EU Health Ministers

Poznan 6-7.11.2011

The Finnish example from North Karelia to national action

Pekka PuskaDirector GeneralNational Institute for Health and Welfare (THL)Helsinki, FinlandPast President, World Health Federation (WHF)

04/12/23

Greetings from Finland

Pekka Puska, Director General04/12/23

History in Finland

• Hardships of war and postwar years

• Increase in standard of livingGreat increase in CVD

• Attention to extremely high CVD mortality

• Previous studies: East-West study (part of Seven Countries Study)

Pekka Puska, Director General04/12/23

699

1010Pekka Puska, Director General04/12/23

North Karelia ProjectPrinciples

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

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

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

• Community based approach to change lifestyles

Pekka Puska, Director General04/12/23

Theory + hard work

• Theory:MedicalBehavioural, social

• Hard work: practical and flexible work with the community

04/12/23 Pekka Puska, Director General

From Karelia to National Action

• First province of North Karelia as a pilot

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

• Continuation is North Karelia as national

demonstration (1977–97)

• Good scientific evaluation to learn of the

experience

• Comprehensive national action

Pekka Puska, Director General04/12/23

Community-based project

(pilot, demonstration, model)

National programme and policies

Pekka Puska, Director General04/12/23

Evaluation / Monitoring

- North Karelia – all Finland

- Monitoring systems

• health behaviour

• risk factors

• nutrition

• diseases, mortality

Pekka Puska, Director General04/12/23

Pekka Puska, Director General

RESULTS

04/12/23

Use of Butter on Bread Use of 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

Pekka Puska, Director General04/12/23

Butter consumption per capita in Finland

0

2

4

6

8

10

12

14

16

18

20

1955 1965 1975 1985 1995 2005

Co

nsu

mp

tio

n (

kg p

er c

apit

a)

Pekka Puska, Director General04/12/23

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

Pekka Puska, Director General04/12/23

Use of Vegetable Oil for 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

%

Pekka Puska, Director General04/12/23

Fat Intake as Percentage of Energy in Finland

0

10

20

30

40

1969-72

1982 1987 1992 1997 2002

Total fat (~ 30 EN%)

SFA (~10 EN%)

MUFA (10-15%)

PUFA (5-10%)En%

Year

Sources: Hasunen et al. 1976 Uusitalo et al. 1986 Kleemola et al. 1994 Findiet Study Group 1998 Männistö et al. 2003

Recommendations

Pekka Puska, Director General04/12/23

Salt intake in Finland 1977-2007FinnDiet Study

04/12/23 Pekka Puska, Director General

0

2

4

6

8

10

12

14

16

18

1977

1979

1981

1982

1987

1991

1992

1994

1997

1998

2002

2007

Calculated, men

Calculated, women

24 hour urine, men

24 hour urine, women

Lin. (24 hour urine, men)

Lin. (24 hour urine, women)

Lin. (Calculated, men)

Lin. (Calculated, women)

Serum Cholesterol in Men Aged 30–59 Serum Cholesterol in Men Aged 30–59 YearsYears

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

Pekka Puska, Director General04/12/23

04/12/23

Systolic blood pressure in Systolic blood pressure in women (30women (30–59 y)59 y)

115

120

125

130

135

140

145

150

155

1972 1977 1982 1987 1992 1997 2002 2007

North Karelia

Kuopio province

Southwest Finland

Helsinki area

Oulu province

Lapland province

North Karelia project evaluation and FINMONICA and the National FINRISK Studies 1972 - 2007

mmHg

Pekka Puska, Director General

Daily smoking in Finland 1950-2008

0

10

20

30

40

50

60

70

80

19

50

19

70

19

85

19

95

20

01

20

03

20

05

20

07

Men

Women

Year

%

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04/12/23 Pekka Puska, Director General

Age-adjusted mortality rates of coronary heart disease in North Age-adjusted mortality rates of coronary heart disease in North Karelia Karelia and the whole of Finland among and the whole of Finland among males aged males aged 35–64 years 35–64 years from 1969 from 1969 to 2006.to 2006.

Mortality per Mortality per 100 000 100 000 populationpopulationAge-standadized to European populationAge-standadized to European population

start of the North Karelia Project

extension of the Project nationally

North Karelia

All Finland

- 85%

- 80%

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

Pekka Puska, Director General04/12/23

Mortality Changes in Finland from 1969–71 to 2006 (Men 35–64 Years, Age Adjusted)

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

19691969––71 71 20062006 19691969––71 to 200671 to 2006

All causesAll causes 13281328 583583 - 56%- 56%

All cardiovascularAll cardiovascular 680680 172172 - 75%- 75%

Coronary heart diseaseCoronary heart disease 489489 103103 - 79%- 79%

All cancersAll cancers 262262 124124 - 53%- 53%

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

19691969––71 71 20062006 19691969––71 to 200671 to 2006

All causesAll causes 13281328 583583 - 56%- 56%

All cardiovascularAll cardiovascular 680680 172172 - 75%- 75%

Coronary heart diseaseCoronary heart disease 489489 103103 - 79%- 79%

All cancersAll cancers 262262 124124 - 53%- 53%

Pekka Puska, Director General04/12/23

04/12/23 Pekka Puska, Director General Sihvonen ym. 2003

Subjective health

0

5

10

15

20

1980 2000 1980 2000

yea

rs0

5

10

15

20

1980 2000 1980 2000

yea

rs

sic / disability

healthy / no disability

sic / disability

healthy / no disability

men women men women

Healthy and sick years of life expectancy of 65 year old Finns in 1980 and in 2000

Managing basic functions

From Karelia to National ActionMajor Elements of Finnish National Action 1.

• Research & international research collaboration

• Health services (especially primary health care)

• North Karelia Project, other demonstration programmes

• Health Promotion Programmes (coalitions,

NGO’s, collaboration with media etc.)

• Schools, educational institutions

04/12/23 Pekka Puska, Director General

Major Elements of Finnish National Action 2.

• Industry, business – collaboration• Policy decisions, intersectoral collaboration,

legislation

• Monitoring system: health behaviours, risk factors, nutrition, diseases, mortality

• International collaboration

From Karelia to National Action

04/12/23 Pekka Puska, Director General

Examples of intersectoral action

• Tobacco legislation & policy

• Nutrition development

• Interaction with the private sector

• NGO’s

04/12/23 Pekka Puska, Director General

Examples of intersectoral work 1.

Development of Finnish Rapeseed oil

Fen: y = -0.16x + 362

Gen: y = -0.16x + 358

41

42

42

43

43

44

44

45

45

1970 1975 1980 1985 1990 1995 2000 2005 2010

Year

g/kg

Fen

Gen

Change in fat content of Finnish cow milk

Change in fat content of Finnish cow milk

04/12/23 Pekka Puska, Director General

© Valio Oy

Change in fat content of Finnish cow milk

Fen: y = -0.16x + 362

Gen: y = -0.16x + 358

41

42

42

43

43

44

44

45

45

1970 1975 1980 1985 1990 1995 2000 2005 2010

Year

g/k

g

Fen

Gen

Pekka Puska, Director General04/12/23

Fruits and Vegetables – SupermarketsFruits and Vegetables – Supermarkets

Pekka Puska, Director General04/12/23

Examples of intersectoral work 2.

Biscuit example:

• Leading Finnish biscuit manufacturer (LU Finland Ltd) has removed some 80.000 kg of SAFA by changing the fats used

• All trans fats removed and major transfer to rapeseed oil

Meat product example:

HK (Leading Finnish meat company)

since 2007 annually:

• 40.000 kg less salt

• 10.000 kg less saturated

fat in their products 1975 1980 1985 1990 1995

YEAR

1.6

1.8

2.0

2.2

2.4

Salt

co

ncen

tratio

n (

%)

Salt level in Finnish sausages

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www.sydanmerkki.fi

The Finnish Heart Symbol

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SOUND COMBINATION OF POPULATION STRATEGY WITH HIGH RISK STRATEGY

1. HIGH RISK STRATEGY:

- Great benefits to the persons concerned

- Effective use of health services

2. POPULATION STRATEGY:- Greatest public health gains- Cost effective- Results also in other health benefits

12/04/23

PUBLICPUBLICPOLICYPOLICY

HEALTH PROGRAMMEHEALTH PROGRAMME

POPULATIONPOPULATIONPRIVATEPRIVATESECTORSECTOR

Pekka Puska, Director General04/12/23

Hard health evidence and broad health promotion activities have resulted in a change process among the population in interaction with respective policy decisions.

Pekka Puska, Director General

The changes in Finland represent broad social change over time

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Pekka Puska, Director General

IDENTIFYINGIDENTIFYING IMPLEMENTINGIMPLEMENTING

PRIORITIESPRIORITIES THEMTHEM

FROM PRIORITIES TO IMPLEMENTATION

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Role of health monitoring

• Comprehensive health monitoring

• Emphasis on monitoring of main risk factors and related behaviours (also in population subgroups)

• Rapid feed-back to policy makers and the public

• Institutional base (THL)

04/12/23 Pekka Puska, Director General

Finland Has Shown

• Prevention of cardiovascular diseases is possible and pays off

• Population based prevention is the most cost effective and sustainable public health approach to CVD control

• Prevention calls for simple changes in some lifestyles (individual, family, community, national and global level action)

• Influencing diet and especially quality of fat is a key issue

• Many results of prevention occur surprisingly quickly

(CVD, diabetes) and also at relatively late age

• Comprehensive action, broad collaboration with dedicated leadership and strong government policy support

Pekka Puska, Director General04/12/23

The North Karelia/Finland experience• Supports and has interacted much with

the WHO NCD strategy:– Integrated prevention–Diet & physical activity strategy–FCTC

• Happy about the recent political support to upgrading of NCD prevention–UN NCD Summit in September 2011

in New York

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Pekka Puska, Director General

For succesful prevention

Strong leadership combined with

Good partnership

* * *Do the right thingsDo enough of those

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Thanks

38Pekka Puska, Director General04/12/23