Ncd2014 nutirion policy finland 2014 3-10-h_kuusipalo

Development of Nutrition Policy in Finland

Heli Kuusipalo, nutritionist

Main Emphasis in Nutrition Policy in Finland

• Historically (since 1940’s): preventing various deficiencies - e.g. free school lunches, fortification programmes

• Chronic disease prevention since 1970’s: reduction of blood cholesterol, blood pressure and cardiovascular diseases

• More recently: weight control and prevention of type 2 diabetes

5

The roots of Finnish health promotion and prevention policy

• In the 1960s and 1970s, attention was drawn to the cardiovascular disease mortality that was very high in international comparison.

• The first wide-reaching prevention program: The North Karelia Project

– Aimed at lowering the high rates of cardiovascular disease prevalence and mortality in Northern Karelia

– Intermediate targets: smoking, cholesterol and blood pressure levels => healthier nutrition, reduce smoking

– Involved actors from several sectors: municipal health services, schools, food industry, WHO, media campaigns et cetera

– Project proved to be successful and contributed to developing a national level prevention policy

For more information, see the book "North Karelia Project:from North Karelia to National Action“

(available online)

How to influence?

• Research and monitoring

• Nutrition policy – collaboration between various actors

• Legislation

• Education (nutritionists, dietitians, nurses, doctors, teachers, food scientists)

• Nutrition recommendations and dietary guidelines

• Implementation programs of the recommendations and guidelines

• Fortification of foods

• Food production

• Catering services

The Finnish nutrition policy

The Finnish nutrition policy relies on

- a regular, nationwide health monitoring system

- and epidemiological studies, which have helped to understand the associations between dietary habits and health.

Based on this knowledge, it has been possible

- to formulate an effective, functioning policy

where actors from various sectors work together.

- also considering healthy environment

National Nutrition Council

• Public Nutrition Committee in 1936

• National Nutrition Council established in 1954

• Appointed by the Ministry of Agriculture and Forestry

• Members are representatives of authorities handling nutrition, food safety, consumer, health promotion, catering, food industry, trade and agricultural issues

• Observes and improves nutritional situation in Finland - by making recommendations - by action programmes

• Promotes comprehensive nutritional risk monitoring

• Coordinates the action plan concerning nutrition in the Government resolution for promoting healthy diet and physical activity

• Observes the development of nutrition policy in Europe

Nutrition recommendations and guidelines

• Finnish nutritional recommendations are based on the Nordic recommendations, published 4 times since 1981

• Additional recommendations for special purposes:

– catering services, schools

– hospitals and nursing homes

– prisons, armed forces

– athletes

– infants and young children

– pregnant and lactating mothers

– beverage use recommendations

– vitamin D supplementation recommendations

Fortification and supplementation

• 1941 Fortification of margarine with vitamins A and D

• 1949 Fortification of salt with iodine

• 1985 Selenium supplementation of all fertilizers

• 1992 Fortification of skimmed and low-fat milk with vitamin D

• 1995 Finland became a member of the EU

• 2003 Fortification of liquid milks and dietary fats with vitamin D renewed

• 2010 Increased fortification of liquid milks and dietary fats with vitamin D

• 2011 Revised supplementation recommendation

for children (0-18 years), pregnant & lactating women

Monitoring the Finnish Diet

• Food Balance Sheets since 1950s (Ministry of Agriculture and Forestry) – per capita food intake data

• FINRISK/Findiet Surveys every 5 years: large population surveys since 1977

• National Health Behaviour Questionnaires – annual data since 1978

• No population-based health monitoring of children and adolescents: available data is based on individual studies

*Total energy does not include the energy derived from fiber.

Changes in 2007-2012:

p < 0.001 (carbohydrates and fat)

p = 0.04 (protein)

Source: Findiet 2012

0

10

20

30

40

50

60

1982 1992 1997 2002 2007 2012

E%

Year

Daily intake of energy nutrients (E%) in working age women

Carbohydrates (~50-60 E%)

Fat (~ 25-35 E%)

Protein (~10-20 E%)



p < 0.001 (Carbohydrates, fat and protein)


0

5

10

15

20

25

30

35

40

1982 1992 1997 2002 2007 2012

Daily intake of fat and fatty acids (E%) in working age women

Fat (~25-35 E%)

Saturated fatty acids (<10 E%)

Monounsaturated fatty acids (10-15E%)

Polyunsaturated fatty acids (5-10 E%)

Fat intake in Finnish children as percentage of energy intake

0

5

10

15

20

25

30

35

40

45

1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015

E%

Vuosi

Total fat

SAFA

MUFA

PUFA

Rural Children

5-v LASER

6-v STRIP

7-v

DIPP Nutrition

6-v

TEDDY

6-v

Year

Food habits in the population aged 15–64 years in Finland in 1978–2011

(women)

0

20

40

60

80

100

Butter on bread Mixture of butter and oil

Vegetables daily Skimmed milk

The significance of medication and dietary changes in the decrease of serum cholesterol in the Finnish population

Year

mm

ol/l

1982 1992 2002 2007

-1.0

-0.8

-0.6

-0.4

-0.2

0.0

Medication effectDietary effectMedication+dietary effectObserved S-Chol

Valsta et al. Pub Health Nutr 2010

How to promote health?

In Finland we aim to

• Affect the structures of the society; community-based interventions

– aim for more permanent and wide-reaching results than with campaigns and one-off measures

• Target the whole population/age-group - the measures are not limited only to the risk groups or the head of the distribution

– Move the whole distribution instead of aiming at the risk groups only

• Nation-wide network of municipal primary care centres and preventive services: health promotion, detecting and caring for NCDs and their risk factors

• Health in all policies: prevention and health promotion - and health in general - should be taken into account in decisions made by different sectors. Intersectoral mechanisms for implementation (horizontal committees, HIA, formal and informal consultations etc.)

Taru Koivisto

30.5.2012

HiAP in Finland

• Legal Base

– Constitution §19 (health promotion),

– Public Health Act (1972) (public health work, .. environments)

– Health Care Act (2011)

• Policies

– Government resol. on Health 2015 Public Health Programme (2001) following Finnish Health For All 2000 strategy (1986)

– Governmental Policy Programme for Health Promotion 2008-2011

– National Action Plan to reduce health inequalities 2008-2011

– National Development Programme for Social and Health Care, KASTE –programme 2012-2015

• Programme of the Finnish Government 2011-2015

– promotion of wellbeing and health and reduction of inequality taken into account in all decision-making, and incorporated into the activities of all administrative sectors and ministries

Toolbox to promote health within the Government

• Information-based guidance such recommendations, guidelines, action plans, benchmarking, etc.

• Allocation of resources including funds for institutions, services, projects (RAY, KASTE, TE)

• Steering of administrative sector: performance guidance, project management, sectoral research

• Cooperation at EU and international level: legislation, intergovernmental cooperation and funds

• Intersectoral cooperation: ”Health in all policies” approach, influencing private sector and NGOs

• Legislation: national/EU

Examples on Finnish policies targeting large parts of the population

• Maternal care and child health care free of charge

• Free school lunches with healthy and versatile foods

• Obligatory health education classes (physical education and home economy as well)

• Well-developed occupational health care system (original aim at prevention and health promotion, has come to include primary care services as well)

• Subsidised workplace lunch

• High excise taxes on tobacco and alcohol, since 2011 excise taxes on sweets, icecream (and soft drinks)

Salt reduction: 30 years of systematic work

• Recommendation to reduce salt intake by the National Nutrition Council in 1978

• 1979-1982 The North Karelia Salt project with population surveys in 1979 and 1982

• Mass media campaigns, co-operation with food industry to reduce salt voluntarily, education of health care personnel

• The public became aware of salt and blood pressure, regular monitoring was established, and the first national labelling decrees were launched in the 1980s

Salt reduction – an integrated approach

• Legislation, consumer information: Compulsory labelling of salt

• The Heart Symbol, better choice in a certain food groups concerning salt content and type of fat

• Product development: e.g. mineral salt, meat products, bread

• Salt seminars (publications) for the nutrition experts and medical community

• Information on salt reduction: non-governmental organizations, e.g., The Finnish Heart Association, consumer organisations

Gradually setting tighter limits for ”highly salted” warning labels

Current

(1.6.2009

Previous Before

1993

Bread 1,2 1,3 … 1,7

Breakfast cereals 1,6 1,7 … 2,5

Sausages 1,7 1,8 2,2

Tools for better diet: warning labels on highly salted foods

• Over 600 ”Heart symbol foods” on the market

• More than 70 food companies

• The Heart Meal has also been launched

• Better choice in a food category (salt, total fat/ fat quality)

• In some food categories also fibre, sugar and cholesterol

• Food group based criteria available: http://www.sydanmerkki.fi

Criteria for the Finnish ”Heart symbol” Bread and cereal products

Bread and cereal products are an important source of carbohydrates and fibre. The criterion of the Heart Symbol

is especially the salt content, because bread is a notable source of sodium. For sodium the criteria correspond to

low-sodium limits set by food laws. In some cereal products there is plenty of fat and hard fat, therefore the

criteria include also fat. The criterion for hard fat follows the national nutrition guidelines.

Product groups Criteria relating to product groups

Bread Fat 5 g/100g

Sodium 280 mg/100g

Fibre > 5 g/100 g

Crisp bread, Finn crisps Fat 5 g/100 g

Sodium 480 mg/100g

Fibre > 10 g/100 g

Pastry (sweet and salted), biscuits and crackers Fat 25 % of energy

Hard fat 33 % of fat

Sodium 280 mg/100g

Sugars < 20 g/100 g

Breakfast cereals Fat 5 g/100 g, or if fat content 5.1-10 g/100g, hard

fat 33 % of fat

Sodium 400 mg/100g

Sugars < 16 g/100 g

Fibre > 6 g/100 g

Pasta, rice and similar

products

Fibre > 6 g/100 g

(dry weight)

Guidelines to develop and monitor mass catering services (2010)

1. Nutritional quality criteria to be

used in procurement of

catering services

2. Means how to increase

production of nutritionally high

quality meals (pricing etc.)

3. Monitoring of nutritional quality

and the use/users of catering

services

Maternity and child welfare clinics, school and student health care, and preventive oral care Decree 380/2011

”…nutrition, physical activity and weight management must be adressed in all health councelling…”

This guidance should be:

- based on client need

- promote willingness to assume personal responsibility for his/her own health

- target the entire family

Instructions and tools have been developed to support proper guidance and good nutrition

Tools for better diet: guidance and support to all families secured by legistlation

• Children in daycare must be provided with sufficient nutrition (Act on Children’s daycare 26/1973)

• Pupils must be provided with properly organised and balance meal free of charge every school day (Basic education Act 628/1998 & etc.)

• Compulsory health education (2001 onwards), physical education and nutrition & cooking skills to all pupils since basic education reform

• Student meals have to be healthy and fulfill nutritional recommendations (Decree on principles of supporting meals at universities 564/2003)

Tools for better diet: balanced meals and education to children and young people

Criteria for Nutritional Quality (CNQ)

• Based largely on work done by Finnish Heart Association (Meals with heart symbol)

• Includes:

– compulsory meal components

– nutritional criteria for all meal components (total fat, SAFA, salt, fibre)

– consumer advice and guidance to healthy choices

Nutritional quality criteria for main meals, upper limits for fat, SAFA and salt per 100g

Dish type Fat, g SAFA, g Salt

(NaCl), g

Soups and porridges1 3 1 0,5

Casseroles, risottos, pasta

dishes, sallads2, pizza

5 2 0,6

Steaks, rolls, pancakes,

chicken

8 3 0,8

Dish with sauce; e.g. minced

meat sauce

9 3,5 0,8

1 Cereal in porridges has to contain at least 6 g dietary fibre in 100 g 2 Sallads have to contain at least 150 g vegetables

Lunch place choices of Finnish employees

8.11.2012

1,5 million Finns eat one the

main meals

outside home everyday!

Fiscal approach for healthy diet

- Producer tax of sweets, ice-cream and soft-drinks from year 2011, total income in 2011 was 134 million euros

- Sugar Tax Working Group report in 2/2013:

• Exploring options for sugar taxation with the aim of increasing central government tax revenues and promoting healthy nutrition.

• Sweet tax is suggested to expand towards counting sugar content in various products e.g. also bakery products and jogurts would be considered.

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6

% of users Yoghurt and milk-based sweet foods

Sweet bakery products and bisquits

Soft-drinks and other cold drinks

Sweets and chocolate

Kyttälä et al Publ Health Nutr 2010

Consumption of sugary foods in small children

Age, yrs

Intake of sucrose (E%) in small children’s diet (Kyttälä et al Publ Health Nutr 2010)

0

2

4

6

8

10

12

14

16

1-v 2-v 3-v 4-v 6-v

E%

n=455 n=230 n=471 n=554 n=713

Long history of school lunches

• 1948: free lunch for all pupils at elementary schools

• 2008: special recommendations for school lunches, part of the National Curriculum

• free, adequate, balanced lunch for all pupils at primary, secondary, upper secondary and vocational schools every school day and subsidised meals for university students

• Good lunch helps to concentrate into learning and promotes pupils’ well-being, growth and development

School meal includes

Main course and

1. High fiber bread, for example rye crispbread

2. Soft margarine as bread spread

3. Fat-free milk or sour milk to drink (EU’s school-milk program for skimmed milk)

4. Fresh vegetables, salad, berries or fruits

5. Vegetable oil based salad dressing

Besides healthy lunch also healthy snacks are needed

• In 2007 the National Board of Education and National institute for health and welfare recommended that

– Selling of sweets, soft drinks and sugary juices should not be allowed in schools

– Only healthy products should be provided

School without candy project

National institute for health and welfare cooperated with dentists in Helsinki metropolitan area in School without candy campaign

- Not to sell any sweets or soft drinks in school premises

- Recommend children not to bring any sweets or soft drinks to school

Three schools received one-month dose of xylitol tablets as a prize.

Eat sweets at least once a week, %

0%

5%

10%

15%

20%

25%

30%

35%

40%

2005 2007 2009 2011

primary and secondary school, girls

upper secondary school, boys

upper secondary school, girls

vocational, boys

vocational, girls

School Health Survey 2011

Some current and future challenges

• CVD still high, population ageing, obesity etc.

• Global trade and marketing very strong >> global solutions and action needed

• Interdependence of dietary habits and technological solutions (SFA-trans)

• Evidence-base often limited (analysis of different policy options, structural measures etc.)

• Long term commitment and vision needed, governments change every 4 yrs

• Public acceptance? Political costs?

• Health literacy among public, policy-makers, media and civil servants in all sectors needs improvement

• Intersectoral structures, processes and mechanisms

*Total energy does not include the energy derived from fiber. Changes in 2007-2012: p < 0.001 (Carbohydrates, fat and protein)

0

5

10

15

20

25

30

35

40

45

1982 1992 1997 2002 2007 2012

E%

Year

Daily intake of fat and fatty acids (E%) in working age men

Fat (~25-35 E%)


Monounsaturated fatty acids (10-15 E%)


*Total energy does not include the energy derived from fiber. Changes in 2007-2012: p < 0.001 (Carbohydrates, fat and protein)

0

5

10

15

20

25

30

35

40

1982 1992 1997 2002 2007 2012

Daily intake of fat and fatty acids (E%) in working age women

Fat (~25-35 E%)


Monounsaturated fatty acids (10-15E%)


Changes in 2007-2012: Men p=0,006 Women p<0,001

0

2

4

6

8

10

12

14

1992 1997 2002 2007 2012

g/d

Year

Intake of salt in working age men and women

Men

Women

13.3.2014

Changing products, changing behaviour: type fat on bread

N=4458 N=3698 N=3028 N=5069 N=4205 N=3373

Users Users

Conclusions and future challengies

• National legislation has worked well, e.g. in setting maximum salt levels for normal products

• EU legislation is challenging, e.g. package labelling and unpacked products

• Forecasting the effects of fiscal means on consumption

• Reducing salt intake or changing the type of fat in the population have required long-lasting, systematic work

• Consumer education is very important and should be started early enough; easy-to-do models and healthy environment

• Nutritional quality in catering services should become a common practice

The Finnish paradox

• Prevalance of obesity increases – population blood pressure and cardiovascular mortality decrease

• Explanations

– The quality of food is more important than its quantity?

• Sodium content

• Quality of fats (saturated vs unsaturated fatty acids)

• Quantity of fruits and vegetables


Change in 2007-2012:



0

10

20

30

40

50

60

1982 1992 1997 2002 2007 2012

E%

Year

Daily intake of energy nutrients (E%) in working age men

Carbohydrates (~50-60 E%)

Fat (~ 25-35 E%)

Protein (~10-20 E%)





0

5

10

15

20

25

30

35

40

45

1982 1992 1997 2002 2007 2012

E%

Year

Daily intake of fat and fatty acids (E%) in working age men

Fat (~25-35 E%)


Monounsaturated fatty acids (10-15 E%)


Nutritional quality criteria for other components of

meals, upper limits for fat, hard fat, salt and fiber

Fat, g/100g Hard fat,

% of total

fat

Salt (NaCl),

g/100g

Dietary

fiber,

g/100g

Bread - soft: max. 0,7

hard: max. 1,2

min. 6

Fat for bread - max. 33 % max. 1 -

Milk or sour

milk

max. 0,5% - - -

Vegetables

- fresh

- cooked

- no added fat

-max.2

vegetable fat

-

-no added salt

-no added salt

Salad dressing max. 20 % max. 1

Nutritional quality criteria for side dishes: upper limits for fat, SAFA, salt and fiber per 100g

Side dish Fat,g SAFA, g Salt

(NaCl), g

Dietary

fibre ( dry

weight) g

Pasta max. 2 0,7 max. 0,3 min. 6

Rice, barley, rice-

rye mixtures etc.

max. 2 0,7 max. 0,3 min. 6

Boiled potatoes No added

fat

No added

salt

Other potato dishes

such as mashed

potatoes, oven

potatoes etc.

max. 2 0,7 max. 0,3

24-hour sodium excretion and salt intake in Finland 1977-2007

0

2

4

6

8

10

12

14

16

18Calculated, men

Calculated, women

24h urine, men

24h urine, women

NaCl

g/d

Year

Karvonen et al. 1977, Nissinen et al. 1982, Pietinen ym. 1981, Pietinen

ym.1990, Valsta 1992, THL/ FINDIET 1992, 1997, 2002 and 2007

Surveys

Criteria for the Finnish ”Heart symbol”

Meat products

The purpose is to decrease the intake of total fat i.e. the intake of invisible fat. At the same time

the intake of hard fat decreases as well. Some meat products may contain high amount of

cholesterol; therefore a cholesterol limit has been set. It is based on the recommended maximum

intake of cholesterol.

Product groups Criteria relating to product groups

Whole meat products Fat 4 g/100 g

Sodium 800 mg/100g

Cold cut sausages and other sausages to be

cooked

Fat 12 g/100 g

Hard fat 40 % of fat

Sodium 600 mg/100g

Cholesterol 100 mg/100g

Weight and height among men entering military service in 1993-2011

Weight (kg) Height (cm)

Santtila et al. 2006, Defence Command Finland

Ncd2014 nutirion policy finland 2014 3-10-h_kuusipalo

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