ROLE OF GOVERNMENTS AND SOCIETY ROLE OF GOVERNMENTS AND SOCIETY IN THE PREVENTION OF OBESITY AND IN THE PREVENTION OF OBESITY AND RELATED CHRONIC DISEASESRELATED CHRONIC DISEASES

Chile, March 24-25, 2008

Pekka Puska, professor, MD, PhD, MPolScDirector General, National Public Health Institute (KTL)President Elect, World Heart Federation (WHF)Vice President, Int. Ass. of National Public Health Institutes (IANPHI)

CHILE, March 24-25, 2008 2

GREETINGS FROM FINLAND

CHILE, March 24-25, 2008 3 33

CHILE, March 24-25, 2008 4

GLOBAL PUBLIC HEALTH GLOBAL PUBLIC HEALTH IN TRANSITIONIN TRANSITION

Chronic diseases – especially Chronic diseases – especially cardiovascular diseasescardiovascular diseases

Leading health problem in Leading health problem in industrialized countriesindustrialized countries

Main killers and rapidly growing Main killers and rapidly growing problem in developing countriesproblem in developing countries

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Projected Main Causes of Death,Worldwide, All Ages, 2005

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CVD’S ARE TO A GREAT EXTENT CVD’S ARE TO A GREAT EXTENT PREVENTABLE DISEASESPREVENTABLE DISEASES

Medical evidence for prevention exists.Medical evidence for prevention exists.

Population-based prevention is the Population-based prevention is the

most most cost-effectivecost-effective and the only and the only

affordableaffordable option for major public option for major public

health improvement in CVD rates.health improvement in CVD rates.

Major changes in population rates can Major changes in population rates can

take place in a surprisingly take place in a surprisingly short time.short time.

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Prevention targets Prevention targets the population levels the population levels of most important of most important risk factors.risk factors.

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0 1000 2000 3000 4000 5000 6000 7000 8000

Occupational risk factors for injury

Unsafe health care injections

Vitamin A deficiency

Zinc deficiency

Urban air pollution

Iron deficiency

Indoor smoke from solid fuels

Unsafe water, sanitation, and hygiene

Alcohol

Physical inactivity

High Body Mass Index

Fruit and vegetable intake

Unsafe sex

Underweight

Cholesterol

Tobacco

Blood pressure

WORLDWORLDDEATHS IN 2000 ATTRIBUTABLE TO SELECTED DEATHS IN 2000 ATTRIBUTABLE TO SELECTED

LEADING RISK FACTORSLEADING RISK FACTORS

Number of deaths (000s)

Source: WHR 2002

CHILE, March 24-25, 2008 9

SIX OF THE SEVEN TOP DETERMINANTS SIX OF THE SEVEN TOP DETERMINANTS OF MORTALITY IN DEVELOPED COUNTRIES OF MORTALITY IN DEVELOPED COUNTRIES RELATE TO HOW WE EAT, DRINK AND MOVERELATE TO HOW WE EAT, DRINK AND MOVE

DIET AND PHYSICAL ACTIVITY, DIET AND PHYSICAL ACTIVITY, TOGETHER WITH TOBACCO AND TOGETHER WITH TOBACCO AND ALCOHOL, ARE KEY DETERMINANTS ALCOHOL, ARE KEY DETERMINANTS OF CONTEMPORARY PUBLIC HEALTHOF CONTEMPORARY PUBLIC HEALTH

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WHO’S NCD STRATEGY 2000WHO’S NCD STRATEGY 2000

NCD’s a priorityNCD’s a priorityPrevention keyPrevention keyIntegrated approach, targeting Integrated approach, targeting

main behavioural factors: diet, main behavioural factors: diet, physical activity and tobaccophysical activity and tobacco

WHO NCD ACTION PLAN (WHA 2008)WHO NCD ACTION PLAN (WHA 2008)

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DeterminantsDeterminants- sosial sosial - economicaleconomical- culturalcultural- politicalpolitical

Risk factorsRisk factorsbehavioural behavioural biologicalbiological

CVD/NCDCVD/NCD ConsequenciesConsequencies

HEALTH HEALTH PROMOTIONPROMOTION

PREVENTIONPREVENTION TREATMENT, TREATMENT, REHABILITATION, REHABILITATION, SEC. PREVENTIONSEC. PREVENTION

DIFFERENT LEVELS OF DIFFERENT LEVELS OF PREVENTION TARGETSPREVENTION TARGETS

POPULATIONPOPULATION HIGH RISKHIGH RISK PATIENTSPATIENTS

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SOUND COMBINATION OF POPULATION SOUND COMBINATION OF POPULATION STRATEGY WITH HIGH RISK STRATEGYSTRATEGY WITH HIGH RISK STRATEGY

1.1. POPULATION STRATEGY:POPULATION STRATEGY:

-- Greatest public health gainsGreatest public health gains

-- Cost effectiveCost effective

-- Results also in other health benefitsResults also in other health benefits

2.2. HIGH RISK STRATEGY:HIGH RISK STRATEGY:

- Great benefits to the persons - Great benefits to the persons concernedconcerned

- Effective use of health services- Effective use of health services

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LIFESTYLES IN KEY POSITIONLIFESTYLES IN KEY POSITION

Individual healthIndividual healthPopulation healthPopulation health

HOW TO INFLUENCE LIFESTYLES?HOW TO INFLUENCE LIFESTYLES?

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LIFESTYLES AND LIFESTYLES AND RISK FACTORS RISK FACTORS CAN CHANGE!CAN CHANGE!

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61616

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North Karelia ProjectNorth Karelia ProjectPRINCIPLES FOR DEFINING PRINCIPLES FOR DEFINING THE INTERMEDIATE OBJECTIVESTHE INTERMEDIATE OBJECTIVES

• • Due to the chronic nature of CVD, Due to the chronic nature of CVD, the potential for the control of the problemthe potential for the control of the problemlies in lies in primary preventionprimary prevention

•• The risk factors were chosen on the basis ofThe risk factors were chosen on the basis ofbest available knowledgebest available knowledge: : - previous studies- previous studies- collective international recommendations- collective international recommendations- epidemiological situation in North Karelia- epidemiological situation in North Karelia

•• Chosen risk factorsChosen risk factors::- smoking- smoking- elevated serum cholesterol (diet)- elevated serum cholesterol (diet)- elevated blood pressure- elevated blood pressure

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FROM KARELIA TO NATIONAL ACTIONFROM KARELIA TO NATIONAL ACTION

• First province of North Karelia as a pilot First province of North Karelia as a pilot

(5 years), then national action (1972–77)(5 years), then national action (1972–77)

• Continuation is North Karelia as national Continuation is North Karelia as national

demonstration (1977–95)demonstration (1977–95)

• Good scientific evaluation to learn of the Good scientific evaluation to learn of the

experienceexperience

• Comprehensive national actionComprehensive national action

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EVALUATION / MONITORINGEVALUATION / MONITORING

- North Karelia – all FinlandNorth Karelia – all Finland

- Monitoring systemsMonitoring systems

• health behaviourhealth behaviour

• risk factorsrisk factors

• nutritionnutrition

• diseases, mortalitydiseases, mortality

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USE MAINLY BUTTER ON BREAD USE MAINLY BUTTER ON BREAD (men age 30(men age 30––59)59)

%

0

20

40

60

80

100

1972 1977 1982 1987 1992 1997 2002

North Karelia

Kuopio province

Southwest Finland

Helsinki area

Oulu province

Lapland province

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MILK CONSUMPTION IN FINLAND IN 1970 AND 2006 (kg per capita)

0

20

40

60

80

100

120

140kg

1960 1970 1980 1990 2000 2010

Whole milk

Whole form milk

Low fat milk

Skim milk

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USE MAINLY VEGETABLE OIL FOR USE MAINLY VEGETABLE OIL FOR COOKING (men age 30–59)COOKING (men age 30–59)

0

10

20

30

40

50

60

70

1972 1977 1982 1987 1992 1997 2002 2007

North Karelia

Kuopio province

Southwest FinlandHelsinki area

Oulu province

Lapland province

%

23

SALT INTAKE IN FINLAND 1977–2002SALT INTAKE IN FINLAND 1977–2002

g/day

Year

Sources: Karvonen et al. 1977, Nissinen et al. 1982, Pietinen et al. 1981, Pietinen et al. 1990, Valsta 1992,

KTL/Nutrition Report 1995, KTL/ FINDIET 1997 and FINDIET2002 Studies, KTL/unpublished information

CHILE, March 24-25, 2008 24

SERUM CHOLESTEROL IN MENSERUM CHOLESTEROL IN MEN AGED 30–59 YEARSAGED 30–59 YEARS

FINRISK Studies 1997 & 2002

mmol/l

5

5,5

6

6,5

7

7,5

1972 1977 1982 1987 1992 1997 2002 2007

North Karelia

Kuopio

Turku/Loimaa

Helsinki/Vantaa

Oulu

Lapland

CHD MORTALITY IN ALL FINLAND AND CHD MORTALITY IN ALL FINLAND AND IN NORTH KARELIA, MEN AGED 35IN NORTH KARELIA, MEN AGED 35––6464

North Karelia

All Finland

start of the North Karelia Project

extension of the Project nationally

Source: Statistics Finland

- 85%

- 80%

0

100

200

300

400

500

600

700

6970 71727374757677787980 81828384858687 888990 91929394959697989900010203040506

Year

Per 100 000

25

CHILE, March 24-25, 2008 26

OBSERVED AND PREDICTED DECLINES IN CORONARY MORTALITY IN EASTERN FINLAND, MEN

-90

-80-70

-60

-50-40

-30

-20-10

0

1972 1977 1982 1987 1992 1997 2002 2007Year

%

ObservedPredictedCholesterolBlood pressureSmoking

CHILE, March 24-25, 2008 27

MORTALITY CHANGES IN NORTH KARELIA MORTALITY CHANGES IN NORTH KARELIA from 1969from 1969––71 to 200671 to 2006 (Men 35(Men 35––64 Years, Age Adjusted)64 Years, Age Adjusted)

Rate (per 100.000)Rate (per 100.000) Change fromChange from

19691969––71 71 20062006 19691969––71 to 71 to

20062006

All causesAll causes 15091509 572572 - 62%- 62%

All cardiovascularAll cardiovascular 855855 182182 - 79%- 79%

Coronary heart diseaseCoronary heart disease 672672 103103 - 85%- 85%

All cancersAll cancers 271271 9696 - 65%- 65%

Lung cancersLung cancers 147147 3030 - 80%- 80%

Rate (per 100.000)Rate (per 100.000) Change fromChange from

19691969––71 71 20062006 19691969––71 to 71 to

20062006

All causesAll causes 15091509 572572 - 62%- 62%

All cardiovascularAll cardiovascular 855855 182182 - 79%- 79%

Coronary heart diseaseCoronary heart disease 672672 103103 - 85%- 85%

All cancersAll cancers 271271 9696 - 65%- 65%

Lung cancersLung cancers 147147 3030 - 80%- 80%

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• A comprehensive, determined and theory-based community program can have a meaningful positive effect on riskfactors and life styles.

• Such changes are associated with respective favourable changes in chronic disease rates and health of the population.

• A major national demonstration program can be a strong tool for favourable national development in chronic disease prevention and health promotion.

North Karelia Project

CONCLUSIONSCONCLUSIONS

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Personal ResponsibilityPersonal Responsibility””Nobody can take better care of Nobody can take better care of your health than yourself”your health than yourself”

Public ResponsibilityPublic Responsibility””Make the healthy choices the easy Make the healthy choices the easy

ones”ones”(Ottawa declaration)

COMBING PERSONAL AND PUBLIC COMBING PERSONAL AND PUBLIC RESPONSIBILITIESRESPONSIBILITIES

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PUBLIC RESPONSIBILITYPUBLIC RESPONSIBILITY

POLICY INTERVENTIONSPOLICY INTERVENTIONS

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STRONG INTERACTION BETWEENSTRONG INTERACTION BETWEENDIFFERENT LEVELS NEEDEDDIFFERENT LEVELS NEEDED

GlobalGlobal

Regional EURegional EU

NationalNational

LocalLocal

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STRONG GLOBAL INFLUENCES – GLOBAL HEALTH STRONG GLOBAL INFLUENCES – GLOBAL HEALTH ACTIONS NEEDED: WHO GLOBAL STRATEGY ON ACTIONS NEEDED: WHO GLOBAL STRATEGY ON DIET, PHYSICAL ACTIVITY AND HEALTH ADOPTED IN 2004DIET, PHYSICAL ACTIVITY AND HEALTH ADOPTED IN 2004

CHILE, March 24-25, 2008 36

WE NEED STRONGER USE WE NEED STRONGER USE OF GLOBAL PUBLIC OF GLOBAL PUBLIC HEALTH INSTRUMENTS!HEALTH INSTRUMENTS!

Further developments with Further developments with Global Strategy on Diet and Global Strategy on Diet and Physical Activity.Physical Activity.

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NATIONALNATIONAL

Governments have a Governments have a basic responsibility basic responsibility

for public health.for public health.

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PARTNERSHIPS FOR NATIONAL PARTNERSHIPS FOR NATIONAL PUBLIC HEALTH WORKPUBLIC HEALTH WORK

Health servicesHealth servicesGovernments (national, local)Governments (national, local)Civil society (NGO’s)Civil society (NGO’s)Private sectorPrivate sector

International collaborationInternational collaboration

CHILE, March 24-25, 2008 39

PRIVATE SECTORPRIVATE SECTORFood, eating, physical activityFood, eating, physical activityCommercial issues are of increasing Commercial issues are of increasing

impact to public healthimpact to public healthHealth is increasingly important Health is increasingly important

business argumentbusiness argumentProduct development, marketingProduct development, marketingSocial responsibility? Regulation? Social responsibility? Regulation?

Market push?Market push?

CHILE, March 24-25, 2008 40

HEALTH SERVICESHEALTH SERVICES

High risk / population approachesHigh risk / population approachesHealth services in interaction with Health services in interaction with

other community activities and other community activities and general health promotion workgeneral health promotion work

Evidence Evidence –– based interventions based interventionsUse of IT technologyUse of IT technology

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CIVIL SOCIETYCIVIL SOCIETY

The role of civil society is The role of civil society is increasing in most countriesincreasing in most countries

NGO’s: mobilize people, NGO’s: mobilize people, serve people, watchdogs, etc.serve people, watchdogs, etc.

Push for childhood obesity to Push for childhood obesity to public / political agendapublic / political agenda

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During the last few years a great During the last few years a great number of strategies and plans for number of strategies and plans for evidence evidence – – based, effective based, effective prevention and health promotion prevention and health promotion have been produced.have been produced.

Many important priorities have Many important priorities have been identified.been identified.

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THE MAIN CHALLENGE IS THE MAIN CHALLENGE IS

NOT NOT WHATWHAT TO DO, TO DO,

BUT BUT HOW HOW TO DO!TO DO!

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IDENTIFYINGIDENTIFYING IMPLEMENTINGIMPLEMENTING

PRIORITIESPRIORITIES THEMTHEM

FROM PRIORITIES TO FROM PRIORITIES TO IMPLEMENTATIONIMPLEMENTATION

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STRONGER SUPPORT FOR STRONGER SUPPORT FOR IMPLEMENTATIONIMPLEMENTATION

Stronger public health Stronger public health infrastructuresinfrastructures

Stronger health surveillance / Stronger health surveillance / monitoringmonitoring

Innovative financial support Innovative financial support mechanismsmechanisms

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MEDICALMEDICAL KNOWLEDGE KNOWLEDGE

SOCIAL &SOCIAL & EFFECTIVE EFFECTIVE BEHAVIORAL BEHAVIORAL PROGRAMS PROGRAMS THEORY THEORY POLICIESPOLICIES

STRONG SUSTAINED SUSTAINED IMPLEMENTATIONIMPLEMENTATION

KEY ELEMENTSKEY ELEMENTS

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HEALTH MONITORINGHEALTH MONITORING

Power of monitoring Power of monitoring Feed back to people and Feed back to people and

decision makersdecision makersNeed to emphasize risk factors, Need to emphasize risk factors,

lifestyles, determinantslifestyles, determinants

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MAJOR ELEMENTS OF MAJOR ELEMENTS OF NATIONAL ACTION NATIONAL ACTION

• ResearchResearch• Health services (especially Health services (especially

primary health care)primary health care)• Demonstration programmesDemonstration programmes• Building coalitions Building coalitions • Schools, educational institutionsSchools, educational institutions

CHILE, March 24-25, 2008 50

MAJOR ELEMENTS OF MAJOR ELEMENTS OF NATIONAL ACTION NATIONAL ACTION

• Industry, business Industry, business

• Policy decisions, intersectoral Policy decisions, intersectoral collaboration, legislationcollaboration, legislation

• Monitoring: health Monitoring: health behavioursbehaviours, risk , risk factors, diseases factors, diseases

• International collaborationInternational collaboration

CHILE, March 24-25, 2008 51

PUBLICPUBLICPOLICYPOLICY

NATIONAL HEALTH NATIONAL HEALTH PROGRAMMEPROGRAMME

POPULATIONPOPULATIONPRIVATEPRIVATESECTORSECTOR

HOW TO PROMOTE POLICY CHANGES?HOW TO PROMOTE POLICY CHANGES?

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FOR SUCCESSFUL PREVENTIONFOR SUCCESSFUL PREVENTION

Strong leadership combined Strong leadership combined withwith

Good partnershipGood partnership

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MUCHAS GRACIASMUCHAS GRACIAS

KIITOSKIITOS

Chile, March 24-25, 2008