Key Blue Zones patterns could help with physician burnout

Introduction

The prevalence of burnout among U.S. physicians is at its peak, and the pandemic is here to blame. In 2021 it was 62.8% which is alarmingly high compared to 38.2% in 2020 or 43.9% in 2017, as reported in Mayo Clinic Proceedings. Physician burnout leads to more work errors, unprofessional behavior, and poor patient satisfaction. Burned-out physicians are generally younger, unmarried, and engaged in certain specialties such as emergency medicine. Is there anything there that could help those who suffer? The answer might come from the Power 9 – a set of 9 lifestyle patterns from the areas of the longest-living – the Blue Zones. 

‍

‍

Highlights

• Blue Zones are areas where people live healthier and longer, and the percentage of centenarians is higher than average
• Inhabitants of Blue Zones share many lifestyle patterns that can be called Power 9
• Power 9 suggests to: move naturally, eat until 80% full, eat a plant-based diet, drink wine moderately and regularly, have a purpose in life, belong to a faith community, and care for family and friends.
• Power 9, used cleverly, could help physicians who struggle with professional burnout

The cost of physician burnout -  Could Blue Zones come as help?

It is estimated that the yearly cost of physician burnout in the U.S. is approximately $4.6 billion. It is the cost of 2300 brand-new Da Vinci surgical robots or twice as many MRI machines. The cost is $7600 per employed physician annually at the institutional level. A practical nationwide program for burnout clinicians could be pricy as well, but for sure will outweigh the negative impact of burnout in the medical care field (1, 2). We also need more data. Burnout needs more tracking, problems of institutions need recognition, and the physicians' voice needs listeners. The question remains how to build such a program, and the Blue Zones could be an inspiration.

There are places on Earth where people tend to live longer, and the percentage of centenarians is higher. They were called Blue Zones by the team of Dan Buettner, who studied those areas and tried to determine the recipe for longevity. In collaboration with the National Institute on Aging and National Geographic, Dan Buettner's team established five areas with the highest percentage of centenarians. They were:

• Loma Linda, California, USA
• Nicoya, Costa Rica
• Sardinia, Italy
• Ikaria, Greece
• Okinawa, Japan

In these areas, people reach the age of 100 ten times more often than in the United States. They live not only longer but also disease-free into their late years. Even though those areas are geographically distant, they share few characteristics. They are located close to the sea, in a warm climate, and in a mountainous area. They are what can be called 'paradise on Earth'. People in these areas live in close-knit communities that value the same essential things: natural physical activity, eating wisely, having the right outlook, and the feeling of belonging (3).

The Power 9

The four areas mentioned above can be separated into nine smaller categories or rules - the Power 9, all of which are intertwined (3).

‍

‍

‍

1. Move naturally.

Blue Zone residents stick to daily natural movement. In 2022 a systematic search by Herbert et al. on available literature on the topic of the physical activity of Blue Zone residents was published. Data synthesis revealed that 81% of the Blue Zone centenarians' activities are of moderate intensity. They are generally high functioning physically, work daily beyond the expected retirement age, mostly in agriculture, have outdoor hobbies, and perform in-home activities. The most significant influencer of their physical activity is the environment and culture of the region. In Okinawa, people tend to work in their gardens, which provides physical activity outdoors, reduces stress, and provides fresh produce for their plant-based diet. In Sardinia or Ikaria, the terrain is mountainous, and people walk to reach their destination, keeping them fit (4, 5). The frequency and intensity of physical activity give the Blue Zone residents higher levels of autonomy and independence (6). Because Blue Zone inhabitants often maintain traditional lifestyles, they rely on economic activities centered around highly physical occupations such as farming, shepherd work, and agriculture (4). The movement is closely correlated with the fifth point in Power 9 list – Purpose.

2. 80% Rule.

Eat mindfully. Before eating, the Okinawan centenarians would say Hara hachi bu—stop eating when 80% full. A study conducted in 2015 proved that men who always ate until they were 80% full consumed less energy than those who did not. They also consumed fewer servings of grains and more servings of vegetables. Interestingly for women, there was no significant difference in the types or energy values of food consumed except regarding BMI (7). The 80% rule helps the prevention of obesity, diabetes, and cardiovascular disease (8, 9). People in the Blue Zones eat their last meal in the form of a small dinner, the latest in the early afternoon. Such an eating pattern leads to calorie restriction, which was proven by a significant amount of data to be the only intervention prolonging the human lifespan (3, 7, 10).

3. Plant slant. 

Regarding longevity, two diets gained major recognition – the Mediterranean and the Okinawan (11). The first one is typical in the region of Ikaria and Sardinia, while the second one comes from Okinawa. Both diets are plant-based, rich in fruits, vegetables, and leafy greens. Legumes are a staple of those diets and one of the main protein sources. The high amount of legumes in the diet was classified as a protective dietary predictor for long-lived people (12). People in Okinawa eat around 300 g of vegetables a day in the form of yellow-green Okinawa vegetables (soybeans, tofu, and goya - a bitter gourd). Older Okinawans also eat 3-4 times more vegetables than younger generations (13). Red meat is rarely on the plate, replaced with omega-3-rich fatty fish. The differences between both diets are that the traditional diet of Okinawa is high in carbohydrates but low in fat. At the same time, the Mediterranean is high in fat but low in carbohydrates (11). Both diets are relatively low in calories but nutrient dense. Very often, the food that Blue Zones inhabitants eat comes from their gardens which is also giving them a source of purpose (rule 5) and natural movement (rule 1) (13). The Adventists of Loma Linda also largely follow vegetarian patterns (14). All of the above lead to a healthier cardiovascular system, lower blood pressure and BMI, and a longer and healthier life.

4. Wine at 5. 

People in most Blue Zones drink alcohol regularly in low amounts, and moderate drinkers live longer than those who do not drink. Red wine is very often the drink of choice. Sardinians drink the often homemade, flavonoid-rich Cannonau wine during main meals or to enjoy their time with friends and family (6). Ikarians also have the habit of drinking 1-2 glasses of local wine daily (15). Wine consumption with a plant-based meal increases flavonoid and antioxidant adsorption and supports a healthy cardiovascular system (16). It also was proven to lower cortisol levels – so it fights stress (rule 6). Wine also contains resveratrol – a known compound connected with healthy longevity (9, 17).

5. Purpose. 

In Japan, the concept of purpose has its name: "ikigai" which can be translated as a life worth living (18). It can also be described as "realizing the value of being alive". The elders here have low depression levels and lower cardiovascular disease risk (19). According to Buettner, knowing the sense of purpose can add up to 7 years of extra life expectancy (3, 13). Japanese residents practice karate, kendo, dancing, walk several kilometers daily, and even work in vegetable gardens and then sell the products to achieve "ikigai". They practice deep breathing, tai-chi, and other activities in the open that positively influence their stress level. They are preoccupied with hobbies, linked to a social network that makes them feel connected to the environment and their fellows and helps develop their spiritual side. Physical activity aims to make the elders feel like active members of the community. They have a positive attitude toward life which partially explains the extremely low stress levels experienced by these elders. (13). Nicoyans have their version of "ikigai"  called plan de vida - soul's purpose.

6. Downshift. 

Blue Zone residents know how to relax and healthily fight daily stress. Centenarians in Okinawa focus on remembering their ancestors. People from Loma Linda pray while Ikarians and Sardinians enjoy a siesta, often with friends and a cup of coffee. Also, the previous points – purpose and physical activity help tremendously in stress control. Research from 2017 proved that Sardinians who participate in leisure activities report better self-perceived well-being and fewer depressive symptoms (20). They also expressed trait resilience and solid social ties supporting their good mental health (21). In Loma Linda, the Adventists celebrate the Sabbath; a day spent whole for downshift. They spend the entire day with their close ones, focusing on God, often hiking in nature (3, 22).  

7. Belong.

Studies showed a positive correlation between spirituality, religious practice, and better health and longevity. Religion helps to reduce unhealthy behaviors (alcohol abuse, smoking, unhealthy diet) and increases social support (23, 24). A study conducted in the Ikarian group of centenarians in 2021 revealed that most believed in God, and 81.4% participated in religious events (24). In  Sardinia, people highly rate religion's importance in their lives and those who are religious report more life satisfaction. According to Fastame et al., older people reporting greater religiosity use it as a coping mechanism to deal with stressful events. They also appear more resilient and optimistic (25). Another Blue Zone,  Loma Linda, is a large population of Seventh-Day Adventists – the whole community is built on religion. Their religion also helps with incorporating other rules of the Power 9 - it advocates vegetarianism and gives a sense of purpose and connection (22).

8. Loved ones first.

For the centenarians in the Blue Zones, the family is the most important. Households are often multi-generational, with grandparents, parents, and children (3). Older ones care for younger ones and vice versa, giving a sense of purpose and social interaction. As an example, Ikiarians tend to commit to one life partner. Marriage could protect from depressive symptoms and supports low rates of depression. Family solidarity also contributes to increased well-being and reduced distress and cognitive impairments. Most Ikarians meet their neighbors, family, or friends daily, which leads to rule 9 described below (24).

9. Right tribe. 

Social interaction benefits health by lowering the risk of cardiovascular and neurovascular diseases and mortality and improving mental health (24). As mentioned before, Blue Zones' inhabitants live in close-knit communities. In Sardinia, it is believed that the location of the community in the mountainous region made them more isolated, therefore, closer to each other (26). They help each other and spend time almost daily in the company of neighbors and friends. In between Ikarians studied by Legrand et al., 77.9% reported a daily frequency of social contact (24). In Okinawa, women follow the tradition of creating moais—groups of 5 friends committed to each other for life. They take care of each other, forming more coherent and supportive relationships than in other parts of the world (3, 13).

Power 9 as guidelines for burned-out medics

But coming back to the culprit – how does the Power 9 could help, if at all? We cannot expect physicians to relocate to a mountainous warm place and start growing their crops to save them from burnout. Doolittle et al. suggested clever ideas connecting the Power 9 and burnout treatment (27). Of course, not all rules need to be incorporated here, such as wine drinking or the importance of religion. Let us start from the beginning.

If it comes to rules: move naturally, eat until 80% full, and plant slant should be applied to the food in the cafeterias, access to outdoor spaces, and physical activity. Healthcare plans should be appropriately priced, with incentives for healthy lifestyles. Rules of purpose, downshift, and right tribe highlight that workplace happiness is derived from the community of those working daily in hospitals and medical centers. There is a need for recognition of the importance of these bonds. They must be fostered and supported as they provide a sense of purpose and belonging and help with downshifting. There should be a culture of training and growth, creating accessible learning and enhancing skills opportunities. By that, physicians could re-discover the purpose, become more engaged, and be better trained. Support is also needed in the financial area. Hiring institutions should provide good retirement and loan repayment programs, tuition support, and financial counseling. And what about loved ones first? We need affordable childcare and good parental leave policies to maintain healthy families.

‍

‍

Conclusions

Physician burnout is a painful and costly reality for many medical care professionals. Nationwide programs to help alleviate the problem should be the government's highest priority. Inspiration for such a program could come from the exceptional longevity regions – Blue Zones. Power 9, a set of lifestyle patterns of those who live in Blue zones, suggests a few crucial points that could help the medical staff in a time of burnout. Those rules would be to move naturally, eat mindfully and plant-based, have a sense of purpose and belonging, and cherish your loved ones and friends.  

References:

1. Han S, Shanafelt TD, Sinsky CA, Awad KM, Dyrbye LN, Fiscus LC, et al. Estimating the Attributable Cost of Physician Burnout in the United States. Annals of Internal Medicine. 2019;170(11):784-90.
2. Shanafelt TD, West CP, Dyrbye LN, Trockel M, Tutty M, Wang H, et al., editors. Changes in Burnout and Satisfaction With Work-Life Integration in Physicians During the First 2 Years of the COVID-19 Pandemic. Mayo Clinic Proceedings; 2022: Elsevier.
3. Buettner D, Skemp S. Blue Zones: Lessons From the World's Longest Lived. Am J Lifestyle Med. 2016;10(5):318-21.
4. Herbert C, House M, Dietzman R, Climstein M, Furness J, Kemp-Smith K. Blue Zones: Centenarian Modes of Physical Activity: A Scoping Review. Journal of Population Ageing. 2022:1-37.
5. Fastame MC, Mulas I, Pau M. Mental health and motor efficiency of older adults living in the Sardinia’s Blue Zone: a follow-up study. International Psychogeriatrics. 2021;33(12):1277-88.
6. Nieddu A, Vindas L, Errigo A, Vindas J, Pes GM, Dore MP. Dietary habits, anthropometric features and daily performance in two independent long-lived populations from Nicoya Peninsula (Costa Rica) and Ogliastra (Sardinia). Nutrients. 2020;12(6):1621.
7. Fukkoshi Y, Akamatsu R, Shimpo M. The relationship of eating until 80% full with types and energy values of food consumed. Eat Behav. 2015;17:153-6.
8. Kim DH, Bang E, Jung HJ, Noh SG, Yu BP, Choi YJ, et al. Anti-aging Effects of Calorie Restriction (CR) and CR Mimetics based on the Senoinflammation Concept. Nutrients. 2020;12(2).
9. Sung MM, Dyck JR. Age-related cardiovascular disease and the beneficial effects of calorie restriction. Heart Fail Rev. 2012;17(4-5):707-19.
10. Erbaba B, Arslan-Ergul A, Adams MM. Effects of caloric restriction on the antagonistic and integrative hallmarks of aging. Ageing Res Rev. 2021;66:101228.
11. Willcox DC, Scapagnini G, Willcox BJ. Healthy aging diets other than the Mediterranean: a focus on the Okinawan diet. Mech Ageing Dev. 2014;136-137:148-62.
12. Darmadi-Blackberry I, Wahlqvist ML, Kouris-Blazos A, Steen B, Lukito W, Horie Y, et al. Legumes: the most important dietary predictor of survival in older people of different ethnicities. Asia Pac J Clin Nutr. 2004;13(2):217-20.
13. Mishra BN. Secret of eternal youth; teaching from the centenarian hot spots ("blue zones"). Indian J Community Med. 2009;34(4):273-5.
14. Liu T, Gatto NM, Chen Z, Qiu H, Lee G, Duerksen-Hughes P, et al. Vegetarian diets, circulating miRNA expression and healthspan in subjects living in the Blue Zone. Precision clinical medicine. 2020;3(4):245-59.
15. Chrysohoou C, Pitsavos C, Lazaros G, Skoumas J, Tousoulis D, Stefanadis C, et al. Determinants of All-Cause Mortality and Incidence of Cardiovascular Disease (2009 to 2013) in Older Adults: The Ikaria Study of the Blue Zones. Angiology. 2016;67(6):541-8.
16. Rifler JP. Is a Meal without Wine Good for Health? Diseases (Basel, Switzerland). 2018;6(4).
17. McCubrey JA, Lertpiriyapong K, Steelman LS, Abrams SL, Yang LV, Murata RM, et al. Effects of resveratrol, curcumin, berberine and other nutraceuticals on aging, cancer development, cancer stem cells and microRNAs. Aging (Albany NY). 2017;9(6):1477-536.
18. Tsujishita S, Nagamatsu M, Sanada K, editors. Overlap of Physical, Cognitive, and Social Frailty Affects Ikigai in Community-Dwelling Japanese Older Adults. Healthcare; 2022: MDPI.
19. Sone T, Nakaya N, Ohmori K, Shimazu T, Higashiguchi M, Kakizaki M, et al. Sense of life worth living (ikigai) and mortality in Japan: Ohsaki Study. Psychosomatic medicine. 2008;70(6):709-15.
20. Fastame MC, Hitchcott PK, Penna MP. The impact of leisure on mental health of Sardinian elderly from the ‘blue zone’: evidence for ageing well. Aging Clinical and Experimental Research. 2018;30(2):169-80.
21. Fastame MC, Hitchcott PK, Mulas I, Ruiu M, Penna MP. Resilience in elders of the Sardinian blue zone: An explorative study. Behavioral Sciences. 2018;8(3):30.
22. Ansello EF. Blue Zones and longevity. 2019.
23. McCullough ME, Hoyt WT, Larson DB, Koenig HG, Thoresen C. Religious involvement and mortality: a meta-analytic review. Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 2000;19(3):211-22.
24. Legrand R, Nuemi G, Poulain M, Manckoundia P. Description of Lifestyle, Including Social Life, Diet and Physical Activity, of People >/=90 years Living in Ikaria, a Longevity Blue Zone. Int J Environ Res Public Health. 2021;18(12).
25. Fastame MC, Ruiu M, Mulas I. Mental health and religiosity in the sardinian blue zone: Life satisfaction and optimism for aging well. Journal of religion and health. 2021;60(4):2450-62.
26. Poulain M, Herm A, Pes G. The Blue Zones: areas of exceptional longevity around the world. Vienna Yearbook of Population Research. 2013;11:87-108.
27. Doolittle BR. The Blue Zones as a Model for Physician Well-Being. Am J Med. 2020;133(6):653-4.

‍