What the World's Longest-Lived Communities Can Teach Us About Preventing Diabetic Foot Ulcers

By Gary M. Rothenberg, DPM, CDCES, CWS — Medical Director, Podimetrics; Clinical Professor of Internal Medicine and Vascular Surgery, University of Michigan

A few weeks ago, I sat in on a conference talk by Kathy Levin, RDN, CDCES, called “Unlocking the Blue Zones.” Her core message stuck with me: longevity doesn’t come from an intentional pursuit of health. It comes from an environment that makes healthy choices the easy, unconscious default.

That single reframe — environment over willpower — is exactly how I think about the work we do every day at Podimetrics for patients at risk of diabetic foot ulcers (DFUs). So I want to share it with you, whether you’re a patient managing diabetes, a provider caring for one, or a payor trying to understand why prevention programs matter.

What are the Blue Zones, exactly?

They’re not a diet, and they’re not a program you can sign up for. Blue Zones are naturally occurring communities around the world where researchers have repeatedly found the same clusters of habits linked to remarkable longevity and dramatically lower rates of chronic disease including diabetes. Researcher Dan Buettner identified five of them: Okinawa (Japan), Sardinia (Italy), Nicoya (Costa Rica), Ikaria (Greece), and Loma Linda (California). People in these places aren’t just living longer. They’re living well longer, with far less of the cancer, dementia, and chronic disease that shorten both lifespan and quality of life elsewhere.

Notably, you don’t need wealth to get there. Nicoya is one of the poorer regions of Costa Rica, yet residents are twice as likely to reach age 90 as their neighbors. That alone should reshape how we think about what actually drives health.

The diabetes numbers are hard to ignore

This isn’t just a longevity story — it’s a diabetes story:

Okinawa’s type 2 diabetes rate is 80% lower than mainland Japan’s.¹
In the Adventist Health Study, vegetarians in Loma Linda showed a 62% lower diabetes risk than non-vegetarians.²
Only about 20% of Ikaria’s oldest residents have diabetes, well below the Greek national average.³
Sardinia’s metabolic syndrome rates run well below Italy’s national average.⁴

And it isn’t only anecdotal evidence from far-flung islands. When Blue Zones principles were deliberately applied to Beach Cities, California including redesigning streets to be walkable, improving food access, and building in community connection, diabetes rates dropped to roughly 5%, well under the U.S. national average of about 13.6%. The environment, redesigned on purpose, moved the needle at a population level.

The “Power 9”: four themes, nine habits

Buettner’s research groups the shared habits of these communities into what he calls the Power 9, organized around four themes:

1. Move Naturally

Movement isn’t scheduled at a gym; it’s woven into daily life through walking, gardening, and manual tasks. The environment removes the decision to move; it’s simply the path of least resistance. The evidence backs this up: 150 minutes of moderate weekly activity lowers diabetes risk by 58%⁵, and every additional 1,000 daily steps lowers type 2 diabetes risk by 6–9%.⁶

2. Right Outlook

Having a clear sense of purpose (the Okinawan concept of ikigai) and actively managing stress. This isn’t just motivational; it’s physiological. Chronic stress raises cortisol, and elevated cortisol drives insulin resistance. Managing stress is a metabolic intervention, not a luxury.

3. Eat Wisely

A diet that’s 95–100% plant-based, paired with hara hachi bu, the Okinawan practice of eating until you’re 80% full. It’s moderation over restriction; an additional mindset (more beans, more whole grains, more vegetables) rather than a subtraction one.

4. Connect

Strong social ties, exemplified by the Okinawan moai, a lifelong social support circle. Isolation is a measurable risk factor for type 2 diabetes⁷, while peer support and community connection are protective.

Why this matters for foot health specifically

Here’s the part I most want patients, providers, and payors alike to sit with: the people we care for at Podimetrics already know what they’re supposed to do. They know they should move more, eat better, manage stress, and check their feet daily. Knowledge has never been the gap. Sustaining the habit is.

That’s exactly what the Blue Zones show us how to do at a population level and it’s exactly what we’re trying to build into diabetic foot ulcer prevention:

The SmartMat by the bedside removes friction the same way a walkable street does. A daily foot scan becomes the default action, not a decision someone has to remember to make and motivate themselves toward.
Our care team check-ins function like a moai — a support circle that notices when someone starts to drift from their care plan and helps pull them back in before a small problem becomes a wound, and a wound becomes an amputation.
Consistent daily scanning is our version of hara hachi bu: a small, sustainable, repeated behavior that beats a heroic, unsustainable one.

One habit, starting this week

We can and should apply the Blue Zone principles to our own daily lives and health journeys. You don’t need to move to Okinawa to benefit from this. Pick one small thing and commit to it for seven days: a “movement snack” (a 10–15 minute walk after a meal, a couple of minutes of stretching during a phone call), stopping at 80% full at your next few meals, a short daily stress-reset ritual, or reaching out to reconnect with your own version of a tribe.

Small, consistent ripples create real change. Diabetes prevention and specifically diabetic foot ulcer prevention isn’t ultimately a story about willpower. It’s a story about environment, support, and habits that are easy to repeat. That’s the world we’re trying to build for our patients, one daily scan and one check-in at a time.