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 0 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 40 20 0 1972 1977 1982 1987 1992 1997 2002 15 Butter consumption per capita in Finland 20 ) 18 16 14 12 10 8 6 4 Consumption (kg per 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 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 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 1981 1 1992 1997 2 9 9 0 77 8 0 7 2 Year 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 600 malesmales agedaged extension of the Project nationally 3535––6464 yearsyears 500 fromfrom 19691969 toto 2006.2006. 400 North Karelia 300 - 85% MortalityMortality perper 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,