When will COVID-19 end (in the US)?  In 23 months or 8 months? 

September 25, 2020    by Mona Ottum, MS, RDN, IFMCP, CLT, CD 

“When will it end?”  I can’t be the only one to ask this question or cry it out in the night.  Life as we knew it stopped about mid-March in the US with full quarantine and social distancing in Michigan March 28.  At this point, the US had already suffered 2,700 deaths due to COVID-19.  There is no doubt that the old saying “we closed the barn doors after the horse got out” applies.  Since the first confirmed US case on January 20, COVID-19 began spreading like wildfire.¹ 

But here we are, me in Michigan watching the last beautiful days of summer trickle away and truthfully squeezing in as much outdoor adventure, camping, kayaking, biking and gardening, as I possibly can.   But I miss the parties, weddings, BBQ’s and seeing my son in Colorado, throwing an appropriate soiree for my daughter’s medical school graduation and engagement.  I miss my church friends, my choir so much.  I “go to virtual church” twice a week thanks to a lovely church with enormous tech resources and effort to stay connected, but it’s not the same.  And I could be characterized as somewhat of an introvert so I know social isolation is causing great suffering for many of you out there and my heart goes out to all of you. 

So I asked myself, “When will it end?” then realized, we have enough information to have a good approximation of an answer.  I am a scientist, engineer, dietitian with three college degrees who LOVES math.  I research and do math for fun.  But when there is an important question to answer, I go deep down the rabbit holes, like I do when I am researching how to get a client well.  This is my nature and my instinct.  When I got the answer, I realized that it was very helpful for me and thought I would share with you. 

Herd immunity:  When a certain percentage of a population has had an infection, or has been vaccinated, and is now (presumably) immune to re-infection, the likelihood of an infected individual passing to a vulnerable person becomes so low that the infection disappears.  Many, many variables enter in to this number.  These include how easily the infection transmits, how long it is transmissible, how concentrated a population is, how mobile it is and much more.   

R0 is highly variable AND somewhat controllable:  Note that the behavior of wearing masks and hand washing alter transmissibility and quarantine and social distancing alters mobility.  So R0, or the scientists way of describing how easily an infection spreads, is highly variable, and to some degree, controllable.  The point where R0 become 1.0 or below is where the infection dies out.  Some places in the world instituted these actions early in the process and managed to almost stop the spread of the virus entirely.  But if you institute social measures too late and inconsistently, and to be fair, only 2 or 3 weeks too late is all it takes, herd immunity is all we have to bring an end to the spread of this virus and our social isolation. 

So back to herd immunity, 43%!  At this point, we want to know what level provides herd immunity under “normal mobility” of travel, gathering, parties, shouting at sporting events and singing at church, all the things we miss and love.  We want to know when we can hug our friends and family and gather for celebrations.  I want to know when I can cook for loved ones, friends and clients (I LOVE doing cooking classes!).  The experts have been saying that herd immunity for COVID-19 is between 60% and 70% of the total population.  But a later model has put herd immunity 43%.²  This new model considered the variable of “social activity”.  In essence, some people in a population are more socially isolated by their very nature.  So I went with 43% because this is the latest and best number and I am an eternal optimist and excited by this lower estimate.  But don’t get too excited.  Here is how many people must have either 1. Recovered from the infection 2.  Been vaccinated. 

Current US population:  328,200,000 X 0.43 = ~141,000,000 must have immunity 

How close are we to herd immunity? The true infection fatality rate or IFR from “community sampling” can tell us:  The percent of people who have actually gotten the infection in a population and died has been an elusive number, not because we do not know who died as a consequence of COVID-19 (contrary to popular belief, a conversation for another day), but because we don’t know how many people have been infected but did not die.  This is due to several important factors.  First, many, MANY, people get COVID-19 and do not get sick or only get mildly sick.  Second, we have only had reliable testing for active infection or post-infection antibodies for a limited time and in limited numbers.  Third, in the setting of limited resources, we are primarily only testing those with symptoms or exposures.  Here is where research and science has had time to fill the blanks with what is called “community sampling”.  Several studies have been done around the world where a representative and broad sampling of a particular community tests people regardless of exposure, symptoms or risk.  A systematic review and meta-analysis of these studies (pre-publication) have found a couple of very important things.³ 

1.  The actual infection fatality rate (IFR) is about 0.68% (0.53 to 0.82%). 

2. The actual infection level is 4 to 11 times the number testing positive and reported, depending on how broadly or narrowly testing is done. 

We can estimate how many people in the US were infected cumulatively three weeks ago by how many total death we have today (there is a 3 week delay between infection and death).  So three weeks ago (from 9/25/2020): 

201,411 Deaths today / 0.0068 = ~30,000,000 Infections in US 

Cumulative infections reported 3 weeks ago in US:  6,189,815 

How many people in the US who had COVID-19 but were untested and missed? 

30,000,000 / 6,181,474 = 4.9 or 

1. The actual infection rate is currently 5 times that reported 

2. For every infection detected, there are 4 that are undetected/unreported 

Yay!  We are a lot closer to herd immunity than we thought, right?  Closer, yes.  Close, no.  Remember:  

Number of survivors/vaccinated needed in US for herd immunity:  141,000,000 

Number of current survivors/vaccinated in US:  ~30,000,000 

At 7 months into the pandemic, we are 19% of the way to herd immunity. 

30MM / 141MM = 21% 

At the current rate, when do we reach “natural” herd immunity?  If we move to herd immunity “naturally” meaning without a vaccine, we would achieve herd immunity when we hit 141MM survivors.  The current death rate is about 1100/day so this is about 5MM infections per month.  With both school and winter approaching, we might rip the Band-Aid off and get it over faster with another bigger spike, but for now I’ll assume that it is stable. 

141MM – 30MM = 111MM more infections / 5MM infections per month = 

22 more months. 

Herd immunity for COVID-19 would be achieved naturally in ~22 months or… 

Natural Herd Immunity: August 2022, 2 years from now 

How many deaths will result from COVID-19 at that point, a total of 30 months in: 

141MM X 0.0068 = 958,800 COVID-19 deaths in US or ~1MM 

What if we vaccinate?  I cannot lie.  I am a functional health practitioner and conservative with conventional medical interventions with respect to preventable and reversible chronic illness.  I am not a fan of universal vaccinations and the heavy rapid load we do to our infants.  I have seen the consequences of adverse reactions to vaccines.  I have also enjoyed the benefits of vaccines that have eradicated horrible diseases like polio and tetanus (not without some serious early mistakes).  But can I live 2 more years of this and 1MM deaths?  Can we?  We are stuck with the current situation, plodding along as small businesses and mental health circle the drain until a major event disrupts the process.  Two major events can speed things up.   

1.  A second wave as a result of going back to school and partial opening of society and perhaps a third wave coinciding with the flu season and indoor confinement.  

2. An effective vaccine. 

Vaccines on the fast track are at least 4 months away and their impact 6 months away.  The most aggressive projections are for vaccines to be tested, manufactured and available for distribution by the 1^st anniversary of the arrival of COVID-19 on our shores, about February 1, 2021.  Assuming an effective and safe vaccine is available, the process of getting at-risk and priority people vaccinated and then the 3 weeks for people to actually mount an immunity is at least 2 more months.  That is 6 more months on our current trajectory.  Where will we be at that point (April 1, 2021)? 

Current deaths 201,411 + (6 months X ~33,000 deaths/mo) = ~400,000 deaths 

Lives saved if we vaccinate in winter 2021: 

~600,000 

Months sooner returning to “normal” life with travel, concerts, sporting events and church if we vaccinate in winter 2021: 

~15 months 

Decisions, Behaviors, Choices and Beliefs:  Here is where I depart from the science and share my heart.  The United States is a collection of the most educated, creative, resourceful, diverse and resilient people on the planet.  I believe that we can collectively get through the next 7 months without unnecessary excess loss of life.  But to do this, we have to be more.  We have to be more patient, kind, compassionate and compliant with wearing masks and social distancing where required.  We have to have more faith in science and medicine as it fulfills its original and pure purpose, to ease suffering and save lives.  We owe it to ourselves to find ways to experience and give love, joy and grace along the way.  If you put others first for 8 more months, you give yourself back your normal life 15 months sooner with COVID-19 vaccines.  Together, we can make the next 8 months our best.   

As for me, knowing that the most vulnerable to COVID-19 are underserved and those with chronic illnesses, my focus on restoring health with functional medicine will continue with more conviction than ever.  Preventing deaths is always better than counting deaths but the journey out of chronic illness is not fast and easy and for many with socioeconomic limitations, not even realistic in this short term.  In the short term, vaccinating to save lives while continuing to fix the systemic broken food supply and health disparities that amplifies chronic illness is the pragmatic and compassionate approach.  In the long term, functional medicine, and I, will not only be working to help people be more resistant to such infections in the future, with vitamin D and other inflammation reducing strategies, but helping people fully recover from the lingering effects of the virus. 

(1) (See https://en.wikipedia.org/wiki/Timeline_of_the_COVID-19_pandemic_in_the_United_States for a detailed timeline if you are curious or prone to mistrust and believe conspiracies)   

(2) Tom Britton, Frank Ball, Pieter Trapman. A mathematical model reveals the influence of population heterogeneity on herd immunity to SARS-CoV-2. Science. 2020 Jun 23 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7331793/  

(3) Gideon Meyerowitz-Katz, Lea Merone. A systematic review and meta-analysis of published research data on COVID-19 infection-fatality rates. Posted July 07, 2020. https://www.medrxiv.org/content/10.1101/2020.05.03.20089854v4  

Timeline of COVID-19: Science, Decisions and Outcomes

Mona S. Ottum, MS, RDN, IFMCP, CLT, CD

I’m a scientist, chemical engineer, registered dietitian and thinker, with arguably a little too much time on my hands.  I have been curious about the idea that the Chinese government or some “mad scientist” created COVID-19 and/or lied about its origin, extent or seriousness (pathogenicity).  So I did what I always do, I went to published journal articles and reputable science reporting to put together scientific facts and a timeline of the course of the COVID-19 pandemic.  See a summary of my discoveries in the diagram.   I identified week 0 as the week of the onset of illness of the first case identified in Wuhan.  I then asked and answered a series of questions that have presented themselves recently.  

When was the first case of COVID-19 in Wuhan identified? 

A New England Journal of Medicine article published on January 29, 2020 reviews studies of the first 425 confirmed COVID-19 patients.¹  They state that the first 4 cases of a “viral pneumonia of unknown cause” were reported by hospitals in Wuhan on December 29, 2019.  All 4 were linked by a seafood market.  The local authorities had the seafood market closed and decontaminated January 1, 2020.  However, an article published in The Lancet on February 15, 2020 reported that, although scientists earlier thought the virus originated from seafood market in Wuhan, careful investigation showed that 1/3 of the first cohort had no exposure to the market.²  Among the group with no connection to the seafood market was the first person to present with symptoms, a gentleman with a symptom onset date of December 1, 2019. ^1,2,3 

When were world experts notified of the virus by Chinese medical experts?   

The Chinese CDC announced the novel virus and 15+ cases, January 8, 2020.  An article published in Viruses January 24, 2020 describes the dissemination of the complete genome map and description of the virus to scientists worldwide on January 11, 2019.  Their intent was not only to notify outside entities of the new novel virus and the serious public health threat but to engage the global research community in analyzing the data.  Within two weeks of the appearance of the cluster of patients in the hospitals, the world scientific and medical community was notified and engaged.^3,4 

When did China isolate and quarantine its affected populations? 

The first fatality due to COVID-19 was reported 1/10/2020 and the second on 1/15/2020.  Four weeks after the first cases appeared in hospitals and two weeks after the first fatalities, Chinese officials instituted a quarantine on Wuhan and other affected cities on January 23, 2020.  A detailed timeline by Gralinski and Menachery in previously mentioned article in Viruses, January 24 reported that at the time there were 655 confirmed cases and 18 deaths in 9 countries.⁴ 

What is the origin of COVID-19? 

The complete genomic sequencing of the novel coronavirus was repeated, shared and analyzed by a variety of scientific entities throughout the world.  “…Andersen and collaborators at several other research institutions used this sequencing data to explore the origins and evolution of SARS-CoV-2 by focusing in on several tell-tale features of the virus.”  All medical and scientific experts, including those in the U.S., now agree that COVID-19 was without doubt of zoonotic origin, a naturally occurring mutation from an animal virus, as has been the case on a variety of previous similar outbreaks.  It is clear that the version of coronavirus that COVID-19 is closest to and must have mutated from was previously non-pathogenic and importantly, non-human infecting.  They go on to explain that if there was any salacious intent, this particular virus would have been a ridiculous choice, from any scientist’s perspective.^5,6 

How long after the first case in China did the U.S. have its first confirmed case and death? 

According to a New England Journal of Medicine article epublished January 31, 2020, the first US confirmed case was reported on January 20, 2020, seven weeks after China’s first illness onset (traced backward) and four weeks after first known illness presentations.  The first reported U.S. death was the week of January 29, 2020, three weeks after China’s first reported death.  It is certainly likely that there were earlier deaths but the virus was new and uncharacterized making linking of death to the infection impossible in early stages of the outbreak.⁷ 

What did the US know at the time of the first U.S. case about the severity and extent of COVID-19 in/from China? 

Immediately following the first U.S. case, earliest publications characterizing the nature of COVID-19 in the scientific community appeared in PubMed January 22 and 24, 2020.  These studies suggest a highly contagious virus with a reproduction number (R₀) of 2.0 to 3.0.  Coinciding with the U.S. first case, an outbreak of COVID-19 occurred on a cruise ship that initiated a quarantine on February 3, 2020 that lasted 4 weeks.  Patient 0 developed symptoms on January 22 and disembarked.  At the time of the first US death, 3 weeks into this quarantine, a great deal of information regarding how contagious and lethal the infection is was gleaned and shared.  The on-board transmission was initiated by food service workers and went unrestricted for 1 ½ weeks prior to quarantine, likely exposing close to 100% on board.  Of the 3,700 passengers and crew, 17% eventually tested positive, 1.3% of those who tested positive died (IFR) and 2.6% of those with illness and symptoms died.  It was here that we learned that even in a generally disproportionately older population, about 50% are infected but remain asymptomatic (but yes, still contagious).  Infection rate was about 17% of this vulnerable older population, case fatality rate was about 2.6% in this population though a more representative population is about 1.4% and infection fatality rate would be about 0.7% in a typical community.  This is conditional on isolation 1 ½ weeks into first illness but relatively high exposure.^8,9,10 

How long after the first illness and death in the US did the US states isolate and quarantine and how does this compare to China? 

Nine weeks after the first confirmed U.S. case and four weeks after the first U.S. death, California, Washington, Oregon, New York, Ohio, Louisiana and Illinois were the first states to issue shelter in place quarantine orders, on March 23, 2020.  At the time, the US had 33,404 confirmed cases and 454 COVID-19 deaths.  The following week, 21 more states issued stay at home orders.  At that point the U.S. had 54,453 confirmed cases and 2,339 COVID-19 positive deaths.  In spite of China being completely naïve to the new viral pneumonia outbreak, it took quarantine actions over two weeks sooner than the U.S.^11,12 

Now that we have substantially more data, is the severity of the disease worse or milder or the same as China originally characterized? 

After the first month of COVID-19, Chinese scientists estimated that the novel COVID-19 virus had a Case Fatality Rate (CFR) of 1.41% in Hubei and 5.25% in the epicenter Wuhan. ¹³  As previously mentioned, early estimates of R₀ was 2.0 to 3.0, indicating a remarkably infectious agent.  With two additional months of experience globally, the CFR worldwide is estimated at 3.6%.  In the U.S. the flu causes about 30,000,000 illnesses and 40,000 deaths every recent season and COVID-19 has caused 746,625 cases so far (4/20/2020) and 41,758 deaths.  This is about a CFR (case fatality rate) of 0.14% for the flu. Said another way, 25 times more people die of COVID-19 when becoming ill than people with the flu.  While penetrance of the flu is enormous (lots of people get it), few people die of it.  Still, the flu has taken approximately equal numbers of lives to COVID-19 this season.  Importantly, the Chinese scientists and officials early estimates were absolutely in line with the infectious capacity and lethality of COVID-19. 

What is the risk with uncontrolled penetrance, meaning what if the U.S. didn’t quarantine at all, or what benefit if we had quarantined earlier? 

If we did not quarantine at all, current estimates suggest 8% of the US population actually becomes infected, 4% become ill and of that 4%, 1.4% die, that would be 13,000,000 illnesses and 183,000 deaths.  That is about 5 times the number that have died thus far and three times the current total projected deaths.  It is currently projected that there will end up being about 60,000 deaths in the U.S., which suggests about ¼ to 1/3 of the U.S. population will have been exposed before the disease is controlled.  Furthermore, if we had quarantined 2 weeks earlier, comparable to China’s aggressive regional restrictions, it is estimated that the peak would have happened 2 weeks earlier and total deaths would have been about 20,000, or 1/3 of the expected total. 

1. Qun Li, M.Med., Xuhua Guan, Ph.D., Peng Wu, Ph.D., Xiaoye Wang, M.P.H., Lei Zhou, M.Med., et al.  Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus–Infected Pneumonia. March 26, 2020. N Engl J Med 2020; 382:1199-1207 epublished 1/29/2020 

2. 1^st known case of coronavirus traced back to November in China.  Jeanna Bryner – Live Science Editor-in-Chief  March 14,2020 Found: https://www.livescience.com/first-case-coronavirus-found.html  

3. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020 Feb 15;395(10223):497-506. 

4. Gralinski LE, Menachery VD. Return of the Coronavirus: 2019-nCoV.  Viruses. 2020 Jan 24;12(2). pii: E135. doi: 10.3390/v12020135. 

5. Science News  COVID-19 coronavirus epidemic has natural origins. https://www.sciencedaily.com/releases/2020/03/200317175442.htm?fbclid=IwAR0MTtvAjpDzf7fBsjyIe_a1dR8_E35HMHoAsoB8XHaQa8gM20y_RMO-Z5c   

6. Ranjit Sah, Alfonso J. Rodriguez-Morales, Runa Jha, Daniel K. W. Chu, et al. Complete Genome Sequence of a 2019 Novel Coronavirus (SARS-CoV-2) Strain Isolated in Nepal Microbiol Resour Announc. 2020 Mar 12;9(11). pii: e00169-20. doi: 10.1128/MRA.00169-20.  

7. Holshue ML1, DeBolt C1, Lindquist S1, Lofy KH1, Wiesman J1, et al; Washington State 2019-nCoV Case Investigation Team.   First Case of 2019 Novel Coronavirus in the United States. N Engl J Med. 2020 Mar 5;382(10):929-936. doi: 10.1056/NEJMoa2001191. Epub 2020 Jan 31. 

8. Ying Liu, Albert A Gayle, Annelies Wilder-Smith, Joacim Rocklöv. The reproductive number of COVID-19 is higher compared to SARS coronavirus. Journal of Travel Medicine, Volume 27, Issue 2, March 2020 epublished 2/13/2020 

9. Kensaku Kakimoto1; Hajime Kamiya2; Takuya Yamagishi2; Tamano Matsui2; Motoi Suzuki2; Takaji Wakita3  Initial Investigation of Transmission of COVID-19 Among Crew Members During Quarantine of a Cruise Ship — Yokohama, Japan, February 2020 Weekly / March 20, 2020 / 69(11);312-313 On March 17, 2020, this report was posted online as an MMWR Early Release. 

10. Russell TW1, Hellewell J2,1, Jarvis CI2,1, van Zandvoort K2,1, Abbott S1, Ratnayake R3,1, Cmmid Covid-Working Group4, Flasche S1, Eggo RM1, Edmunds WJ1, Kucharski AJ  Estimating the infection and case fatality ratio for coronavirus disease (COVID-19) using age-adjusted data from the outbreak on the Diamond Princess cruise ship, February 2020. Euro Surveill. 2020 Mar;25(12). 

11. The New York Times: See Which States and Cities Have Told Residents to Stay at Home found at: https://www.nytimes.com/interactive/2020/us/coronavirus-stay-at-home-order.html  

12.  CDC National Center for Health Statistics.  National Vital Statistics System: Provisional Death Counts for Coronavirus Disease (COVID-19) Available at:  https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm  

13. Yang S1,2, Cao P3, Du P4, Wu Z5,6, Zhuang Z7. Early estimation of the case fatality rate of COVID-19 in mainland China: a data-driven analysis. Ann Transl Med. 2020 Feb;8(4):128. 

14. Morteza Abdullatif Khafaiea and Fakher Rahimb, Cross-Country Comparison of Case Fatality Rates of COVID-19/SARS-COV-2. Osong Public Health Res Perspect. 2020 Apr; 11(2): 74–80  

15. CDC.  Disease Burden of Influenza. Available at: https://www.cdc.gov/flu/about/burden/index.html  

Gluten-Free Pumpkin Spice Muffins

Mona Ottum, MS, RDN, IFMCP, CLT, CD Essential Balance Nutrition L.L.C.

I’m a dietitian and I’m a food snob.  I want things to taste really good. But I also want them to be really nutritious and health supporting.  Let’s face it. Muffins at the local warehouse store are small sugary cakes. The only difference between them and a giant decadent dessert cupcake is the absence of frosting.  In fact, as a Functional Medicine trained dietitian, one of the most frustrating things to me is how poorly Americans eat at breakfast. When you have just gone 11 or 12 hours without any food, the first thing we typically put in our bodies is a big load of refined grains and sugar with absolutely no protein to kick start your brain (make neurotransmitters) or fat to flush your gallbladder and smooth out your blood sugar so you can make it through the morning.  This stable blood sugar enhances longevity and prevents diabetes and heart disease. Breakfast cereal, toast, bagels, coffee cake and those store bought muffins I mentioned will not get you through a busy morning or keep you well long-term. But these muffins will. And they are as delicious as they look!

Let me show you.  I analyzed my recipe and a popular and comparable pumpkin spice recipe.

So mine have more than twice the protein, five times the fiber and 1/3 of the sugar.  They have twice the calcium and five times the magnesium. They have 2.5 g of Omega 3 fats compared to 0.01 g for the typical muffins.  And they have 14 g of net carbs versus 41 g of net carbs. There is still a lot of debate regarding the nutritional value of a gluten-free diet among nutrition professionals.  But they are never comparing apples to apples (apples are, by the way, gluten free). This is a true, side-by-side comparison of a gluten free item and its regular wheat version.  The only thing it does not have as much of is folate because the government began heavily fortifying refined wheat flour with folate. Why? Because no one in America can be expected to eat the natural foods that contain folate, leafy greens (foliage, get it?).  Well I do eat leafy greens and if you really knew how important they were, you would too, but I digress. I hope you enjoy the delicious flavors and aromas of fall in these wonderful muffins.

Preheat oven to 375 F.  Line a 12 cup muffin tin with paper liners or grease/oil.

1.   In a large bowl combine dry ingredients

• 1 cup almond flour
• ½ cup garbanzo bean or garbanzo/fava flour (may use coconut flour if paleo)
• ½ cup GF oat flour (may use 1/3 cup Cassava, potato or Tapioca Starch if paleo)
• ½ cup ground flax seed
• 2 tsp pumpkin pie spice
• 1 tsp cinnamon
• 1 tsp baking soda
• 1 tsp GF baking powder
• ½ tsp sea salt

2.  To a food processor bowl add and pulse till blended:

• 1 ½ cups cooked pumpkin or butternut squash
• 4 eggs
• 1/3 cup honey

3.  Soften and stir into dry ingredients

• ¼ cup coconut oil

4.  Add liquid ingredients from food processor to dry ingredients and stir just until mixed.
5.  Fill the muffin cups until ¾ full.
6.  Bake 20 minutes or until toothpick comes out clean.

Watch for more delicious recipe makeovers that are gluten, dairy, and soy free and heart, diabetes and autoimmune friendly.

Nicoya, Costa Rica: A Puzzling Blue Zone Diet Light on Vegetables and High in Carbohydrate and Sugar

My fourth investigation into exactly what our Blue Zone folks eat has left this dietitian, well, intrigued.  I have been exploring the data reported by National Geographic and Dan Buettner in the Blue Zones Solution: Eating and Living Like the World’s Healthiest People¹.  I am attempting to understand how to eat to increase my odds of living a long, robust life to 100 and perhaps beyond.  This hot equatorial Central American community, while not an island like Okinawa, Sardinia or Ikaria, is a peninsula surrounded by ocean on three sides.  Again, equatorial.  Again, surrounded by ocean.  Yet again, they eat little if any fish.

Gallo Pinto (Rice and Black Beans), Corn tortillas and Squash: The “Three Sisters” Native American Triad Staple

Breakfast, lunch and dinner are all varying amounts of pretty much the same things with some variations on sides.  My daughter recently went on a mission trip to a rural part of Nicaragua, just north of Costa Rica and came home to inform me that that was it.  Rice and black beans, homemade corn tortillas and fried plantain with a little salsa or jalapeno, avocado or fresh fruit, an occasional fried egg or small piece of chicken or pork or sprinkle of cheese, maybe some squash, sweet potato or shredded cabbage salad.  The same thing every day for every meal.  I have to tell you, it blows the concept of health being borne out of variety out of the water!  What is it about their food, lifestyle and/or environment that gives Nicoyans such long-lasting robust health?

Breakfast in Nicoya, Costa Rica

What other foods do Nicoyan centenarians eat?  A lot of sugar!  What?

According to the book, in addition to corn tortillas, rice and beans, about 4 ounces of low-glycemic vegetables like tomato, peppers, cabbage, carrot and onion.  They eat about 2 ounces a day of fried or boiled plantain, sweet potato or a local variety of winter squash, both rich in beta carotene.  They eat about 4 ounces of local fruit, including papaya, lime, orange and banana.  They eat a very small amount of cashews that grow regionally.  But according to the book, they consume 11% by weight of added sugar.  That is 33 teaspoons or about 2/3 cup every day.  They start their day with very strong, very sweet coffee.  And again in the afternoon, more very sweet coffee or nanju (Hibiscus esculentus seeds).  So if they drink 4 cups of a hot beverage a day, there is almost 3 tablespoons of sugar, and probably some of the milk, in each one.  I cannot lie.  There is a part of me that does not want to shine a light on this part of their diet.  But it is truth and I wish to share the whole truth.  If I can figure out how this does not produce adverse health effects somewhere along the way, I will be sure to come back and let you know.  No doubt, high antioxidant content of their local coffee to offset the pro-oxidant effects of the sugar is part of the story.

Lime treated grains, something Okinawa and Nicoya share!

I was surprised to find that a local Nicoyan dietitian described the way corn is treated to prepare it for grinding into flour is to soak it in lime (a caustic water solution of calcium hydroxide).  This treatment adds an enormous amount of calcium, breaks down some proteins to more absorbable forms and makes minerals more bioavailable.  In fact, the nutritionist believed this to be the most important food contribution to Nicoyan longevity.  While not noted in the book regarding Okinawa tradition, I actually read on line that this is also used in Okinawa to prepare wheat for making into noodles.  Huh!  With all the talk about various intolerances to grain, I wonder if the answer is here in these ancient cultures and traditions that render grains both more nutritious and more tolerable.

In addition to the generous amounts corn, rice and black beans, modest amounts of fruits, vegetables and meats, Nicoyans consume a rather generous amount of dairy, about ¼ of the total weight of their food, a little cheese and about a cup of milk a day.  The following table compares their consumption to the US and other Blue Zones I have discussed so far.

The Nicoyan diet contained more protein and fat and less carbs than Buettner “implies”.  To thoroughly understand amounts and proportions of food in terms that we normally think about, I carefully entered all the foods in the weight percent amounts described in the book’s pie chart and the food descriptions provided into my nutrient analysis software.  Here is what I found:

I don’t have a bias toward or against any macronutrient.  I just want the truth.  I am seeking meaningful and translatable information.  A deep dive again reveals recipes in the book modified traditional recipes to substitute canola oil for traditional lard and soy milk for their traditional whole cow or goat milk.  The recipes completely omit the cheese that their 107 year old host Panchita considered an important garnish on her gallo pinto.  But the food weight % numbers did not lie and created a very clear picture of exactly what the macronutrient distribution looks like.  The idea that all fat and saturated fat is damaging to health must be very hard to let go of based on the subtle misleading information in the book.  Research is very clear now that these ideas that fat in general and saturated fat are bad have had serious adverse consequences in increased diabetes and cardiovascular health in the US.  There are important lessons hidden in surprises.  Rather than suppress unexpected information in research, wouldn’t it be better to fully reveal and explore them?

A Moderate Protein Diet:  Once again, this diet is moderate in protein, not low protein.  In fact, again, this population is very small in stature, averaging about 5’ ½” tall for women.  The proper way to characterize protein intake is per kilogram of body weight.  So here is how protein intake in the traditional Nicoyan diet compares to the other Blue Zones and the typical US diet.

Beyond Food Again:  Faith and Gratitude

Dan Buettner and his team did a wonderful job of capturing the “beyond food” side of living well to 100 and beyond!  I want you to know that there is clearly more to the story and he has told it well.  What struck me as I read about his experience in Nicoya, Costa Rica and the lovely 107 year old Panchita that he befriended was her enormous sense of joy and gratitude.  She had a faith practice and was spiritual.  She continued to live with a family member and contribute in a meaningful way, giving her life continued purpose, including cooking an example meal for her surprise guests.  She wore a bright colored dress and beads to do her daily chores and greeted strangers with a big smile and reminder that…

“God blesses us.”

If you know me, you know that a bright colored dress and beads and a big smile certainly resonates with me personally (though my dress would be purple flowers).  In truth, a plant-based diet might just fade in importance by comparison to these things.  I am grateful to Dan Buettner and National Geographic for researching and publishing their findings which has allowed me to translate the information into practical dietary changes that might just enhance your quality and quantity of life!

1. Buettner, D. (2015) The Blue Zones Solution: Eating and Living Like the World’s Healthiest People. Washington, D.C.:National Geographic Society.
2. Buettner, D. (2016) Blue Zones: The Science of Living Longer. Washington, DC: National Geographic.
3. United States Department of Agriculture Economic Research, Food Availability (Per Capita) Data System. https://www.ers.usda.gov/data-products/food-availability-per-capita-data-system/food-availability-per-capita-data-system/#Loss-Adjusted%20Food%20Availability

The First and Only Interpretive Definition of “Plant-Based Diet”

Plant-Based:  What does this mean?  How do you know you are doing it?

These questions have nagged at me a great deal over the past few years because this is the single most important piece of advice given by all variety of longevity studies from the China Study to the Blue Zones.  The words are thrown out there all the time with no definition.  Even I, an expert in nutrition, do not know exactly what they are saying.  Now you and I know that French fries, sugar and soda are plant-based.  Surely we need to be more specific than that!  Does it mean “no animal products whatsoever”, as in vegan?  Well that is not how Blue Zone communities eat.  Not a single one is vegan.  Is it amount by weight?  Is it proportion of calories?  Let’s see how Nicoya and other Blue Zones compare to our Standard American Diet on these two metrics.

What is a “Plant-Based” Diet:  Blue Zones vs USA?

Based on Calories:

The average person in the US gets about 70% of their calories from plants while Blue Zones get about 80% of their calories from plants.  In practical terms, it is more important which plants and in what form.  Americans need to eat more unrefined, whole plant foods, especially low-glycemic vegetables and less baked goods and sugar.  But in terms of the proportion of total calories, only replacing 10% of their animal food with plant food will match Blue Zone levels.

Based on Weight:

The average person in the US gets about 2/3 of the weight of their food from plant products where Blue zones get 70% to 90% of their food from plants.  This is starting to paint a clearer picture because the plant foods with lots of weight but few calories are low glycemic vegetables followed by fruit, high glycemic vegetables and cooked beans and grains.  Sugars, sugary foods, fried foods (donuts and French fries) have a lot more calories per ounce and per milliliter of volume as well.  Volume is important because it produces a sensation of fullness by stretching your stomach.  This is the idea of “calorie density”, eating more food and feeling full while consuming less calories.

Based on Protein Contribution:

I have previously noted that Blue Zones eat a similar amount of protein per kilogram of body weight to people in the US.  To be very clear, this research has not supported the idea that people in the US to eat too much protein nor more than Blue Zones.  What is important is where the protein comes from!  Blue Zones get more of their protein from plants, especially beans but also nuts.  People in the US get about 65% of their protein from animal sources while people living in Blue Zones traditionally get 40% to 50% of their protein from animal sources.

What Can I Do Today?

Reduce your animal protein consumption by 1/3.  US Women average about 7 ounces of animal protein per day so reduce to about 5 ounces of meat, fish, eggs and cheese a day and replace the other 2 ounces with 1/3 cup of cooked beans with each meal (yes, including breakfast!), 1 cup of cooked beans per day!  US Men consume about 10 ounces of animal protein per day and would need to reduce to 7 ounces per day.  Men need about ½ cup of cooked beans with each meal or 1 ½ cups per day to replace the animal protein.  In addition, women should add 1 ounce (1/4 cup) of nuts and seeds to your daily routine and men should eat about 1.5 ounces per day or about 1/3 cup.
This gentle nudge of shifting 1/3 of your protein from animal sources to plant sources will align you perfectly with the blue zones and achieve the intention of a “plant-based diet”.

Beans and Legumes:

Beans, legumes and pulses are enormously nutritious beyond their protein content.  As a nation, the US has essentially forgotten about this food group.  Soy is fine if non-GMO and organic but soy is part of this larger food group that in its entirety is so very health promoting.  Legumes are rich in fiber, folate and minerals.  I see an entire series of blogs ahead on the joy of eating beans and recipes that include them in creative and delicious ways!

Nuts and Seeds:

Again, this group of “plant embryos” are so packed with nutrition that we as a nation largely ignore.  While rich in protein and fiber, this group also contains healthy fats and oils.  They are practically the sole source of vitamin E which we all are deficient in, everyone!  Though you would generally think of almonds, walnuts, pumpkin seeds and flax, so too are chocolate, coffee and coconut in the nuts and seeds category.  There are also two fruits which, from a nutrition profile perspective align more with nuts and seeds than fruit, olives and avocado.  This category also inspires many possible future blogs with endless possibilities for delicious ways to get your nuts and seeds in every day!

I sure hope this has been helpful to you because the investigation was certainly helpful to me.  Having an engineering background means I need numbers!  I need to know how words translate into action.  I bet you do to!

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!

1. Buettner, D. (2015) The Blue Zones Solution: Eating and Living Like the World’s Healthiest People. Washington, D.C.:National Geographic Society.
2. Buettner, D. (2016) Blue Zones: The Science of Living Longer. Washington, DC: National Geographic.
3. Wikipedia: List of countries by life expectancy https://en.wikipedia.org/wiki/List_of_countries_by_life_expectancy
4. Wikipedia: Sardinian People. https://en.wikipedia.org/wiki/Sardinian_people
5. 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
6. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/fastats/body-measurements.htm

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
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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.