ROLE OF GOVERNMENTS AND SOCIETY IN THE PREVENTION OF OBESITY AND RELATED CHRONIC DISEASES Chile, March 24-25, 2008 Pekka Puska, professor, MD, PhD, MPolSc Director General, National Public Health Institute (KTL) President Elect, World Heart Federation (WHF) Vice President, Int. Ass. of National Public Health Institutes (IANPHI)

CHILE, March 24-25, GREETINGS FROM FINLAND

CHILE, March 24-25,

4 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

CHILE, March 24-25, Projected Main Causes of Death, Worldwide, All Ages, 2005

CHILE, March 24-25, CVD’S 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 CVD rates.  Major changes in population rates can take place in a surprisingly short time.

CHILE, March 24-25, Prevention targets the population levels of most important risk factors.

CHILE, March 24-25, WORLD DEATHS IN 2000 ATTRIBUTABLE TO SELECTED LEADING RISK FACTORS Number of deaths (000s) Source: WHR 2002

CHILE, March 24-25, 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

CHILE, March 24-25, WHO’S NCD STRATEGY 2000  NCD’s a priority  Prevention key  Integrated approach, targeting main behavioural factors: diet, physical activity and tobacco WHO NCD ACTION PLAN (WHA 2008)

CHILE, March 24-25, Determinants - sosial - economical - cultural - political Risk factors behavioural biological CVD/NCDConsequencies HEALTH PROMOTION PREVENTION TREATMENT, REHABILITATION, SEC. PREVENTION DIFFERENT LEVELS OF PREVENTION TARGETS POPULATION HIGH RISK PATIENTS

CHILE, March 24-25, SOUND COMBINATION OF POPULATION STRATEGY WITH HIGH RISK STRATEGY 1.POPULATION STRATEGY: -Greatest public health gains -Cost effective -Results also in other health benefits 2.HIGH RISK STRATEGY: - Great benefits to the persons concerned - Great benefits to the persons concerned - Effective use of health services - Effective use of health services

CHILE, March 24-25, LIFESTYLES IN KEY POSITION  Individual health  Population health HOW TO INFLUENCE LIFESTYLES?

CHILE, March 24-25, LIFESTYLES AND RISK FACTORS CAN CHANGE!

CHILE, March 24-25,

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CHILE, March 24-25, 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 preventionThe risk factors were chosen on the basis of best available knowledge: - previous studies - collective international recommendations - epidemiological situation in North KareliaChosen risk factors: - smoking - elevated serum cholesterol (diet) - elevated blood pressure Due to the chronic nature of CVD, the potential for the control of the problem lies in primary preventionThe risk factors were chosen on the basis of best available knowledge: - previous studies - collective international recommendations - epidemiological situation in North KareliaChosen risk factors: - smoking - elevated serum cholesterol (diet) - elevated blood pressure

CHILE, March 24-25, FROM KARELIA TO NATIONAL ACTION First province of North Karelia as a pilotFirst province of North Karelia as a pilot (5 years), then national action (1972–77) Continuation is North Karelia as national demonstration (1977–95)Continuation is North Karelia as national demonstration (1977–95) Good scientific evaluation to learn of the experienceGood scientific evaluation to learn of the experience Comprehensive national actionComprehensive national action

CHILE, March 24-25, EVALUATION / MONITORING - North Karelia – all Finland - Monitoring systems health behaviourhealth behaviour risk factorsrisk factors nutritionnutrition diseases, mortalitydiseases, mortality

CHILE, March 24-25, USE MAINLY BUTTER ON BREAD (men age 30 – 59) % North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province

CHILE, March 24-25, MILK CONSUMPTION IN FINLAND IN 1970 AND 2006 (kg per capita) kg Whole milk Whole form milk Low fat milk Skim milk

CHILE, March 24-25, USE MAINLY VEGETABLE OIL FOR COOKING (men age 30–59) North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province %

23 SALT INTAKE IN FINLAND 1977–2002 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

CHILE, March 24-25, SERUM CHOLESTEROL IN MEN AGED 30–59 YEARS FINRISK Studies 1997 & 2002 mmol/l 5 5,5 6 6,5 7 7, North Karelia Kuopio Turku/Loimaa Helsinki/Vantaa Oulu Lapland

CHD MORTALITY IN ALL FINLAND AND IN NORTH KARELIA, MEN AGED 35–64 North Karelia All Finland start of the North Karelia Project extension of the Project nationally Source: Statistics Finland - 85% - 80% Year Per

CHILE, March 24-25, OBSERVED AND PREDICTED DECLINES IN CORONARY MORTALITY IN EASTERN FINLAND, MEN Year % Observed Predicted Cholesterol Blood pressure Smoking

CHILE, March 24-25, MORTALITY CHANGES IN NORTH KARELIA from 1969–71 to 2006 (Men 35–64 Years, Age Adjusted) Rate (per )Change from 1969– –71 to 2006 All causes % All cardiovascular % Coronary heart disease % All cancers % Lung cancers %

CHILE, March 24-25, 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. CONCLUSIONS North Karelia Project CONCLUSIONS

CHILE, March 24-25,

CHILE, March 24-25,  Personal Responsibility ”Nobody can take better care of your health than yourself”  Public Responsibility ”Make the healthy choices the easy ones” (Ottawa declaration) COMBING PERSONAL AND PUBLIC RESPONSIBILITIES

CHILE, March 24-25,

CHILE, March 24-25, PUBLIC RESPONSIBILITY POLICY INTERVENTIONS

CHILE, March 24-25, STRONG INTERACTION BETWEEN DIFFERENT LEVELS NEEDED Global Regional EU NationalLocal

CHILE, March 24-25,

CHILE, March 24-25, STRONG GLOBAL INFLUENCES – GLOBAL HEALTH ACTIONS NEEDED: WHO GLOBAL STRATEGY ON DIET, PHYSICAL ACTIVITY AND HEALTH ADOPTED IN 2004

CHILE, March 24-25, WE NEED STRONGER USE OF GLOBAL PUBLIC HEALTH INSTRUMENTS! Further developments with Global Strategy on Diet and Physical Activity.

CHILE, March 24-25, NATIONAL Governments have a basic responsibility for public health.

CHILE, March 24-25, PARTNERSHIPS FOR NATIONAL PUBLIC HEALTH WORK  Health services  Governments (national, local)  Civil society (NGO’s)  Private sector  International collaboration

CHILE, March 24-25, PRIVATE SECTOR  Food, eating, physical activity  Commercial issues are of increasing impact to public health  Health is increasingly important business argument  Product development, marketing  Social responsibility? Regulation? Market push?

CHILE, March 24-25, HEALTH SERVICES  High risk / population approaches  Health services in interaction with other community activities and general health promotion work  Evidence – based interventions  Use of IT technology

CHILE, March 24-25, CIVIL SOCIETY  The role of civil society is increasing in most countries  NGO’s: mobilize people, serve people, watchdogs, etc.  Push for childhood obesity to public / political agenda

CHILE, March 24-25, During the last few years a great number of strategies and plans for evidence – based, effective prevention and health promotion have been produced. Many important priorities have been identified.

CHILE, March 24-25,

CHILE, March 24-25, THE MAIN CHALLENGE IS NOT WHAT TO DO, BUT HOW TO DO!

CHILE, March 24-25, IDENTIFYINGIMPLEMENTING PRIORITIESTHEM FROM PRIORITIES TO IMPLEMENTATION

CHILE, March 24-25, STRONGER SUPPORT FOR IMPLEMENTATION  Stronger public health infrastructures  Stronger health surveillance / monitoring  Innovative financial support mechanisms

CHILE, March 24-25, MEDICAL KNOWLEDGE SOCIAL & EFFECTIVE BEHAVIORAL PROGRAMS THEORYPOLICIES SUSTAINED IMPLEMENTATION MEDICAL KNOWLEDGE SOCIAL & EFFECTIVE BEHAVIORAL PROGRAMS THEORYPOLICIES STRONG SUSTAINED IMPLEMENTATION KEY ELEMENTS

CHILE, March 24-25, HEALTH MONITORING  Power of monitoring  Feed back to people and decision makers  Need to emphasize risk factors, lifestyles, determinants

CHILE, March 24-25, MAJOR ELEMENTS OF NATIONAL ACTION ResearchResearch Health services (especially primary health care)Health services (especially primary health care) Demonstration programmesDemonstration programmes Building coalitionsBuilding coalitions Schools, educational institutionsSchools, educational institutions

CHILE, March 24-25, MAJOR ELEMENTS OF NATIONAL ACTION Industry, businessIndustry, business Policy decisions, intersectoral collaboration, legislationPolicy decisions, intersectoral collaboration, legislation Monitoring: health behaviours, risk factors, diseasesMonitoring: health behaviours, risk factors, diseases International collaborationInternational collaboration

CHILE, March 24-25, PUBLICPOLICY NATIONAL HEALTH PROGRAMME POPULATION PRIVATESECTOR HOW TO PROMOTE POLICY CHANGES?

CHILE, March 24-25, FOR SUCCESSFUL PREVENTION  Strong leadership combined with  Good partnership

CHILE, March 24-25,

MUCHAS GRACIAS KIITOS Chile, March 24-25, 2008