Finnish Experience on Diet, Cholesterol and Prevention of Cardiovascular Diseases

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1 Pekka Puska Director General National Public Health Institute KTL Helsinki, Finland Finnish Experience on Diet, Cholesterol and Prevention of Cardiovascular Diseases Lontoo

2 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 Lontoo Lontoo

3 Public Health Development in Finland after World War II Before the War Long, heavy war and difficult post war years In the 1950 s s and 60 s 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 Lontoo

4 Lontoo North Karelia Project Principles 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 Lontoo

5 Lontoo 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 Lontoo

6 Lontoo From Karelia to National Action First province of North Karelia as a pilot (5 years), then national action ( ) 77) Continuation is North Karelia as national demonstration ( ) 95) Good scientific evaluation to learn of the experience Comprehensive national action Lontoo

7 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 Lontoo Major Elements of Finnish National Action 2. Industry, business - collaboration Policy decisions, intersectoral collaboration, legislation Monitoring system: health behaviours, risk factors, nutrition International collaboration Lontoo

8 Main Emphasis in Nutrition Education / Policy in Finland Historically: - preventing various deficiencies Chronic disease prevention since 1970 s: - reduction of blood cholesterol and blood pressure levels More recently: - also weight control and prevention of diabetes Lontoo Finnish Nutrition Recommendations: Plate Model Source: National Nutrition Council 1999 Lontoo

9 Evaluation / Monitoring - North Karelia all Finland - Monitoring systems health behaviour risk factors nutrition diseases, mortality Lontoo Type of Fat Consumed on Bread in North Karelia, (25 (25-59-year-old) % No fat at all Low fat spread Plant stanol margarine Soft margarine Mixture of butter and oil Butter year Lontoo

10 Saturated Fat from Milk and Fat on Bread gr/day North Karelia Kuopio province Southwest Finland Helsinki area Year Lontoo Lontoo

11 Consumption of Milk and Sour Milk in kg/person/year whole milk (on farms) whole milk low-fat milk skimmed milk sour milk Lontoo Rapeseed Oil Lontoo

12 Changes in Type of Fat Usually Used for Cooking, % year Health behaviour and health among Finnish adult population (AVTK) 2002 Vegetable oil Low-fat margarine Margarine Butter-oil mixture Butter Lontoo Fat Intake as Percentage of Energy in Finland En % Recommendations Total fat (~ 30 EN%) SFA (~10 EN%) MUFA (10-15%) PUFA (5-10%) Sources: Hasunen et al Uusitalo et al Kleemola et al Findiet Study Group 1998 Männistö et al Year Lontoo

13 Fruits And Vegetables Supermarkets Lontoo Consumption of Foods of Plant Origin in kg/person/year cereals potatoes 20 sugar fruit 10 vegetables Food balance sheets (2001 = preliminary) Lontoo

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15 Salt Intake in Finland 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 Per capita statistics Dietary surveys, men Dietary surveys, women Sodium excretion, men Sodium excretion, women Lin. (Sodium Lontoo Serum Cholesterol in Men Aged Years mmol/l 7,5 7 6,5 6 5,5 North Karelia Kuopio Turku/Loimaa Helsinki/Vantaa Oulu Lapland FINRISK Studies 1997&2002 Lontoo

16 Age-adjusted mortality rates of coronary heart disease in North Karelia and the whole of 700 Finland among males aged years 500 from 1969 to start of the North Karelia Project extension of the Project nationally North Karelia 300 Mortality per population 100 Year All Finland - 75% - 82 % Lontoo Observed and Predicted Declines in Coronary Mortality in Eastern Finland, Men Population dietary changes explain much of the reduction in heart disease mortality in Finland. Observed Predicted Cholesterol Blood pressure Smoking Vartiainen, Puska et al BMJ Decline in mortality Lontoo

17 British Parliamentarians at KTL Lontoo Obesity (BMI>30) Trends Among Men* in England and Finland prevalence, % Fin Eng England Finland / / / * England y./>15 y, Finland y. Data sources: IOTF, UK/Dept Health: Health Surveys for England 1997 & 2002, KTL: The FINRISK studies Lontoo

18 Obesity (BMI>30) Trends Among Women* in England and Finland 30 prevalence, % Fin Eng England Finland / / / * England y./>15 y, Finland y. Data sources: IOTF, UK/Dept Health: Health Surveys for England 1997 & 2002, KTL: The FINRISK studies Lontoo Not Only Obesity: Contribution of 5 Risk Factors to Coronary Heart Disease Mortality in England (Mc Pherson et al., 2002) Blood cholesterol (>5,2 mmol/l) 46 % Lack of physical activity 37 % Smoking 19 % Blood pressure (>140/90 mmhg) 13 % Obesity 6 % Lontoo

19 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 Lontoo Why Did the Diet Change in Finland? 1. Long history of nutritional studies programs and policy Increasing level of nutrition education; home economic teaching at schools Active researchers, international collaboration Economic development, urbanization, changes in occupation structure; women's employment Catering services at worksite, free school lunch program Lontoo

20 Why Did the Diet Change in Finland? 2. Demonstration programs e.g. the North Karelia Project Public education programs, public interest - different organizations - The great fat debate Political consensus and consensus within the medical community supportative policy Food industry got interested - availability e.g. of low fat milk products - domestic vegetable oil - domestic vegetable and berry production Increased health awareness media interest Lontoo 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 Lontoo

21 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 Lontoo Developed Countries Deaths in 2000 Attributable to Selected Leading Risk Factors Blood pressure Tobacco Cholesterol High Body Mass Index Low fruit and vegetable intake Physical inactivity Alcohol Urban air pollution Lead exposure Occupational carcinogens Illicit drugs Unsafe sex Occupational particulates Occupational risk factors for injury Number of deaths (000s) Lontoo

22 Six of the Seven Top Determinants of Mortality in Developed Countries Relate to How We Eat, Drink and Move Diet and physical activity are key determinants of contemporary public health Lontoo 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. Lontoo

23 Lontoo WHO/FAO Expert Report Recommendations Limit saturated fat (<10 %) and replace by unsaturated Total fat intake: % Limit salt (sodium) intake (<5 g) Limit sugar intake (<10 %) Increase fruit and vegetable intake (>400 g) Ensure physical activity: at least min Ensure energy balance RECOMMENDATIONS OF WHO/FAO EXPERT REPORT ON DIET, NUTRITION AND PREVENTION OF CHRONIC DISEASES (WHO/TRS s. 16; 2003) Lontoo

24 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) Lontoo Strong Global Influences Global Health Actions Needed: WHO Global Strategy on Diet, Physical Activity and Health Adopted in 2004 Lontoo

25 Strong Interaction Between Different Levels Needed Global Regional EU National Local Lontoo PUBLIC POLICY POPULATION PRIVATE SECTOR HEALTH PROGRAMME Lontoo

26 Finland Has Shown Prevention of cardiovascular and related 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 to lower blood cholesterol 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 Lontoo Lontoo

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