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Join us for a conversation with Michelle Tollefson, a physician specializing in lifestyle medicine, obstetrics, and gynecology. Michelle shares her transformative experiences visiting Costa Rica’s Nicoya Peninsula, one of the world’s Blue Zones where people live longer, healthier lives. We’ll explore how these communities’ habits align with the principles of lifestyle medicine, her personal health journey as a cancer survivor, and the potential of Blue Zone certification to revolutionize health care.

Mentioned on the show:

Become Certified in Lifestyle Medicine Practice: https://lifestylemedicine.org/certification/

Blue Zones Partnership: https://lifestylemedicine.org/blue-zones-partnership/

Michelle Tollefson is a lifestyle medicine, obstetrics, and gynecology physician.

She discusses the KevinMD article, “Blue Zones uncovered: a physician’s first-hand experience.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Michelle Tollefson. She’s a lifestyle medicine, obstetrics and gynecology physician. Today’s KevinMD article is “Blue Zones uncovered: a physician’s first-hand experience.” Michelle, welcome to the show.

Michelle Tollefson: Thank you so much for having me, Kevin. I enjoy the opportunity to speak to you and your audience.

Kevin Pho: So you’re at the intersection of lifestyle medicine, obstetrics and gynecology. Tell me your story about how that all came to be.

Michelle Tollefson: Sure. So I was board certified in obstetrics and gynecology, but really saw the need for using more healthy lifestyle behaviors in helping my patients achieve more optimal wellness. And so I left full-time clinical practice to do some volunteering at a local nonprofit clinic, and started working with our university, where I created and oversee the first Bachelor of Science in lifestyle medicine in the United States.

I’ve been really involved with the lifestyle medicine field for about 20 years, serving on the executive board of the American College of Lifestyle Medicine, which is a professional organization for health professionals who are dedicated to addressing lifestyle related disease with the whole food plant predominant diet, physical activity, stress management, sleep prioritization, and social connection.

So I was on that exec board, was very involved, was busy at our university, and was updating some course content when I got that call that no one ever wants to receive, that I had a screening mammogram that was abnormal, I needed to come back in. So I was diagnosed with a really aggressive breast cancer, went through seven surgeries and 16 rounds of chemotherapy.

And while I was going through chemo, I decided that I would reread all of the Blue Zones books and update my course, to kind of get my mind off of some of the things that were going on. And I was really inspired by the stories of the people who were living these really long, vibrant lives, about how their environment was really set up to help them make the healthy choices the easier choices.

And so as I read through the books again, and as I learned more about the original longevity Blue Zones and then some of the Blue Zones of Happiness work, I knew that moving forward from chemo that I wanted to incorporate some of those lessons learned from the Blue Zones into my own life that I hadn’t been incorporating so much. As a lifestyle medicine physician I knew a lot about nutrition and physical activity and stress and sleep, but I hadn’t really dove into purpose or the power of social connection. And Blue Zones, some of their Power 9, they focus on the social connection and its importance with family and with friends and with the faith community.

So I decided that moving forward after active treatment that I would try to incorporate more of those lessons from the Blue Zones into my life, and then also wanted to do some travel to the Blue Zones as soon as I was able to.

Kevin Pho: All right, you talk more about that story in your KevinMD article, “Blue Zones uncovered: a physician’s first-hand experience.” So tell us, for those who aren’t familiar with Blue Zones, exactly what they are, and certainly lead that into the intersection and how that is relevant to you as a lifestyle medicine physician. So what are Blue Zones exactly?

Michelle Tollefson: Yeah, so the Blue Zones are five areas identified by Dan Buettner and his team with National Geographic, areas of exceptional longevity where people are not only living long lives, but they’re also living healthier lives. And so they don’t have the same rates of cancer and diabetes and dementia that we often see in the United States.

And so those five areas are Okinawa, Japan; Ikaria, Greece; Loma Linda, California, our only Blue Zone in the United States; Sardinia, Italy; and then the Nicoya Peninsula in Costa Rica. And from their research in those Blue Zones, they found there are nine principles that they found associated with their longer, healthier lives. They also did a lot of exploration of their environments and found that their environments often make the healthy choices the easy choices.

And so the Blue Zones, they have the longevity Blue Zones, and you can watch the Netflix documentary, which tons of people have watched, it’s tremendous. But then they go beyond just the work in those longevity Blue Zones. They’ve taken the lessons learned in those longevity Blue Zones and then applied them to communities in the United States in order to help them live healthier as well.

Kevin Pho: And you visited one of these Blue Zones. Tell us about that.

Michelle Tollefson: I did. I visited Costa Rica several times. So I finished chemotherapy right before the pandemic began, and so I couldn’t travel obviously for a while, but Costa Rica was one of the first countries to be safer to travel in after the pandemic. And so my family and I went there and spent several weeks.

And in Costa Rica, everything just seems to move slower. Like when you get off the plane it’s just like time moves at a different pace. I’m very fast-paced and involved in a lot of different things, and I can get very stressed and excited, and in Costa Rica there’s just that calmness. The people in Costa Rica, they have that sense of purpose, a deep love of family and faith and friends. They eat beans with most every meal. That’s one of the things we see in a lot of the Blue Zones, is that there’s often a focus on that plant slant diet and on eating more beans and nuts and whole foods that are minimally processed.

So I’ve spent a lot of time in Costa Rica, fell in love with the people, fell in love with the culture and their way of life, and my family and I have gone back every summer since and spent about a month or so in Costa Rica year after year.

Kevin Pho: So talking to the people in Costa Rica, what would you note are some of the traits that set them apart?

Michelle Tollefson: Yeah, so I would say their joy of life, just their desire to connect with others. So often, like at restaurants or with different interactions, our interactions in the United States are fast and we’re moving on to the next thing, and in Costa Rica you notice that people just come over and want to connect and want to chat, whether it’s a waiter or waitress at a restaurant, or whether it’s an interaction walking down the road, that people want to have those connections and learn more about you.

When you ask, what do you do, or what they ask you what you do, it’s not just the focus on work. So work is important, they’re very hardworking people, but also their free time, their connections with their family and friends, and those are all really important too, and they often bring those up. There’s not such a focus on material goods or possessions. However, if you look at the research, Costa Rica is often ranked as being happier than the United States.

And so they prioritize those relationships, they prioritize spending time outdoors in the beautiful Costa Rican environment, spending time in nature, whether it’s in the rainforest or at the beach. The Costa Rican people too are very active even at older ages. So my family and I got lost going to a waterfall and we needed help with directions, and so there was a man on his horse, and we stopped and I got out and spoke with him, and he was probably in his late 80s or 90s, but he was vibrant, gave us directions and helped us go on our way.

But it’s not unusual to see people in their 70s, 80s, 90s walking up steep hills, cutting their grass, doing manual labor in their gardens. They have amazing gardens where they eat an abundance of what they cook. So the Costa Rican people are just truly, truly amazing.

Kevin Pho: And how did Costa Rica get to be like this? Was it a cultural evolution that evolved naturally? Was there any type of directive in the past that kind of led them down this path? How did Costa Rica evolve to become this Blue Zone?

Michelle Tollefson: Yeah, so it’s actually part of Costa Rica that is officially the Blue Zone, the Nicoya Peninsula, and so it’s an area that’s more isolated from the rest of Costa Rica. So I would say I love Costa Rica in general, but the area that is so special to me and that is one of the longevity Blue Zones is the Nicoya.

That group comes from the Chorotega Indians, and so they probably have had some of those healthy habits for longer than other areas. So probably not as much of that influence of like fast food and that fast-paced way of life. They ate a lot of, they call them the three sisters, so squash and beans and corn, so a lot of really healthy plant-based foods that give you a lot of fiber and a lot of protein. So it’s probably a combination of all of those things.

Also Costa Rica, in the Nicoya Peninsula, it is very steep, and so the hills, most of the people there can probably walk up the hill faster than I can. And so we see that in several of the Blue Zones, we see that they have a lot of steep terrain, and so that’s probably one of the things about moving naturally that helps with longevity as well.

And then that group just has those deep connections to one another. They’re often living nearby or in communities. When I was there last summer, we had the opportunity to go to some of their different community events where they would gather and have homemade corn tortillas, and they would have rice and beans and just different community celebrations. And so that deep connection with others, and we know that connection to family, to a faith community, to friends, we know that that helps to increase happiness but also helps to increase longevity.

We also know that downshifting is one of the Power 9 of the Blue Zones, and they definitely know how to downshift, or to be more relaxed I guess than we typically are in the United States. They don’t eat really large portions of food, especially before bedtime, so the rule of hara hachi bu, or stopping eating when our stomachs are about 80 percent full, is important to them as well.

And then a sense of purpose. They have a deep sense of purpose. They call it the plan de vida, or their life plan, or their reason for being. So they have a really strong connection to why they get up in the morning, for what makes them want to keep going. And often I would say for them it’s their family and their friends and their faith and their deep love of their country and nature. They’re very, very connected.

So we see a lot of those same traits throughout all of Costa Rica, but I would say that the Nicoya Peninsula is extra special, in that we see some of those different environmental aspects that make the healthier choices the easier and sometimes the only choice. And I would say that that’s probably had a large influence in making that Nicoya Peninsula one of the Blue Zones.

Kevin Pho: Now, having visited the Nicoya Peninsula several times and studying the other Blue Zones, how much of this is transferable to other areas of the country and the world?

Michelle Tollefson: So that’s what is so exciting. So I knew quite a bit about the longevity Blue Zones, those five original Blue Zones identified by Dan Buettner, but I didn’t know a lot about the work that Blue Zones was doing in communities in the United States.

So a lot of it is transferable. Now obviously we can’t all move to a beach or necessarily move to Costa Rica, but there are many of the principles that we see in these Blue Zones, the Power 9, that align with the lifestyle medicine pillars of eating a whole food plant-based diet, moving naturally, stress management, sleep, social connection, and then like the Blue Zones with the purpose and that community focus. We can take those and apply them to our lives anywhere.

And so Blue Zones has been partnering with different communities. In fact I think they’re partnering with over 75 communities, in order to help these communities take the lessons learned from the Blue Zones and actually implement them in their communities. So really working on what they call the life radius, or the area where people spend the majority of their time, and looking at, is this an environment that really supports my health, or is it an area that makes healthy living difficult?

In the United States so often our environment sets us up for failure, or at least for it to be really hard to make healthy choices. And so Blue Zones works with grocery stores, and they work with schools to make healthier choices easier choices for kids, and they work with businesses and organizations and companies, they’ll partner with faith communities. So they go into these communities and really help address what is already there and what’s working, and what opportunities do they have to use these lessons learned from the Blue Zones in order to work with that community over the course of years to optimize health.

And one of the things I found really interesting is that they don’t just focus on projects. Projects are really important, I’m glad that we have projects that help us in the community, but they focus on people, places, and policy. And policy work is hard work. It’s something I didn’t learn about in medical school, and it often takes years and years. And so Blue Zones does an excellent job with going into these communities and working with the people in the community, hiring from the community, and working with them to help to change policies that really impact the health of the community, such as making walking paths more accessible, or policies around healthy food access, or around tobacco cessation.

So they come in and really work with these communities in an individual way. And one of the things I found so exciting too, in learning more about the Blue Zones work within the communities in the United States, is that they’re really helping to address health disparities. We see that so often it’s marginalized communities that don’t have access to healthy plant-based food, or it’s expensive, or they have to take a couple bus stops to get there, or they don’t have access to healthy places to get out and exercise.

Or it’s, you know, they take a car. I know I commute to Denver sometimes to teach and I’m in a car for an hour, whereas they can help to set up cities so that in the life radius or nearby, that it encourages walking. So Blue Zones does a tremendous job with helping communities to make long-term changes, not just projects but long-term changes in policy and in permanent and semi-permanent changes that really impact a community hopefully for years and years to come.

Kevin Pho: And how about in your own practice? What kind of characteristics from Blue Zones are you implementing in your exam room and office when you talk to other patients and clients?

Michelle Tollefson: Yeah, so now I spend most of my time teaching as a professor, and spend time doing some group visits with patients. But I would say what I enjoy incorporating the most is purpose. And I actually work with Beth Frates with PAVING the Path to Wellness, a nonprofit organization, and that’s one of their dimensions that they focus on as well, is purpose.

And so I would say purpose is the one that I have the most excitement toward implementing. Of course I love nutrition and that plant slant and physical activity, and all of those are incredibly important. But purpose is something that I didn’t really stop to consider the science behind. I didn’t really stop to consider the power that it has in a person’s health and longevity and happiness until I went through cancer treatment, and then until I really dove into the Blue Zones work and worked with PAVING the Path to Wellness, both of which emphasize purpose.

And so that’s when I really started to look at maybe some of the burnout symptoms that I was experiencing prior to my diagnosis. I knew those healthy lifestyle behaviors, but I’m a push, push, go, go person. So I know the healthy things to eat and I eat them and I move on, and I know stress management is important, but oh, don’t ask me the last time I actually meditated or did yoga, right? Like I know those things.

But when I slowed down and thought about purpose and learned more about the science of purpose, and actually asked myself those hard questions, such as, am I really, is my schedule aligned with what my highest priorities are? And I still struggle, I do not have it figured out at all yet, but I’ve learned a lot and learned more about aligning my activities with my purpose.

I really feel my purpose is to help spread the message about healthy lifestyle behaviors and the power of healthy lifestyle behaviors to our country, to the world. People are struggling. We know that so much of chronic disease is preventable by healthy lifestyle behaviors. And if somebody already does have a chronic lifestyle disease, or like you get cancer, I had breast cancer, still there’s a lot that we can do during treatment in order to help people to not just survive, and I think that’s what I was doing before, is I was just surviving, but to help people thrive when they incorporate purpose, focus on purpose and the science of purpose, and some of the happiness science and attitude and all of those different things. So that’s what I’m loving incorporating now, in addition to all of the regular lifestyle content.

Kevin Pho: We’re talking to Michelle Tollefson. She is a lifestyle medicine, obstetrics and gynecology physician. Today’s KevinMD article is “Blue Zones uncovered: a physician’s first-hand experience.” Michelle, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Michelle Tollefson: Of course. So I am so excited to be the lead faculty for the Blue Zones certification for physicians and health professionals. I have been helping with creating that course along with a big team of people from American College of Lifestyle Medicine and the Blue Zones.

And so health professionals who are certified in lifestyle medicine by the American Board of Lifestyle Medicine, such as I am, or the American College of Lifestyle Medicine, after that certification those certified lifestyle medicine health professionals and physicians will be able to do an additional certification, a Blue Zones certification for physicians and health professionals, that will be about six hours or so of content. It’ll be online, it’s going to be a fabulous course, we’re busy designing it right now.

And so that course will give health professionals tools that they can use in their clinical practice or at the point of care, but also will give them tools that they can use in their community. I think so often we as health professionals were taught to do amazing things in the clinic or with patients when we interact, but we weren’t really taught to use our voice and our leadership role in a way that can have a larger impact on our community, such as policy or advocacy. That’s something that I was unaware of, but now, learning more from the Blue Zones and learning more about ACLM’s work, it’s an area where I feel that part of my purpose and my responsibility is to use my leadership role in those ways.

And so the Blue Zones certification will help our clinicians and health professionals move beyond, they already have the lifestyle medicine expertise, but then we’ll also use the power of the Blue Zones and lessons learned from the Blue Zones about longevity and happiness and health, in order to have an even larger impact on our patients and on our communities.

I’ve been in the lifestyle medicine field now for about 20 years, and I’m still surprised by how many people have not heard of lifestyle medicine. And we’re doing a lot to change that, there’s a lot of great work going on. But since starting the work on this Blue Zones certification, it’s been fascinating to learn how many people know of the Blue Zones from the documentaries. And so I feel like this Blue Zones-ACLM partnership and the Blue Zones certification course will allow health professionals and physicians to reach an even larger audience with the lifestyle medicine message.

I think so often we have all these different competing, this latest study came out and this latest study came out, you should eat this or do this exercise, we have all these different mixed messages. And I think that often among that, people start to think, is healthy lifestyle behavior even worth it, right? There isn’t usually somebody championing plant-based eating as strongly as they might be some latest diet craze.

And so with the Blue Zones-ACLM partnership, I feel like it really allows clinicians and physicians a way to reach even more people and say, hey, there’s a different way to age. You don’t have to be on the typical status quo aging trajectory that we see in the United States, where so much of the last 10 to 15 years of a person’s life is often spent with disability and lifestyle related diseases. There’s a different way to age. And so that’s why I’m so excited about the partnership and about the certification course, because I think we’ll be able to reach even more people and address health disparities on a larger scale.

Kevin Pho: Michelle, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Michelle Tollefson: Thank you.