those kinds of things in terms of diet, I think one of the things is just, you talked about micro blue zones, your own house can really be a micro blue zone, just like don't buy that unhealthy food.

I mean, when I'm tired and exhausted and it's like 10 at night and I'm working and I see that bag of chips in the cupboard, I mean, I'm going to eat that, but if it's not there and there's only healthy things around, I'm like, well, I'm not running down to the store for that. And so I think just having a new view of those environments that are around you. Another thing at my office, there's this vending machine downstairs and folks have candy out there, but if I buy some healthy food and have it in my office available when I get hungry, just makes it easier. So doing those things I think can make it easier on yourself, and they don't even feel like a lot of effort or having to do anything extra. It's just like you make it easier on yourself. The second part of that is how you go, I think, from just your own micro areas to what you sort of advocate for and see in your community. So this can be as simple as there's a public hearing about putting in bike lanes or fixing sidewalks somewhere. People could, advocating for safer neighborhoods, advocating for a grocery store to come in. And so those can just be little things. I mean, it could be sort of like an hour a month or something that you kind of see what's around, think about your community and how you can make that, and then that'll benefit everyone living in your neighborhoods.

Maya Adam:

Excellent. Such good tips. Okay. I have a couple of profound questions for you and take your time to answer these. In those moments where you are, let's say overwhelmed and feeling like you have too many things on your to-do list, what fuels your passion for this work?

David Rehkopf:

So I come back to how we can use data and how we can use science to improve people's wellbeing and make the world a better place. So that's very motivating. I don't know if I do that most of the time, but I try and I think this kind of came from, I talked about my experience early on about seeing different parts of Washington state. The other important part of growing up was the time I spent with my grandfather who was an engineer, and we spent a lot of time with him just building things and fixing things. And the thing that I learned from him is you think about it enough, you work on it hard enough, you can fix something, you can build anything. And so I kind of combine those experiences together into really wanting to take action, do something to make things better. So not just studying things, but really kind of a bit more of an engineering perspective. How can we design things differently? How can we have an impact on the world to make things better for people and help people be healthier?

Maya Adam:

That sounds wonderful. It sounds like he really taught you to be curious and innovative at the same time to amazing grandparents, right?

David Rehkopf:

Yeah, absolutely. All of my grandparents were amazing. I learned from all four of them.

Maya Adam:

Lovely. David, I'm so grateful to you for taking the time to chat with us today, and I'm going to, I think, let you go at this stage, unless there's anything I forgot to ask you

David Rehkopf:

Ask. No, thanks so much. I mean, I guess the only thing I would add is that I think it's important to think about Blue Zones, not just as places that used to be there, but what we can create now and how we can sort of create Blue Zones everywhere and help people live healthier lives.

Maya Adam:

Thank you so much for your time, David. I appreciate it.

David Rehkopf:

Thank you.

Maya Adam:

Today's conversation explored the research of David Raup and his colleagues on Blue Zones, places in the world where certain social and health behaviors support unusually long and healthy lives. My big takeaways, your behavior affects not just how you feel but your molecular self, and you don't need to live in a blue zone to experience the benefits of certain Blue Zone behavioral characteristics. Thank you for listening to Stanford Medicine's Health Compass podcast. If you like what you heard today and want to keep up with Health Compass, you can subscribe on Apple Podcasts, Spotify, or the Stanford Medicine YouTube channel.