Pekka Puska Director General National Institute for Health and Welfare (THL) Helsinki, Finland Past President, World Health Federation (WHF) The North Karelia project Europrevent Geneva 15.4.2011 5/6/2011 Greetings from Finland 5/6/2011 Pekka Puska, Director General 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) 5/6/2011 Pekka Puska, Director General 69 10 5/6/2011 Pekka Puska, Director General North Karelia Project Principles • Due to the chronic nature of CVD, the potential for the control of the problem lies in primary prevention • The risk factors were chosen on the basis of best 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 5/6/2011 Pekka Puska, Director General 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 5/6/2011 Pekka Puska, Director General Community-based project (pilot, demonstration, model) National programme and policies 5/6/2011 Pekka Puska, Director General Evaluation / Monitoring - North Karelia – all Finland - Monitoring systems • health behaviour • risk factors • nutrition • diseases, mortality 5/6/2011 Pekka Puska, Director General RESULTS 5/6/2011 Pekka Puska, Director General Use of Butter on Bread (men age 30–59) % 100 North Karelia Kuopio province 80 Southwest Finland Helsinki area 60 Oulu province Lapland province 40 20 0 1972 1977 1982 1987 1992 1997 2002 5/6/2011 Pekka Puska, Director General Butter consumption per capita in Finland 20 18 16 14 12 10 8 6 4 Consumption (kg per capita) per (kg Consumption 2 0 1955 1965 1975 1985 1995 2005 5/6/2011 Pekka Puska, Director General 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 5/6/2011 Pekka Puska, Director General 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 5/6/2011 Pekka Puska, Director General Fat Intake as Percentage of Energy in Finland 40 Recommendations 30 Total fat (~ 30 EN%) SFA (~10 EN%) 20 MUFA (10-15%) 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 Männistö et al. 2003 72 Year 5/6/2011 Pekka Puska, Director General Salt intake in Finland 1977-2007 FinnDiet Study 18 16 Calculated, men 14 Calculated, women 12 10 24 hour urine, men 8 24 hour urine, women 6 4 Lin. (24 hour urine, men) 2 Lin. (24 hour urine, women) 0 Lin. (Calculated, men) 1977 1979 1981 1982 1987 1991 1992 1994 1997 1998 2002 2007 Lin. (Calculated, women) 5/6/2011 Pekka Puska, Director General Serum Cholesterol in Men Aged 30–59 Years 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 5/6/2011 Pekka Puska, Director General Systolic blood pressure in women (30–59 y) mmHg 155 North Karelia 150 Kuopio province Southwest Finland 145 Helsinki area 140 Oulu province Lapland province 135 130 125 120 115 1972 1977 1982 1987 1992 1997 2002 2007 North Karelia project evaluation and FINMONICA and the National FINRISK Studies 1972 - 2007 5/6/2011 Pekka Puska, Director General Daily smoking in Finland 1950-2008 % 80 70 60 50 40 30 Men 20 Women 10 0 1950 1970 1985 1995 2001 2003 2005 2007 Year 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 start of the North Karelia Project 35–64 years from 1969 to 2006. extension of the Project nationally North Karelia Mortality per - 85% 100 000 All Finland population - 80% Age-standadized to European population 5/6/2011 Pekka Puska, Director General Observed and Predicted Declines in Coronary Mortality in Eastern Finland, Men % 0 -10 -20 Observed Predicted -30 Cholesterol -40 Blood pressure -50 Smoking -60 -70 -80 -90 1972 1977 1982 1987 1992 1997 2002 2007 Year 5/6/2011 Pekka Puska, Director General 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 Healthy and sick years of life expectancy of 65 year old Finns in 1980 and in 2000 Managing basic functions Subjective health men women men women 20 20 15 15 years years 10 10 5 5 0 1980 2000 1980 2000 0 1980 2000 1980 2000 Sick/disability Healthy/no disability 5/6/2011 Pekka Puska, Director General Sihvonen ym. 2003 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 From Karelia to National Action 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 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 5/6/2011 Pekka Puska, Director General 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 5/6/2011 Pekka Puska, Director General 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 Change in fat content of Finnish cow milk 45 45 44 Fen: y = -0.16x + 362 44 43 g/kg Fen 43 42 Gen Gen: y = -0.16x + 358 42 41 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year © Valio Oy 5/6/2011 Pekka Puska, Director General The Finnish Heart Symbol www.sydanmerkki.fi 5/6/2011 POPULATION PUBLIC PRIVATE POLICY SECTOR HEALTH PROGRAMME 5/6/2011 Pekka Puska, Director General Social change Broad change process among the population in interaction with respective policy decisions 5/6/2011 Pekka Puska, Director General FROM PRIORITIES TO IMPLEMENTATION IDENTIFYING IMPLEMENTING PRIORITIES THEM 5/6/2011 Pekka Puska, Director General 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 5/6/2011 Pekka Puska, Director General 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 For succesful prevention Strong leadership combined with Good partnership * * * Do the right things Do enough of those 5/6/2011 Pekka Puska, Director General Thanks 5/6/2011 38 5/6/2011 Pekka Puska, Director General.