Sardinia, Italy: Home of the Healthiest and Longest Living Men.
Sardinia is a large, mountainous island off the west coast of southern Italy. Here is where I decided to focus my third blog on National Geographic’s and Dan Buettner’s blue zones.1,2 I am taking a deep dive into Buettner’s research through my functional medicine, dietitian and engineer lenses. The engineer in me allows me to make sense of confusing numbers and it really came in handy with this Blue Zone data as you will see. Sardinia is where men live the longest and healthiest of anywhere on the planet. Notably, they live nearly free of cardiovascular disease. Men have an average life expectancy of 79.7 years compared to 76.9 years in the US.3,4 There are 22 people 100 or older per 100,000 people in Sardinia which ties for first place with Okinawa. However, unlike anywhere else in the world, half of the centenarians are men!
Shepherding is a strenuous job that burns lots of calories. The men of central Sardinia that live long healthy lives are sheep and goat herders. They are on their feet and walking up and down mountains all day long. It became very difficult to compare the diet of a Sardinian shepherd to an American because they consume an enormous amount of calories to sustain their level of activity. According to Buettner, Sardinians average 2,720 calories per day, so a Sardinian male would consume an average of 3,100 calories per day, typical of a male high school athlete in the US. What’s more, while they are certainly sturdy men, they are small in stature, averaging 63” tall or 5’ 3” and about 150 pounds!5 A common way dietitians report and compare calorie needs is in calories per kilogram of body weight. Here is how an average Sardinian male compares to an average US male (at 69.5”, 195 pounds and 3,000 calories per day).6
Sardinian Man 45.5 kilocalories/kilogram US Man 33.8 kilocalories/kilogram
Clearly, calorie restriction is not part of the story here! This is an enormous calorie consumption on a body weight and size basis (or for anyone except maybe Michael Phelps!). How many extra steps would a 195 pound man have to take to burn this extra 11 kilocalories/kilogram? 28,600 steps and about 13 miles a day, well over 3 hours of walking daily! That is almost three times the 10,000 steps per day recommended minimum for a healthy lifestyle! Unless you are a professional athlete, a landscape or construction contractor, or a professional dancer, 13 miles of walking or equal physical activity a day is just not possible. But the lifestyle of Sardinian men highlight the importance of movement and physical activity to longevity, especially for men. I have seen plenty of research of fitness and associated health benefits that show that 10,000 to 15,000 steps achieve at least 80% of the benefits. Beyond that you just get more work done, move more sheep!
What can I do today? Walk 15 to 20 minutes, three times a day, 45 to 60 minutes total a day, or jog 25 to 35 minutes a day and you’ve got it done.
Sardinian men drink nearly 1 1/2 cups (12 oz) of full fat goat or sheep’s milk a day. Buettner reported that 26% by weight of all food consumed by Sardinian shepherd household is sheep milk and goat cheese. Careful entry of food stuff as reported on the pie chart led to a total food weight of 1500 grams at 3100 calories. That is 390 grams of dairy. With about an ounce of flavorful pecorino Romano cheese a day, the remaining dairy is 362 grams of milk, over 12 ounces or 1.5 cups. This organic, whole, grass fed sheep milk is loaded with nutrition and healthy fats.
Protein was about 40% animal sources and 60% from plant sources. Buettner reports “The other 15% of the diet (calories) was protein, three quarters from plants, mostly beans.” When I entered the food from his pie chart into my diet analysis software along with the two research studies he provided, I found that both the contribution from plants was slightly exaggerated but the contribution from beans was more-so. I assumed the beans were dry to make the bean contribution as large as possible. (Beans nearly triple in weight when cooked.)
23g from meat, 21g from dairy, 12g from beans and 54g from other plant sources.
This is a high protein diet, not a low protein diet. From Buettner’s book “Americans tend to think that more protein is good for us. But here was a long-lived population that grew up on a low protein diet.” I’m sorry but on this point I must disagree! Protein needs are properly represented on a per kilogram of body weight basis, not as a percent of calories. In this very high calorie diet, it appears artificially low. Let us look at what it really is.
Sardinia Men 1.6 grams/kilogram US Men 1.4 grams/kilogram
Sardinian men consume 15% more protein than US men on a grams per kilogram weight basis and double the DRI of 0.8 grams/kg! While 15% of calories would at least be classified as a moderate protein diet, this is a true high protein diet!
What can I do today? 1.6 grams/kilogram protein is appropriate for an athlete or highly active individual, like these Sardinian men. 1.4 to 1.5 grams/kilogram is a more appropriate goal for more moderate activity levels. However, getting about half your protein from beans, nuts and seeds is key. For a US man, that is 7 ounces of meat/eggs, 1 cup whole dairy, and 3 servings of beans, 1 ounce of nuts and seeds and 6 to 8 servings of whole grain.
Sardinian men drink 6-9 ounces of Cannonau red wine a day. From Buettner’s book…“Wine contributed about 110 calories, or about 2 small glasses, to the daily Sardinian diet.” Elsewhere in the same book “Sardinians drink an average of three to four small (three-ounce) glasses of wine a day.” So is it 2, or is it 3-4? 
On the pie chart it says “A shepherd’s average wine consumption of 114 grams (4 ounces) a day is not included in this graphic.” Elsewhere in the same book it says that the 1930 study by Fermi found that a typical resident of the hills of Sardinia consumed 7 liters of wine a month. That is 8 ounces per day. I used 6 ounces for men, who must consume more calories and more wine than the women.
This is a very conservative estimate! Here is a question for you to mull over (pun intended). Is red wine more a fruit or an alcohol? From a health standpoint, I would make the case that it is at least half and half. If the grape juice in wine is counted as a fruit, fruit consumption goes from 1% to 8% of weight of food! Both the locals and the visitors believe that this daily dose of potent anti-oxidants and polyphenols like resveratrol make an important contribution to the longevity of these people. Research supports the heart health benefits of a modest amount of dry red wine daily.
What can I do today? Drink a 5 ounce glass of dry red wine for men and 3 ounce glass for women, or perhaps a small piece of 80%+ dark chocolate for both the health benefits and the accompanying joy.
Barley is the Sardinian’s primary grain, but 24 Slices of Bread a day? “Barley was the food most highly associated with living to be 100 in Sardinian men.” “…much lower glycemic index than wheat” Figuring out exactly how much grain is consumed in the Sardinian diet was very confusing because the various numbers reported in the book conflicted by order of magnitude differences, ranging from 196 grams/day (Peretti) to 397 grams/day (Fermi) to about 662 grams/day (Buettner). No matter how I entered the food into my diet analysis software, I could not make sense of 47% of the total weight of food consumed as grains and stay under 3100 calories/day. If the weight was dry grain, 47% would be 662 gm of grain, which would produce 39 slices of bread and 2730 calories. If weight of finished bread and cooked pasta was used a heavy whole grain barley bread is much heavier than refined bread and about 28 grams per slice, so 24 slices per day and 1800 calories. If you use Peretti’s numbers, bread is only 14% of weight of food, a long way from the 47% reported in the pie chart! This would equal 8 slices of bread day, while still a high grain intake, a far more reasonable number by any standards!
Fat intake: An Unreconcilable Story. According to the pie chart, dairy is 26% by weight of all food consumed by Sardinian shepherds. In a traditional rural shepherd culture this would be whole unprocessed milk, likely raw, and as reported, a small amount of hard cheese. It would not have been the reduced fat or skim pasteurized and homogenized cow’s milk we drink. This 26% would have been 12 ounces of whole sheep milk. Together with about 1.5 ounces of hard cheese, this provides 24 grams of fat from dairy alone. That is 7% of calories from dairy fat alone. The added fat of 2% would be about 34 grams of lard and olive oil which would contribute another 10% of calories from fat. This is 17% of calories from fat from these two sources alone. The small amount of meat and egg would add another 14 grams and 4% of calories from fat and a remaining 14 grams from whole grains, beans vegetables and nuts is another 4% of calories. That brings the total fat to 25% of calories. From the book “Fat accounted for 20% of their diet, mostly from animal sources such as goat’s milk or sheep’s cheese but also from olive oil.”
What if I use the description of food intake over a typical day by the Melis Family described in the National Geographic Blue Zones Book? I just couldn’t wrap my mind around consuming 24 slices of whole grain bread a day. Do these centenarians really eat that much? So I entered the description of a typical day in the Melis family into my diet analysis software with 2 servings of the family recipe for minestrone that they make daily. I made up the difference with bread. I got a total of 10 servings of bread for a man at 3100 calories per day, far more reasonable! At the same time, vegetables went from 12% to 38% of food weight! Is it possible that the 1930’s researchers didn’t have good data on how much perishable vegetables these folks went to their back yard, picked and ate on a daily basis? Here is how the macronutrients compared.
The actual intake by the Melis family, who by the way have several centenarians, consumed 32% of calories from fat, not the 20-25% reported in 1930’s data, and 50% of calories from carbohydrate, importantly shifting 7% of calories from carbohydrate to fat and more accurately reflecting a Mediterranean diet pattern. Further, this includes, as it most certainly should, wine.
What does that mean in food? We don’t eat proteins, carbohydrates, fats and alcohol. We eat food and drink beverages. The pie chart that Buettner presented in his books had to use dry beans and but probably not dry grains, because at what point in human history has anyone eaten 39 slices of bread a day? What these researchers were actually measuring in the 1930’s is impossible to distinguish. It excluded nuts and wine, then later listed them as important and relevant to this diet. The description of the Melis’ diet and their minestrone recipe was enormously enlightening. Revamping the Buettner “percentage of daily intake, by weight” pie chart data shown in the first column to reflect wine and nuts, cooked beans and grains produced the following:
What can I do today? Eat lots of low glycemic vegetables. Specifically, to equal this longevity diet, men should eat 1 ½ pounds and women 1 ¼ pound every day! That’s 9 servings for men and 7 servings for women, not the 2 a day implied by the “5 a day” chide which includes fruit and starchy vegetables as well!
The Sardinian (Melis’) diet have important consistencies with Ikaria and Okinawa. I added a row for how a person who only walks one hour a day might scale down calories to 2400 from 3100 in the last row. Note that calories removed came primarily from bread, sugar and added fat in relatively equal proportion and protein is maintained to appropriate levels for body size.
How does the Sardinian Diet compare to Ikaria and Okinawa? Patterns are beginning to emerge regarding how centenarian-rich populations eat. I will be discussing them in much more detail soon, but a couple of highlights are:
- 7 to 10 – 3 ounce servings of low glycemic vegetables daily
- No more than 7 teaspoons of sugar a day for men and 4 teaspoons for women
- Homemade, whole and unprocessed food, mostly local sources
- Optimal fat in the diet is 25 to 50% of calories if unprocessed and monounsaturated rich, especially olive oil but also lard.
- Optimal protein is about 1.4 grams/kg body weight and at least half from plant sources, especially beans and legumes.
- The little things count. A little wine, a little nuts and seeds and a little lemon juice keep showing up.
More than food again. Love of work and a strong family and community connection emerge once again as important factors among Sardinian centenarians. The more I read about Blue Zone people and communities, the more I believe the magic lies in a large measure in their love of life and each other. And the more I long to meet them, cook and eat with them!
- Buettner, D. (2015) The Blue Zones Solution: Eating and Living Like the World’s Healthiest People. Washington, D.C.:National Geographic Society.
- Buettner, D. (2016) Blue Zones: The Science of Living Longer. Washington, DC: National Geographic.
- Wikipedia: List of countries by life expectancy https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy
- Wikipedia: Sardinian People. https://en.wikipedia.org/wiki/Sardinian_people
- Luisa Salaris, Michel Poulain, Thomas T. Samaras. Height and Survival at Older Ages among Men Born in an Inland Village in Sardinia (Italy), 1866–2006 Biodemography and Social Biology http://www.tandfonline.com/loi/hsbi20
- Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/body-measurements.htm