Lessons Learnt from Finnish experiences on NCD Prevention and Control Erkki Vartiainen, MD, Professor, Assistant Director General 07/05/2018 Erkki Vartiainen 1

START OF THE NORTH KARELIA PROJECT (1) Seven countries study in North Karelia Since 1955 Public attention to the high CVD mortality and to the statistics that the province of North Karelia is in the worse situation Petition by the representatives of people in North Karelia for national assistance to cope with the problem (January 1971) Delegation led by the Governor to Helsinki, the petition was handed to the Prime Minister and other decision makers Involvement of Finnish experts and WHO

Two main questions in 1970’s Can risk factors and behaviors be changed on population level ? If risk factors will reduce what will happen to the mortality?

North Karelia Project AIMS OF THE NORTH KARELIA PROJECT MAIN OBJECTIVE: - Initially: To reduce the CVD mortality - Later: To reduce major chronic disease mortality and promote health INTERMEDIATE OBJECTIVES: - To reduce the population levels of main risk factors, emphasizing lifestyle changes and to promote secondary prevention NATIONAL OBJECTIVE: - Initially: To be pilot for all Finland - Later: To be demonstration and model program

North Karelia Project HIERARCHY OF OBJECTIVES. GENERAL GOAL: North Karelia Project HIERARCHY OF OBJECTIVES GENERAL GOAL: Improved health MAIN OBJECTIVES: Medical /Epidemiological Prevention of chronic framework: diseases & promotion of health - earlier research - local prevalence INTERMEDIATE OBJECTIVES: Risk factors, life-styles and treatment Social / Behavioural framework: - theory PRACTICAL OBJECTIVES: - community analysis Intervention programme

FROM KARELIA TO NATIONAL ACTION First province of North Karelia as a pilot (5 years), then national action Good scientific evaluation to learn of the experience

25 % 5 % 70 % Theoretical presentation of the difference between People with low risk factor level People with average risk factor level People with clinically high risk factor level Individual risk of CHD Distribution of people according to risk factor level Theoretical presentation of the difference between individual risk and the proportional attributable risk

North Karelia Project THEORETICAL PRINCIPLES OF THE INTERVENTIONS MEDICAL FRAMEWORK: - Primary prevention - Main targets: smoking, diet, cholesterol, blood pressure - popupation approach, general risk factor reduction emphasizing lifestyle changes SOCIAL / BEHAVIOURAL FRAMEWORK - Social marketing - Behaviour modification - Communication - Innovation - diffusion - Community organization

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, massmedia, campaigns) 2. Preventive services (primary health care etc.) 3. Training of professional and other workers 4. Environmental changes (smokefree areas, supermarkets, food industry etc.) 5. Monitoring and feed-back

North Karelia Project EVALUATION. EVALUATION TASKS. 1 North Karelia Project EVALUATION EVALUATION TASKS 1. Feasibility, performance 2. Effects: risk factors, lifestyles, disease rates, mortality 3. Change process 4. Costs 5. Other consequencies EVALUATION TYPES - summative: 5-year periods - formative, internal evaluation

Erkki Vartiainen

Serum cholesterol in men aged 30-59 years mmol/L

Serum cholesterol in women aged 30-59 years mmol/L

Use of butter for cooking %

Use of vegetable oil for cooking (men age 30-59)

Use of butter on bread (men age 30-59) %

FINNISH DIETARY SURVEYS 1982, 1992, 1997, 2002,2007 FINMONICA/FINRISK surveys Age and sex-stratified random sample, 25-64-years, in 3-5 study areas Diet subsample 3000-4000 Response rates, 60-70% 3-day food record, 1982, -92 24 h recall, 1997 48 h recall, 2002 and 2007 www.ktl.fi/nutrition, Pirjo Pietinen

Fat intake Recommendations EN% Year

Estimated effects on serum cholesterol

Estimated effects on serum cholesterol

Estimated effect of statins on population cholesterol 4% 1%

Serum cholesterol level by myocardial infarction and statins

Systolic blood pressure in men aged 30-59 mmHg

Systolic blood pressure in women aged 30-59 years mmHg

Diastolic blood pressure in men aged 30-59 years mmHg

Diastolic blood pressure in women aged 30-59 years mmHg

Salt intake in Finland 1977-2007 g/day

Body mass index in men aged 30-59 Kg/m2

Body mass index in women aged 30-59 years Kg/m2

BMI by education, women 25-64 years kg/m2

DPS-F study Diabetes by treatment group during the total follow-up period 50 Log-rank test: p=0.0001 Intervention ceased Control Hazard ratio=0.57 (95% CI 0.43-0.76) 40 30 Cumulative incidence of T2D, % 20 Intervention 10 1 2 3 4 5 6 7 8 Follow-up time, years Lindström et. al. Lancet 2006:368;1673-79

Why did diet change? North Karelia Project (community based CVD prevention program) Consensus in the medical community Political consensus Recommendations Cholesterol screening Fat debates Educational programs Business got interested

Smoking in men aged 30-59 years %

Smoking in women aged 30-59 years %

Figure 2. Male and female ever-regular smoking by birth cohort Figure 1. Daily smoking prevalence 1960–2005 WW I generation/ Early independence generation Depression generation Post WW II Baby-boomer generation Early 1960’s generation entering into typical smoking initiation age when TCA 1976 was enforced % % 60 100 90 50 80 Men Men 70 40 60 30 50 40 20 30 Women Women 20 10 10 1960 1970 78-79 83-85 89-90 93-94 1997 1999 2001 2003 2005 1916–20 1921–25 1926–30 1931–35 1936–40 1941–45 1946–50 1951–55 1956–60 1961–65 1966–70 1971–75 1976–80 Year 19-34 35-49 50-64 25-49 19-34 35-49 50-64 25-49 Separate dots = observed prevalence for age groups by gender Solid lines = log-linear model estimates for prevalence by gender Dotted lines = extrapolation assuming the effect of the 1976 Tobacco Control Act to be zero for genders

Mortality per 100 000 population 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 2006. Mortality per 100 000 population Age-standadized to European population start of the North Karelia Project extension of the Project nationally North Karelia All Finland

North Karelia Project. PREVENTION OF CVD. Do the risk factor changes North Karelia Project PREVENTION OF CVD Do the risk factor changes explain the CVD mortality changes?

Observed and predicted decline in CHD mortality in men

CHD mortality fall in Finland 1982 – 1997 Risk Factors -71% Cholesterol - 53% Smoking - 11% Blood pressure - 7%   Treatments -24% AMI treatments - 4% Secondary prevention - 8% Heart failure - 2% Angina: CABG & PTCA - 8% Angina: Aspirin etc - 2% Other Factors -5% 373 fewer deaths 1982 1997 T Laatikainen et al Am J Epid 2005

Subjective health: percent stating their health as good or very good (men)

North Karelia Project FROM PILOT/DEMONSTRATION PROGRAM TO NATIONAL ACTION National health program Medical Public need knowledge for change Visible experiences, results National policy Diffusion NATIONAL DEMONSTRATION PROGRAM NATIONAL ACTION

North Karelia Project MEDICAL KNOWLEDGE. COMMUNITY SOCIAL & BEHAVIORAL North Karelia Project MEDICAL KNOWLEDGE COMMUNITY SOCIAL & BEHAVIORAL PROGRAM THEORY HARD PRACTICAL WORK

Chow et Int J Epidemiol 2009;38:1580 Erkki Vartiainen

CONSTRAINTS Suspicions from the cardiological scientific community Medical knowledge on prevention questionable, community prevention new concept North Karelia socially deprived area, poor and with many social problems (unemployment, migration, shortage of doctors etc) War and post war years: Great poverty, after that increase in consumption Dairy farming main agriculture: Butter and animal fat highly valued culturally Strong commercial pressures (“FAT WAR”), supported by political pressures Raising the funding (intervention and evaluation research) To maintain interest and funding over decades

ADVANTAGES Magnitude of problem, concern of people Relatively homogenous population, traditions of community action Trust in experts and in public action Good information system Good collaboration with people

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

MAJOR ELEMENTS OF SUCCESSFUL NATIONAL PREVENTIVE PROGRAM 1 RESEARCH HEALTH SERVICES (ESPECIALLY PRIMARY HEALTH CARE) HEALTH EDUCATION PROGRAMMES (COALITIONS, NGO’S, COLLABORATION WITH MEDIA ETC.) SCHOOLS, EDUCATIONAL INSTITUTIONS INDUSTRY, BUSINESS

MAJOR ELEMENTS OF SUCCESSFUL NATIONAL PREVENTIVE PROGRAM 2 NATIONAL DEMONSTRATION PROGRAMME(S), FOCAL POINT(S) POLICY DECISIONS, INTERSECTORAL COLLABORATION, LEGISLATION MONITORING SYSTEM INTERNATIONAL COLLABORATION

NORTH KARELIA HAS SHOWN Prevention of major chronic diseases is possible and pays off Population based prevention is a 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) Many results of prevention occur surprisingly quickly (CVD, diabetes) and also at relatively late age At the same time increases in subjective health and physical capacity

North Karelia Project CONCLUSIONS 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 and health of the population A major national demonstration program can be a strong tool for favourable national development in chronic disease prevention and health promotion

FINNISH HEART PLAN How to reduce the number of cardiovascular disease morbidity and mortality by half PROMOTING CARDIOVASCULAR HEALTH AND PREVENTING CARDIOVASCULAR DISEASES REHABILITATION AND SECUNDARY PREVENTION STRAGEGIES OF EARLY DIAGNOSTICS AND TREATMENT Developing cooperation between special health care and primary health care Rehabilitation resources ”Out patient rehabilitation model” in health centres for heart patients Heart patient working and returning to work Developing cooperation between special health care and primary health care Local treatment plans Diminishing differences in treatment between social groups Increasing the number of coronary angiographies Increasing the number of coronary angioplasties On call cardiology service Increasing the number of cardiologists Adequate medical treatment Woman’s heart Risk group strategy Prevention programme of type 2 diabetes Current Care Guidelines for Hypertension Current Care Guidelines for Smoking, Nicotine Dependency and Interventions for Cessation Guidelines of European Society of Cardiology on cardiovascular disease prevention in clinical practice Prevention Population strategy Cardiovascular diseases and life style Physical activity Nutrition Heart Symbol Canteen catering Weight control Non-Smoking Health Promotion Health in all decision making in the society Differences in health between population groups Resources on national and regional level – local units/networks in health promotion

Thank you !