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The North Karelia Project in Finland

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The North Karelia Project in Finland ISSUE 5 · MARCH 2013 In this issue The North Karelia Project in Finland: A portrait of the North Karelia Project, the A societal shift favouring healthy lifestyles basis for community programs in chronic 2 disease prevention. In the early 1970s, the coronary heart disease mortality rate in Finland was the highest in the world, and North Karelia was the most affected. In every family in the region, physically active men in their prime were dying And answers to the following prematurely. questions The goal of the North Karelia Project was to reverse the situation by changing the population’s lifestyles. The goal was successfully attained: in 35 years, • What were the project’s goals? death by coronary heart disease in the North Karelia population dropped • What actions were taken in this context, and 85%. To this day, the project still serves as a model in promoting healthy what results were obtained? lifestyles.(1) • What were the details surrounding the community mobilization that contributed to the project’s success? • Is the success of the North Karelia Project transferable? What is TOPO? The TOPO collection is produced by the multidisciplinary team on nutrition, physical activity, and weight-related problems prevention (Nutrition, activité physique et prévention des problèmes reliés au poids or NAPP)1 at the Institut national de santé publique du Québec (INSPQ). The collection disseminates knowledge to inform the choices of practitioners and decision makers in the prevention North Karelia is a region of Finland with a population of 166 000 spread over an area of 21 585 km2. Traditionally of weight-related problems. Each issue addresses based on forestry and agriculture, the region’s economy has diversified and today is primarily centred on industry a theme and combines a critical analysis of the and services. relevant scientific literature with observations or illustrations that can assist in applying this knowledge in the Québec context. The TOPO collection may be found at http://www.inspq.qc.ca/topo. 1 The NAPP team is mandated to develop expertise on the 2 Coronary heart diseases specifically affect the blood vessels that feed the heart muscle, while issue of weight to support and assist the public health cardiovascular diseases are a group of diseases of the circulatory system including the heart network’s efforts in this field. The NAPP team is part of the and blood vessels (Public Health Agency of Canada: http://www.phac-aspc.gc.ca/cd-mc/cvd-mcv/ Habitudes de vie unit, in the Direction du développement des index-eng.php). individus et des communautés of the INSPQ. A WORLD FIRST Over the course of 30 years, the dietary habits of the population of North Karelia changed radically (Figure 1). In the spring of 1972, 86% of men and 82% of In the 1960s, research on an international scale women stated they ate butter with their bread. In the early 2000s, only 10% of established a link between dietary habits and men and 4% of women said they did so. During the same period, consumption cardiovascular diseases. This advance in knowledge of skim or partially skimmed milk increased among both men and women. In prompted action.(2, 3) Part of this movement, the 2000, 24% of men and 33% of women in North Karelia said they drank skim North Karelia Project was the world’s first major or 1% milk. Consumption of vegetables and fruit also increased. Data compiled community-based study in the field of cardiovascular from 1979 to 2004 shows that the proportion of people eating vegetables 6 or disease prevention.(4) The project was launched in 7 days a week went from 10% to 26% among men and from 12% to 47% among 1972 and officially ended 25 years later in 1997. women. % GOAL: TO RADICALLY CHANGE LIFESTYLES 100 The first goal that the government of Finland set for 80 the team responsible for the project was to radically change certain lifestyles among North Karelia’s 60 population. The vast majority of men aged 30 to 59 (the segment of the population most at risk) 40 were physically active and had no weight problems; however, their consumption of saturated fat and 20 their smoking habits were problematic. Saturated fat intake and smoking were therefore the two issues targeted in the project’s early years; later the 0 consumption of vegetables and fruit was added. To 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Year reduce the saturated fat intake of North Karelia’s eating vegetables 6 or 7 times a week residents, the team had to specifically convince drinking skim or 1% milk them to replace whole milk and butter with low-fat buttering their bread milk, non-hydrogenated margarine, and vegetable eating vegetables 6 or 7 times a week, Finland drinking skim or 1% milk, Finland oil, less rich in saturated fat. buttering their bread, Finland IMPRESSIVE RESULTS Figure 1: Proportion (%) of men aged 25 to 59 years consuming vegetables daily, drinking skim or 1% milk, and eating butter on bread, in North Karelia and in Finland, from 1972 to 2004 The evaluations carried out by the project’s promo- ters and their partners demonstrated results that Adapted from Helakorpi, Uutela and Puska, 2009.(8) were encouraging at the end of the first five years and conclusive in the long term.(5–7) During the first five years of the project, the decline in average total blood cholesterol levels was more marked among men from North Karelia than among those in the reference region, the province of Kuopio (Figure 2). In 1978, the project became a demonstration program, and the principles ensuring its success were applied throughout the country. Over the years, data has been gathered in other regions, and a downward trend in average blood cholesterol levels has been observed in the population of eastern Finland. 2 PEKKA PUSKA, CHAMPION OF IMPROVED PUBLIC mmol/l HEALTH3 8,0 7,5 North Karelia 7,0 Province of Kuopio Southwest Finland 6,5 Helsinki region Province of Oulu 6,0 Province of Laponie 5,5 Photo: G. Baril 5,0 Pekka Puska in his National Institute for Health and Welfare office in Helsinki. 1972 1977 1982 1987 1992 1997 2002 2007 Today at the helm of the National Institute for Health Figure 2: Decline in the average total blood cholesterol level among men and Welfare in Finland, Dr. Pekka Puska believes 30 to 59 years of age, from 1972 to 2007 that the North Karelia Project’s long-term vision was Adapted form Vartiainen et al. 2009.(5) a key factor in its success. He recounts that one of the project’s designers, Professor Martti Karvonen, Over a 35-year period, cardiovascular disease mortality rates in Finland declined one day told him: “You know Pekka, one of the constantly. Among North Karelian men 35 to 64 years of age, the coronary heart wisest decisions of my career was to appoint you… disease mortality rate dropped 85%. Even after taking into account other factors Not because you were good, but because you were conducive to this trend, improved treatment in particular, the greater part of this young!” In fact, Pekka Puska, a young graduate, was result is attributable to the investments in prevention launched in North Karelia only 27 years old when, in 1972, he was given a in the early 1970s.(6,7) leading role in the project. He was named project director in 1978 and would provide the project with (in thousands) continuity for 25 years. 800 In 1972, the idea of promoting health by mobilizing 700 an entire population to change its lifestyles was very Start of the North Karelia Project innovative. However, young Dr. Puska had training 600 and experience that had prepared him to adopt such Extension of the Project nationally an approach. Besides his medical training, he had 500 completed a master’s degree in social and political North Karelia sciences. Furthermore, his interests had led him to 400 become involved in a student organization to such All Finland a degree that he became president of its national 300 association. The North Karelia Project involved a professional commitment that corresponded with his 200 convictions. Today, he notes that “changing the world 100 may have been utopic, but changing public health was possible.” 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 Year Figure 3: Decline in the mortality rate* by coronary heart disease among men 35 to 64 years of age, from 1969 to 2006, in North Karelia and all of Finland *Mortality per 100 000 individuals; adjusted for age based on the European population. Adapted from Puska, Torppa and Salomaa, 2009.(7). 3 The author interviewed Pekka Puska in Helsinki in 2009 on the occasion of his presentation at the Noncommunicable Disease Seminar. 3 Changing public health meant going into the field and meeting people to tell them they had the Favourable factors power to improve their health. While the population Among the factors that contributed favourably to the North Karelia Project’s warmly welcomed these young doctors, dieticians, success(3,9,10) were some related to the region’s specific context and others based nurses, and other public health practitioners, the more on the project’s direction. project encountered its share of obstacles in the early years. Some cardiologists were not impressed Cited among the favourable factors associated with the project’s direction are that a team with such little experience was given the project’s theoretical foundations, sound analysis of the situation, rigorous significant government funds to carry out a project planning, flexible implementation, and, above all, an intervention that was of such scope.
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