North karelia

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

FOOD AND PUBLIC HEALTH
NORDIC FOOD WEEK,
St. Petersburg 19.9.2007

NORDIC FOOD WEEK 19.9.2007

3

3

Global Public Health
Transition

in

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

4

Projected Main Causes of Death,
Worldwide, All Ages, 2005



5

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.

6

Diabetes Prevention Study (DPS)
Cumulative incidence of T2D, %

50
Control
40

30

20
Intervention
10
Intervention ceased

0
0

1

Follow-up time, years

2

3

4

5

6

7

Lindström et al, Lancet
2006:368;1673-79

8
8

Prevention targets the
population levels of
most important risk
factors.

8

Developed Countries Deaths in 2000

Attributable to Selected Leading Risk Factors
B lo o d p ressu re
To b acco
C h o lestero l
H ig h B o d y M ass I n d ex
L o w fru it an d veg etab le in take
Ph ysical in activity
Alco h o l
U rb an air p o llu tio n
L ead exp o su re
Occu p atio n al carcin o g en s
I llicit d ru g s
U n safe sex
Occu p atio n al p articu lates
Occu p atio n al risk facto rs fo r in ju ry

Number of deaths (000s)
0

500

100 0

1500


20 00

2 500

3 000
9

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


10

WHO’s NCD Strategy 2000
NCD’s a priority
Prevention key
Integrated approach, targeting
main behavioural factors: diet,
physical activity and tobacco


11

Integrated Prevention - Common
Risk Factors
CVD

TOBACCO USE

DIABETES

UNHEALTHY DIET

CANCER

PHYSICAL
INACTIVITY

COPD
MUSCULOSCELETAL

ALCOHOL

ORAL HEALTH

12

Lifestyles in Key Position
Individual health
Population health
Attention to determinants
of lifestyle changes

13

Two Prevention Strategies
1) High risk strategy (individual)
1) Population strategy (public health)


14


16

15

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)

16

PUBLIC RESPONSIBILITY
POLICY INTERVENTIONS


17

Strong Interaction Between
Different Levels Needed

Global
Regional EU
National
Local

18

Global Level: Role of WHO
Global health policy leadership
(”organization of governments”)
combined with good partnership and
collaboration (other international
organizations, NGO’s, private sector)


19

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


20

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


21

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
(WHA 2004)
• Addresses global responses

22

WHO / FAO Expert Report
Recommendations
Limit saturated fat (<10%) and replace by
unsaturated
Total fat intake: 15-30%
Limit salt (sodium) intake (<5 g)
Limit sugar intake (<10%)
Increase fruit and vegetable intake (>400 g)
Ensure physical activity: at least 30-60 min
Ensure energy balance
RECOMMENDATIONS OF WHO / FAO EXPERT
REPORT ON DIET, NUTRITION AND PREVENTION OF
CHRONIC DISEASES (WHO / TRS s. 16; 2003)

23


24


26

25

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


27

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 (1977–95)
• Good scientific evaluation to learn of
the experience
• Comprehensive national action

28

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

29

Rapeseed Oil


30

Fruits And Vegetables
– Supermarkets


31

Functional food development:
Benecol example
•BENECOL® products available:
•Spread
•Cream Cheese
•Pasta
•Butter Milk
•Yoghurt
•Yoghurt Drink
•Turkey Sausage
•Milk Drink
•Turkey cold cuts

NORDIC FOOD WEEK
19.9.2007 32
sivu

www.sydanmerkki.fi

33


34

Evaluation / Monitoring
- North Karelia – all Finland
- Monitoring systems
• health behaviour
• risk factors
• nutrition
• diseases, mortality


35

BIG CHANGES IN
LIFESTYLES AND RISK
FACTORS


36

Kg/m2

Use of Butter on Bread
(men age 30–59)

100
90
80
70
60
50
40
30
20
10
0

North Karelia
Kuopio province
Southwest Finland
Helsinki area
Oulu province
Lapland province

1972 1977 1982 1987 1992 1997 2002

37

Use of Vegetable Oil for Cooking
(men age 30–59)
70

North Karelia
Kuopio province
Southwest Finland
Helsinki area
Oulu province
Lapland province

60
50
40
30
20
10
0
1972 1977 1982 1987 1992 1997 2002

38

g/day

Salt Intake in Finland 1977–2002

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

39

mmol/l

Serum Cholesterol in Men
Aged 30–59 Years

7.5
7

North Karelia
Kuopio
Turku/Loimaa
Helsinki/Vantaa
Oulu
Lapland

6.5
6
5.5
5
1972

1977

1982

1987

1992

1997

2002

FINRISK Studies 1997&2002

40

Systolic Blood Pressure in Women
Aged 30–59 Years
mmHg
160

North Karelia
Kuopio province
Southwest Finland
Helsinki area
Oulu province
Lapland province

150
140
130
120
1972

1977

1982

1987

1992

1997


2002

41

Age-adjusted mortality rates of coronary
heart disease in North Karelia
and the whole of 700
start of the North Karelia Project
Finland among
600
males aged
extension of the Project nationally
35–64 years
500
from 1969
North Karelia
to 2002.
400
300

Mortality per
100 000
population

All Finland

200

Year

100

- 82%
- 75%

69 72 75 78 81 84 87 90 93 96 99 2002


42

Mortality Changes in North Karelia
1970–1995 (per 100.000, men 35–64
years, age adjusted)

Rate in
1970
All causes
1509
All cardiovascular
Coronary heart disease
All cancers
Lung cancers

855
672
271
147


Change in
1970–95
- 49%

- 68%
- 73%
- 44%
- 71%
43

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.

Decline in mortality

0
-10
-20
-30
-40

Observed
Predicted
Cholesterol
Blood pressure
Smoking
Vartiainen, Puska et al BMJ 1995

-50
-60

72

74

76

78

80

82

84

86

88

90

92

44

North Karelia Project

Conclusions from the North
Karelia Project
• A comprehensive, determined and
theory-based community program can
have a meaningful positive effect on risk
factors and life styles
• Such changes are associated with respective
favourable changes in chronic disease rates
health of the population

and

• A major national demonstration program can be a
strong tool for favourable national development in
chronic disease prevention
and health promotion

45


47

46

DISCUSSION ON FOOD,
NUTRITION INTERVENTIONS AND
PUBLIC HEALTH FROM THE
FINNISH EXPERIENCE


47

Strong Concensus for Nutrition
Recommendations
WHO / FAO
NORDIC RECOMMENDATION
FINNISH NAT. NUTR.
COUNCIL RECOMMENDATIONS

2003
2004
2005

Numerous national and expert body
recommendations

48

International Strategies
• WHO Global Strategy on Diet, Physical
Activity and Health 2004
• Nordic Plan for Action 2006
• WHO / EU Ministerial Charter on
Counteracting Obesity (Istanbul 2006)
• EU White Paper on Nutrition Overweight and
Obesity (2007)


49

FOOD IS NOT ONLY HEALTH, BUT ALSO
- taste
- culture
- social
FOOD RELATES TO
- tradition
- agriculture
- commercial drivers

50

Healthy Food Can Taste
Good or Bad
Depending on
- how prepared
- how served
- what people are used to
(esp. children)
- individual preferences

51

Healthy Food is not One
Type of Diet
Instead healthy food can be based on
different food cultures, if
recommendation for nutritional
composition is observed


52

Healthy Food
-

Positive choices
Can be based on local traditions
Can be domestic or international
Can be cheap or expensive


53

Partnerships for Public Health
Governments (national, local)
Civil society (NGO’s)
Private sector
International collaboration


54

Governments
Governments have a basic
responsibility for public
health


55

Private Sector
Health is increasingly important business
argument
Product development, marketing
”Health promoting business” –
sustainable business
Social responsibility

56

PUBLIC
POLICY

POPULATION

PRIVATE
SECTOR

HEALTH PROGRAMME


57

Experience in Finland
• People are interested in the health message
• People attempt and make great changes in
their diet
• Food industry adopts and supports the new
trends; health is a major driver for product
development and marketing
• Health claims, nutrition labelling and
information important


58

Economic Drivers for Chronic
Prevention

Disease

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


59

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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NORDIC FOOD WEEK,
St. Petersburg 19.9.2007

North karelia

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