1. 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)

2. CHILE, March 24-25, 20082 GREETINGS FROM FINLAND

3. CHILE, March 24-25, 20083 3

4. 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

5. CHILE, March 24-25, 20085 Projected Main Causes of Death, Worldwide, All Ages, 2005

6. CHILE, March 24-25, 20086 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.

7. CHILE, March 24-25, 20087 Prevention targets the population levels of most important risk factors.

8. CHILE, March 24-25, 20088 WORLD DEATHS IN 2000 ATTRIBUTABLE TO SELECTED LEADING RISK FACTORS Number of deaths (000s) Source: WHR 2002

9. CHILE, March 24-25, 20089 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. CHILE, March 24-25, 200810 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)

11. CHILE, March 24-25, 200811 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

12. CHILE, March 24-25, 200812 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

13. CHILE, March 24-25, 200813 LIFESTYLES IN KEY POSITION  Individual health  Population health HOW TO INFLUENCE LIFESTYLES?

14. CHILE, March 24-25, 200814 LIFESTYLES AND RISK FACTORS CAN CHANGE!

15. CHILE, March 24-25, 200815 15

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17. CHILE, March 24-25, 200817 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

18. CHILE, March 24-25, 200818 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

19. CHILE, March 24-25, 200819 EVALUATION / MONITORING - North Karelia – all Finland - Monitoring systems health behaviourhealth behaviour risk factorsrisk factors nutritionnutrition diseases, mortalitydiseases, mortality

20. CHILE, March 24-25, 200820 USE MAINLY BUTTER ON BREAD (men age 30 – 59) % 0 20 40 60 80 100 1972197719821987199219972002 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province

21. CHILE, March 24-25, 200821 MILK CONSUMPTION IN FINLAND IN 1970 AND 2006 (kg per capita) 0 20 40 60 80 100 120 140 kg 196019701980199020002010 Whole milk Whole form milk Low fat milk Skim milk

22. CHILE, March 24-25, 200822 USE MAINLY VEGETABLE OIL FOR COOKING (men age 30–59) 0 10 20 30 40 50 60 70 19721977198219871992199720022007 North Karelia Kuopio province Southwest Finland Helsinki area Oulu province Lapland province %

23. 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

24. CHILE, March 24-25, 200824 SERUM CHOLESTEROL IN MEN AGED 30–59 YEARS FINRISK Studies 1997 & 2002 mmol/l 5 5,5 6 6,5 7 7,5 19721977198219871992199720022007 North Karelia Kuopio Turku/Loimaa Helsinki/Vantaa Oulu Lapland

25. 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% 0 100 200 300 400 500 600 700 6970717273747576777879808182838485868788899091929394959697989900010203040506 Year Per 100 000 25

26. CHILE, March 24-25, 200826 OBSERVED AND PREDICTED DECLINES IN CORONARY MORTALITY IN EASTERN FINLAND, MEN -90 -80 -70 -60 -50 -40 -30 -20 -10 0 19721977198219871992199720022007 Year % Observed Predicted Cholesterol Blood pressure Smoking

27. CHILE, March 24-25, 200827 MORTALITY CHANGES IN NORTH KARELIA from 1969–71 to 2006 (Men 35–64 Years, Age Adjusted) Rate (per 100.000)Change from 1969–71 20061969–71 to 2006 All causes1509572- 62% All cardiovascular855182- 79% Coronary heart disease672103- 85% All cancers 27196- 65% Lung cancers 14730- 80%

28. CHILE, March 24-25, 200828 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

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30. CHILE, March 24-25, 200830  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

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32. CHILE, March 24-25, 200832 PUBLIC RESPONSIBILITY POLICY INTERVENTIONS

33. CHILE, March 24-25, 200833 STRONG INTERACTION BETWEEN DIFFERENT LEVELS NEEDED Global Regional EU NationalLocal

34. CHILE, March 24-25, 200834 34

35. CHILE, March 24-25, 200835 STRONG GLOBAL INFLUENCES – GLOBAL HEALTH ACTIONS NEEDED: WHO GLOBAL STRATEGY ON DIET, PHYSICAL ACTIVITY AND HEALTH ADOPTED IN 2004

36. CHILE, March 24-25, 200836 WE NEED STRONGER USE OF GLOBAL PUBLIC HEALTH INSTRUMENTS! Further developments with Global Strategy on Diet and Physical Activity.

37. CHILE, March 24-25, 200837 NATIONAL Governments have a basic responsibility for public health.

38. CHILE, March 24-25, 200838 PARTNERSHIPS FOR NATIONAL PUBLIC HEALTH WORK  Health services  Governments (national, local)  Civil society (NGO’s)  Private sector  International collaboration

39. CHILE, March 24-25, 200839 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?

40. CHILE, March 24-25, 200840 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

41. CHILE, March 24-25, 200841 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

42. CHILE, March 24-25, 200842 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.

43. CHILE, March 24-25, 200843

44. CHILE, March 24-25, 200844 THE MAIN CHALLENGE IS NOT WHAT TO DO, BUT HOW TO DO!

45. CHILE, March 24-25, 200845 IDENTIFYINGIMPLEMENTING PRIORITIESTHEM FROM PRIORITIES TO IMPLEMENTATION

46. CHILE, March 24-25, 200846 STRONGER SUPPORT FOR IMPLEMENTATION  Stronger public health infrastructures  Stronger health surveillance / monitoring  Innovative financial support mechanisms

47. CHILE, March 24-25, 200847 MEDICAL KNOWLEDGE SOCIAL & EFFECTIVE BEHAVIORAL PROGRAMS THEORYPOLICIES SUSTAINED IMPLEMENTATION MEDICAL KNOWLEDGE SOCIAL & EFFECTIVE BEHAVIORAL PROGRAMS THEORYPOLICIES STRONG SUSTAINED IMPLEMENTATION KEY ELEMENTS

48. CHILE, March 24-25, 200848 HEALTH MONITORING  Power of monitoring  Feed back to people and decision makers  Need to emphasize risk factors, lifestyles, determinants

49. CHILE, March 24-25, 200849 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

50. CHILE, March 24-25, 200850 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

51. CHILE, March 24-25, 200851 PUBLICPOLICY NATIONAL HEALTH PROGRAMME POPULATION PRIVATESECTOR HOW TO PROMOTE POLICY CHANGES?

52. CHILE, March 24-25, 200852 FOR SUCCESSFUL PREVENTION  Strong leadership combined with  Good partnership

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54. MUCHAS GRACIAS KIITOS Chile, March 24-25, 2008