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Europrevent

Geneva 15.4.2011

The North Karelia project

Pekka Puska

Director General

National Institute for Health and Welfare (THL)

Helsinki, Finland

Past President, World Health Federation (WHF)

5/6/2011

Greetings from Finland

Pekka Puska, Director General5/6/2011

History in Finland

• Hardships of war and postwar years

• Increase in standard of living

Great increase in CVD

• Attention to extremely high CVD mortality

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


10


North Karelia Project

Principles• 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


Theory + hard work

• Theory:

Medical

Behavioural, social

• Hard work: practical and flexible work with the community

5/6/2011 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


Community-based project

(pilot, demonstration, model)

National programme and policies


Evaluation / Monitoring

- North Karelia – all Finland

- Monitoring systems

• health behaviour

• risk factors

• nutrition

• diseases, mortality


Pekka Puska, Director General

RESULTS

5/6/2011

Use of Butter on Bread (men age 30–59)

%

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


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

per

cap

ita)


Milk Consumption in Finland in 1970 and 2006 (kg per capita)

0

20

40

60

80

100

120

140

kg

1960 1970 1980 1990 2000 2010

Whole milk

Whole form milk

Low fat milk

Skim milk


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 Finland

Helsinki area

Oulu province

Lapland province

%


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


Salt intake in Finland 1977-2007FinnDiet Study


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 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


5/6/2011

Systolic blood pressure in women (30–59 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


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

%



Age-adjusted mortality rates of coronary heart disease in North

Karelia

and the whole of Finland among

males aged

35–64 years

from 1969

to 2006.

Mortality per

100 000

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

%

Observed

Predicted

Cholesterol

Blood pressure

Smoking


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

Rate (per 100.000) Change from

1969–71 2006 1969–71 to 2006

All causes 1328 583 - 56%

All cardiovascular 680 172 - 75%

Coronary heart disease 489 103 - 79%

All cancers 262 124 - 53%


5/6/2011 Pekka Puska, Director General Sihvonen ym. 2003

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

Subjective health

0

5

10

15

20

1980 2000 1980 2000

years

Managing basic functions

0

5

10

15

20

1980 2000 1980 2000

ye

ars

Sick/disability

Healthy/no disability

men women men women


Major 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


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



Examples of intersectoral action

• Tobacco legislation & policy

• Nutrition development

• Interaction with the private sector

• NGO’s


Development of Finnish Rapeseed Oil


Fruits and Vegetables – Supermarkets


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

• Major change to rapesead oil


HK Example:(One of the two main meat/sausage companies in Finland)

• Since 2007 annually:

– 40.000 kg less salt

– 10.000 kg less saturated fat

in their products

• 87 of their products comply with the Heart Symbol criteria in their category


© 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


www.sydanmerkki.fi

The Finnish Heart Symbol

5/6/2011

PUBLIC

POLICY

HEALTH PROGRAMME

POPULATIONPRIVATE

SECTOR


Broad change process among the population in interaction with respective policy decisions


Social change

5/6/2011


IDENTIFYING IMPLEMENTING

PRIORITIES THEM

FROM PRIORITIES TO IMPLEMENTATION

5/6/2011

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


The North Karelia/Finland experience

• Supports and has interacted much with the WHO NCD strategy:

– Integrated prevention

–Diet & physical activity strategy

–FCTL

• Looks forward to global upgrading of NCD prevention

–UN NCD Summit in September 2011 in New York



For succesful prevention

Strong leadership combined with

Good partnership

* * *

Do the right things

Do enough of those

5/6/2011

5/6/2011

Thanks

38


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