FAT and HEART DISEASE - Yes, We CAN Make a Change

Pekka Puska Director General National Institute for Health and Welfare (THL) Helsinki, Finland President, World Heart Federation (WHF)

FAT AND HEART DISEASE - Yes, we CAN make a change. The case of North Karelia, Finland

International Expert Meeting in Health significance of fat quality of the diet Barcelona 1-2.2.2009 World Heart Federation 7 rue des Battoirs, P.O. Box 155 1211 Geneva 4, Switzerland www.worldheart.org 22 Global Health Burden

Estimated global deaths by cause, all ages, 2005

20000000

Cardiovascular 18000000 diseases

16000000

14000000

12000000

10000000

8000000 Cancer

6000000 Chronic respiratory diseases 4000000 HIV/AIDS

Tuberculosis 2000000 Diabetes Malaria

Source : WHO 2005: «Preventing Chronic Diseases: A Vital Investment» 3 GlobalGlobal PublicPublic HealthHealth inin TransitionTransition

ChronicChronic diseasesdiseases –– especiallyespecially cardiocardio--vascularvascular diseasesdiseases ¾¾LeadingLeading healthhealth problemproblem inin industrializedindustrialized countriescountries ¾¾MainMain killerskillers andand rapidlyrapidly growinggrowing problemproblem inin developingdeveloping countriescountries

4 LifestyleLifestyle TransitionTransition

¾¾ EmergingEmerging globalglobal epidemicepidemic ofof NCDsNCDs isis toto aa greatgreat extentextent aa consequenceconsequence ofof changeschanges inin thethe diets,diets, ofof decliningdeclining physicalphysical activityactivity andand ofof increaseincrease ofof tobaccotobacco useuse ¾¾ TheThe determinantsdeterminants ofof thesethese changeschanges areare urbanisation,urbanisation, changeschanges inin occupations,occupations, populationpopulation ageingageing andand manymany globalglobal influencesinfluences ¾¾ RisksRisks areare increasinglyincreasingly accumulatingaccumulating inin lowerlower sociosocio--economiceconomic groupsgroups ofof thethe populationpopulation

5 WORLDWORLD DeathsDeaths inin 20002000 AttributableAttributable toto SelectedSelected LeadingLeading RiskRisk FactorsFactors

Blood pressure Tobacco Cholesterol Underweight Unsafe sex Fruit and vegetable intake High Body Mass Index Physical inactivity Alcohol Unsafe water, sanitation, and hygiene Indoor smoke from solid fuels Iron deficiency Urban air pollution Zinc deficiency Vitamin A deficiency Unsafe health care injections

Occupational risk factors for injury Number of deaths (000s) 0 1000 2000 3000 4000 5000 6000 7000 8000

Source: WHR 2002

6 SixSix ofof thethe SevenSeven TopTop DeterminantsDeterminants ofof MortalityMortality inin DevelopedDeveloped CountriesCountries RelateRelate toto HowHow WeWe Eat,Eat, DrinkDrink andand MoveMove

DietDiet andand physicalphysical activity,activity, togethertogether withwith tobaccotobacco andand alcohol,alcohol, areare keykey determinantsdeterminants ofof contemporarycontemporary publicpublic healthhealth

7 8 8 69 10 10 NorthNorth KareliaKarelia ProjectProject PrinciplesPrinciples forfor DefiningDefining thethe IntermediateIntermediate ObjectivesObjectives

•• DueDue toto thethe chronicchronic naturenature ofof CVD,CVD, thethe potentialpotential forfor thethe controlcontrol ofof thethe problemproblem lieslies inin primaryprimary preventionprevention

•• TheThe riskrisk factorsfactors werewere chosenchosen onon thethe basisbasis ofof bestbest availableavailable knowledgeknowledge:: -- previousprevious studiesstudies -- collectivecollective internationalinternational recommendationsrecommendations -- epidemiologicalepidemiological situationsituation inin NorthNorth KareliaKarelia

•• ChosenChosen riskrisk factorsfactors:: -- smokingsmoking -- elevatedelevated serumserum cholesterolcholesterol (diet)(diet) -- elevatedelevated bloodblood pressurepressure 11 FromFrom KareliaKarelia toto NationalNational ActionAction

•• FirstFirst provinceprovince ofof NorthNorth KareliaKarelia asas aa pilotpilot (5(5 years),years), thenthen nationalnational actionaction (1972(1972––77)77) •• ContinuationContinuation isis NorthNorth KareliaKarelia asas nationalnational demonstrationdemonstration (1977(1977––95)95) •• GoodGood scientificscientific evaluationevaluation toto learnlearn ofof thethe experienceexperience •• ComprehensiveComprehensive nationalnational actionaction

12 NorthNorth KareliaKarelia ProjectProject PracticalPractical interventionintervention -- EmphasisEmphasis onon persuasion,persuasion, practicalpractical skills,skills, socialsocial && environmentalenvironmental supportsupport forfor changechange -- ResearchResearch teamteam && locallocal projectproject officeoffice withwith comprehensivecomprehensive communitycommunity involvementinvolvement -- MainMain areas:areas: 1.1. MediaMedia activitiesactivities (materials,(materials, massmass media,media, campaigns)campaigns) 2.2. PreventivePreventive servicesservices (primary(primary healthhealth carecare etc.)etc.) 3.3. TrainingTraining ofof professionalprofessional andand otherother workersworkers 4.4. EnvironmentalEnvironmental changeschanges (smoke(smoke freefree areas,areas, supermarkets,supermarkets, foodfood industryindustry etc.)etc.) 5.5. MonitoringMonitoring andand feedbackfeedback

13 EvaluationEvaluation // MonitoringMonitoring

-- NorthNorth KareliaKarelia –– allall FinlandFinland -- MonitoringMonitoring systemssystems •• healthhealth behaviourbehaviour •• riskrisk factorsfactors •• nutritionnutrition •• diseases,diseases, mortalitymortality

14 UseUse ofof ButterButter onon BreadBread (men(men ageage 3030––59)59)

% 100 North Karelia Kuopio province 80 Southwest Finland Helsinki area 60 Oulu province Lapland province

0 1972 1977 1982 1987 1992 1997 2002

15 Butter consumption per capita in Finland

) 18 16 14 12 10 8 6 4

Consumption (kgper capita 2 0 1955 1965 1975 1985 1995 2005

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

kg 140 120 Whole milk

100 Low fat milk 80 Whole form milk 60 40 20 Skim milk 0 1960 1970 1980 1990 2000 2010

17 Change in fat content of Finnish cow milk

45 45 Fen: y = -0.16x + 362 44 44 43 g/kg Fen 43 Gen 42 Gen: y = -0.16x + 358 42 41 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year

©Valio Oy 18 Use of Vegetable Oil for Cooking (men age 30– 59)

% 70 North Karelia 60 Kuopio province Southwest Finland 50 Helsinki area Oulu province 40 Lapland province 30 20

10 0 1972 1977 1982 1987 1992 1997 2002 2007

19 BiscuitBiscuit ExampleExample

• 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 rapeceed oil

20 FruitsFruits andand VegetablesVegetables –– SupermarketsSupermarkets

21 Fat Intake as Percentage of Energy in Finland

40 Recommendations Total fat (~ 30 EN%) 30 SFA (~10 EN%) MUFA (10-15%) 20 En% PUFA (5-10%) 10 Sources: Hasunen et al. 1976 Uusitalo et al. 1986 0 Kleemola et al. 1994 1969- 1982 1987 1992 1997 2002 Findiet Study Group 1998 72 Männistö et al. 2003

Year

22 SaltSalt IntakeIntake inin FinlandFinland 19771977––20022002 g/day 16 Per capita statistics

12 Dietary surveys, men

Dietary surveys, 8 women Sodium excretion, men

4 Sodium excretion, women

0 1 9 1981 1 1992 1997 2 77 9 0 8 0 Year 7 2

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 FINDIET 2002 Studies, KTL/unpublished information 23 The Finnish Heart Symbol

www.sydanmerkki.fi 24 SerumSerum CholesterolCholesterol inin MenMen AgedAged 3030––5959 YearsYears

mmol/l 7,5

7 North Karelia Kuopio 6,5 Turku/Loimaa Helsinki/Vantaa 6 Oulu Lapland

5,5

5 1972 1977 1982 1987 1992 1997 2002 2007 FINRISK Studies 1997 & 2002

25 EstimatesEstimates ofof SS--CholChol changeschanges inin 19821982––2002*2002*

Men 0,1 PUFA 0 Dietary cholesterol -0,1 SFA -0,2 Keys

mmol/l -0,3 SFA+trans

-0,4 Keys (trans) **

-0,5 Measured S-Chol -0,6 1982 1992 2002

* Based on calculated intakes of dietary fatty acids and cholesterol. Standardized to the 2001 Finnish population. Users of cholesterol lowering medication excluded in -92 and -02. ** Trans fatty acids included as SFA

(Source: KTL/Valsta, Tapanainen, Laatikainen, Männistö, Vartiainen, in preparation ) 26 EstimatesEstimates ofof SS--CholChol changeschanges inin 19821982–– 2002*2002*

Women 0,1 PUFA 0 Dietary cholesterol -0,1 SFA -0,2 Keys

mmol/l -0,3 SFA+trans

-0,4 Keys (trans) **

-0,5 Measured S-Chol -0,6 198219922002 *Based on calculated intakes of dietary fatty acids and cholesterol. Standardized to the 2001 Finnish population. Users of cholesterol lowering medication excluded in -92 and -02. ** Trans fatty acids included as SFA

(Source: KTL/Valsta, Tapanainen, Laatikainen, Männistö, Vartiainen, in preparation ) 27 AgeAge--adjustedadjusted mortalitymortality ratesrates ofof coronarycoronary heartheart diseasedisease inin NorthNorth KareliaKarelia andand thethe wholewhole ofof 700 FinlandFinland amongamong start of the North Karelia Project malesmales agedaged 600 extension of the Project nationally 3535––6464 yearsyears fromfrom 19691969 500 to 2006. North Karelia to 2006. 400

300 MortalityMortality perper - 85% 200 100100 000000 All Finland populationpopulation 100 - 80% Age-standadized to European population 0 Year 69 72 75 78 81 84 87 90 93 96 99 2002 2005 28 ObservedObserved andand PredictedPredicted DeclinesDeclines inin CoronaryCoronary MortalityMortality inin EasternEastern Finland,Finland, MenMen % 0 -10 -20 Observed Predicted -30 Cholesterol -40 Blood pressure Smoking -50 -60 -70 -80 -90 1972 1977 1982 1987 1992 1997 2002 2007 Year

29 MMororttaalitlityy ChChangesanges iinn FiFinnllanandd ffromrom 19691969–– 7171 toto 20062006 (Men(Men 3535––6464 Years,Years, AgeAge Adjusted)Adjusted)

RateRateRate (per(per(per 100.000)100.000)100.000)ChangeChange Change fromfromfrom 196919691969–71––7171 20062006 200619691969 1969–71––7171 tototo 200620062006

AllAllAll causescausescauses13281328 1328583583 583-- -56%56% 56% AllAllAll cardiovascularcardiovascularcardiovascular680680 680172172 172-- -75%75% 75% CoronaryCoronaryCoronary heartheartheart diseasediseasedisease489489 489103103 103-- -79%79% 79% AllAllAll cancerscancerscancers262262 262124124 124-- -53%53% 53%

30 31 31 FromFrom KareliaKarelia toto NationalNational ActionAction

MajorMajor ElementsElements ofof FinnishFinnish NationalNational ActionAction 1.1.

•• ResearchResearch && internationalinternational researchresearch collaborationcollaboration •• HealthHealth servicesservices (especially(especially primaryprimary healthhealth care)care) •• NorthNorth KareliaKarelia Project,Project, otherother demonstrationdemonstration programmesprogrammes •• HealthHealth PromotionPromotion ProgrammesProgrammes (coalitions,(coalitions, NGONGO’’s,s, collaborationcollaboration withwith mediamedia etc.)etc.) •• Schools,Schools, educationaleducational institutionsinstitutions

32 MajorMajor ElementsElements ofof FinnishFinnish NationalNational ActionAction 2.2.

•• Industry,Industry, businessbusiness –– collaborationcollaboration •• PolicyPolicy decisions,decisions, intersectoralintersectoral collaboration,collaboration, legislationlegislation •• MonitoringMonitoring system:system: healthhealth behavioursbehaviours,, riskrisk factors,factors, nutrition,nutrition, diseases,diseases, mortalitymortality •• InternationalInternational collaborationcollaboration

33 SoundSound CombinationCombination ofof PopulationPopulation StrategyStrategy WithWith HighHigh RiskRisk StrategyStrategy

1.1. PopulationPopulation strategy:strategy: -- GreatestGreatest publicpublic healthhealth gainsgains -- CostCost effectiveeffective -- ResultsResults alsoalso inin otherother healthhealth benefitsbenefits

2.2. HighHigh riskrisk strategy:strategy: -- GreatGreat benefitsbenefits toto thethe personspersons concernedconcerned -- EffectiveEffective useuse ofof healthhealth servicesservices

34 POPULATIONPOPULATION PUBLICPUBLIC PRIVATEPRIVATE POLICYPOLICY SECTORSECTOR

HEALTHHEALTH PROGRAMMEPROGRAMME

35 CVDsCVDs areare toto aa GreatGreat ExtentExtent PreventablePreventable DiseasesDiseases

•• MedicalMedical evidenceevidence forfor preventionprevention exists.exists. •• PopulationPopulation--basedbased preventionprevention isis thethe mostmost costcost-- effectiveeffective andand thethe onlyonly affordableaffordable optionoption forfor majormajor publicpublic healthhealth improvementimprovement inin NCDNCD rates.rates. •• MajorMajor changeschanges inin populationpopulation ratesrates cancan taketake placeplace inin aa surprisinglysurprisingly shortshort time.time.

36 FinlandFinland HasHas ShownShown

• 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

37 38 38

AverageAverage contributioncontribution toto SAFASAFA intakeintake byby foodfood groupsgroups amongamong FinnishFinnish adults,adults, 2525--7474 yearsyears (n(n == 22 039)039)

SAFA %

Sweets Vegetable and potato dishes Dairy and Other foods cheese

Cereal and bakery products

Meat and poultry dishes Fat spreads and dressings

FINDIET 2007

40 AverageAverage contributioncontribution toto PUFAPUFA intakeintake byby foodfood groupsgroups amongamong FinnishFinnish adults,adults, 2525--7474 yearsyears (n(n == 22 039)039)

PUFA %

Dairy and cheese Vegetable and potato dishes Fat spreads, dressings

Other foods

Meat and Cereal and poultry dishes bakery products

FINDIET 2007