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

4. 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

5. 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?

6. 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

7. 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

8. 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

9. 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

11. 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

12. 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

13. 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

14. Erkki Vartiainen

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

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

17. Use of butter for cooking%

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

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

20. 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
Response rates, 60-70%
3-day food record, 1982, -92
24 h recall, 1997
48 h recall, 2002 and 2007
Pirjo Pietinen

21. Fat intake
Recommendations
EN%
Year

22. Estimated effects on serum cholesterol

23. Estimated effects on serum cholesterol

24. Estimated effect of statins on population cholesterol4% 1%

25. Serum cholesterol level by myocardial infarction and statins

26. Systolic blood pressure in men aged 30-59
mmHg

27. Systolic blood pressure in women aged 30-59 years
mmHg

28. Diastolic blood pressure in men aged 30-59 years
mmHg

29. Diastolic blood pressure in women aged 30-59 years
mmHg

30. Salt intake in Finland 1977-2007
g/day

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

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

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

34. 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 ) 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;

35. 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

36. Smoking in men aged 30-59 years%

37. Smoking in women aged 30-59 years%

39. 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

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

43. 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?

44. Observed and predicted decline in CHD mortality in men

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

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

47. 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

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

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

50. 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

51. 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

52. 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

53. 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

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

55. 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

56. 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

57. 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

58. Thank you !