EQOL Journal (2019) 11(1):
REVIEW ARTICLE
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 |
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© The Author(s) 2019. This article is published with open access. |
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Abstract
Longevity and high quality of life are amongst the most desired traits of humanity. However, the incidences of
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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.
Introduction
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
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EQOL Journal (2019) 11(1):
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
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
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Exercise
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
Kodama and colleagues identified 25 studies with an average of seven months of intervention, where aerobic training resulted in increases of
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
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.
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
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
Even
A
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EQOL Journal (2019) 11(1):
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
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.
Nutrition
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
A healthy diet maintains a healthy balanced intestinal microbiota, and recent research indicates that this symbiosis establishes an
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(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
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,
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mortality (Bonaccio et al., 2018; Trichopoulou et al., |
persons and societies understand that the food they |
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2009). |
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consume, its micro and macronutrients, but also its |
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Thus, adherence to the Mediterranean diet, the |
contaminations |
intentionally |
or |
unintentionally |
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incorporated |
in |
the production |
process, drastically |
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impact their |
health, |
and |
especially their |
brain |
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longevity with |
a reduced risk |
for chronic non- |
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function, behaviour, mood and cognition. Hopefully, |
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communicable |
diseases. Such |
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more people |
will demand |
a larger |
production of |
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diseases, including depression and dementia, among |
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nutrious, |
and |
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people in the blue zones are rare. |
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sustainable foods in the future. |
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Cognitive engagement
For Parkinson’s disease, a |
Peoples in the blue zones are part of |
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disorder |
in |
which |
the |
dopaminergic |
producing |
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small |
communities, |
where |
with |
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neurons in the brain during a person’s life are dying, |
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intensive |
family and |
neighbourhood |
support |
are |
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affecting the person’s movement, gait, and balance, it |
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practiced. |
Individuals |
of |
such |
community |
have |
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was recently |
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shown |
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that |
adherence |
to |
a |
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purpose, |
and |
often |
practice |
spiritualism |
(not |
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Mediterranean diet intervention was associated with |
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necessarily |
religious), |
while relaxation within the |
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a decreased risk of parkinsonism, and with slower |
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community setting, in the form of socialising, is a |
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progression |
of |
parkinsonian |
signs |
(Agarwal |
et |
al., |
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daily |
routine resulting |
in |
the sharing |
of |
thoughts |
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2018). |
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foods and drinks. The community and its individuals |
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Higher adherence to the Mediterranean diet has |
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execute activities through mindful engagement |
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been associated with the reduction of the incidence of |
within natural surroundings. |
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depression |
from |
a |
among |
twenty |
To pursuit such daily activities up till old age, in |
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longitudinal and |
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the absence of |
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as well in four longitudinal studies (Lassale et al., |
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and deteriorations, it is likely prolonged exposure to |
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2018). A recent randomized controlled trial showed |
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blue |
zone |
lifestyle |
components, |
requires |
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that |
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simultaneous implementation of motor and cognitive |
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significantly |
reduced |
the |
symptoms |
of |
major |
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tasks. This |
training |
then |
accumulates |
and |
brings |
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depression (Jacka et al., 2017). In line with these are |
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about, |
generally fit |
centenarians |
who |
are |
trained |
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the results from a systematic review on 11 cohorts |
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through |
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(including only |
one |
randomized |
controlled |
trial), |
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will discuss several forms of cognitive engagement |
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which |
indicates |
that |
higher |
adherence |
to |
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that can |
be hypothetically |
considered |
a |
basis for |
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Mediterranean |
diet was |
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associated with improved |
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these. |
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cognitive function, lower rates of cognitive decline, |
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and reduced risk of Alzheimer's disease (Lourida et |
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al., 2013), and a more recent systematic review that |
Physical activity, alone or combined with cognitive |
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included |
25 |
unique |
cohorts, |
five |
randomized |
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training can enhance functional fitness in older adults |
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controlled trials and 27 observational studies, confirm |
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(Paravlić |
et al., |
2016). Simultaneously |
performing |
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these observations (Petersson & Philippou, 2016). |
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cognitive (e.g., working memory task) and motor |
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Interestingly, |
nutritional |
medicine |
approaches: |
(e.g., strength exercises) tasks in elderly are more |
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adding supplements to the diet and including more |
frequently used for preventing falls. In this way, the |
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proper diets, to persons with chronic non- |
individual trains automated execution of simple |
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communicable diseases is gaining attention (e.g., |
motions (Ghai et al., 2017). The combination of |
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Sarris et al., 2015). And for good reasons, because |
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combined with metabolically enhancing the capacity |
attention, control of executive functions, memory and |
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of Alzheimer's disease patients, it was recently |
reasoning (reviewed by Bherer, 2015; Lauenroth et |
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observed to reverse cognitive decline (Bredesen et al., |
al., 2016). |
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2016). |
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More specific, for example the training of |
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Diet and nutrition will become essential future |
executive functions by |
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focus points of a person's lifestyle. Especially since |
sedentary elderly gives rise to improved walking |
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climate change and environmental pressure will |
efficiency (Verghese et al., 2010). While |
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demand the reduction of energy for food production, |
computerized |
intervention |
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transport, and the elimination of food waste. Once |
training, |
emphasizing |
movement |
through |
a |
virtual |
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maze, positively influenced both normal and complex |
comparable methodology, and some reports have |
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walking in healthy elderly men during bed rest |
found less convincing evidence, the most striking is |
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(Marušič et al., 2015). The continued spatial |
that, studies investigating neuroanatomical brain |
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navigational testing showed improvements up to four |
differences between older monolinguals and |
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hundred days |
bilinguals, did show that there is more atrophy among |
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Hence it was suggested that such spatial navigation- |
bilinguals (Schweizer et al., 2012). Also, a difference |
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based computerized training can be protective of |
in the brain areas being activated for various tasks is |
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detrimental mobility effects. This reflects the |
observed (Ansaldo et al., 2015; Gold et al., 2013b), as |
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potential for |
well as differences in brain tissue integrities are |
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trained domain. Moreover, only to imagine |
recorded (Gold et al., 2013a; Olson et al., 2015), and |
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demanding rehabilitation exercises, a specific |
different cortical thicknesses (Anderson et al., 2018; |
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cognitive function, does influence the process of |
Duncan et al., 2018; Olson et al., 2015). |
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functional skills as well (Marušič et al., 2018b). |
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Typically, the bilingual advantage seems to be |
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In conclusion, cognitive motor exercises are |
applicable to other diseases with neuronal damage: |
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promising. Although variation is noticed, and study |
like a faster recovery after brain stroke (Alladi et al., |
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results are even contradicting, the cognitive part can |
2016), a delay in the onset of frontotemporal |
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be designed to train various executive functions in |
dementia (Alladi et al., 2017), and increased |
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combination with physical exercise. Hence, new |
frontotemporal grey matter integrity in Huntington’s |
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bilingual patients |
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Such |
approaches |
studied |
and |
optimized |
to |
be |
Despite the described effects of bilingualism, it |
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effective, will certainly find its way to educational |
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has not been thoroughly explored how the use of |
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systems and private homes, by delivery in society |
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language, or adding another foreign language to a |
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through entrepreneurs. |
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person’s communication proficiency, can affect |
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Language usage |
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cognition and executive functioning. Social |
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Another form, less physically active, but more of a |
engagement, trying to understand and communicate |
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another person through language might certainly be |
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cognitive challenge, is the use of language. Especially |
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part of the basis of cognitive health seen in the blue |
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the use |
of |
multiple |
languages |
(bilingualism |
or |
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zones. Bilingualism |
as |
a |
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multilingualism), |
demands |
rapid |
and |
simultaneous |
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approach, would be a welcome addition to improving |
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activation |
of |
various |
executive functions, |
like |
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wellbeing |
or |
even health |
in |
Western |
societies. |
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attention, inhibition, working memory, etc., in a way |
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Especially since it would support education structures |
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that the brain performs dual tasks. Being proficient in |
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and |
increase |
respect |
for |
foreign |
customs and |
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multiple |
languages, |
that is: speaking, reading |
and |
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societies. |
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writing, has been correlated to enhanced cognition |
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(Bialystok & Poarch, 2014), and to beneficially |
Meditation |
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influence |
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children’s |
cognitive |
development |
Meditation |
is |
a |
practice that |
originally |
combines |
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(Bialystok & Viswanathan, 2009). |
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spiritual attention with physical exercise in the form |
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Languages learned early on in life, and maintained |
of body posture and the control of breathing. |
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throughout adult life, establishes bi- or |
Depending of its nature, the practice usually demands |
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multilingualism, and continually train the brain in a |
cognitive and physical mindfulness. For example, |
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yoga originating in India, is now often practiced |
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advantages from such lifelong brain training, seem to |
throughout the Western societies both for health and |
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emerge in the form of delaying the onset of various |
relaxation. |
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neurodegenerative diseases, like dementia. Various |
Recently, |
participants |
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of |
yoga |
classes |
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cohorts |
from |
distinct |
geographic |
areas |
in |
the |
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incorporated |
as |
an |
intervention |
in |
randomized |
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Americas and Europe (Alladi et al., 2013; Bialystok |
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controlled studies, showed that yoga from various |
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et al., 2007; Bialystok et al., 2014; Chertkow et al., |
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disciplines has clear advantages as compared to their |
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2010; |
Craik |
et |
al., 2010; Gollan |
et al., |
2011; |
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control groups. Eight to nine weeks of yoga exercises |
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Woumans |
et |
al., |
2015), |
entailing |
about |
2,000 |
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for |
mood |
or |
major |
depressive |
disorder patients |
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participants, showed that the use of two languages, |
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positively affected depressive symptoms (Vollbehr et |
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can delay |
the |
onset |
of |
symptoms |
of cognitive |
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al., |
2017), |
and |
significantly |
reduced |
the anxiety |
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impairment, the early signs of Alzheimer’s disease, |
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symptoms (Sharma et al., 2017). In patients with post- |
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with four to five years. Although there is debate about |
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EQOL Journal (2019) 11(1):
traumatic stress syndrome, yoga for
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
Long term intervention effects of meditation recording biomarkers have also been studied. For example, anxiety disorder patients instructed during an
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
Sleep
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
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
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
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EQOL Journal (2019) 11(1):
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
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
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
44
1999). More dramatic responses were observed by specific reduction of the
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
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.
Discussion
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):
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
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
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,
Additional blue zone traits have been explored in this review. For example,
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,
It is presumed that blue zone inhabitants, will perform
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
Conclusions
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
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EQOL Journal (2019) 11(1):
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
Acknowledgments
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.
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