Okinawa: Mel Gibson might know what women want but this place has what women need, to thrive even into their second century, that is.

Welcome to my second deep dive into the lifestyle of people who not only live beyond 100 years, but do so with a high functioning body and mind.  Come with me as I use my nutrition and functional medicine lenses to translate lessons from these research findings into actionable diet changes.  Dan Buettner, National Geographic, Bradley Willcox MD, Craig Willcox PhD and Makoto Suzuki MD^1,2,3,4 have studied older people on this subtropical island because here is where women live beyond 100 at a greater rate than anywhere else on the planet.  They live longer, on the average, than women of the rest of Japan and neighboring China.  They live longer than their male counterparts (though men live long also) and far longer, on the average than women in the US.

Do Okinawan people have better genes?  Clearly not.  Modern western foods are rapidly gaining popularity in Okinawa among younger people.  Along with these eating patterns are developing obesity, diabetes, cardiovascular disease and cancers among the younger population.  In fact, these diseases are exceeding typical levels overall in Japan.  In addition, Okinawans who move to Western countries have chronic disease rates and life expectancies typical of the country they move to.  Only elders who are eating and living in traditional ways are reaping the health benefits.

What do traditional Elder Okinawan women eat?  This turned out to be a much more difficult question to answer than I thought.  Not only is the traditional Okinawan diet profoundly different from a typical western diet, it is very different from the rest of Japan and China, though influences from both are clear.  The biggest challenge is that even the traditional food composition has been in dramatic flux since the time that current centenarians were born.  The studies report foods consumed as a percent of total weight of food consumed.  Sweet potatoes went from over 90% to about 5% in modern times.  They were replaced by grains, mostly rice, that went from 15% to 32% according to the Willcox books.  It was unclear how much the elders retained sweet potato as a staple and how much of their diet is actually grains.  I had to analyze a few traditional dishes to get a clearer picture.  Like Ikaria, alcohol and nuts and seeds are not counted.  Alcohol is part of the traditional cuisine, especially for cooking (and what cook among us doesn’t sip a little as we cook?)  Sesame and peanuts are very common ingredients in traditional foods of Okinawa.  The amount is small, but important.  The amount and type of fat is a serious point of contention as I’ll explain.

Historical Perspective⁵, Adaptation and the Importance of the Satsuma Purple Sweet Potato. The purple sweet potato was introduced to the island around 1600 from Mexico by way of China.  Okinawa is not a friendly environment for agriculture, especially rice, the usual staple in this part of the world.  Cycling between periods of extreme famine, poverty and typhoons, one thing grew really well in the mineral rich, hot, dry soils and subtropical climate, the Satsuma purple sweet potato.  First record of food intake puts the purple sweet potato at 93% by weight of all food consumed in Okinawa in 1879.   In 1949 post-war, the entire population of Okinawa was under stress of starvation again and the purple sweet potato was 67% by weight of food consumed.  Rice was favored as a staple food in both China and Japan throughout their history.  When times got tough, these nutrient rich purple vegetables always came to the rescue of the people of Okinawa.  I read many times over how the elders view the purple sweet potato as the reason they survived.  But it is a love-hate relationship.  Given the option of rice, even they would still choose rice over sweet potatoes, if they didn’t know the powerful health advantages.  They have a similar view regarding sweet potato as many elders in the US have regarding beans.  Our elders had to eat beans during the depression and war times when meat was scarce.  This has shaped attitudes in the US toward this entire class of “super foods”.  It was a similar love-hate relationship, but we did not notice or treasure the health benefits of being a bean-eater the way Okinawans noticed the benefits of eating their precious purple sweet potatoes.  I want you to note that a Western World native food not only saved the Okinawa people but in part lifted them to among the healthiest on the planet.

Pork is the Companion Health-food to Sweet Potato in Okinawa^5,6,7.  Here is where my research departs from that reported by the Willox’s and seriously downplayed by Buentner.  Raising pork became possible on the island when sweet potatoes arrived and pork has been an important part of the traditional cuisine ever since.  Pork is revered by locals as a health food like the sweet potato.  This idea must have been just too outrageous for our esteemed researchers to accept.  Yes, they consume very modest quantities and mostly during festivals.  However, they have a total of 32 festivals a year, more than one every two weeks!  Distributed evenly over 365 days, the traditional average daily intake of pork is 21g, or ¾ of an ounce⁶.  Americans eat about 3 times that much pork on the average, along with even more beef, too much, no doubt.  It seems as though researchers should have included holidays in the Okinawan diet journals like dietitians include weekend days!  It is reasonable to see pork as a “health food” in moderation when you consider pork is a very high quality protein rich in thiamine, other B vitamins and monounsaturated fats.  It is Okinawa tradition to use every part of the pig, including the blood, ears, organs and feet.  Nothing goes to waste.  The meat is generally stewed with a form of acid (vinegar or citrus) or alcohol (Awamori: a millet brandy) that reduces oxidation of fats and formation of advanced glycation end products.  The meat and bones are cooked slowly for a long time, producing a version of bone broth that is rich in collagen protein and minerals.  Such a practice is part of traditional food cultures around the world and is touted for its health benefits.  The solid fat is skimmed off in a process called Akunuki.  Is it thrown away?  This is suggested, but I doubt it.

Lard is the traditional cooking fat.  Our researchers suggest that the traditional added fat that Okinawans cook with is canola oil.  Really?  No.  It was and is lard from these pigs.  Many traditional recipes reflect this⁷, and a recent study has shown that traditionally Okinawa consumed more protein and more fat than Japan as a whole and Okinawans average lower polyunsaturated fat intake levels, about 4.8% of calories⁷.  Canola oil is surprisingly similar in fatty acid content to lard but higher in O-6 fatty acids and lower in saturated fat.  However, Okinawan lard may be different than American lard.  These pigs root freely on the island, in bright sunlight, eating nutrient rich sweet potatoes.  The omega 3 fatty acids and vitamin D levels must be higher.  Regardless of where pigs are raised, their fat is 43% heart healthy monounsaturated fatty acids compared to canola and olive oil at 59% and 74%!  Women need fat in their diet for glucose regulation and cholesterol and saturated for hormone synthesis.  Everyone needs a more traditional balance between O-3 and O-6 fatty acids and arachidonic acid for a healthy immune system.  This newer research is still being overshadowed by old “low fat diet” studies that lump all fat in the same “bad bucket”.  Research has recently found that elder Okinawan women in the second highest fat consumption quintile have the lowest mortality and highest cognitive function, at 28% of calories.⁸

Huri Hachi Bu   “Stop eating when 80% full.”  A human experiment in calorie restriction?  Many animal studies have found conclusively that life-span can be extended by calorie restriction.  These studies all state that no human experiment can be done due to ethics and sustainability limitations.  The researchers describe the Okinawan elders they observe whispering the words Huri Hachi Bu before every meal as if saying a prayer of gratitude.  The practice of ending their meal when they feel 80% full is not borne out in their actual calorie consumption when you consider Okinawans are significantly smaller in stature than the rest of Japan.  Japanese and Okinawans both are significantly smaller than people of the US and have significantly smaller frames as well.  Look at the following table.

*Traditional diet like current elders             **Mifflin-St. Jeor AF 1.5

It appears that Okinawans actually consume about 10% fewer calories than their apparent energy needs. Japan overall is close to energy balance and in the US, we overconsume calories by about 20%.  Note that my calculations used energy needs for “ideal weight”.  It does take more calories to maintain weight for a body with excess fat.  But that is not the energy level we need to be healthy.  That is the energy level that keeps us sick.  Most of us would lose weight if we simply ate adequate calories to maintain our “lean self”.  (This idea is an important part of my weight loss program for sustainability.)

The Okinawa Elder Diet Falls Short on the USDA My Plate

The traditional Okinawan diet contains ¾ of the recommended servings of grains. This is a generous estimate, based on more recent numbers that are far higher than historic levels with higher sweet potato intake.  Vegetables are about twice that recommended while fruit is only 1/3.  There is no dairy, though osteoporosis and hip fractures do not plague this population.  Protein is higher than recommended because of the high bean content of the traditional Okinawan diet, though grams of protein is not as high as this would suggest.  Here is a deeper dive into what and how much Okinawan Elders are eating.

This chart shows that, while touted as a low fat and low protein diet, it must be characterized as moderate on both accounts.  Similar to Ikaria and the USDA recommendations, it is high in fiber.  The following chart shows more detail about how much food is consumed.

The traditional Okinawan diet includes one pound of low glycemic vegetables a day or about 5 servings while Americans only consume 2 ounces, less than one serving.  This includes a 3 ounce serving of leafy green vegetables like bok choy, sweet potato leaves and radish leaves and over an ounce of seaweed, kombu and wakami.  Don’t be intimidated by the unfamiliar vegetables.  You will get

90% of the benefit by putting a rounded cup (about 6 ounces) of steamed or stir-fried veges on your plate for every meal.  In addition, they eat about 6 ounces or two servings of their purple sweet potato and often pumpkin, both high glycemic vegetables, for a total of 7 to 8 servings of vegetables every day.  The traditional Okinawan diet includes 1/8 the added sugars and ½ the added fats of typical US adults.

Water.  Yup, water.  Calorie density is a big part of the traditional Okinawan food story.  In the traditional Okinawan diet, soups, broths and non-starchy vegetables are the mainstay, breakfast, lunch and dinner.  Calorie density is represented by the calories consumed per day divided by the grams of food consumed.  In the traditional Okinawan diet calorie density is about 1:1 so they consume about 1800 grams of food with 1800 calories, about 4 pounds of food per day.  A typical American calorie density is about 1.5:1 so we typically eat about 3.5 pounds of food, feeling genuinely less full because we are, by the way, but consuming about 2400 calories!  This is the basis of Barbara Rolls and Robert Barnett’s insightful weight loss book “The Volumetrics Weight-Control Plan”¹¹.

Okinawans eat a variety of foods that simulate calorie restriction and enhance metabolism.  Goya, or Bitter Melon is an important vegetable used in a dish almost synonymous with Okinawa cuisine, Goya Champuru.  Bitter melon has insulin sensitizing and appetite suppressing qualities and is very rich in vitamin C and minerals.  Sea vegetables and sea weed are an important part of Okinawan cuisine.  They are very rich in minerals, vitamins A and D and essential fatty acids.  Shikwaasaa, Citrus Depressa or flat lemon is an indiginous citrus fruit of Okinawa used in many dishes.  It is lower in sugar and higher in acid than typical lemons and limes.  It is being studied for anti-cancer and anti-inflammatory properties.  Used in meat preparation, it significantly reduces formation of Advanced glycation end-products, reducing oxidative stress and inflammation.   Many herbs including potent turmeric, garlic and ginger are also essential ingredients that have well documented health benefits.  Jasmine and Green tea are a daily ritual that also have weight management and metabolism enhancing benefits.¹²

Tofu and soy is consumed every day in the traditional Okinawan diet.  It is traditionally consumed at all three meals and Okinawa has their own extra firm full fat versions that they purchase fresh, still warm, at the market.  It was a little difficult to extract exactly how much because 6%, 16% and 12% of food was all presented in the research and books.  My best estimate of traditional diet level is 40 g or about 2 ounces a day of tofu.  Soy is often discussed as a superfood separate from beans, especially because of its isoflavone composition, a compound that stimulates estrogen receptors.¹⁴  This might actually be really important since a female Okinawan centenarian women lives half her life after menopause!   Still, soy is a bean.  Other beans, like adzuki beans and bean sprouts, make a significant appearance in Okinawan dishes as well.  Much of the health advantages that soy brings to the table (pun intended!) are shared with other members of this underappreciated food group.  A rich source of plant protein, folate, minerals and very high fiber, beans once again make a significant presence on the longevity food scene.

There is much to Okinawan Longevity beyond Food!

Hormesis The word hormesis means exposure of a biological system to moderate stressors makes the system more robust and healthier.  This idea is emerging in forward-thinking medical circles.  The old adage “That which does not kill you makes you stronger.” is bearing out in research and systems biology!  No doubt, the harsh environment and historical challenges the people of Okinawa have endured have made them a special breed of survivor!

“The attitude of the Okinawans to their food is unique and from antiquity their everyday diet has contained a number of elements with medicinal qualities connected with longevity.  This is because Okinawa is composed of small subtropical islands, with a harsh environment often subject to droughts and typhoons from ancient times. Particularly in the outlying islands, a great deal of ingenuity was needed just to survive.” Sho⁵ 2001

Food Doctors are not alternative nor complementary in Okinawa, they are primary care providers.  In Okinawa, the first called and most revered physicians are the ones trained in food as medicine^5,7.  These are their primary care physicians and their medicine is literally special food and herb soups and broths, teas and decoctions for all common ailments and illnesses of ordinary life.  They use real food, not pills or extracts, herbal or otherwise.  These physicians receive rigorous and specialized science-based training just as emergency-focused physicians of their culture do.  Here in the United States, the expression “Food is Medicine” is used by only a few of us heretics and the general world view of healing is that only drugs and scalpels contain powerful medicine and food is weak and impotent against our modern health maladies.  Everyone in Okinawa treasures food for its medicinal power and makes food choices in their daily life with this belief system on their mind.

Moai, Friendships for life, and Yuimaru, The Power of Community.  An Okinawan moai is a lifelong close circle of friends that support each other through life’s ups and downs.  They are assigned in a formal way in youth and Okinawans take their responsibility to their moai very seriously.  Here in the US, my mother-in-law has been part of a prayer circle in Madison, Wisconsin for 50+ years and she talks about the “girls” in this group as if they were sisters so I understand a little about how powerful this can be.  Yuimaru is described as “a practice of sharing and helping others”².  As it is described in The Okinawa Program book, it reminds me of what my grandmother described to me as a “barn raising”.  When something needed done, the community gathered together to get it done, be it building a barn or harvesting crops.  Everyone watches out for each other, even strangers.  It is a sense of responsibility beyond charity.  It lifts up something that you feel an integral part of.

Watch for more conversations from me in the future on the importance of sense of community to transforming health.  Next week I will discuss the place where men live longest, Sardinia, Italy and identify possible differences in optimal diet between men and women.  We have assumed that the optimal diet would be the same for both sexes. This is a very new line of inquiry and there is early evidence that optimal diets are not the same!

Aramun jooguu ya duu ganjuu. One who eats plain food is healthy.

1. Buettner, D. (2015) The Blue Zones Solution: Eating and Living Like the World’s Healthiest People. Washington, D.C.:National Geographic Society.
2. Willcox B. J., Willcox, D. C., Suzuki, M. (2001) The Okinawa Program: How the World’s Longest-Lived People achieve Everlasting Health- And How You Can Too. New York, NY: Three Rivers Press
3. Willcox, B. J., Willcox, D. C., Suzuki, M. (2004) The Okinawa Diet Plan: Get Leaner, Live Longer, and Never Feel Hungry. New York, NY: Three Rivers Press.
4. Buettner, D. (2016) Blue Zones: The Science of Living Longer. Washington, DC: National Geographic.
5. Sho H. History and characteristics of Okinawan longevity food. Asia Pacific J Clin Nutr (2001) 10(2): 159–164
6. Economic Structure of Local, Regional and National Hog Markets in the Self-Sufficient Region-Okinawa’s Case (Department of Agriculture). Found at http://ci.nii.ac.jp/naid/110000220190/en.
7. Food for thought: A traditional Okinawan diet may help prolong life by Stephen Mansfield http://www.japantimes.co.jp/life/2015/12/12/lifestyle/food-thought-traditional-okinawan-diet-may-help-prolong-life/#.WA_X8smRxaa
8. Wakai K, Naito M, Date C, Iso H, Tamakoshi A. Dietary intakes of fat and total mortality among Japanese populations with a low fat intake: the Japan Collaborative Cohort (JACC) Study. Nutrition & Metabolism. 2014;11:12
9. Willcox, B. J.; Willcox, D. C.; Todoriki, H.; Fujiyoshi, A.; Yano, K.; He, Q.; Curb, J. D.; Suzuki, M. (October 2007), Caloric Restriction, the Traditional Okinawan Diet, and Healthy Aging: The Diet of the World’s Longest-Lived People and Its Potential Impact on Morbidity and Life Span, Annals of the New York Academy of Sciences, 1114: 434–455, doi:10.1196/annals.1396.037, PMID17986602
10. Nishihira J, Tokashiki T, Higashiuesato Y, Willcox DC, Mattek N, Shinto L, Ohya Y, and Dodge H. Associations between serum omega-3 fatty acid levels and cognitive functions among community-dwelling octogenarians in Okinawa, Japan: The KOCOA study. J Alzheimers Dis. 2016 February 16; 51(3): 857–866. doi:10.3233/JAD-150910.
11. Rolls B, Barnett RA..(2000) The Volumetrics Weight-Control Plan. New York, NY: Harpertorch.
12. Willcox BJ, Willcox DC. Caloric restriction, caloric restriction mimetics, and healthy aging in Okinawa: controversies and clinical implications. Curr Opin Clin Nutr Metab Care. 2014 Jan;17(1):51-8.
13. Okinawa.com. http://okinawa.com/category/research/proverbs
14. Hooper L1, Ryder JJ, Kurzer MS, Lampe JW, Messina MJ, Phipps WR, Cassidy A. Effects of soy protein and isoflavones on circulating hormone concentrations in pre- and post-menopausal women: a systematic review and meta-analysis. Hum Reprod Update. 2009 Jul-Aug;15(4):423-40.