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)
Pekka Puska, Director General5/6/2011
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Pekka Puska, Director General5/6/2011
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
Pekka Puska, Director General5/6/2011
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
Pekka Puska, Director General5/6/2011
Community-based project
(pilot, demonstration, model)
National programme and policies
Pekka Puska, Director General5/6/2011
Evaluation / Monitoring
- North Karelia – all Finland
- Monitoring systems
• health behaviour
• risk factors
• nutrition
• diseases, mortality
Pekka Puska, Director General5/6/2011
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
Pekka Puska, Director General5/6/2011
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)
Pekka Puska, Director General5/6/2011
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
Pekka Puska, Director General5/6/2011
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
%
Pekka Puska, Director General5/6/2011
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 General5/6/2011
Salt intake in Finland 1977-2007FinnDiet Study
5/6/2011 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 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
Pekka Puska, Director General5/6/2011
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
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
%
5/6/2011 Pekka Puska, Director General
5/6/2011 Pekka Puska, Director General
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
Pekka Puska, Director General5/6/2011
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%
Pekka Puska, Director General5/6/2011
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
From Karelia to National Action
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
5/6/2011 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
5/6/2011 Pekka Puska, Director General
Examples of intersectoral action
• Tobacco legislation & policy
• Nutrition development
• Interaction with the private sector
• NGO’s
5/6/2011 Pekka Puska, Director General
Development of Finnish Rapeseed Oil
5/6/2011 Pekka Puska, Director General
Fruits and Vegetables – Supermarkets
Pekka Puska, Director General5/6/2011
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
Pekka Puska, Director General5/6/2011
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
5/6/2011 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 General5/6/2011
www.sydanmerkki.fi
The Finnish Heart Symbol
5/6/2011
PUBLIC
POLICY
HEALTH PROGRAMME
POPULATIONPRIVATE
SECTOR
Pekka Puska, Director General5/6/2011
Broad change process among the population in interaction with respective policy decisions
Pekka Puska, Director General
Social change
5/6/2011
Pekka Puska, Director General
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
Pekka Puska, Director General5/6/2011
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
5/6/2011 Pekka Puska, Director General
Pekka Puska, Director General
For succesful prevention
Strong leadership combined with
Good partnership
* * *
Do the right things
Do enough of those
5/6/2011
5/6/2011
Thanks
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Pekka Puska, Director General5/6/2011
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