EQOL Journal (2019) 11(1): 37-50


Lifestyle components of the global oldest old assessed as effective non- pharmacologic strategies to maintain lifelong cognitive and functional health

Cécil J.W. Meulenberg 1

Received: 3rd May, 2019

DOI: 10.31382/eqol.190605

Accepted: 19th June, 2019


© The Author(s) 2019. This article is published with open access.



Longevity and high quality of life are amongst the most desired traits of humanity. However, the incidences of non-communicable diseases are rising, while sedentary lifestyles and malnutrition are more common than ever, and in general both functional and cognitive health is declining. Besides the concurrent costs to provide healthcare for such an aging population are dramatically increasing and depend on pharmacological treatment. There is an urgent need to raise awareness for cost-saving healthier customs and to adjust lifestyles. From specific geographic areas around the globe, where its citizens tend to grow (very) old, that is over 100 years of age (indicated as ‘oldest old’), without the obvious health-deficits, the so-called blue zones, lifestyle factors have been identified, or will be proposed, and taken as candidate for non- pharmacologic approaches to improve general health. This paper will summarize scientific studies focussing on cardiovascular and cognitive health benefits induced by: Physical activity through exercise, light to moderate intensity, and non- exercise outdoors activities; Nutrition through the Mediterranean diet and the incidence of neurodegeneration; Cognitive engagement through cognitive-motor exercises, language usage, and me-


1Science and Research Centre Koper, Institute for Kinesiology Research, Koper, Slovenia

ditation; and finally: Sleep. The identified denominators are reviewed through various scientific studies regarding substantiated health- inducing effects. Adherence to such non- pharmacologic lifestyles is eventually a personal choice, and for governments to take notice of, and to include in policies.

Keywords bilingualism • cognition • dementia • sleep • vitamin D • yoga.


Several geographical regions in the world have gained attention since their inhabitants grow older and stay healthier than in any other place in the world. These regions, identified by a remarkably high density of healthy and physically fit centenarians (indicated as ‘oldest old’), are designated blue zones (Buettner & Skemp, 2016). The regions are distributed throughout the world: Sardinia in Italy; Okinawa in Japan; Loma Linda in California, USA; Nicoya in Costa Rica; and Ikaria in Greece. They distinguish themselves from other areas around the globe, by embracing lifestyle denominators responsible for longevity and better life quality, identified through anthropological and epidemiologic research analysis (e.g., Fastame et al., 2018; Panagiotakos et al., 2011). The identified denominators are: frequent physical activity incorporated in every- day life through natural movement and agricultural activities; consuming a high-quality sustainable plant-based diet (of moderate portion size) for


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which the ingredients are cultivated and prepared for consumption by their own handwork of farming and meal preparation; and daily consumption of a glass of wine. Besides, the inhabitants of these communities are equally-minded, involved in positive social engagement, where meal-sharing and communication are highly appreciated, and family and friends will be taken care of and taken care by. The individuals, through the community and the activities therein, experience a rich sense of purpose to life and take time to relax and to (self)reflect.

In first instance these identified blue zone denominators seem to contradict the habits adopted to in modern Western societies, although many citizens are getting aware of the underlying benefits of these blue zone characteristics. The current paper will identify the scientific equivalents of the blue zone denominators and summarize the associated cognitive and functional health effects induced by these lifestyle factors.

There are crucial reasons to do this, as many of the identified denominators do have a positive cost- benefit ratio, and are of a sustainable character. Thus, another reason for this paper is to direct attention to several of these factors, which can be adhered to by individuals, even in modern Western societies. It will give them the benefit of obtaining higher vitality and quality of health, and simultaneous take care of our environments. Modern western societies might profit from such individual actions.

Physical activity

From the point of view of modern Western-European professional life, a large population of the societies throughout Europe spend their working time in offices, accumulating excessive sitting time, that is, a sedentary and physically-inactive daily routine. This is regardless of meeting the recommended moderate to vigorous physical activity guidelines, like spurts of exercises in gyms during leisure time. In the last decade, some researchers have argued that such combination may be harmful for health (Owen et al., 2010). Among 220,000 Australian adults, more than 11 daily hours of sitting compared with less than four daily hours being physically active, has been shown to increase the all-cause mortality hazard ratio to 1.4 (van der Ploeg et al., 2012). Thus, physical inactivity is becoming a leading risk factor for overall mortality, which is why governments and authorities are promoting physical activity.



Plenty of intervention studies with resistance exercise as physical activity improving skeletal and muscular health are available in the scientific literature, but here we want to demonstrate the effect of controlled intervention studies, and summarize the content of relevant systematic reviews and meta-analysis of randomized controlled trials.

Kodama and colleagues identified 25 studies with an average of seven months of intervention, where aerobic training resulted in increases of high-density lipoprotein cholesterol levels, with no association between exercise frequency or intensity (Kodama et al., 2007). 13 randomized controlled trials where physical resistance training was applied on average three times a week for 1.5 to 12 months, compared with a control group and patients with abnormal glucose regulation (Strasser et al., 2010). The physical activity reduced the fat mass and systolic blood pressure, while no statistically significant effects on total cholesterol, high- and low-density lipoprotein cholesterol, triglycerides and diastolic blood pressure were observed. The comparison of 93 trials by Cornelissen and Smart (2013) showed that endurance, dynamic resistance, and isometric resistance training, lowered both systolic and diastolic blood pressures for interventions smaller than six months. Whereas interventions longer than six months induced smaller reductions in blood pressures, and the combination of these types of physical training lowered only diastolic blood pressure. From 29 randomized controlled trials with a median duration of three months, it was shown that exercise significantly improved cardiorespiratory fitness and lowered the levels of fasting insulin, triglycerides and leptin, while increasing the levels of both high-density lipoprotein cholesterol and apolipoprotein A1, and interleukin-18 (Lin et al., 2015).

The effects of exercise physical activity were more pronounced in persons over 50 years of age, men, and persons suffering from type 2 diabetes, hypertension and metabolic syndrome. In general, exercise physical activity directly improves the blood pressure independent on the type of exercise, and positively influences the indicators of metabolic syndrome.

Light to moderate physical activity

The influence of moderate to light intensity physical activity on general health is hardly been investigated in detail, but considering that numerous activities in a

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peron's life are of this category, and thus are executed regularly and frequently, it prevents a person from being sedentary. Some recent studies of importance are being considered here.

2,354 middle-aged white adults from the Unites States of America underwent both functional brain scans and carried accelerometers for eight days (Spartano et al., 2019). The results showed that every additional hour of light-intensity physical activity per day was linked to 0.22% greater brain volume, equivalent to approximately a year of less brain aging. This light-intensity physical activity included walking and household activities.

A recent study among 400,000 man and women from the UK studied the likelihood of being depressed while exerting physical activity using Mendelian randomization (Choi et al., 2019). Persons with gene variants believed to increase the likelihood someone will be active, indeed were active, and few of them had experienced depression. Persons without these gene variants, tended to move less, while they also showed greater risks for depression. The ideal amount of exercise to prevent depression started at about fifteen minutes a day of running or other exercise. Walking and household work also protected against depression, but to be effective about an hour a day needed to be performed.

Exercise patterns as described in the previous section are not similar to the physical activity executed in the blue zones. But moderate and light physical activity are more frequently executed in the blue zones. Although limited research is available in this respect, it is worth having a look at research regarding more traditional farming and leisure activities.

Non-exercise outdoors activities

An early paper from the UK showed a higher prevalence of depressive symptoms among farmers (Hounsome et al., 2012). However, factors like climate and environmental changes, financial instability and social isolation were not taken into account. More to the south, a cross-sectional study in Western Greece, among a rural population with a total of 672 farmers of both young and old age, showed that the young farmers had lower prevalence of hypertension, better cognitive health and low depression rates (Demos et al., 2013), while these findings were reversed in older ages. Without the economic burden due to retirement a Japanese cross- sectional study among 1,005 older farmers, showed that farming habits of long duration (more than

seven hours per week) significantly lowered the odds ratio for depressive symptoms, as compared to no farming habits (Asai et al., 2018). This positive association held as well for short durations (less than seven hours per week). Additionally, the association was partly mediated by daytime outdoors physical activity, and thus light exposure.

It is likely that the agriculture physical activity, often performed outdoors and thus coinciding with light exposure, secures the activation of vitamin D in the human skin. Deficiency in vitamin D is associated with impaired cognition, which is likely to be linked to loss in plasticity, particularly affecting the hippocampus (Mayne & Burne 2019), a region involved in learning and memory. Thus, securing sufficient serum levels of vitamin D is of crucial importance to human well-being.

Even light-intensity physical activity, like household, agriculture, gardening and walking, can contribute to better health. However, controlled studies among farmers, investigating the association of health with their occupational activities, which often are indicated to be of light to moderate intensity level, are lacking till now. On the other hand, actively engaging in the outdoors environment, especially distant from every-day professional routine, like in nature, gained much interest in the last decade.

A cross-sectional study among 2,079 working adults from the UK, showed that perception of local green space predicted the visit frequency and was positively correlated with reaching recommended levels of physical activity (Flowers et al., 2016). An individual's level of being connected with the natural world has been linked to psychological well-being (Zelenski & Nisbet, 2014). Studies from Japan, but also Europe and the USA, show that performing outdoor walking, gardening or nature viewing, were significantly positively associated with the measured heart rate, blood pressure and various self-reported measures, besides, showed reductions in the experience of stress and improvements of mental health (Hunter et al., 2019; Kondo et al., 2018; Marselle et al., 2019). Thus spending time in outdoors nature environments has positive effects. Walkers as compared to non-walker, showed a reduction in perceived stress, depression, and negative affect, as well as an increase in positive affect and mental well- being (Marselle et al., 2019). Such nature experiences reduced cortisol levels significantly within 20 minutes (Hunter et al., 2019), while an additional 10 minutes, summing up to half an hour, was even more


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effective, regardless whether it was spent sitting or walking.

Recent experiments with immersive virtual environments were performed to compare their effect with actual nature walks, and to investigate connectedness to nature and perception of the natural environment. It was shown that nature walks were associated with higher enjoyment and enhanced emotional state as compared to the virtual environment, specifically in relation to a reduction of tiredness and negative affect (Calogiuri et al., 2018). Moreover, from a recent systematic review on nature- based instructions, it was shown that educational time in nature, next to the obvious relief of stress, enhances attention, promotes self-motivation, boosts self- discipline, gives enjoyment and initiates engagement (Kuo et al., 2019), while all these factors improved learning. Besides, outdoors nature education increases physical activity and fitness, to which the leveling up of serum vitamin D levels most likely contributes (Mayne & Burne 2019).

Clearly, a positive respectful relation with the natural environment, with repeated visits, brings mental balance. Both leisure and educational time spent outdoors in nature, promote relaxation and reflection, and is perhaps comparable with the sense of belonging, as practiced in the blue zones.


The diet adhered to by the people of the blue zones, is based on fresh agricultural products, cropped by gardening surrounding lands. The diet is plant-based, predominantly consists out of vegetables, fruits and beans, while meat is added only occasionally, and hence depends on geography and climate.

A healthy diet maintains a healthy balanced intestinal microbiota, and recent research indicates that this symbiosis establishes an intestine-brain axis of major support to the health of the brain (Cryan & Dinan, 2012; Dash et al., 2015; Johnson & Foster, 2018). This axis influences the development of the brain, as well as behavior and mood. Here it is very important to notice that the inclusion of fermented foods, often present in traditional diets, promotes the presence of body-positive microbiota in the intestines (Wen & Duffy, 2017). In the intestines the microbial fermentation of host-indigestible dietary fibers, produces short-chain fatty acids that act as signals in the host (Kelly et al., 2017; Johnson & Foster, 2018). On the other hand, the presence of pesticides and herbicides also influence human physiology


(although used little to none in traditional blue zone farming).

Hence the food consumption not only determines the quantity and quality of the micronutrients available to the host, but influences both the symbiosis with microorganisms and the presence of chemical contaminations. Consequently, having effect on the physiology of the host by toxicity, and the microorganism's metabolism and its production of endocrine signals.

Mediterranean diet

A diet widely introduced for a healthier way of consumption – or reducing weight -, is the Mediterranean diet. It too comprises a traditional dietary pattern that is plant-based with freshly- harvested vegetables, fruits, nuts and seeds, beans and legumes, many herbs and spices, and whole grains (e.g., Davis et al., 2015; Katz & Meller, 2014). The diet includes the frequent consumption of fish and other seafoods, but on the other hand promotes selective dairy intake and quite limited consumption of meat, eggs and sweets. It emphasizes the use and consumption of healthful fats like extra virgin olive oils and fish fats. Besides, just like traditionally in the blue zones, both moderation in amount for each of the constituents is promoted, and strikingly, the addition of a few glasses of wine.

Studies on the health effect induced by adherence to the Mediterranean diet are numerously available, with some early systematic reviews (e.g., Serra- Majem et al., 2006; Sofi et al., 2008; Sofi et al., 2010). From 35 experimental studies it was shown that the Mediterranean diet has favourable effects on

lipoprotein levels, endothelium-dependent vasodilatation, insulin resistance, metabolic syndrome, antioxidant capacity, myocardial and cardiovascular mortality, and cancer incidence (Serra-Majem et al., 2006). Besides, 18 prospective cohorts running for 3-18 years, showed reduced risk of overall mortality, with a clear reduction of the incidence for cardiovascular, cancer, and neurodegenerative diseases and stroke (Sofi et al., 2008; Sofi et al., 2010). Other confirmed health effects are improved insulin sensitivity, reduced cancer risk, and particularly well demonstrated, the reduced risk of cardiovascular diseases, lower prevalence of general obesity and metabolic syndrome, and also the improvement of quality of life and diminished pulmonary inflammation in asthmatic patients (reviewed by Martinez-Lacoba et al., 2018; Sofi et al., 2014;). Finally, higher adherence to a Mediterranean diet was associated with a reduction in

Nutrition & neurodegeneration

EQOL Journal (2019) 11(1): 37-50

mortality (Bonaccio et al., 2018; Trichopoulou et al.,

persons and societies understand that the food they




consume, its micro and macronutrients, but also its

Thus, adherence to the Mediterranean diet, the







the production

process, drastically

plant-based diet as described above, seems to provide

impact their



especially their


longevity with

a reduced risk

for chronic non-

function, behaviour, mood and cognition. Hopefully,


diseases. Such


more people

will demand

a larger

production of

diseases, including depression and dementia, among

nutrious, high-quality



people in the blue zones are rare.



sustainable foods in the future.










Cognitive engagement

For Parkinson’s disease, a motor-neurodegenerative

Peoples in the blue zones are part of likewise-minded












neurons in the brain during a person’s life are dying,


family and




affecting the person’s movement, gait, and balance, it







was recently
















Mediterranean diet intervention was associated with



while relaxation within the

a decreased risk of parkinsonism, and with slower

community setting, in the form of socialising, is a









routine resulting


the sharing






























foods and drinks. The community and its individuals

Higher adherence to the Mediterranean diet has

execute activities through mindful engagement

been associated with the reduction of the incidence of

within natural surroundings.












To pursuit such daily activities up till old age, in

longitudinal and twenty-one cross-sectional studies,

the absence of age-related falls, health complications

as well in four longitudinal studies (Lassale et al.,

and deteriorations, it is likely prolonged exposure to

2018). A recent randomized controlled trial showed






that 12-week intervention with a Mediterranean diet

simultaneous implementation of motor and cognitive







tasks. This






depression (Jacka et al., 2017). In line with these are


generally fit





the results from a systematic review on 11 cohorts

through high-end cognitive engagement. Next, we

(including only





will discuss several forms of cognitive engagement







that can

be hypothetically



basis for


diet was


associated with improved















cognitive function, lower rates of cognitive decline,


























and reduced risk of Alzheimer's disease (Lourida et

Cognitive-motor exercises







al., 2013), and a more recent systematic review that

Physical activity, alone or combined with cognitive







training can enhance functional fitness in older adults

controlled trials and 27 observational studies, confirm


et al.,

2016). Simultaneously


these observations (Petersson & Philippou, 2016).

cognitive (e.g., working memory task) and motor



















(e.g., strength exercises) tasks in elderly are more

adding supplements to the diet and including more

frequently used for preventing falls. In this way, the

proper diets, to persons with chronic non-

individual trains automated execution of simple

communicable diseases is gaining attention (e.g.,

motions (Ghai et al., 2017). The combination of

Sarris et al., 2015). And for good reasons, because

cognitive-motor exercises has shown to improve

combined with metabolically enhancing the capacity

attention, control of executive functions, memory and

of Alzheimer's disease patients, it was recently

reasoning (reviewed by Bherer, 2015; Lauenroth et

observed to reverse cognitive decline (Bredesen et al.,

al., 2016).

























More specific, for example the training of















Diet and nutrition will become essential future

executive functions by computer-based training in

focus points of a person's lifestyle. Especially since

sedentary elderly gives rise to improved walking

climate change and environmental pressure will

efficiency (Verghese et al., 2010). While

demand the reduction of energy for food production,




transport, and the elimination of food waste. Once







EQOL Journal (2019) 11(1): 37-50

maze, positively influenced both normal and complex

comparable methodology, and some reports have

walking in healthy elderly men during bed rest

found less convincing evidence, the most striking is

(Marušič et al., 2015). The continued spatial

that, studies investigating neuroanatomical brain

navigational testing showed improvements up to four

differences between older monolinguals and

hundred days post-bed rest (Marušič et al., 2018a).

bilinguals, did show that there is more atrophy among

Hence it was suggested that such spatial navigation-

bilinguals (Schweizer et al., 2012). Also, a difference

based computerized training can be protective of

in the brain areas being activated for various tasks is

detrimental mobility effects. This reflects the

observed (Ansaldo et al., 2015; Gold et al., 2013b), as

potential for cognitive-based training to affect a non-

well as differences in brain tissue integrities are

trained domain. Moreover, only to imagine

recorded (Gold et al., 2013a; Olson et al., 2015), and

demanding rehabilitation exercises, a specific

different cortical thicknesses (Anderson et al., 2018;

cognitive function, does influence the process of

Duncan et al., 2018; Olson et al., 2015).



functional skills as well (Marušič et al., 2018b).


Typically, the bilingual advantage seems to be















In conclusion, cognitive motor exercises are

applicable to other diseases with neuronal damage:

promising. Although variation is noticed, and study

like a faster recovery after brain stroke (Alladi et al.,

results are even contradicting, the cognitive part can

2016), a delay in the onset of frontotemporal

be designed to train various executive functions in

dementia (Alladi et al., 2017), and increased

combination with physical exercise. Hence, new

frontotemporal grey matter integrity in Huntington’s

cognitive-motor exercises will be quite powerful.

bilingual patients (Martínez-Horta et al., 2018).








Despite the described effects of bilingualism, it

effective, will certainly find its way to educational

has not been thoroughly explored how the use of

systems and private homes, by delivery in society

language, or adding another foreign language to a

through entrepreneurs.













person’s communication proficiency, can affect















Language usage









cognition and executive functioning. Social

Another form, less physically active, but more of a

engagement, trying to understand and communicate

another person through language might certainly be

cognitive challenge, is the use of language. Especially

part of the basis of cognitive health seen in the blue

the use






zones. Bilingualism









approach, would be a welcome addition to improving




executive functions,




even health




attention, inhibition, working memory, etc., in a way

Especially since it would support education structures

that the brain performs dual tasks. Being proficient in






customs and



that is: speaking, reading













writing, has been correlated to enhanced cognition























(Bialystok & Poarch, 2014), and to beneficially





















practice that



(Bialystok & Viswanathan, 2009).









spiritual attention with physical exercise in the form















Languages learned early on in life, and maintained

of body posture and the control of breathing.

throughout adult life, establishes bi- or

Depending of its nature, the practice usually demands

multilingualism, and continually train the brain in a

cognitive and physical mindfulness. For example,

non-conscious way. Especially in older persons, some

yoga originating in India, is now often practiced

advantages from such lifelong brain training, seem to

throughout the Western societies both for health and

emerge in the form of delaying the onset of various












neurodegenerative diseases, like dementia. Various





















Americas and Europe (Alladi et al., 2013; Bialystok

controlled studies, showed that yoga from various

et al., 2007; Bialystok et al., 2014; Chertkow et al.,

disciplines has clear advantages as compared to their




al., 2010; Gollan

et al.,


control groups. Eight to nine weeks of yoga exercises













disorder patients

participants, showed that the use of two languages,

positively affected depressive symptoms (Vollbehr et

can delay





of cognitive






the anxiety

impairment, the early signs of Alzheimer’s disease,

symptoms (Sharma et al., 2017). In patients with post-

with four to five years. Although there is debate about














EQOL Journal (2019) 11(1): 37-50

traumatic stress syndrome, yoga for 6-12 weeks moderately decreased the re-experiencing and hyperarousal symptoms (Mitchell et al., 2014). Along this line schizophrenia patients executing yoga for eight weeks significantly improved their perceived quality of life in the physical and psychologic domains with clear improvements of positive and negative schizophrenia symptoms (Visceglia & Lewis, 2011). Interestingly, for patients with eating disorders one hour of yoga before dinner significantly reduced their pre-meal negative affect. Although the effect was attenuated post-meal (Pacanowski et al., 2017). Despite that these are preliminary studies, the results clearly show some promise, incorporating mindful yoga as a lifestyle for the benefit of general health.

The breathing aspect of yoga has gained a lot of attention recently, and trials with respiratory muscle exercises have been performed. For example, older women with metabolic syndrome undergoing respiratory muscle exercises for seven days (three sets of 15 minutes, with a three-minutes interval), improved both their respiratory and cardiac functions (Feriani et al., 2017). In middle-aged to older adults, six weeks of high-resistance respiratory muscle exercises (thirty breaths per day for six days in the week), the cardiorespiratory fitness was significantly improved, and the exercise time before exhaustion was reached, was prolonged (Heinbockel et al., 2019). The advantages of respiratory muscle exercises are multiple. The threshold to adhere to rigorous breathing exercises is often low, especially as compared to time-consuming aerobic exercise paradigms. Besides, it could be applied to patients with disabilities alongside existing therapies. Thus, respiratory muscle exercises seem to be a practical and promising, modulatory lifestyle factor.

Long term intervention effects of meditation recording biomarkers have also been studied. For example, anxiety disorder patients instructed during an eight-week mindfulness course (yoga, breathing and posture instructions) followed by home-practice intervention, showed a greater reduction in adrenocorticotropic hormone and pro-inflammatory cytokines concentrations, after a social stress test, as compared to control participants (Hoge et al., 2018). Similarly, long-time meditation practitioners compared to non-meditating controls, recovered faster from such cortisol response induced by the same social stress test (Gamaiunova et al., 2019). While the long-term meditation practitioners also reported experiencing less self-conscious emotions after the stressful task.

Thus, it is known that stress is responsible for a variety of negative health outcomes, and it seems that meditation, can initialize to be able to cope better with stress situations, and can minimize typical psychophysiological stress responses. Being part of an equally-minded society, in which one performs meaningful habits, according to certain purposeful routines, might be regarded, at least partly, as a meditation, and can add to quality of life as observed in the blue zones.


In general, the inhabitants of the blue zone get sufficient rest (e.g., Pes et al., 2018). Meaning being inactive for an average of 8.5 hours, with an average of 6.3 hours of night-time sleep (Pes et al., 2018). While especially in the warmer and more humid climates, easing down through socializing, and brief daytime naps usually restricted to maximally half an hour, also known as siesta, are very common (Naska et al., 2007; Pes et al., 2018). A meta-analysis showed that deviating a lot more or less from this average night-time sleep duration, increases the all-cause co- morbidity for older adults (Shen et al., 2016). Despite recent understandings of sleep-wake homeostasis, its physiological regulation, and it effect on appetite, energy intake and expenditure (Copinschi et al., 2014), the general public in Western societies does have a wrong impression of sleep and its contribution to general health (Robbins et al., 2019).

Physiological sleep involves several stages characterized by brain activity, that repeat four to six times per night within cycles of about ninety minutes (Copinschi et al., 2014): two stages of light non-rapid eye (REM) movement, are followed by slow-wave sleep (a deeper, non-REM stage), REM sleep, and finally transient awakenings. As the night-time sleep progresses, the number and the duration of the awakenings increase, while the non-REM sleep becomes shallower, and the duration of REM sleep becomes longer, till the final awakening occurs. Intact stages of slow-wave durations often reflect a good quality of sleep (Copinschi et al., 2014), and in elderly persons the durations of the slow-wave and REM stages usually are reduced, leading to an increase of time spent awake.

Various hormones contribute to metabolic homeostasis during sleep. For example, cortisol is produced by the adrenal glands, but production is reduced during sleep especially in the slow-wave stage, giving rise to low circulating cortisol levels during sleep (Charloux et al., 1999). The transient and final awakenings trigger the production of cortisol.


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Reducing sleep time and introduction of daytime sleeping, induces overall higher levels of cortisol, which increases the arousal state of the body, usually requesting energy intake. On the other hand, during the slow-wave stages, growth hormone is released while insulin is reduced. These patterns coincide with the reduced use of glucose by the brain and peripheral tissues during the first half of sleep. While glucose demand becomes higher during the night's second half of sleep, that is shallower and more fragmented (Van Cauter & Spiegel 1999).

Leptin, a hormone released from adipocytes, informs the hypothalamus, the brain's metabolic centre, about the energy status of the body. Leptin levels reflect the feeding status of the body, with high circulating levels corresponding to saturation and overfeeding, and low levels correspond to hunger and underfeeding. Sleep time reduction gives rise to lower leptin levels, while enhanced duration of sleep induced a rise of leptin levels (Spiegel et al., 2004a; Spiegel et al., 2004b).

Ghrelin, produced by gastric cells in the stomach wall, also informs the hypothalamus especially indicating hunger, and being a digestion activator. Ghrelin blood levels repeatedly rise during daytime (generally 3 cycles of 3 hours). However, with food consumption the levels drop fast (next 2 hours), before rising again. During the first half of sleep ghrelin levels rise (from last the meal), and decline during the second half of sleep (mirroring cortisol).

The ratio of ghrelin to leptin has been correlated to hunger and appetite and this ratio is a good indicator of energy requirements (Spiegel et al., 2004a; Spiegel et al., 2004b). For example, with sleep extension the ratio declined, showing consistently higher levels of leptin and lower levels of ghrelin (Copinschi et al., 2014), usually favouring energy restriction during daytime. On the other hand, in normal weight persons, during sleep reduction, the ratio of grehlin to leptin increased, inducing enhanced hunger and appetite ratings. Thus, in middle-aged overweight persons, sleep restriction also lead to higher ghrelin to leptin ratio (Nedeltcheva et al., 2010), and induced an increased loss of fat-free body mass, while the resting metabolic rate decreased, and fasting metabolic rate increased, overall negatively influencing energy metabolism.

Under controlled laboratory conditions with healthy participants, limitation of sleep time typically reduced the glucose uptake through reduction of the insulin release (Leproult & Van Cauter 2010; Spiegel et al., 1999; Tasali et al., 2008; Van Cauter & Spiegel


1999). More dramatic responses were observed by specific reduction of the slow-wave stage (Leproult & Van Cauter 2010; Spiegel et al., 1999; Tasali et al., 2008). Thus, both reduction of the sleep time and limited sleep quality give rise to increased risk of type 2 diabetes.

Sleep restriction influences brain activity as well (Greer et al., 2013). Showing decreased activity in cortical regions and enhanced activity in the amygdala. A combination that strongly correlated with increased desires for high-calorie foods and subjective sleepiness. Furthermore, sleep deprivation has been associated with increased levels of anxiety (Pires et al., 2016), and makes us interpret things more negatively (Tamm, 2019). Which all in turn affect general health.

Sleep has been recognized as an important physiologic period of rest, during which, because of the absence of physical activity, the metabolic homeostasis is reset through hormones. However, its contribution to general health is often undervalued in hectic Western societies. This in contradiction to the blue zone communities, where sleep and non- physically active periods of rest, are valued. Research shows that especially the sleep's quality of the slow- wave stages and the duration of the overall sleep, contributes to effective daytime homeostasis, and are crucial for execution of optimal functional and cognitive activities.


The present paper reviews several non- pharmacologic approaches to improve general, cardiovascular and cognitive health. These approaches were identified from blue zone denominators, standing out from epidemiologic and demographic research within the areas, were the oldest old can be found to live today. These blue zone lifestyle factors are supposedly good for any person to adhere to, in any habitat, although not always easily to adapt to in Western societies.

The benefits of moving naturally and using natural transportation, perform regular agricultural activities, gardening and household activities, have been identified as light to moderate physical activity, that executed regularly, fights sedentary lifestyles and depression. And while being beneficial to health and psychology, controlled studies show that execution for over an hour produces predominant benefits in the psychological domain, while walking (or sitting) for

EQOL Journal (2019) 11(1): 37-50

half an hour in an outdoors natural environment significantly reduces stress and is positively associated with heart rate and blood pressure, through enhanced enjoyment and emotional state, and reduced tiredness. However, the effects of light to moderate physical activity have been poorly studied.

On the other hand, physical activity in the form of exercise and the Mediterranean diet (that most closely resembles the blue zone nutritional pattern), with long-term adherence to daily fifteen minutes of aerobic exercise (e.g. running), will induce a better

health through cardiovascular, cognitive, psychological and functional benefits, reduction of weight, and the risks of hypertension, type 2 diabetes, and metabolic syndrome. In general, they reduce the risk for chronic non-communicable diseases, as confirmed through various studies. The benefits of adherence to a plant-based diet are numerous, as plant-based meals are especially in the long run favoring sustainable food systems. Besides, depending on the scale of cropping and the chemicals introduced, plant-based diets will be more beneficial for the environment and an individual’s health. Thus, a plant-based diet seems to reduce depression, fight cognitive decline and dementia, and is beneficial in reducing Parkinson’s disease symptoms.

Strikingly many of the blue zone denominators (like agriculture habits and natural transportation), are performed outdoors. While farming habits of several hours per week significantly lowers the risk for depressive symptoms, it also means a person is exposed to fresh air, and receives direct sunlight, boosting the vitamin D levels, that can affect several cognitive functions, like memory and attention, while even affecting schizophrenia in a positive way (Mayne & Burne, 2019). Being outdoors in a natural environment will be beneficial for all ages, brings mental balance, and several studies show that young people will display higher amounts of physical activity, enhance their creativity and fitness. Being educated in nature has the potential of positively enhancing academic performance through multiple factors not fully understood, but the contribution of enhanced attention, self-motivation, and self- discipline, are among them.

Additional blue zone traits have been explored in this review. For example, cognitive-motor exercises, language use and meditation. Although not specifically identified as blue zone traits, the strong societal traits of the blue zones, like a purposeful life, (self)reflection, and appreciated time to relax and sleep, particularly do give some relevance to the

weight of meditation. Adherence to various degrees of yoga or mindfulness exercises for several weeks can induce benefits in the form of better coping with stress factors, while improving both respiratory and cardiac functions. Effective for patients with major depression, post-traumatic stress syndrome, schizophrenia and eating disorders.

It is presumed that blue zone inhabitants, will perform dual-tasks, being cognitively busy while performing light physical activity. This would benefit the domains of attention, memory and reasoning, while for elderly especially, would improve their mobility through improved walking skills and fall prevention. Blue zone inhabitants’ social time- sharing periods, conversation and meal-sharing, during rest periods, add to their purpose in life and the

maintenance of social communication. Understanding your neighbors, friends and family, requires communication, and in a sense demands psychologic interpretation of the limited verbal expression of anyone’s mental thoughts. Lifelong multilingualism, in which communication through languages, can benefit cognition in general, and delay the symptoms of cognitive decline with as much as five years. As the incidence of neurodegenerative diseases in blue zones is very low, as compared to modern Western societies, this review included the issues of bilingualism and dementia.

Pes and colleagues notice that the duration of sleep for Sardinian elderly exceeds 82% and 77% of the resting time in the men and women respectively, while adhering to the other blue zone denominators, and maintain excellent physical functionality indexes (Pes et al., 2018). Therefore, sleep physiology research was recapitalized and emphasized, and its crucial role for general health was explained. Sufficient quality sleep is essential to maintain a healthy physiology. Moreover, crucial deviations, especially long-term, can drastically impact the psychological domain of individuals, influence metabolic and caloric states, hence, change body weight, cognition and functionality (increasing the risks for both type 2 diabetes and obesity).


Diet and exercise as effective lifestyle paradigms are taken up in various health promotion programmes at national levels throughout Europe, with resistance exercise an established denominator to maintain skeletal and muscular health. However, the purpose


EQOL Journal (2019) 11(1): 37-50

of this paper was to identify denominators to additionally improve cardiovascular and cognitive health, like gardening, agricultural physical activity, sleep and relaxation in the form of meditation that deserve attention as well, but could be scientifically researched in more detail. Combined with cognitive brain training (for elderly), in the form of cognitive- motor exercises and promoting the use of multiple languages, these non-pharmacologic approaches, in general, can add to a healthy brain, longer lifespan and happier lives. Hopefully this paper contributes to the development and promotion of these denominators.


This manuscript was prepared as part of the research programme Kinesiology for Quality of Life (P5- 0381) funded by the Slovenian Research Agency.

Conflict of interest: The author declares no conflict of interest.


Agarwal, A., Wang, Y., Buchman, A.S., Holland, T.M., Bennett, D.A., & Morris, M.C. (2018). MIND diet associated with reduced incidence and delayed progression of Parkinsonism in old age. Journal of Nutrition, Health & Aging, 22(10), 1211-1215.

Alladi, S., Bak, T.H., Duggirala, V., Surampudi, B., Shailaja, M., Shukla, A.K., … & Kaul. S. (2013). Bilingualism delays age at onset of dementia, independent of education and immigration status. Neurology, 81(22), 1938-1944.

Alladi, S., Bak, T.H., Mekala, S., Rajan, A., Chaudhuri, J.R., Mioshi, E., … & Kaul. S. (2016). Impact of bilingualism on cognitive outcome after stroke. Stroke, 14(1), 258-261.

Alladi, S., Bak, T.H., Shailaja, M., Gollahalli, D., Rajan, A., Surampudi, B., … & Kaul. S. (2017). Bilingualism delays the onset of behavioral but not aphasic forms of frontotemporal dementia. Neuropsychologia, 99, 207- 212.

Anderson, J.A.E., Grundy, J.G., de Frutos, J., Barker, R.M., Grady, C., & Bialystok, E. (2018). Effects of bilingualism on white matter integrity in older adults. Neuroimage, 167, 143-150.

Ansaldo, A.I., Ghazi-Saidi, L., & Adrover-Roig, D. (2015). Interference control in elderly bilinguals: Appearances can be misleading. Journal of Clinical and Experimental Neuropsychology, 37(5), 455-470.

Asai, Y., Obayashi K., Oume, M., Ogura, M., Takeuchi, K., Yamagami, Y., … & Saeki, K. (2018). Farming habit, light exposure, physical activity, and depressive symptoms. Journal of Affective Disorders, 241, 235- 240.

Bherer, L. (2015). Cognitive plasticity in older adults: Effects of cognitive training and physical exercise. Annals of the New York Academy of Sciences, 1337, 1- 6.

Bialystok, E., Craik, F.I.M., & Freedman. M. (2007). Bilingualism as a protection against the onset of symptoms of dementia. Neuropsychologia, 45(2), 459- 464.

Bialystok, E., Craik, F.I.M., Binns, M.A., Ossher, L., & Freedman, M. (2014). Effects of bilingualism on the age of onset and progression of MCI and AD: evidence from executive function tests. Neuropsychology, 28(2), 290-304.

Bialystok, E., & Poarch, G.J. (2014). Language experience changes language and cognitive ability. Zeitschrift fur Erziehungswissenschaft, 17(3), 433-446.

Bialystok, E., & Viswanathan, M. (2009). Components of executive control with advantages for bilingual children in two cultures. Cognition, 112(3), 494-500.

Bonaccio, M., Di Castelnuovo, A., Costanzo, S., Gialluisi, A., Persichillo, M., Cerletti, C., … & Lacoviello, L.

(2018). Mediterranean diet and mortality in the elderly:

aprospective cohort study and a meta-analysis. British Journal Nutrition, 120(8), 841-854.

Bredensen, D.E., Amos, E.C., Canick, J., Ackerley, M., Raji, C, Fiala, M., & Ahdidan J. (2016). Reversal of cognitive decline in Alzheimer's disease. Aging, 8(6), 1250-1258.

Buettner, D., & Skemp, S. (2016). Blue zones: Lessons from the world’s longest lived. American Journal of Lifestyle Medicine, 10(5), 318-321.

Calogiuri, G., Litleskare, S, Fagerheim, K.A., Rydgren, T.L., Brambilla, E., & Thurston, M. (2018). Experiencing nature through immersive virtual environments: Environmental perceptions, physical engagement, and affective responses during a simulated nature walk. Frontiers in Psychology, 8, 2312.

Charloux, A., Gronfier, C., Lonsdorfer-Wolf, E., Piquard, F., & Brandenberger, G. (1999). Aldosterone release during the sleep-wake cycle in humans. American Journal of Physiology, 276(1), E43-E49.

Chertkow, H., Whitehead, V., Phillips, N., Wolfson, C., Atherton, J., & Bergman, H. (2010). Multilingualism (but not always bilingualism) delays the onset of Alzheimer’s disease: evidence from a bilingual community. Alzheimer Disease and Associated Disorders, 24(2), 118-125.

Choi, K.W., Chen, C.Y., Stein, M.B., Klimentidis, Y.C., Wang, M.J., Koenen, K.C., & Smoller, J.W. (2019 January 23). Assessment of bidirectional relationships between physical activity and depresseion among adults: A 2-sample Mendelian randomization study.


EQOL Journal (2019) 11(1): 37-50

JAMAPsychiatry,doi: 10.1001/jamapsychiatry.2018.4175.

Copinschi, G., Leproult, R., & Spiegel, K. (2014). Chapter The important role of sleep in metabolism: Chapter taken from How Gut and Brain Control Metabolism ISBN: 978-3-318-02638-2 Frontiers of Hormone Research, Karger (Vol. 42, pp. 59-72).

Cornelissen, V.A., & Smart, N.A. (2013). Exercise training for blood pressure: A systematic review and meta- analysis. Journal of the American Heart association, 2(1), e004473.

Craik, F.I.M., Bialystok, E., & Freedman, M. (2010). Delaying the onset of Alzheimer disease: bilingualism as a form of cognitive reserve. Neurology, 75(19), 1726-1729.

Cryan, J.F., & Dinan, T.G. (2012). Mind-altering microorganisms: the impact of the gut microbiota on brain and behaviour. Nature Reviews Neuroscience, 13(10), 701-712.

Davis, C., Bryan, J., Hodgson, J., & Murphy, K. (2015). Definition of the Mediterranean diet: A literature review. Nutrients, 7(11), 9139-9153.

Dash, S., Clarke, G., Berk, M., & Jacka, F.N. (2015). The gut microbiome and diet in psychiatry: focus on depression. Current Opinion in Psychiatry, 28(1), 1-6.

Duncan, H.D., Nikelski, J., Pilon, R., Steffener, J., Cherthow, H., & Phillips, N.A. (2018). Structural brain differences between monolingual and multilingual patients with mild cognitive impairment and Alzheimer

disease: Evidence for cognitive reserve. Neuropsychologia, 109, 270-282.

Fastame, M.C., Hitchcott, P.K., Mulas I., Ruiu, M., & Penna, M.P. (2018). Resilience in elders of the Sardinian blue zone: An explorative study. Behavioral Sciences, 8(3), pii: E30.

Feriani, J.D., Coelho, H.J. Junior, Scapini, K.B., de Moraes, O.A., Mostarda, C., … & Rodrigues, B. (2017). Effects of inspiratory muscle exercise in the pulmonary function, autonomic modulation, and hemodynamic variables in older women with metabolic syndrome. Journal of Exercise Rehabilitation, 13(2), 218-226.

Flowers, E., Freeman, P., & Gladwell, V.F. (2016). A cross-sectional study examining predictors of visist frequency to local green space and the impact this has on physical activity levels. BMC Public Health, 16, 420.

Gamaiunova, L., Brandt, P.Y., Bondolfi, G., & Kliegel, M. (2019 February 26). Exploration of psychological mechanisms of the reduced stress response in long-term meditation practitioners. Psychoneuroendocrinology, 104, 143-151. doi: 10.1016/j.psyneuen.2019.02.026

Ghai, S., Ghai, I., & Effenberg, A.O. (2017). Effects of dual tasks and dual-task training on postural stability:

Asystematic review and meta-analysis. Clinical Interventions in Aging, 12, 557-577.

Gold, B.T., Johnson, N.F., & Powell, D.K. (2013a). Lifelong bilingualism contributes to cognitive reserve

against white matter integrity declines in aging. Neuropsychologia, 51(13), 2841-2846.

Gold, B.T., Kim, C., Johnson, N.F., Kryscio, R.J. & Smith C.D. (2013b). Lifelong bilingualism maintains neural efficiency for cognitive control in aging. Journal of Neuroscience, 33(2), 387-396.

Gollan, T.H., Salmon, D.P., Montoya, R.I., & Galasko, D.R. (2011). Degree of bilingualism predicts age of diagnosis of Alzheimer’s disease in low-education but not in highly educated Hispanics. Neuropsychologia, 49(14), 3826-3830.

Greer, S.M., Goldstein, A.N., & Walker, M.P. (2013). The impact of sleep deprivation on food desire in the human brain. Nature Communications, 4, 2259.

Heinbockel, T.C., Rossman, M.J., Jankowski, L.R., Jackman, R.A., Bailey, E.F., Chonchol, M.B., … & Graighead, D.H. (2019). Effects of inspiratory muscle strength training on cardiorespiratory fitness in middle-

aged to older adults. FASEB Journal, 33(1_supplement), 695.4. Retrieved April 10, from https://www.fasebj.org/doi/10.1096/fasebj.2019.33.1_ supplement.695.4

Hoge, E.A., Bui, E., Palitz, S.A., Schwarz, N.R., Owens, M.E., Johnston, J.M., … & Simon, N. M. (2018). The effect of mindfulness meditation training on biological acute stress responses in generalized anxiety disorder. Psychiatry Research, 262, 328-332.

Hounsome, B., Edwards, R.T., Hounsome, N., & Edwards- Jones, G. (2012). Psychological morbidity of farmers and non-farming population: Results from a UK survey. Community Mental Health Journal, 48(4), 503- 510.

Hunter, M.C., Gillespsie, B.G., & Chen, S.Y.P. (2019 April 4). Urban nature experiences reduce stress in the context of daily life based on salivary biomarkers.

Frontiers in Psychology, 10, 722. doi: 10.3389/fpsyg.2019.00722.

Jacka, F.N., O'Neil, A., Opie, R., Itsiopoulos, C., Cotton, S., Mohebbi, M., … & Berk, M. (2017). A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’ trial). BMC Medicine, 15(23), 1-13.

Johnson, K.V., & Foster K.R. (2018). Why does the microbiome affect behaviour? Nature Reviews Microbiology, 16(10), 647-655.

Katz, D.L., & Meller, S. (2014). Can we say what diet is best for health? Annual Review of Public Health, 35: 83-103.

Kelly, J.R., Minuto, C., Cryan, J.F., Clarke, G., & Dinan, T.D. (2017). Cross-talk: The microbiota and

neurodevelopmental disorders. Frontiers in Neuroscience, 11, 490.

Kodama, S., Tanaka, S., Saito, K., Shu, M., Sone, Y., Onitake, F., … & Sone, H. (2007). Effect of aerobic exercise training on serum levels of high-density lipoprotein cholesterol: A meta-analysis. Archives of Internal Medicine, 167(10), 999-1008.

Kondo, M.C., Jacoby, S.F., & South, E.C. (2018). Does spending time outdoors reduce stress? A review of real-


EQOL Journal (2019) 11(1): 37-50

time stress response to outdoor environments. Health & Place, 51, 136-150.

Kuo, M., Barnes, M., & Jordan, C. (2019 February 19). Do experiences with nature promote learning? Converging evidence of a cause-and-effect relationship. Frontiers

in Psychology, 10, 305. doi: 10.3389/fpsyg.2019.00305.

Lassale, C., Batty, G.D., Baghdadli, A., Jacka, F., Sánchez- Villegas, A., Kivimäki, M., & Akbaraly, T. (2018). Healthy dietary indices and risk of depressive outcomes: A systematic review and meta-analysis of

observational studies. Molecular Psychiatry. https://doi.org/10.1038/s41380-018-0237-8.

Lauenroth, A., Ioannidis, A.E., & Teichmann, B. (2016). Influence of combined physical and cognitive training on cognition: A systematic review. BMC Geriatrics, 16, 141.

Leproult, R., & Van Cauter, E. (2010). Role of sleep and sleep loss in hormonal release and metabolism. Endocrine Development, 17, 11-21.

Lin, X., Zhang, X., Guo, J., Roberts, C. K., McKenzie, S., Wu, W.C., … & Song, Y. (2015). Effects of exercise training on cardiorespiratory fitness and biomarkers of cardiometabolic health: A systematic review and meta- analysis of randomized controlled trials. Journal of the American Heart Association, 4(7), e002014.

Lourida, I., Soni, M., Thompson-Coon, J., Purandare, N., Lang, I.A., Ukoumunne, O.C., & Llewllyn, D.J. (2017). Mediterranean diet, cognitive function, and dementia:

Asystemic review. Epidemiology, 24(4), 479-489. Marselle, M.R., Warber, S.L., & Irvine, K.N. (2019 March

19). Growing resilience through interaction with nature: Can group walks in nature buffer the effect of stressful life events on mental health? International Journal of Environmental Research and Public Health, 16(6), pii: E986. doi: 10.3390/ijerph16060986.

Martínez-Horta, S., Moreu, A., Perez-Perez, J., Sampedro, F., Horta-Barba, A., Pagonabarraga, J., … &

Kulisevsky, J. (2018). The impact of bilingualism on brain structure and function in Huntington's disease. Parkinsonism and related disorders, pii: S1353-

8020(18)30405-X.doi: 10.1016/j.parkreldis.2018.09.017

Martinez-Lacoba, R., Pardo-Garcia, I., Amo-Saus, E., & Escribano-Sotos, F (2018). Mediterranean diet and health outcomes: a systematic meta-review. European Journal of Public Health, 28(5), 955-961.

Marušič, U., Kavčič, V., Giordani, B., Gerževič, M., Meeusen, R., & Pišot., R. (2015). Computerized spatial navigation training during 14 days of bed rest in healthy older adult men: Effect on gait performance. Psychology and Aging, 30(2), 334-340.

Marušič, U., Giordani, B., Moffat, S. D., Petrič, M., Dolenc, P., Pišot., R., & Kavčič, V. (2018a).

Computerized cognitive training during physical inactivity improves executive functioning in older adults. Neuropsychology, Development and Cognition Section B, Aging Neuropsycholology and Cognition, 25(1), 49-69.


Marušič, U., Grospretre, S., Paravlić, A., Kovač, S., Pišot R., & Taube, W. (2018b). Motor imagery during action observation of locomotor tasks improves rehabilitation outcome in older adults after total hip arthroplasty. Neural Plasticity, 5651391.

Mayne, P.E., & Burne, T.H.J. (2019 April). Vitamin D in synaptic plasticity, cognitive function, and neuropsychiatric illness. Trends in Neurosciences, 42(4), 293-306. doi: 10.1016/j.tins.2019.01.003.

Mitchel, K.S., Dick, A.M., DiMartino, D.M., Smith, B.N., Niles, B., Koenen, K.C., & Street, A. (2014). A pilot study of a randomized controlled trial of yoga as an intervention for PTSD symptoms in women. Journal of Traumatic Stress, 27(2), 121-128.

Naska, A., Oikonomou, E., Trichopoulou, A., Psaltopoulou, T., & Trichopoulos, D. (2007). Siesta in healthy adults and coronary mortality in the general population. Archives of Internal Medicine, 167(3), 296- 301.

Nedeltcheva, A.V., Kilkus, J.M., Imperial, J., Schoeller, D.A., & Penev, P.D. (2010). Insufficient sleep undermines dietary efforts to reduce adoposity. Annals of internal Medicine, 153(7), 435-441.

Olson, R.K., Pangelinan, M.M., Bogulski, C., Chakravarty, M.M., Luk, G., Grady, C., & Bialystok, E. (2015). The effect of lifelong bilingualism on regional grey and white matter volumes. Brain Research, 1612, 128-139.

Owen, N., Sparling, P.B., Healy, G.N., Dunstan, D.W., & Matthews, C. (2010). Sedentary behavior: Emerging evidence for a new health risk. Mayo Clinic Proceedings, 85(12), 1138-1141.

Pacanowski, C.R., Diers, L., Crosby, R.D., & Neumark- Sztainer, D. (2017). Yoga in the treatment of eating disorders within a residential program: A randomized controlled trial. Eating Disorders 25(1), 37-51.

Panagiotakos, D.B., Chrysohoou, C., Siasos, G., Zisimos, K, Skoumas, J., Pitsavos, C., & Stefanadis, C. (2011). Sociodemographic and lifestyle statistics of oldest old people (>80 years) living in Ikaria island: The Ikaria study. Cardiology Research and Practice, 2011, 679187.

Paravlić, A., Marušič, U., Gerževič, M., Urzi, F., & Šimunič, B. (2016). The effects of different exercise- based interventions on functional fitness of older adults. Annales Kinesiologiae, 7(2), 117-137.

Pes, G.M., Dore, M.P., Errigo, A., & Poulain, M. (2018). Analysis of physical activity among free-living nonagenarians from a Sardinian longevous population. Journal of Aging and Physical Activity, 26(2), 254-258.

Petersson, S.D., & Philippou, E. (2016). Mediterranean diet, cognitive function, and dementia: A systemic review of the evidence. Advances in Nutrition, 7(5), 889-904.

Pires, G.N., Bezerra, A.G., Tufik, S., & Andersen, M.L. (2016). Effects of acute sleep deprivation on state anxiety levels: A systematic review and meta-analysis. Sleep Medicine, 24, 109-118.

Poulin, M., Pes, G.M., Grasland, C., Carru, C., Ferrucci, L., Baggio, G., … & Deiana, L. (2004). Identification

EQOL Journal (2019) 11(1): 37-50

of a geographic area characterized by extreme longevity in the Sardinia island: The AKEA study. Experimental Gerontology, 39(9), 1423-1429.

Robbins, R., Grandner, M.A., Buxton, O.M., Hale, L., Buysse, D.J., Knutson, K.L., … & Jean-Louis, G. (2019). Sleep myths: An expert-led study to identify false beliefs about sleep that impinge upon population sleep health practices. Sleep Health, pii: S2352- 7218(19)30025-7. doi: 10.1016/j.sleh.2019.02.002.

Sarris, J., Logan, A.C., Akbaraly, T.N., Amminger, G.P., Balanzá-Martínez, V., Freeman, M.P., … & Jacka, F.N. (2015). Nutritional medicine as mainstream in psychiatry. The Lancet Psychiatry, 2(3), 271-274.

Schweizer, T.A., Ware, J., Fisher, C.E., Craik, F.I.M., & Bialystok, E. (2012). Bilingualism as a contributor to cognitive reserve: Evidence from brain atrophy in Alzheimer's disease. Cortex, 48(8), 991-996.

Serra-Majem, L., Roman, B., & Estruch, R. (2006). Scientific evidence of interventions using the Mediterranean diet: A systematic review. Nutrition Reviews, 64(2), S27-S47.

Sharma, A., Barrett, M.S., Cucchiara, A.J., Nalaka, S., Gooneratne, M.D., & Thase M.E. (2017). A breathing- based meditation intervention for patients with major depressive disorder following inadequate response to antidepressants: A randomized pilot study. Journal of Clinical Psychiatry, 78(1), e59-e63.

Shen, X., Wu, Y., & Zhang, D. (2016). Nighttime sleep duration, 24-hour sleep duration and risk of all-cause mortality among adults: A meta-analysis of prospective cohort studies. Scientific Reports, 6, 21480.

Sofi, F., Cesari, F., Abbate, R., Gensini, G. F., & Casini, A. (2008). Adherence to Mediterranean diet and health status: meta-analysis. BMJ, 337, a1344.

Sofi, F., Abbate, R., Gensini, G.F., & Casini, A. (2010). Accruing evidence on benefits of adherence to the Mediterranean diet on health: An updated systematic review and meta-analysis. American Journal of Clinical Nutrition, 92(5), 1189-1196.

Sofi, F., Macchi, C., Abbate, R., Gensini, G.F., & Casini, A. (2014). Mediterranean diet and health status: An updated meta-analysis and a proposal for a literature- based adherence score. Public Health Nutrition, 17(2), 2769-2782.

Spartano, N.L., Davis-Plourde, K.L., Himali, J.J., Andersson C., Pase, M.P., Maillard, P., … & Seshadri,

S.(2019 April 5). Association of accelerometer- measured light-intensity physical activity with brain volume: The Framingham heart study. JAMA Network

Open,2(4),e192745.doi: 10.1001/jamanetworkopen.2019.2745.

Spiegel, K., Leproult, R., & Van Cauter, E. (1999). Impact of sleep debt on metabolic and endocrine function. Lancet, 354(9188), 1435-1439.

Spiegel, K., Leproult, R., L'Hermite-Baleriaux, M., Copinschi, G., Penev, P.D. & Van Cauter, E. (2004). Leptin levels are dependent on sleep duration:

Relationships with sympathovagal balance, carbohydrate regulation, cortisol, and thyrotropin.

Journal of Clinical Endocrinology and Metabolism, 89(11), 5762-5771.

Spiegel, K., Tasali, E., Penev, P., & Van Cauter, E. (2004). Brief communication: Sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Annals of Internal Medicine, 141(11), 846- 850.

Strasser, B., Siebert, U., & Schobersberger, W. (2010). Resistance training in the treatment of the metabolic syndrome: A systematic review and meta-analysis of the effect of resistance training on metabolic clustering in patients with abnormal glucose metabolism. Sports Medicine, 40(5), 397-415.

Tamm, S. (2019). A Neuroimaging perspective on the emotional sleepy brain. Doctoral Dissertation. Stockholm, Sweden: Karolinska Institute.

Tasali, E., Leproult, R., Ehrmann, D.A., & Van Cauter, E. (2008). Slow-wave sleep and the risk of type 2 diabetes in humans. Proceedings of the National Academy of Sciences of the United States of America, 105(3), 1044- 1049.

Trichopoulou, A., Bamia, C., & Trichopoulos, D. (2009). Anatomy of health effects of Mediterranean diet: Greek EPIC prospective cohort study. BMJ, 338, b2337.

van der Ploeg, H.P., Chey, T., Korda, R.J., Banks, E., & Bauman. A. (2012). Sitting time and all-cause mortality risk in 222,497 Australian adults. Archives Internal Medicine, 172(6), 494-500.

Van Cauter, E. & Spiegel, K. (1999). Chapter-Circadian and sleep control of endocrine secretions: Chapter taken from Circadian and Sleep Control of Endocrine Secretions ISBN: New York, Dekker (Vol. 13, pp. 43- 61).

Verghese, J., Mahoney, J., Ambrose, A.F., Wang, C., & Holtzer, R. (2010). Effect of cognitive remediation on gait in sedentary seniors. Journals of Gerontology Series A, Biological Sciences and Medical Sciences, 2010, 65A(12), 1338-1243

Visceglia, E. & Lewis, S. (2011). Yoga therapy as an adjunctive treatment for schizophrenia: A randomized, controlled pilot study. Journal of Alternative and Complementary Medicine, 17(7), 601-607.

Vollbehr, N.K., Hoenders, R.H.J., Bartels-Velthuis, A.A.,

&Ostafin, B.D. (2017, August 4). The influence of yoga on chronic depression and potential cognitive mediators. Paper presented at the conference of the American Psychological Association, Washington D.C., U.S.A. Retrieved April 11, 2019, from https://www.apa.org/news/press/releases/2017/08/yog a-depression.pdf

Wen, L., & Duffy, A. (2017). Factors influencing the gut microbiota, inflammation, and type 2 diabetes. Journal of Nutrition, 147(7), 1468S-1475S.

Woumans, E., Santens, P., Sieben, A., Versijpt, J., Stevens, M. & Duyck, W. (2015). Bilingualism delays clinical manifestation of Alzheimer's disease. Bilingualism: Language and Cognition, 18(3), 568-574.


EQOL Journal (2019) 11(1): 37-50

Zelenski, J.M., & Nisbet, E.K. (2014). Happiness and feeling conncected: The distinct role of nature relatedness. Environment and Behavior, 46(1), 3-23.

How to cite this article:


Meulenberg, C. (2019). Lifestyle components of the global oldest


old assessed as effective non-pharmacologic strategies to maintain

lifelong cognitive and functional health. Exercise and Quality of



Life, 11(1), 37-49. doi:10.31382/eqol.190605


Meulenberg, Cécil J.W. . "Lifestyle components of the global


oldest old assessed as effective non-pharmacologic strategies to

maintain lifelong cognitive and functional health." Exercise and



Quality of Life 11.1 (2019): 37-49.


Meulenberg, Cécil J.W. . "Lifestyle components of the global


oldest old assessed as effective non-pharmacologic strategies to

maintain lifelong cognitive and functional health." Exercise and



Quality of Life 11, no. 1 (2019): 37-49.