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

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Pekka PuskaDirector GeneralNational Public
Health Institute KTLHelsinki, Finland

• GLOBAL CHRONIC DISEASE PREVENTION - FROM SCIENCE
  TO EFFECTIVE PROGRAMMES AND POLICIES

Redfern oration, Melbourne 3.5.2007
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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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Projected Main Causes of Death, Worldwide, All
Ages, 2005
Redfern oration, Melbourne 3.5.2007
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Lifestyle Transition

• Emerging global epidemic of NCDs is to a great
  extent a consequence of changes in the diets, of
  declining physical activity and of increase of
  tobacco use
• The determinants of these changes are
  urbanisation, changes in occupations, population
  ageing and many global influences
• Risks are increasingly accumulating in lower
  socio-economic groups of the population

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NCDs are to a Great Extent Preventable Diseases

• Medical evidence for prevention exists.
• Population-based prevention is the most
  cost-effective and the only affordable option for
  major public health improvement in NCD rates.
• Major changes in population rates can take place
  in a surprisingly short time.

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• Prevention targets the population levels of most
  important risk factors.

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World Deaths in 2000 Attributable to Selected
Leading Risk Factors
Number of deaths (000s)
Source WHR 2002
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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 and alcohol, are key determinants of
  contemporary public health

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WHOs NCD Strategy 2000

• NCDs a priority
• Prevention key
• Integrated approach, targeting main behavioural
  factors diet, physical activity and tobacco

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Common NCD Risk Factors

• Non-modifiable
• Risk Factors
• Age
• Sex
• Genes

• Coronary heart
• disease
• Stroke
• Peripheral vascular
• disease
• Several cancers
• COPD/emphysema

Endpoints
Behavioural Risk Factors

• Tobacco
• Diet
• Alcohol
• Physical Activity

Socio-economic, Cultural Environmental Conditio
ns
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Integrated Prevention - Common Risk Factors

• CVD
• DIABETES
• CANCER
• COPD
• MUSCULOSCELETAL
• ORAL HEALTH

• TOBACCO USE
• UNHEALTHY DIET
• PHYSICAL INACTIVITY
• ALCOHOL

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Lifestyles in Key Position

• Individual health
• Population health
• Attention to determinants of lifestyle changes

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Two Prevention Strategies

• High risk strategy (individual)
• Population strategy (public health)

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Combing Personal and Public Responsibilities

• Personal Responsibility
• Nobody can take better care of your health than
  yourself
• Public Responsibility
• Make the healthy choices the easy ones
• (Ottawa declaration)

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• PUBLIC RESPONSIBILITY
• POLICY INTERVENTIONS

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Contents of Policies

• Stick Carrot
• Restrictions and enabling actions
• Good mix

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Evidence for Policy

• Evidence on causes of diseases
• risk factors
• disease mechanisms
• determinants of risk factors
• Evidence on intervention effectiveness
• clinical interventions
• health promotion interventions
• policy interventions

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Different Kind of Evidence for Policy

• Medical evidence on causes and possibilities of
  prevention
• Epidemiological evidence on local prevalence
  rates
• Evidence on interventions
• Evidence on policy related factors (resources,
  costs, stakeholder views, culture, ..)

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Policy Interventions Upstream Prevention

• The more upstream we go, the more complicated
  the issues of evidence becomes.

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What Policies?

• Health policy vs. Health in all policies
• Health impact assessment

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Strong Interaction BetweenDifferent Levels Needed
Global Regional EU National Local
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Globalization

• Brings about advantages and problems
• CVD globalization of unhealthy consumptions
• Relates to trade, marketing, communication etc.
• Global policies are needed to counteract negative
  consequences (to protect people, environment
  etc.)
• FCTC a good example

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Global Level Role of WHO

• Global health policy leadership (organization of
  governments) combined with good partnership and
  collaboration (other international organizations,
  NGOs, private sector)

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Global WHO Development

• FCTC (Framework Convention on Tobacco Control) -
  2003
• Global strategy on diet, physical activity and
  health - 2004

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Partnerships

• International / global
• UN / int. agencies
• NGOs
• Private sector
• National
• Governments (national, local)
• Civil society (NGOs)
• Private sector

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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, 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
• Demonstration formational action

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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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Evaluation / Monitoring

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

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Use of Butter on Bread (men age 3059)
Kg/m2
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Use of Vegetable Oil for Cooking (men age 3059)
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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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Serum Cholesterol in Men Aged 3059 Years
mmol/l
FINRISK Studies 19972002
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Systolic Blood Pressure in Women Aged 3059 Years
mmHg
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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
Mortality per 100 000 population
- 82
All Finland
200
- 75
100
Year
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Mortality Changes in North Karelia 1970-1995
(per 100.000, men 3564 years, age adjusted)

• Rate in Change in 1970
  1970-95 All causes 1509 - 49 All
  cardiovascular 855 - 68 Coronary heart
  disease 672 - 73 All cancers 271
  - 44 Lung cancers 147 - 71

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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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Important Aspects in the Continuation

• North Karelia continues to be an encouraging
  experience
• Solid public health infrastructure KTL,
  monitoring etc.
• Continued healthy public policy
• Positive media interest, NGO contributions
• Positive interaction with private sector
• International development (EU, WHO)

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For Successful Prevention

• Strong leader ship combined with
• Good partnership

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Partnerships

• Governments (national, local)
• Civil society (NGOs)
• Private sector
• International collaboration

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Governments

• Governments have a basic responsibility for
  public health

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Private Sector

• Social responsibility?
• Product development, marketing
• Government role, NGOs watch dogs, consumer
  choices
• Health promoting business sustainable
  business

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Health Services

• Balance between effective specialized / hospital
  care and good primary health care with evidence
  based prevention and health promotion
• Health services in interaction with other
  community activities

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Role of Community in CVD Prevention Rationale
of Community Based Interventions

• Risk related lifestyles are deeply enrooted in
  the community social and physical environments
• Influencing lifestyles calls for broad action
  through and by multiple community organizations

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Community Intervention Different Perspectives

• Pilot programme
• Demonstration programme
• Model programme
• Community study / trial
• Community programme evaluation

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MEDICAL KNOWLEDGE SOCIAL
EFFECTIVE BEHAVIORAL PROGRAM THEORY
HARD PRACTICAL WORK
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POPULATION
PUBLIC POLICY
PRIVATE SECTOR
HEALTH PROGRAMME
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In Chronic Disease Prevention
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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Constraints in NCD Prevention

• To overcome the myths
• Needs of curative treatment overcome prevention
• Commercial interests, lobbying
• Confusing health debates in the media
• Training of health personnel, institutional bases
  

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Future Challenges

• How to match the public health importance of
  NCDs and potential health gains with needed
  attention, resource use and political decision
  making.

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Economic Drivers For Chronic Disease Prevention

• Availability and health of the shrinking working
  age population
• Health and functional capacity of the increasing
  elderly population

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Healthy Ageing Ultimate Goal

• Future public health is overwhelmingly dominated
  by chronic diseases
• The real challenge is postponing the diseases to
  late years of life and compressing the morbid
  period, i.e.
• HEALTHY AGEING!
• Healthy ageing is both the human goal and the key
  to controling health care costs

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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
Redfern oration, Melbourne 3.5.2007