Pekka Puska Director General National Public Health Institute KTL Helsinki, Finland

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Pekka PuskaDirector GeneralNational Public
Health Institute KTLHelsinki, Finland

• Finnish Experience on Diet, Health Related
  Lifestyles and Prevention of Chronic Diseases

Warsova, November 21-22, 2005
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National Public Health Institute KTL

• Major research expert institute under Ministry
  of Social Affairs and Health
• Combines high level research with a broad range
  of public health functions (incl. health
  monitoring)
• Covers broad range of health issues
• Employs some 1000 persons

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Public Health Development in Finland after World
War II

• Before the War
• Long, heavy war and difficult post war years
• In the 1950s and 60s

• Mainly Infectious
• Diseases
• The country was very poor
• Rapid increase in the CVD and other NCD rates
  Public health response mainly building hospitals
  and health services

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North Karelia ProjectPrinciples for Defining
the Intermediate Objectives

• 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

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Main Principles of the North Karelia Project

• Prevention is the only sustainable public health
  approach
• Risk factors identified by prospective studies,
  closely linked with certain behaviours - deeply
  enrooted in the community
• Community based preventive programme
• 1 Target the community (not individuals)
• 2 Intervention through community structures
  (not external intervention)
• Emphasis on community organization, general
  community changes

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Two Different Preventive Strategies

• 1) HIGH RISK STRATEGY
• - Great benefit for high risk individuals
• - Central work of health services
• - Restricted impact on public health
• - Often includes use of drugs
• POPULATION STRATEGY
• - Greatest impact on public health
• - Great cost effectiveness
• - Health services work with other sectors
• - Targets general lifestyle changes

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North Karelia Project Practical Intervention

• - Emphasis on persuasion, practical skills,
  social environmental support for change-
  Research team local project office with
  comprehensive community involvement- Main
  areas 1. Media activities (materials, mass
  media, campaigns) 2. Preventive services
  (primary health care etc.) 3. Training of
  professional and other workers 4. Environmental
  changes (smoke free areas,
  supermarkets, food industry etc.) 5. Monitoring
  and feedback

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Examples of Innovative Nutrition Activities in
North Karelia

• Lay leader programme
• Berry and vegetable project
• Risk reduction TV programmes
• Collaboration with housewives organization
• Cholesterol lowering village competitions
• Widespread fingertip cholesterol measurements
• Collaborative projects with industry
  supermarkets
• Health fairs

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From Karelia to National Action

• First province of North Karelia as a pilot
• (5 years), then national action (197277)
• Continuation is North Karelia as national
  demonstration (197795)
• Good scientific evaluation to learn of the
  experience
• Comprehensive national action

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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,
• NGOs, collaboration with media etc.)
• Schools, educational institutions

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Major Elements of Finnish National Action 2.

• Industry, business - collaboration
• Policy decisions, intersectoral collaboration,
  legislation
• Monitoring system health behaviours, risk
  factors, nutrition
• International collaboration

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Finnish Nutrition Recommendations Plate Model
Source National Nutrition Council 1999
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Evaluation / Monitoring

• North Karelia all Finland
• Monitoring systems
• health behaviour
• risk factors
• nutrition
• diseases, mortality

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Type of Fat Consumed on Bread in North Karelia,
19722000 (2559-year-old)

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Saturated Fat from Milk and Fat on Bread
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Consumption of Milk and Sour Milk in 19792001
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Rapeseed Oil
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Changes in Type of Fat Usually Used for Cooking,
19792002
Health behaviour and health among Finnish adult
population (AVTK) 2002
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Fat Intake as Percentage of Energy in Finland
Recommendations
En
Sources Hasunen et al. 1976
Uusitalo et al. 1986 Kleemola
et al. 1994 Findiet Study Group
1998 Männistö et al. 2003
Year
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Fruits and Vegetables Supermarkets
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Consumption of Foods of Plant Origin in 19792001

Food balance sheets (2001 preliminary)
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www.sydanmerkki.fi
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(No Transcript)
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Innovative Food Development

• BENECOL products available
• Spread
• Cream Cheese
• Pasta
• Butter Milk
• Yoghurt
• Yoghurt Drink
• Turkey Sausage
• Milk Drink
• Turkey cold cuts

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Serum Cholesterol in Men Aged 3059 Years
mmol/l
FINRISK Studies 19972002
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Salt Intake in Finland 19772002
g/day
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 FINDIET2002 Studies,
KTL/unpublished information
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Systolic Blood Pressure in Men Aged 3059 Years
mmHg
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Proportion of daily smokers in the population
aged 1564 years in Finland, 19782004
Health Behaviour among the Finnish Adult
Population (AVTK) 2004
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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 2002.
700
start of the North Karelia Project
600
extension of the Project nationally
500
North Karelia
400
300
- 82
All Finland
Mortality per 100 000 population
200
- 75
100
Year
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Population dietary changes explain much of the
reduction in heart disease mortality in Finland.
Observed and Predicted Declines in Coronary
Mortality in Eastern Finland, Men
Observed Predicted Cholesterol Blood
pressure Smoking
Vartiainen, Puska et al BMJ 1995
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North Karelia Project Mortality Changes in North
Karelia 19701995(per 100.000, men 3564-years,
age adjusted)

• RATE IN CHANGE IN 1970
  1970-95 All causes 1509 - 49 All
  cardiovascular 855 - 68Coronary heart
  disease 672 - 73All cancers 271 -
  44Lung cancers 147 - 71

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Obesity (BMIgt30) Trends Among Men in England
and Finland
30
25
Fin
20
England
Eng
prevalence,
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Finland
10
5
0
1980/1982
1986/1987
1991/1992
1997
2002
Data sources IOTF, UK/Dept Health Health
Surveys for England 1997 2002, KTL The FINRISK
studies 1982-2002
England 16-64 y./gt15 y, Finland 25-64 y.
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Obesity (BMIgt30) Trends Among Women in England
and Finland
30
25
Fin
20
Eng
England
prevalence,
15
Finland
10
5
0
1980/1982
1986/1987
1991/1992
1997
2002
Data sources IOTF, UK/Dept Health Health
Surveys for England 1997 2002, KTL The FINRISK
studies 1982-2002
England 16-64 y./gt15 y, Finland 25-64 y.
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Not Only Obesity Contribution of 5 Risk Factors
to Coronary Heart Disease Mortality in England
(Mc Pherson et al., 2002)

• Blood cholesterol (gt5,2 mmol/l) 46
• Lack of physical activity 37
• Smoking 19
• Blood pressure (gt140/90 mmHg) 13
• Obesity 6

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Why Success in North Karelia

• Appropriate epidemiological and behavioural
  framework
• Restricted, well defined targets
• Good monitoring of immediate targets (Behaviours,
  process)
• Flexible intervention
• Emphasis in changing environment and social norms
• Working closely with the community
• Positive feedback, work with media
• International collaboration, support from WHO
• Close interaction with national health policy,
  integration with National Public Health Institute
• Long term, dedicated leadership

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Global Public Health in Transition

• Chronic diseases especially cardiovascular
  diseases
• Leading health problem in industrialized
  countries
• Main killers and rapidly growing problem in
  developing countries

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WHOs Chronic Disease Strategy (2000)

• NCDs / Chronic Diseases Priority
• Comprehensive action needed
• Priority in prevention
• Integrated approach, targeting main behavioral
  factors tobacco, diet, physical activity

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WHOs Main Global Actions on NCD Risk Factors

• Framework convention on tobacco control
• Global strategy on diet, physical activity and
  health

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World Health Report 2002 Reducing Risks,
Promoting Healthy Life

• Latest estimates of disease burden
• Health effects of selected major health risks
  globally and in regions
• Strategies to reduce risk

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Developed Countries Deaths in 2000 Attributable
to Selected Leading Risk Factors
Number of deaths (000s)
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Six of the Seven Top Determinants of Mortality
in Developed Countries Relate to How We Eat,
Drink and Move

• Diet and physical activity, together with
  tobacco, are key determinants of contemporary
  public health

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Diet and Risk of NCD

• Up to 80 of coronary heart disease and up to 90
  of type 2 diabetes could be avoided through
  changing lifestyle factors.
• About one third of cancers could be prevented by
  eating healthily, maintaining normal weight and
  being physically active throughout the life span.

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Limit saturated fat (lt10 ) and replace by
unsaturatedTotal fat intake 15-30 Limit salt
(sodium) intake (lt5 g)Limit sugar intake (lt10
)Increase fruit and vegetable intake (gt400
g)Ensure physical activity at least 30-60
minEnsure energy balance
WHO/FAO Expert ReportRecommendations

• RECOMMENDATIONS OF WHO/FAO EXPERT REPORT ON DIET,
  NUTRITION AND PREVENTION OF CHRONIC DISEASES
  (WHO/TRS s. 16 2003)

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Who Global Strategy on Diet, Physical Activity
and Health

• Comprehensive roadmap for Member States and other
  stakeholders
• Based on strong evidence and broad consultations
• Emphasizes positive actions and collaboration
• Supports Member States
• Addresses global responses

(WHA 2004)
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Strong Global Influences Global Health Actions
Needed WHO Global Strategy on Diet, Physical
Activity and Health Adopted in 2004
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Pekka Puska and Kaare Norum
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Strong Interaction BetweenDifferent Levels Needed
Global Regional EU National Local
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POPULATION
PUBLIC POLICY
PRIVATE SECTOR
HEALTH PROGRAMME
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Against Us

• Lack of understanding the potential
• Needs of curative medicine
• Vested interest / lobbying
• Inertia in change

For Us

• Evidence / truth
• Health is important for all
• Increasing number of partners

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Finland Has Shown

• Prevention of major chronic diseases is possible
  and pays off
• Population based prevention is the only cost
  effective and sustainable public health approach
  to chronic disease control
• Prevention calls for simple changes in some
  lifestyles (individual, family, community,
  national and global level action)
• Influencing national diets and lifestyles 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

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THANK YOU
Warsova, November 21-22, 2005