1. CVD prevention/ Tiina Laatikainen
International Seminar on the Public Health Aspects of Noncommunicable Diseases
Lausanne -Geneva
Finland’s experience in implementing NCD prevention Dr. Tiina Laatikainen, Director Department of Chronic Disease Prevention Erkki Vartiainen, MD, Professor, Assistant Director General
10/05/2019
CVD prevention/ Tiina Laatikainen

2. 5

3. In the 1970’s Statistics showed very bad public health situation
CHD mortality rates among men highest in the world
Short life expectancy
Increasing public discussion
General opinion related CHD to stress, ageing and genetics (but little to lifestyle)
Cardiologists were aware that there are numerous “Statistical Associations”
North Karelia Community Demonstration Project started in National role out in 1977.

4. Karelia was instrumental behind...
Country-wide integrated NCD intervention programme (CINDI) in EURO
The Inter-Health Programme in 1986 with national programmes for action
The CARMEN integrated prevention and control of NCDs in the Americas (Collaborative Action for Risk factor prevention and effective Management of E NCDs

6. Serum cholesterol distribution in Finland and Japan in the 1970s
Frequency %
mmol/l

7. Aims of the North Karelia Project
MAIN OBJECTIVE:
Initially: To reduce 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

8. Main Principles of the North Karelia Project
Primary prevention is the only sustainable approach
Community based preventive programme
1 Target: the community (not individuals)
2 Intervention: through changes in the community organization/structures (not external intervention)
Risk factors identified by prospective studies, closely linked with certain behaviours - deeply enrooted in the community, i.e. smoking, elevated serum cholesterol (diet) and elevated blood pressure

9. RISK
FACTORS
PUBLIC
HEALTH
INTERVENTION

10. Constraints Suspicions from the scientific community of cardiologists
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)
Post war years: great poverty, then increase in consumption
Dairy farming main agriculture: butter and animal fat culturally highly valued
Strong commercial pressures (“FAT WAR”), supported by political pressures
Raising the funding (intervention and evaluation research)
To maintain interest and funding over decades

11. Opportunities 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
Good leadership

12. Community intervention model of the North Karelia Project12

13. 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: Media activities (materials, mass media, campaigns) Preventive services (primary health care etc.) Training of professional and other workers Environmental changes (smoke-free areas, supermarkets, food industry etc.) Monitoring and feed-back

14. ANTISMOKING LEGISLATION IN FINLAND IN 1977:
Prohibition of all forms of advertising
Restrictions in smoking in public places
Health warnings etc.
Tobacco tax for antismoking activities
Prohibition of sale to under 16 years old
ANTISMOKING LEGISLATION IN FINLAND IN 1995, 2000 AND 2007:
Worksite smoking policy
Sales to persons under 18 years of age prohibited
Restaurant, bar smoking policy

15. Smoking control programmes
Worksite programmes
School programmes
TV programmes
Radio programmes
Smoke Free Class Competition
Quit and Win - Do Not Start and Win for Young People

16. North Karelia Project Cholesterol programme
SPECIAL INTENSIFIED PROGRAM
New consensus recommendations
New reference values (< 5 mmol/L = “normal”)
Fingertip determination method
Interest of food industry, e.g. Finnish rapeseed oil
MAIN COMPONENTS
Population-wide cholesterol measurements
Dietary counseling
Mass media and many campaigns (incl. village competitions)
Collaboration with industry and supermarkets to increase availability of fresh fruit and vegetables
Use of lay opinion leaders to promote health innovations in community Co-operation with the Martta (housewives) organization

17. North Karelia Project Berry project
Aim to increase the consumption of eastern Finnish berries
Rationale: 1) Berries are healthy
2) Enhances switch from dairy farming
First Berry Project
Second Berry Project
Methods: various co-operative and innovative interventions
Funding from government

18. Cholesterol changes in 1991 competition
Village
Baseline
% Change 1
5.9
-10.8 2
5.8
-9.2 3
-8.9 4
-6.8 5
6.0
-4.0 6
5.7
-2.3 7
+1.4
Mean

19. Cholesterol distribution in North Karelia in 1972 and 2007, men4 6 8 10 12
mmol/l

20. Changes in Finnish food habits
Year

22. Fat used for cooking at home in Finland in 1978-2006
Health Behaviour among the Finnish Adult Population 1978–2006

23. Milk Consumption in Finland in 1970 and 2006 (kg per capita)
140
Whole milk
120
100
Low fat milk 80
Whole form milk 60 40 20
Skim milk
1960
1970
1980
1990
2000
2010 23

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

25. Systolic blood pressure in men (30–59 y)
mmHg
North Karelia project evaluation and FINMONICA and the National FINRISK Studies

26. Decline in CHD mortality in men aged 35-64
North Karelia
All Finland
per

27. Observed and Predicted Decline in CHD mortality
35-64 year old men
Vartiainen E et al.

28. 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 %
Angina: CABG & PTCA - 8%
Angina: Aspirin etc %
Other Factors -5%
T Laatikainen et al
Am J Epid 2005

29. 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 of CVD calls for simple changes in some lifestyles (individual, family, community, national and global level action)
Many results of prevention occur surprisingly quickly (CVD, diabetes)
Comprehensive action, broad collaboration with dedicated leadership and strong government policy support are crucial

30. Why success in North Karelia
Appropriate epidemiological and behavioural framework
Restricted, well defined targets
Good monitoring of immediate targets (behaviours, processes)
Emphasis in changing environment and social norms
Working closely with the community
Work with media
International collaboration, support from WHO
Close interaction with national health policy, integration with National Public Health Institute
Long term, dedicated leadership

31. Major Elements of Finnish National Action
Research & international research collaboration
Health services (especially primary health care)
North Karelia Project, other demonstration programmes
Health Promotion Programs (coalitions, NGOs, media,etc)
Schools, educational institutions
Collaboration with industry, business
Policy decisions, intersectoral collaboration, legislation
Monitoring system: health behaviours, risk factors, nutrition

32. Working with other sectors: tackling NCDs through a multsectoral response – salt reduction in the UK

33. Salt reduction in the UK
2003: UK Scientific Advisory Committee on Nutrition published Salt and Health
Levels gradually increased to 9.5g per day in 2002
Evidence for link between salt intake and hypertension stronger than ever before
Approximately 75% of the salt consumed in developed countries is found in processed foods such as bread, breakfast cereals, ready meals, cheese and sauces
Product reformulation is an important way in which to reduce population salt intake
Recommended that work should be undertaken to reduce salt intake
A reduction in intake by just 1g/person/day in the UK was save 6,000 lives every year

34. Principles of UK salt reduction strategy
Salt intake
Reduction needed
Target intake
Source
g/d
Table cooking (15%)
1.4
40%
0.9g
Natural (5%)
0.5
None
0.5g
Food industry (80%)
7.6
4.6g
Total salt intake
9.5g
6.0g

35. Salt reduction in the UK
2003: HMG accepted SACN’s recommendation – towards 6g salt/day for adults
2003: Public Health minister initiated a series of meetings with individual organizations and stakeholder groups to discuss salt reduction
2006: Voluntary salt reduction targets published following public consultation, with commitment to review targets in 2008
Three strands
Public health campaign
Collaboration with industry of reformulation
Development of single front-of-pack nutrition labeling scheme
2009: Further salt reduction targets published

36. Voluntary vs prescriptive regulation
Prescriptive regulation on reformulation would have:
been overly complex due to the wide range of foods and additives which contain sodium,
potentially delayed Government intervention whilst regulations were drafted and approved,
placed significant burdens on industry
required a costly enforcement regime.
Been especially difficult as food law is an EU competence
Prevented the FSA advocate for the highest reductions possible instead of setting less ambitious targets which would have been the case if these were set in legislation
Prevented review on a more regular basis, taking into account technological advances and developing targets based on what leading companies have achieved.

37. Mechanism
Voluntary salt reduction targets for a range of processed foods were established in collaboration with the food industry.
Targets published in 2006 and following a 2008 review, more challenging targets set across more than 80 categories of food.
Take up of the scheme achieved through an effective partnership with industry, involving businesses in the development of the targets, working to understand and address technical barriers and helping participant businesses gain a competitive advantage by acting responsibly.
Competitive advantage has been facilitated through government promotion of positive behaviors; in the case of the Salt Reduction Strategy this has included the publication of the salt commitment table, press and ministerial statements highlighting successful/progressive businesses and brands.
Government to bring stakeholders together (including media), establish targets and parameters for review, to monitor progress, provide technical expertise, and promote and utilize research.

38. Progress made…
Salt content of processed food has progressively reduced by between 10-50% depending on the category of food
The salt content of packaged bread, the biggest contributor of salt to the UK diet, has reduced by 20% from 1.23g/100g to 0.98g/100g (for pre-packed, sliced bread around a third)
Reductions of about 44% have been achieved in branded breakfast cereals
Reductions of between 16% and 50% have been achieved in some top-selling cakes and biscuits between 2006 and 2007
There have also been reductions in processed cheese products, including a range of soft white cheeses with 50% less salt for the UK market, a 32% reduction in some retail standard cheese slices, and 21% in the equivalent reduced-fat cheese slices.
Earlier work led by the Food and Drink Federation (Project Neptune) produced reductions of about 30% in cooking and pasta sauces and 25% in soups by a range of the largest manufacturers.

39. Progress made…
81 companies are committed to reducing salt in their products
The target based approach has been successful with, for example, the number of bread products meeting 2012 targets increasing from 31% to 71%
Many products have front of pack nutrition information displayed, and many companies are now committed to including both traffic light colours and percentage guidelines daily amounts
The UK has successfully achieved a reduction in average salt intake from 9.5g/person/day in 2002 to 8.1g/person/day in 2012.
(Urinary sodium excretion, for adults aged 19 to 64 years was 8.1g per day, mean estimated intake for men = 9.3g per day, women 6.8g per day.)

40. 9.5g per day to 8.1g per day

41. Reducing salt intakes through voluntary reformulation and increasing public awareness has been a highly cost effective policy option
10% reduction in salt intake achieved to date has
saved the economy £1.5 billion
prevented around 8,500 premature deaths annually.
Approximately £18.6 million has been spent on the public awareness campaign to date which supports the reformulation part of the programme.

42. Risks
Designing a scheme which was overly onerous and thereby causing businesses to disengage
Establishing targets which are easily achievable but fail to deliver the policy objectives
If businesses perceive that the policy is no longer on the Government’s agenda
Potential for responsible businesses to lose custom to those who do not take up the scheme, including companies exporting to the UK.

43. Lessons learnt from the voluntary approach
Can work where there is consensus as to the validity of the government’s policy objectives.
Should be supported by an equivalent evidence base to a regulatory measure with sufficient research to support the policy and its cost effectiveness.
A mechanism designed in partnership is most likely to produce targets which are both effective and realistic.
Useful to establish a broad base of support in principle and work with these early adopters to develop targets which industry can buy into.
An effective working relationship with industry is vital and will involve officials meeting regularly both with trade associations and individual companies and also highlighting and promoting the initiative regularly at trade conferences. It also requires ongoing political support.
Policy makers should accept that businesses will face barriers they have not considered and that any initiative will need to have the flexibility to adapt to these challenges. Drawing out these challenges is most effective early in the development stage.
In designing the scheme policy makers should understand the political, commercial and technical challenges facing businesses and be prepared to adapt appropriately. There will be businesses who believe targets go too far or cannot be achieved; however, effective engagement should inform targets which are challenging but achievable and a staged approach might usefully be considered.

44. Lessons learnt from the voluntary approach
Government should be aware that even in a voluntary scheme businesses may incur significant costs in participating. As a result there should be an opportunity for businesses to develop competitive advantage by signing up to the scheme particularly in the current economic climate. Early consideration of ‘reward’ for industry co-operation is advised; openly praise early adopters and those businesses making significant progress and recognise the costs they have incurred in complying.
Challenge inertia but accept the difficulties faced by some businesses and work with them to identify solutions.
Keep the initiative ‘live’ by including references in speeches by ministers and high level officials
Engage policy makers outside the UK where appropriate.